Toilet-Training A Child with
a Developmental Disability:
A Family-Focused, Low Intensity Approach
Susan Hepburn, Ph.D.
Clinical Psychologist
Asst. Professor/Director of Research
JFK Partners/Dept. of Psychiatry
University of Colorado at Denver and Health Sciences
Acknowledgments

Association of University Centers for Excellence
in Developmental Disabilities (UCEDD)/JFK
Partners

Developmental Pathways

Teachers and administrators in Cherry Creek
School District and Littleton Public Schools

Families of children who have participated in
individual and group toilet-training interventions
This talk is dedicated to
Nathaniel Roberts,
a dear boy, who taught us much
about social motivation
and the joys of independence.
We develop this work in his memory.
Overview

Part I: Philosophy and Core Principles

Part II: Getting Ready: Changes we Make While the
Child is Still in Diapers or Pull-ups

Part III: Practicing in Routines and Building Habits

Part IV: Working on Pooping in the Toilet

Part V: Getting Rid of Diapers and Pull-ups

Part VI: Reflect on Your Progress
Part I:
Philosophy
and
Core Principles
Philosophy
Patience
Persistence
Humor
Creativity
“Toilet training in less than a year”

“It’s a marathon, not a
sprint”
-- Gary Heffner,
father and
advocate
Many people believe…
1. Your child has to be “ready”
2. More trips is always better.
3. You have to get rid of the diapers to make
progress.
4. Children need to be able “tell someone” that they
have to use the bathroom as a first step.
HOWEVER….
Core Principle I

We don’t hold tightly to “readiness” criteria



We think that children learn through practice within
their natural routines and don’t necessarily have to be
“ready” for us to make the toileting issues less
stressful for the family.
We use a “slow and steady” approach, allowing us to
adjust our strategies depending upon the child’s
progress.
We emphasize the importance of the parents being
ready – particularly when it comes time to remove the
diapers or pullups.
There is always something we can
do to get to the next step….
 Within
your regular routines
 Without
 For
removing the diapers or pull-ups
most children, it makes sense to start
toilet training when they have a
developmental age of about 15 months
Core Principles II
 More



is not always better.
Too many unsuccessful trips to the bathroom may
actually slow progress.
If a child is overwhelmed by the training process,
problem behaviors and resistance will occur.
Parents tell us that intensive approaches are difficult
and stressful.
Core Principles III

Getting rid of the diapers happens towards the end of the
process – most of the training is done with the child still
in protective gear.



For a child who doesn’t “feel” the wet diaper or become
uncomfortable being soiled, removing the diapers doesn’t speed
up the training process.
Several steps and concepts need to be mastered before diapers
should be removed.
By minimizing the amount of messes parents deal with, we hope
to reduce the stress of the process.
Core Principles IV

Teaching the child to communicate that he or
she needs to go the bathroom often comes
toward the end of the training program.


Communication is always built into the routine and is
practiced, but not “required”
It is often helpful to have a nonverbal way of signaling
the need to go – although we can’t prompt a child to
verbally request the bathroom, we can prompt a
gesture or picture exchange
Part II:
“Getting Ready”
First Steps
in almost any
toilet-training intervention
1. Observe

Make lists of foods/drinks
your child usually
consumes

Note the approximate
times of day the child is
eating/drinking

Look for anything unusual
in frequency or
consistency of child’s pee
and poop
Are there any behavioral signs
that your child needs to go?
2. Ask the Pediatrician

Dietary
recommendations

Are supplements
needed to prevent
constipation?

Any possible GI
issues or treatments
to consider?
3. Consider Dietary Changes

Lots of fluid: water or
juice are best!!

Lots of fiber:
Age plus 5 grams!
spread across 3
meals

Less dairy
4. Consider small changes in daily habits

Dress child in easy to remove clothing

Change as quickly as possible

If possible, change diapers in (or near) bathroom

Show child that waste goes in toilet

Have child flush and wash hands at diaper changes
5. Interactions with Your Child

Decide on your toileting words and use them
every day across people and places

Be very matter-of-fact and positive about using
the toilet

Be very positive about their efforts and
cooperation – do not emphasize producing into
the toilet, but emphasize willingness to try

Try to make sure that something good or fun
happens when you leave the bathroom
6. Showing and Telling Kids About Toileting

Allow child to watch mom or dad or siblings

Look at toileting books and videos together

Listen to toileting songs together

Teach toileting through play

Make a homemade book about toileting

Make a home movie about toileting
7. Think About Rewards for Participation





A fun activity – particularly good if it is natural to the
child’s schedule – for example – going outside to play
Special food or drink
Special toys
Special sensory experiences
Target practice (cheerios, sinkems, wax paper)
To improve the power of your rewards: try to limit access
only to toileting times!!!
8. Set Up Your Bathroom

Make it a pleasant place to be (smells good, warm,
perhaps music is playing)

Make sure the child is comfortable on the toilet and if
needed, get a potty chair insert

Provide foot stool or other way for child to feel stable
while seated

Make sure your rewards are nearby

Put up some visual supports
More on Visual Supports



Visual supports for
the overall routine
and when you will
visit the toilet
Visual supports for
the steps within the
routine
Transitional object

Visual reminders

Visual supports to
clarify how long he
has to sit there

Visual supports to
show what will
happen when it’s over
9. Think about who can help out….





