Potty Training Children with Special Needs

The issue of when and how to begin toilet training can be particularly challenging for parents of children with special needs. The sense of accomplishment when they do succeed in this important aspect of self-care can make an enormous difference in their level of self-esteem.

Perhaps more than other parents, those who have children with physical, intellectual, or developmental disabilities can appreciate the toilet-training process as a way to follow and celebrate a child’s overall growth. Rather than focusing negatively on setbacks, which are inevitable in any case, they can use the setbacks as opportunities to discover how their child learns best and to demonstrate to them that they are able to progress.

Toilet training works best when parents of children with special needs have access to the guidance, instruction, and encouragement of their pediatrician, other trained professionals (including school personnel), support groups, or a combination of all . The first step you must take is to determine whether your child is ready to begin.

Signs of potty training readiness are the same for your child as for all children:

• Is your child aware of the difference between being wet and being dry?

• Can they stay dry for at least two hours at a time?

• Can they sense when he needs to urinate or have a bowel movement?

• Are they capable of reaching the toilet or potty in time (perhaps with your help)?

• Can they undress and dress themselves or are they ready to learn?

• Are they motivated at some level to take this next step?

If your child is in a resistant phase, is not ready to take on a new challenge, or does not yet feel the urge to behave "like other kids" in this way, you might take some extra time to prepare them mentally before starting the potty training process.

If you feel that your child is ready, ask your pediatrician for their opinion. They can examine your child to offer a physical assessment and perhaps special insight into the particular needs of your child. They can also provide further information that you may need before starting, and let you know what types of special equipment may be advisable.

It is also important to prepare yourself emotionally before you and your child begin the process. Children with special needs often begin toilet training later than other children, frequently completing the process at age five years old or even later. Of course, children with some conditions may always need help with their clothing (button, zippers, tights) and some might need help getting to the bathroom. Some will develop innovative ways of achieving independence.

Learning to use the toilet can be physically painful to some, and challenging for others to understand. Accidents will happen, of course, and you will need to draw on an extra dose of patience and humor when they occur. Ask for help from your spouse, relatives or friends before you begin.

Physical challenges

A number of physical disabilities and illnesses can hinder a child’s ability to become fully toilet-trained or easily adjust to bathroom use. If your child faces such a challenge, you will need to think about how their unique situation affects each stage of toilet training and how you can compensate. Whether your child is unable to sense the need to urinate, has difficulty getting onto or staying on a standard potty or toilet or must adjust or readjust to toilet use after having used an ostomy device, they will need extra support from you and their other caregivers as they learn to master this new skill.

Visual disabilities

Children with visual disabilities and those with sight deficiencies experience a disadvantage at several stages of toilet training. First, they might be unable to observe family members and peers using the toilet, so they cannot mimic their behavior. So many details of toilet or potty use—where the potty is in the bathroom, how the body is oriented to it as one sits down, how the urine and poop get into the potty, how one tears off and uses toilet paper—are simple to understand if a child can observe the process but difficult if they cannot. Without sight to help them, your child will need to rely more on language to understand how the process works. Because of this, you will probably want to wait a little longer to begin potty training—until they are three or four years old (or even later, since language delays can accompany blindness)—so that they can fully comprehend what you are telling her.

When you are ready to introduce your child with a visual impairment to the concept of toilet use, start bringing them with you when you use the bathroom. Allow them to explore the bathroom and locate the toilet. (Be sure it’s well ventilated and smells pleasant so they will want to return.) Place their hands on your shoulders so they can feel you sitting on the toilet, explain what you are doing and why, and guide her hands to the toilet paper dispenser. Also show them the flush handle and the sink for hand washing.

Once you have placed a potty in the bathroom, lead them to it, let them accustom herself to its presence, and keep it in the same place throughout the toilet-training process. Talk to them about toilet use at other times, too—pointing out that most of the people they knows use the toilet and that toilet use is a sign of being a big kid who can take care of themselves.

Once your child begins practicing potty use themselves, keep the bathroom and the passage to it clear of obstacles. A musical potty that is activated when urine hits the bowl might make the learning process more fun. Teach them to feel the inner edge of the seat before tossing in the toilet paper and, if the child is a boy urinating standing up at a toilet, to position his body so he doesn’t urinate on the toilet itself. (You may want to have your son first sit to urinate; once he masters that skill, then you can teach him to stand in front of the toilet.)

Finally, as your child grows more comfortable with bathroom use, make a point of taking them to the bathroom at each public place you visit. By helping them familiarize themselves with the wide variety of bathroom layouts and toilet styles, you will help build their self-confidence when away from home and prevent accidents. And don’t forget to reward their progress with praise, hugs or a small reward.

