A Developmental Approach to Toileting: Part 1
Alysha Paiaro, Developmental, Individual differences, Relationship-based (DIR) Occupational Therapist and the Assistant Director of Little Buddies Pediatric Therapy, Inc. DIR Occupational Therapy practice just outside Vancouver, British Columbia returns for Part 2 of our podcast on toileting with a developmental approach. If you missed Part 1, please check it out here. This week we have parent questions from Affect Autism Members and some more important aspects of the developmental approach to toileting.
Parent Question #1
We have been working on toileting with our 4-year-old daughter. Right now she is using a small training toilet throughout the day. She is mostly non-speaking, so she will either lead us to it by hand when she needs to go, or go sit on it by herself. Sitting down on it does not appear to bother her. However, as soon as she starts to go, she covers her ears and starts screaming. (She also does this if a bath or other faucet is running in the house. When washing hands, we start the faucet at a very slow trickle and then gradually increase the water to avoid loud noise.) She has noise cancelling headphones, but generally doesn’t like to wear them. We typically just sit with her while she’s using the toilet and do our best to comfort her in the moment and be present. Is there anything else we can do to make the process a little easier or less-stressful for her?
Alysha says that this is where we have to play detective as parents. The most ‘lowest-hanging’ fruit, she continues, is that the child has strong auditory sensitivities, especially when it is a sudden noise such as a faucet turning on, or urine hitting the toilet. It’s quite startling. How might we play with that, she wonders. It’s about trying to figure out what makes sense for them. But first, Alysha wants to celebrate that despite all of this, the little one is still going independently to sit on the potty, which is fantastic! We’re not seeing that complete aversion. Every time she goes to sit on that toilet, we want to do that little celebration, which might be as subtle as, “Ah, it looks like you have to go pee!“
Alysha suggests experimenting with adding in a little bit of auditory input in that moment that she might be able to focus on. Dampening headphones is one way to limit the intensity of the stimuli, but you can also give another stimulus such as humming, change the tone of humming, or making it higher or lower pitch. You can slowly turn on the faucet nearby as she sits on the faucet and say, “I’m going to turn it on just a little bit.” Continue to try to cultivate that common element of, “You don’t like that. I’m here with you.” and maybe gently rock back and forth or put your hands on her hips.
Some parents have folded some paper towels in the bottom of the potty to dampen the sound of the urine falling in. Then scoop up that paper towel into the garbage. Follow the child’s lead and continue to co-regulate through the experience. She is making sense of this and is paving the way by sitting down to let you know she has to go. Over time, the positive memory bank will foster the next experiment, so continue to comfort her rather than having the experience of sitting down, screaming, parent getting startled, etc.
Parent Question #2
What about an older child who is toilet trained, not quite yet a teenager, and still needs assistance with toileting. It might not be the same person helping them at the community centre program or at school. We have concerns about random strangers seeing our children on the toilet. What can we do to give tips, but also to help our child’s awareness if their only experience has been going to the bathroom in front of any ol’ stranger to know that this is a private experience.
Alysha says that it’s important for us to model the importance of privacy and the ethics of touch early on, even for our children that might be seemingly unaware. Are there limits on who is taking our children to the washroom, especially if the child is just happy to be with just anybody. It’s scary to know that as parents if our child doesn’t have those alarm bells. Alysha was in a school with a team making a plan around toileting to build independence in the bathroom, but what was missing is that they were unintentionally modelling no privacy.
The entire team was in the bathroom including multiple Education Assistants, a Resource Coordinator, the Occupational Therapist, etc. all problem solving with the door wide open, thinking they hadn’t crossed a boundary. We need to model personal privacy and boundaries, even if our child isn’t the first one to say, “Close the door“. If you’re the designated practitioner, let the child know intuitively and experientially that we are modelling privacy. You can say, “Busy! We need privacy right now. I’ll come out when we’re finished!” It’s not appropriate for a child to be exposed sitting on the toilet while adults are having a conversation.
This is a part of the toileting journey: making sense of peeing at home and seeing family members pee, but if company comes over that’s when we close the door, and if I don’t want to be alone, I can ask Mom to come in with me. Sometimes we forget about these pieces with children who aren’t speaking and seemingly not paying attention. We go through that modelling and learning process, even if non speaking. They’re paying attention and deserve us to be treating them as if they are fully aware of what’s happening around them, which they probably are.
Parent Question #3
Do you have any tips for how to help children wipe themselves?
For the child who is toilet trained and pooping in the toilet but just hasn’t yet been able to clean up afterward, it could be lack of coordination or motor planning. Alysha says that it’s tricky. The Occupational Therapist can do an assessment to determine what it is about the action of wiping that is difficult for the child. It could be the fine motor skill of grasping the paper or ripping the paper off the roll. Sometimes it’s the starting fundamentals: postural stability and gross motor control. It’s the foundational piece: the ability to balance being on the edge of the toilet and reach.
