Toilet Training Children
with Moderate-Severe
Disability


Lisa Samson-Fang
MD
University of Utah
and Salt Lake City
School District
Objectives


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
Background/
literature
Practical
programming
Supportive
equipment
Adolescent issues
Can This Child Be Toilet
Trained?
Case I
• 5 year old
• autism
• no functional
verbalizations
• assistance for ADLs.
finger feeds.
• Social quotient
(Vineland Social
Matuirty Scale)
0.36.
Case II
7 year old
 total body involved
CP
 cognitive
impairments
 Communication:
differential cries and
eye gaze.

Is this an important goal?

Impacts on
– independence
– caregivers
Impacts
In the institutional setting.
• Incontinence reduced
• Decreased linen usage
• Work load minimally decreased.
Therapeutic vs. Custodial role
• Positive impacts in other areas of self
care
Not studied in the home or school
setting.
Important?


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Removes negative
impacts on social
interactions
Increased freedom
in more
environments
Privacy
Who’s Job Is It??
The child with disability
Not just an adaptation
of the process used
for “the typical
toddler”
Cognitive Impairments
Understanding goal
Attention
Initiation
Impulse control
Generalization
Birth Cohort Follow-up
Wendt et al.


Information available on 105 of 132
individuals with mental retardation.
Bowel continence.
– 70% by age 7 and 80% by age 20.

Bladder continence.
– 63% by age seven, 83% by age 20.
Autism

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Social motivation
Language
Sequencing/attendi
ng
Routine changes
– The diaper is a
routine

Sensory
– Sensation – function
– Sensory overload
– Enjoyment of
Survey of Parents
Dalrymple
et al.
Overall results
Training required
urine 1.6 yrs
bowel 2.1 years
Start at 4-5 years
95% successfully
trained
78% self initiated
Common issues
Regression
Night incontinence
Constipation
Behavioral concerns
Cerebral Palsy

Motor Issues
– Mobility
– Safety
– Upper extremity function

Medical issues
– Chronic constipation
– Neurogenic bladder
Preschool children with
Shaw
CP
Population
n = 27
2.5 - 4 years old
Results
6 dry at entry
7 immediately dry
12 achieved
2 wet
Factors in success
Higher expectations
Routine
Shared aim w/ peers
More appropriate
toilets
Access to PT/OT
advice
CP: Neurogenic Bladder
McNeal et.al.
30% prevalence of symptoms
Enuresis
 Stress incontinence
 Urgency
 Frequency
 Dribbling
 Difficulty urinating
 History of a UTI.

Urologic Findings
Decter et
al.

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Referred population for symptoms
Significant findings - 86%
–
–
–
–
–
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Uninhibited contractions
Detrusor-sphincter dyssynergia
Small capacity bladder
Bladder hypertonia
Periodic relaxation of the external sphincter
Improved w/ treatment - 78%
Constipation

Bowel training
– difficult
– unpleasant.

Affects bladder
– Lower volume
– Uninhibited
contractions

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Optimize treatment
Monitor for
recurrence
Multi-modal
Treatment
Nickel and Desch
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Positioning and seating
Behavioral issues
Dietary changes
Cleanout procedure
Maintenance
medications
Emptying program
Note:
The behavioral protocols discussed are
not intended for the achievement of
continence in individuals who lack
bowel and bladder control
(e.g., individuals with spinal cord
lesions).
The Literature

Populations:
– Cognitive disability, autism, physical
disability

Settings:
– Institutional, school, home

Designs:
– Case studies/ small cohorts
The Literature

Methods:
– Timed and Regular
– Group vs. Individual

Goal:
– Trained vs. Conditioned
– Degree of independence
– Attainment of “sub-skills”
– Generalize to other situations
Most Replicated
Azrin and
Foxx
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Induce frequency
Timed toilet sitting
Positive reinforcement
Dry pants checks
Minimal
assistance/prompt for
dressing/ faded
Modeling
Pants and potty alarm
devices
Verbal reprimandcleanliness training
Comparing Methods Smith
Individualized regular
potting
– Monitor child’s
rhythms
– Toilet when high
probability
– Stimulus to void is
full bladder
Arbitrary timed
potting:
– Set schedule
– Stimulus to void is
toileting routine
Comparing Methods
Method
Nursing Hours
(5 Children, 12 weeks)
Intensive Regular
Potting
Group Regular
Potting
Timed Potting
2330
1260
2079
Preschool Setting Richmond
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Frequent potting
(q15minutes faded to q
2 hours over 1 month)

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Praise, liquid
rewards
Brief reprimand and
simple correction
Self initiation not a
goal

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4 children
4.5 hours / day
No equipment
Otherwise no
change in
classroom routine
Weekly Accident Rates
Child’s Chronologic and
Developmental Age
School
Accident
(per wk)
Baseline
Post
q2hrs
CA36m, DA12m
6
2
CA46m, DA13m
6
1.4
CA 36m, DA12m
5.3
0.9
CA=32m DA= 8 m
7.3
0.6
Is continuity important
Dunlap et.al.
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3 children with Autism (5-7 yrs)
1 new to toileting, 2 w/ 2 years of no
success
Baseline training program in 1
environment vs. training in ALL
environments.
Results
Alarms