Hearing disabilities

Children who are deaf or have difficulty hearing may or may not find toilet training challenging, depending on their ability to communicate. A child who is already fluent in sign language can rely on a combination of visual observation and explanations from you to understand what’s expected of them—much like any other child. Children who do not yet have the ability to understand your signals and simple signs may not be ready for toilet training until they are somewhat older.

The key to training in these cases is to keep the process simple. When introducing the concept, emphasize the visual: Allow your child to observe you (and, even better, other children) using the bathroom, and show them picture books about it. Choose one gesture or sign for the essential terms (pee, poop, potty, wet, dry, and need to go). Use these gestures each time you use the bathroom, and use them with them as well—signing "wet" (with a sad face) when you change her diaper or wet underwear, "dry" (with a happy expression) once they've been changed, and "need to go" after lunch when it’s time to sit on the potty.

As long as you are consistent and stick with the half-dozen signals you need, your child will get the hang of potty use without longer explanations. When they do, be sure to reward them with plenty of hugs, stars on a potty chart or another small reward.

Continence problems

Some conditions have no effect on a child’s ability to understand the process of toilet training but make it difficult for a child to comply. Your child may grow increasingly frustrated in their efforts to stay dry and may even give up trying.

The best solution to this dilemma is to put your child on a regular potty schedule. By placing them on the potty frequently (reminding them every hour or so to visit the bathroom), you remove the burden of having to acknowledge so many times each day that they must interrupt an activity to tend to their physical needs. Going to the bathroom at the top of every hour can become a habit similar to brushing teeth twice a day or getting dressed in the morning—freeing her up to focus on other activities between visits.

Cerebral palsy

Children with cerebral palsy not only tend to be slow in developing bladder control, but may not have enough bladder awareness to begin toilet training at age two or three. If your child has cerebral palsy, they will need help to develop an awareness they needs to go (which may be signaled to you when you see them clutching their genitals or fidgeting anxiously) before they can begin toilet training. They will have to be able to delay urination until they are in position on the potty. They will need to remove their clothing and then hold themselves on the potty (with supports) long enough to achieve success. Again, these challenges mean that it is usually best to wait to toilet-train until they are older.

It is possible that limited physical activity, undeveloped muscle tone, or medications may cause constipation for your child with cerebral palsy. So, pay special attention to their diet as you start toilet-training. Make sure they are drinking plenty of fluids and eating foods high in fiber such as fruits and vegetables. As they begin to practice removing her clothes before getting onto the potty, make it easier by providing clothes with Velcro fasteners or loose elastic waistbands. (They may find it easier to remove her clothes while lying down.)

Spina bifida and spinal cord injury

Spina bifida, spinal cord injury, or spinal tumors create toilet-training problems for young children similar to those of cerebral palsy. But since most children with this condition never develop an awareness of when they need to go, few can ever fully use a toilet. You can, however, teach your child to remove urine through a catheter on a regular basis, and to visit the bathroom for bowel movements on a regular schedule. (A high-fiber diet with plenty of liquids and meals served on a regular schedule will make this process easier. Sometimes a stool softener or even a suppository or enema is needed.) Since your child will find it difficult to remove her clothing, be sure to provide them with Velcro fastened clothes and allow them to lie down to undress if necessary.

A child with spinal cord dysfunctions will likely not feel the need to move their bowels and have a greater risk of being constipated. Help prevent constipation by giving them enough fluids and a diet high in fiber. They may need to be on a bowel regimen designed so that they have a bowel movement at home and then does not have a bowel movement at school. Your pediatrician and therapist should be able to help develop a successful program for your child. They will need regular catheterizations, and either an aide or school nurse will have to help until your child can perform their own catheterizations.

Parents of children with physical disabilities such as cerebral palsy or spina bifida may become so distracted by the need for special equipment or physical support that they neglect the cognitive and emotional support that all children need to succeed at toilet training.

While installing that special potty in the bathroom, talk with your child about using the potty and why it’s important. Let them observe you and others using the bathroom, and praise and reward them when they succeed even a little bit. Resist the temptation to "let things go" when there is difficulty and remain firm about the schedule or routine you have created—unless the experience becomes negative and your child becomes very resistant. Remember, their progress is especially significant if it increases their self-confidence and prepares them for more challenges. Give them all the information, attention and support they need to succeed.

Behavioral and mental disorders

Your experience toilet-training a toddler who has been identified as having developmental or behavioral difficulties will depend a great deal on your particular child’s temperament, behavior patterns and coexisting conditions. Your knowledge of your child’s strengths, weaknesses, tendencies and interests will help the process.