Then once you’ve wiped, does it go in the toilet or do you get it all over your hands? Alysha says it can be about social learning as well. Some kids don’t find poop all that gross! We want to teach them that poop goes in the toilet. Poop can carry germs, so we are careful and wash our hands. So, it starts with an assessment, then going step-by-step. Invite the child to participate in the wiping. It might start with counting a certain number of squares off the roll. We count together and pull, then build understanding, efficacy, and independence to pull the right amount of toilet paper. Then, the caregiver will step in a rip it off and wipe. Next, we might get them to help rip the paper.
Alysha says it can be tricky to figure out a way to hold the paper and wipe without getting it on your hands. Problem solve how your child will hold it. You can grab a bunch and squish it all up. You can wrap it all around your hand. One child she worked with loved the Very Hungry Caterpillar book and so they started by playing by wrapping the paper around his hand like the caterpillar in the cocoon in the book. He had a tactile sensitivity and didn’t like poop getting on his hands. So in the bathroom, they said, “Time for the cocoon!” so he knew to put the paper around his hand. Going slow you can break up the component skills–even starting with pulling up and down your pants.
Working Towards the Final Goal
I asked Alysha how to convey to parents that sometimes our kids aren’t ready as quickly as we’d like them to be. Many parents ask about this at age 3, which is so early for many kids. Parents are rightly concerned, and there are many requirements for kids to be toilet trained for community activities, camps, or swimming lessons. Alysha says we can start at anytime. There is always going to be something we can work on towards the goal. It’s a long haul. Their routine is ingrained and it’s hard to change routines and habits, she points out. But that doesn’t mean we can’t start building independence today, even though we won’t reach the finish line tomorrow.
You might see some readiness in various ways when they are giving you cues that they are feeling and experiencing awareness. They might start wandering into the bathroom for the first time, or they might be counting toilet paper squares. Each little step is huge, she asserts. We want to build intrinsic motivation rather than impose toileting on the child. The more parents get into the mindset of, “I’m done!” and insisting the child must be trained, the more Alysha will see that attitude in the child as well. The child isn’t interested in talking about it anymore or participating at all. They hate the bathroom and refuse to go. They flat out refuse.
The parent can see the child as resistant. But it’s a reflection of what is happening with the child’s most trusted people! How do we take that next step? What are we offering to the situation around that readiness piece? Alysha wants to support that self-reflective journey of curiosity, patience, and courage to try something just a little bit different. If you sit in this new space, what happens? Alysha played with funny ideas such as, “Knock knock! Who’s there? Poop!” and talking about her dog pooping. The child was curious and wanted to see pictures and asked if cartoons poop. It’s uncomfortable for some parents to play with these ideas.
Bringing it back to Play
This playfulness is contagious. The child then wanted to start telling jokes about poop instead of the narrative, “He doesn’t want to do it. He won’t talk about it. He just won’t!” It was about humour and playfulness and now the child is talking about it and is curious. Why do dogs poop? Where do they poop? Where does poop come from? One day they talked about where poop comes from? How do we know when you have to go? The child replied, “The clocks tell us!” Alysha replied, “Really? The clock doesn’t tell me when to go…” This child really did believe this because for his whole life he was going on timed trips to the toilet.
The child had lost the body connection to realize that it’s his body that told him to go to the bathroom. They had missed out on this important learning experience of interoception of perceiving discomfort, pressure, or whatever it feels and understand that ‘that’ means ‘this’. Nobody was modelling this language anymore because the child was in an older grade. But he still needed that repetitive coaching and prompted reflection to make the brain-body connection. It then shifted from the tug of war with the child to, “Oh! I feel something! I’m doing my body dance.” or, “I can smell my fart.” When you fart a lot that means your body is filled with poop and he problem solves to realize that he has to go.
Building the internal awareness and interoception is essential. We need to support the meaning making piece of where does poop come from? How do we make sense of why the body creates this stuff? Alysha and him made a silly story about the poop loop. They made a video about how you eat food, it goes into the stomach and becomes goop then goes into the loop of their intestines and then becomes poop. He had a story he could tell now. As long as we eat, we keep having poop. Now the child had the understanding that the loop filled with poop and he had to go to the bathroom. This was this child’s learning experience.
Even though the child had been toilet trained for years, there was frustration of being told to go to the bathroom over and over again and there was no play nor fun. There was no intrinsic motivation and understanding. It’s now good most of the time. It’s come along so far. I pointed out that when children are young, it is appropriate to bring the child to the bathroom every 15 or 45 minutes when it’s most likely that they’ll have to go so they can experience what is happening versus doing this as a regimented routine until they’re 8 years old, for example. The experience, meaning making, and story telling is part of that. It’s a back-and-forth of experiencing and feeling what is happening.
A Developmental Process
What is happening in my body? Why is this happening? It’s normal. All of this story telling will vary depending on the child’s developmental capacities and individual differences. Everybody’s culture is different. Everybody’s diet and sensory experiences are different. There is no prescriptive rulebook for how to toilet train. It’s a process and Alysha pointed out all of the Floortime aspects of what we do to determine readiness and break down the skill areas to begin to tackle. Parents need to carve out time everyday to make headspace for thinking about this. To focus on something as big as toileting, you need space to focus on this.