Spouse/partner
School
Daycare providers
Grandparents
Respite staff
And talk to them about what you are trying
to do.
Part III:
Practicing In Routines
and Building Habits
How to Trip Train
 You
set the schedule
 You
train the child’s body to go during your
schedule
 For
peeing: trip is 10-30 seconds on toilet
 For pooping: “Sit for Six”
**for children with low muscle tone, they
may need longer to pee or to poop
Trip Training: Time to Go!

Within the flow of your regular routine, while child is still
wearing diapers or pull-ups: prompt child to go to the
toilet; encourage but don’t require that child
communicate urge to go

Request that child sit for a very brief time, but don’t force
it! Try to distract with songs or favorite toys while
practicing sitting

Complete the entire routine and after drying hands – give
reward (or go to a cool next activity) simply for
cooperating

If child actually If voids  big reward
Choosing the Times to Go
 DO


CHOOSE:
A clear and predictable
activity for the “before”
time, such as dinner,
or coming in from
outside
A fun activity for the
“after” time
 DO
NOT
CHOOSE:


To interrupt the child’s
favorite or preferred
activities, such as tv or
computer time
Times in the day that
are too hectic for you
to realistically do
So, we have to do 3 things:
1.
Try to predict how long between input
(drink) and output (pee)
2.
Pick natural transitions – or times when
child is already changing from one activity
to another – for example, coming in the
door from school
3.
Practice making trips to the bathroom
within routines no more than 3-6 times per
day.
A Toileting Routine

Regular routine or transition (such as coming inside from
school)

Visual reminder or physical cue to go to the bathroom

Quick 30 second to 1-minute trip, following all the steps
of the routine whether or not he has produced anything

Leave the bathroom and something good or fun happens
Practice, persist, and persevere

Give the routines time to take hold

Be as consistent as you possibly can

Forgive yourself and others when it just can’t be
done

Remind yourself that this is a hard skill and will
come with time and practice

Change up the rewards
Example of steps of a routine









Walk to bathroom
Pull down pants/underwear
Sit on toilet
Go in toilet
Wipe
Stand up and dress
Flush
Wash hands
Go play
Another tip….
 Look
for times when your child is really
motivated for something (such as wanting
to watch a favorite TV show) and develop
a routine:
FIRST POTTY ……..THEN TV
Part IV:
Working on Pooping in
the Toilet
Steps

Continue to monitor and treat any constipation issues

If child has low muscle tone, talk to an OT or PT
about exercises that can strengthen core muscles.

Choose 1 toilet trip per day that will be a “Poop Trip”



The child will be asked to stay a few minutes longer (about
4-6 minutes)
The adult will need to be there (at least in the beginning).
Choose a very special reward for pooping.
Some Additions to
the Routine for Poop Trips
 Consider
exercise just before the trip
 Consider
taking the child’s hand and
applying pressure to their belly to focus
their attention on that area
 Try
very hard to interrupt accidents and
get them onto the toilet if already pooping

If they get a tiny bit in – it’s a success!!
If a child is afraid of pooping in the toilet

We often do increased work on the social stories, home
movies, and other ways to help them to get used to the
idea

We gently encourage them and support them to face
their fears

We often start with small steps and help them to
desensitize to what’s scary

Sometimes we can provide some environmental
supports to reduce loud noises and other scary parts
Part V:
Getting Rid of Diapers
and Pull-Ups
When do I get rid of the
diapers?

No right or wrong answer here

Varies a lot by child’s style

Some need us to make a clean break

Others maintain them throughout 75% of the training
process

For many children with sensory and/or motor issues:
 Getting rid of the diapers may not help the child to learn
the skill more quickly;
BUT …. can actually increased stress and frustration
We want to get rid of the diapers when:
1)
The child is cooperating with the routine, and has
successfully urinated in the toilet several times.
2)
We can commit 3 weeks to really good consistency
and follow-up.
3)
We know there will be accidents and we are prepared
to try to use those accidents as chances to teach the
skill.
4)
If at all possible, best to do while child is in school or a
program where others are also willing to make this
step. This helps the child learn the skill more fully and
transfer it to other places more easily.
Choose a Good Time in Your Family’s Life

Consider: your work schedule, other children, holidays,
special events and other demands that may make it
easier or harder to begin

Remember: First 3 weeks are very important and most
labor intensive!

It has to work for the family – if we can persist through
this difficult phase we are more likely to be successful!!
Decide How to Handle Accidents

Do not punish or scold!!

Option 1: Gentle correction and change

Option 2: Immediately place on toilet and R+ if
just the tiniest bit gets in

Option 3: Allow to feel sensation and involve in
clean-up
Remember, many kids with
developmental disabilities
need longer to mature into
being dry at night.
When we remove the diapers
during the day, we often keep
them on at night.
Part VI:
Reflect on Your Progress
And Make Changes As Needed
After 3-6 weeks: How’s it going?
Do you need to modify your
approach?
Options for making changes after
3-6 weeks of trip-training

Play with the schedule
 Change up the rewards
 Change the social context
 Change diet
 Find another way to teach the connection – music,
videos, modelling, play
Once you’ve decided on the changes, give them 3-6 weeks
to work and re-evaluate. Are you seeing improvement?
If you are approaching 3 months of trip-training
and not seeing a lot of change…

Sometimes….we pause, take a break from working on
this skill and come back to it a little later, preserving 1
routine a day if at all possible

Sometimes…we identify a problem and provide some
new instructional component or change in our teaching
methods

Sometimes….we move to a more intensive intervention,
like eliminating the diapers and learning through
accidents

Sometimes….we decide to stay the course. It all
depends on the child’s style and all of the other variables
that affect this skill.
Conclusion