Toilet training can be particularly trying for parents of children who have developmental disorders or behavioral difficulties. This includes those with autism, fetal alcohol syndrome (FAS), oppositional defiant disorder (ODD), and, in cases when it is diagnosed this early, attention deficit /hyperactivity disorder (ADHD). Many children with these conditions may not be strongly motivated, or sufficiently equipped, to respond to the social reinforcements that work so well with other children ("What a big boy!"). For some, small tangible rewards such as a sticker or small toy can be effective.

Many find it extremely difficult to adjust to any change in routine. Some are particularly sensitive to touch and other sensory input and become upset by the frequent pulling off and on of clothing, the physical closeness with an adult and the unfamiliar surroundings of the bathroom.

For some children, simply learning the abstract concept of potty use can be complicated. For example, some children with behavioral disorders do not naturally imitate their parents’ or peers’ behavior. Others learn only through simple imitation or other concrete, nonverbal demonstrations. Such complications in the training process mean that early efforts can create a high level of frustration in your child and may lead to displays of temper, stubbornness, and refusal to cooperate.

Despite challenges, most children with special needs—whether they have physical challenges or behavioral issues—can be toilet trained, though in some cases the process may take up to a year or even longer. They may require help from an occupational or physical therapist or a rehabilitation engineer.

Your first step is to determine whether your child is ready to start training. Usually the time to think about beginning is when you notice that they can stay dry for an hour or more at a time, has regular bowel movements, is aware that he is about to pee or poop and dislikes being wet or soiled. It is also important to have your child examined by their pediatrician, since they may be at a higher risk for constipation or loose stools, which may interfere with training.

Once you have decided to begin, observe your child and consider carefully the specific traits, patterns of behavior, and obstacles that may impact their learning process. If they seems to dislike entering the bathroom, determine the cause of their discomfort. Is it the smell of disinfectant? The cold floor? The flushing toilet? Change or fix it if possible (change cleansers, put socks on their feet, move their potty away from the noisy toilet).

If they do not overtly signal the need to go, do they pause just before voiding or otherwise behave in a way that will provide you with a cue? At what times, or how long after eating or drinking, does he usually pee or poop? What foods, toys or other objects are they most passionate about? These can be used as tangible potty-training rewards, which may prove more effective than praise.

Identify how your child learns best. Some respond to firm but gentle physical demonstrations (being placed on the potty at regular times). Others do best with a formal routine containing a series of simple and predictable steps (verbally explained and reexplained, illustrated with pictures, or listed on a chart). Still others do best with offhand comments and conversations that inform without inviting resistance.

Intellectual Disabilities and Developmental Disorders

Most children with a developmental delay, an intellectual disability, or an autism spectrum disorder can be toilet-trained. The time it takes to achieve success ranges from a few months to a year or more. The process becomes easier as your child achieves at least a minimal level of verbal ability, is able to manage their clothes (perhaps with some help from you), and shows awareness of the need to go.

Toilet training for children with developmental delay, intellectual disability or autism spectrum disorder can be quite similar to training for other children, but sometimes it is not. Like with other children, as you introduce your child to the concept of potty use, it often helps to keep explanations simple. Start by checking the state of their diaper or pants every hour or so and offering a one-word, nonjudgmental comment when they are wet ("Wet!"). After you change them, smile and say "Dry!" If their verbal skills are limited, you might substitute a special gesture or sign for the words wet, dry, potty, need to go, and so on.

Begin bringing them to the bathroom with you when you need to use it. Smile and say "Dry!" after you’ve finished and pulled your pants up. If at all possible, have your child observe other children using the bathroom, too. They may make the connection between themselves and another child more easily than between themselves and you. After you’ve finished and are dressed, show them how happy you are and tell them "Dry!" If they have a favorite doll or stuffed animal, use it to play "potty," demonstrating again how the potty is used.

When they are ready to begin using the potty, begin setting them on it at regular times—quite frequently at first (as frequently as you checked them for wetness earlier) and then gradually settling down to the times when they usually go. Try to keep them on the potty for five or ten minutes at a time—keeping them company, reading to them, playing children’s music and otherwise ensuring that they stays in place long enough to succeed. Once they do urinate into the potty, give him a big smile and say "Pee!" (or whatever word you have chosen for this event). Help them wipe off and then praise them with a happy "Dry!" and give them a reward. Eventually, with enough repetition, they will understand the connection.

If your child has an intellectual disability or developmental delay, it is best to toilet train one step at a time. Don’t expect your child to learn to signal or announce their need to go, pull down their pants, use the potty, wipe their bottom and wash their hands all at once, the way their peers might. Toilet training will work best if you focus on the actual act of peeing and pooping first and address the other skills later. It is more important to keep them motivated than to achieve instant success.