A lot of progress can be made if you can stick with it. Find moments to check in with your child, and wait, watch, and wonder. Sit in each space and feel confident in each level of the process and wait. Make sure the foundation is there before you rush on to the next thing. It’s important to look at the ‘why‘ behind the behaviour.
Regressions in Toilet Training
In the podcast on Developmental Growth Spurts with Maude Le Roux, Maude talked about how sometimes our kids are toilet trained and then they start wetting the bed again. When our children are assimilating a new skill, something they’ve previously mastered regresses because their brain is expending so much energy learning this new skill. All of a sudden after about six weeks, the child makes a developmental leap. When a child has new doors opening up and there’s so many new things to focus their attention on, or they have new motor capacities and figure out there are new things they can be doing, this can happen.
Learning a new skill is taking all of the child’s cortical and cognitive load so they don’t have as much capacity to focus on their bladder and the sequencing of actions to communicate that they need to go to the right person, who’s across the room, and then figure out where they need to go all the while navigating and regulating their emotional responses to this overwhelming experience and disappointment because they’re disengaging from something else. Our child hasn’t suddenly decided they don’t want to be toilet trained anymore.
They haven’t suddenly lost the neurological capacity to be toilet trained. These can be scary thoughts. It’s not that the toilet training is gone. Something else is being emphasized for your child. Something else is very meaningful for them at this moment that is really important. If we’re patient, we can get back to a place of full integration, Alysha assures.
With toileting, there’s always this dance of, “Is pausing what I’m doing right now more important than what I’m doing?” And for kids, no, probably not. Going to the bathroom is not the most exciting thing to be doing. So, if I’m in this different developmental space and experiencing theses types of interactions and learning opportunities that just feel so good, it makes sense to me that children are going to say, “I want to stay here and do this! That’s not as important to me right now! That’s alright. I’ll have some wet pants for a little bit. We’ll deal with that.” That kind of higher level prioritization comes much later with these executive functioning processes of prioritizing and planning. “When am I going to do this?” Usually in that moment for our children it’s, “What feels the best for my body right now?”
Why the Developmental Approach?
Being aware of all of the feelings our children are experiencing throughout the toileting process is also so important. Children can feel a lot of shame around wearing diapers and not being toilet trained. We never want to shame our children for something they aren’t doing on purpose and can’t control. Even if a child is peeing on purpose for a reaction, you wouldn’t want to punish them. Children are always testing the waters as they build independence. It can also be just about curiosity and wondering what will happen if they pee their pants! They’ll make different choices and it’s a learning process.
Alysha advises us to move away from thinking that a child doing something on purpose to get a reaction is a negative thing. There’s a reason. They’re trying to see what happens next and that teaches them something. Maybe it allows them to leave a situation that they’re really uncomfortable in. She’s heard this in ABA (Applied Behaviour Analysis) that children pee themselves to get out of their work. This flavours the child as if they’re misbehaving and not listening to the rules. It’s based on hierarchy and that the child will do what I want on my timeframe.
But it’s important to recognize that the child doesn’t want to do what is presented in front of them to the extent that they’re willing to soil themselves to not be in this environment anymore, Alysha emphasizes. That’s a heavy idea. Imagine being so pushed to the limit that this is the only way they can get out of it. What about this environment is so undesirable for them that soiling themselves feels better than to participate? There’s probably a lot more we can do as the adult in that scenario, Alysha suggests, to change our approach that can change the child’s approach than teaching them that you don’t soil your pants or giving them the social story about what we do when we have to go to the bathroom. That’s just rote learning that’s just expectation-based.
It’s not even really a social story because it doesn’t promote social learning or understanding and lacks meaning. A true social story would be more like, “We like to go to the bathroom. Mom likes to go to the bathroom by herself and spend a long time in the bathroom. Mom likes how quiet the bathroom can be and she loves a break by herself, so she likes to pee for a long time. But your cousin Stu, he couldn’t get out of the bathroom faster! He doesn’t like wetting his pants so much, because that’s uncomfortable. But he certainly loves to play way more than peeing, so he goes pee quickly.” Just because someone does something on purpose doesn’t mean it’s bad. It gives us a lot of information.
Like in all of Floortime and a developmental, relationship-based approach, we want to wait, watch, and wonder. DIR/Floortime gives us the insights to think about so you can apply it to your own situation and your child, rather than providing a prescriptive set of goals or rules that may or may not work for you. It’s about thinking and applying a process, individualizing it to each person’s unique experience. Alysha has given us so many insights that we can now reflect on in true Floortime fashion.
This week’s PRACTICE TIP:
This week let’s think about ways in which we model toileting.
For example: Are you modelling privacy? Let’s show our kids that toileting is a private matter and that at home is different than in public? If they are old enough to comprehend the concept of privacy, talking about it with them.
A huge thank you to Alysha Paiaro for all of the helpful information on how we can approach toileting across the developmental capacities with our children. If you found this podcast and blog helpful or informative, please share it on Facebook or Twitter and feel free to share relevant experiences, questions, or comments in the Comments section below. Back in two weeks!
Until next time, here’s to choosing play and experiencing joy everyday!