Success at toilet training is a significant milestone for every child and his or her family. Through mastery of this most basic self–help skill, the child gains independence and the parents are freed of the considerable time, effort, and cost previously required. Succeeding at toilet training is just as important for children with developmental disabilities and their families; however, these children may need specific methods and a different time frame to achieve the desired goal.
CONTINENCE: NOT ONE SKILL, BUT MANY
To achieve continence, a child must master a series of skills (Table 1). First, he has to "feel it coming." Some parents recognize by the look on their child's face that he knows he "needs to go." Next, the child has to be able to "hold it in." When parents see their child do the "pee pee dance" or the "doody dance," kneel on a heel, or stand very still in an effort to postpone urination or defecation, they may be inclined to view such attempts to hold it in as avoidance techniques. Instead, parents can be encouraged to recognize the ability to hold it in as an important and necessary step toward continence. At this point, the child must be able to communicate, either with words or gestures, his need to get to a toilet; this skill is essential for those times when he is in unfamiliar environs or far from a known bathroom. Motor skills are also needed to get to the bathroom physically.
Many children who are not yet toilet trained will regularly go to the same spot in their home to have a bowel movement—for example, behind a couch, under a table, or to their own bedroom. These children are demonstrating a number of toilet readiness skills: feeling it coming, holding it in, and getting to another place to toilet privately. However, rather than "toilet trained," they are "couch trained" or "dining room table trained"! Again, taking this perspective is helpful because it encourages the family to recognize what the child already can do, rather than focusing solely on his failures.
Once in the bathroom, the child needs the motor skills to pull pants and underwear down and to climb up and sit comfortably and securely on the toilet. The ability to relax while sitting is also essential: you can't poop when you're clenched. For this reason, one of the first things we ask all children to do when teaching them to use the toilet is to practice sit–down times; the goal is to master the essential skill of relaxing while sitting. Typically, sit–down times take place 30 minutes after meals, to take advantage of the gastrocolic reflex. Each sit lasts 10 minutes, and the goal is simply to practice being relaxed on the toilet, not immediately to produce urine or stool.
The child now needs to empty the bladder or evacuate stool. Stool evacuation requires pushing. A child can use the simple biofeedback technique of placing one hand on the lower abdomen while blowing, and feeling the abdomen protrude as a sign of a successful Valsalva maneuver. Pretending to blow out birthday candles or blowing on a kazoo or other party blow toy are additional options. Wiping comes next, a skill that requires fine motor coordination and hand strength. Getting off the toilet, pulling up underwear and pants, flushing, and hand washing complete the sequence.
Breaking toileting into these 13 steps not only clarifies the skills needed to consolidate training but also provides a framework for identifying the many skills a child may already possess. For typically developing children who are struggling with toilet training, breaking the toileting process into these discrete skills focuses frustrated parents on the many abilities the child does demonstrate and lays the groundwork for a plan to add the small steps still needed to produce continence.