Books are fun, they are an entertainment that is widely available and accessible. They are easy to enjoy during the current national crisis where most of us are at home most of the time. Books help children learn new words, they contribute towards development of memory, concentration and thinking skills. They allow a child the opportunity to use their imagination, to learn about the world, their emotions and feelings and how to express these. Stories can help children to accept new experiences and changes. They allow them to make sense of day-to-day life.

Using Stories to Learn about Toilet Training

At Bladder & Bowel UK we regularly suggest to parents that they consider using stories to help young children learn about toilet training. From the day a child is born many of us use disposable nappies to keep our little ones dry and comfortable. For the child it then becomes normal to wee and poo wherever they are. Parents are often told to wait until their children are ready before trying to toilet train them, but often no information is given to families about what ready looks like. They may be advised that by waiting their child will toilet train in a few days.

For lots of children this approach works. The child wants to be like an older brother or sister, or their parents and have ‘big boy/girl’ pants. However, toilet training is happening later than ever before for most children in the UK and there is concern that this is causing more bladder and bowel problems later in childhood. For children who are not as socially aware as their peers, and for those who have differences in the way they are developing, they may not realise that they need to change something that they have always done. At Bladder & Bowel UK we expect children to start potty training around their second birthday. For those who have additional needs, they can also start to learn the skills at this age.

Lots of children are visual learners. That is why picture books are so important in early childhood. They introduce different ideas and different ways of doing things in a safe and comfortable environment, particularly if they are shared with someone the child loves, cuddled up on the sofa, or in bed.

There are many picture books about toilet training. Using these at a time when both you and your child are relaxed can help them to start thinking about this. If used regularly for a few days before introducing the potty, it may help them to accept this change into their routine. The books can then be used while your child is sitting on the potty. This will not only reassure them and help them understand what is expected. It will also provide the reward of one-to-one time with you, which will help them learn to sit for long enough to do a wee or poo, although this is unlikely to happen the first few times they sit.

Some children find it easier to learn if the story is about them. For these children making a story specially for them can be helpful. You could use pictures of them, with their potty or toilet and write your own words. If you are artistic you could draw your own pictures. However, there are also pictures available online at https://do2learn.com/picturecards/printcards/selfhelp_toileting.htm that are free to download and print.

Most young children, but particularly those who have additional needs, often learn best if there is a picture for each of the steps involved e.g. go to the potty or toilet, pull down your trousers, pull down your pants, sit on the potty or toilet, do a wee (or do a poo), wipe your bottom etc. Do not forget to have something about handwashing, everyone being happy and proud of the child for using the potty and them going off to play at the end.

Books are important for children’s development and wellbeing. Time spent reading with a child can help them feel close to their parent or carer as well as help them feel safe and secure while learning a new skill. As we head into Children’s Book Week on Monday 4^th May, we are living through a very strange and different time, where so many of us are spending more time than ever at home. If you have a child aged who is approaching their second birthday, or is older than this who has not yet potty trained, you might want to think about using books or stories about potty training with your child as the first step towards introducing this essential skill with them.

More Information from Bladder & Bowel UK

There is lots of information about all aspects of bladder and bowel health on the Bladder & Bowel UK website at www.bbuk.org.uk. For information about potty/toilet training for all children including those with additional needs visit the Children’s Resources page of the Bladder & Bowel UK website athttps://www.bbuk.org.uk/children-young-people/children-resources/

Connect with us on Facebook and Twitter to tell us what you’re up to during Children’s Book Week 2020!

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I always explain to parents that becoming toilet trained is like climbing a ladder

At the bottom of the ladder is the fully dependent nappy-wearing infant. And at the top of the ladder is the fully independent, bottom wiping, toilet flushing, hand washing, toilet trained child. What we aim to do during the whole toilet training process is to enable the child to get as high up the ladder as we can. Some children we only get half way up. So, although they are clean and dry and wearing normal underwear, they will always need some help and support regarding toileting.

However children always surprise us and, as we do not have a magic wand, the fact that some of these children reach far higher up the ladder than we would ever have thought possible, means that they had that unrecognised potential to do so. We clearly have a duty of care to support families to enable every child to reach their full potential.

Many parents say they have not started toilet training their child as they have been told they were not ’ready’. I have been toilet training children for nearly 30 years and never in that time has a child put their hand up and told me they were ‘ready’ to be toilet trained!

Becoming toilet trained is a developmental skill, similar to learning to walk and talk, yet we seem to treat delayed toilet training differently. For example if we are aware of a child who has speech and language delay then we would automatically refer them on to a speech and language therapist. Similarly if we had a child who was struggling to learn to walk then we would refer them for an assessment, to try and identify the underlying cause, with a referral on to a physiotherapist if necessary. We definitely would not say that as the child shows no interest in walking we would wait until he was ’ready’ to walk and only then we would refer them on. Neither would we ignore a child with delayed speech saying that when they showed an interest in talking only then would we do anything about it.

So why is it that, in the vast majority of cases, when a child is clearly struggling to become toilet trained at an appropriate age, parents are told that the child is ‘not ready’ and nothing is done about it?

Becoming toilet trained is the interaction of two processes. The first is physical maturity of the bladder and bowel. This improves with toilet training, but develops in most children from about two years old. The second is social awareness and motivation of the child. We can therefore clearly see why some children with additional needs may struggle with the toilet training process; they often have no social awareness and are not at all motivated to use the toilet, because their nappies keep them warm, feeling dry and comfortable!

That said children with additional needs are just as likely as their typically developing peers, if not more so in some cases, to have an underlying problem with their bladder and bowel. This may be the cause of the delay in them achieving bladder and bowel control. For that reason all children, who are struggling or delayed with toilet training (not toilet trained by their third birthday) should undergo a comprehensive assessment to exclude and address any underlying problems such as constipation.

All activities of daily living, such as washing your face and cleaning your teeth, have to be taught in an appropriate timely way. We don’t, for example, wait until a child has a full set of milk teeth at age 3 before we present them with a tooth brush and a tube of tooth paste, without them ever seeing them before, and expect them to independently start brushing their teeth. We introduce the toothbrush when their teeth start to come through and also spend time showing them what to do. So, by the time they are 3 years old most toddlers can make a decent attempt of tooth brushing.

Why then do we suddenly present a toddler with a potty, sit them on and expect them to happily sit there and produces a wee or a poo when they have really no idea what it is all about!

The potty should be introduced at around six months of age. After, weaning the poos usually become more predictable and most children have developed a good sitting balance by then. By gradually introducing the potty at set times during the day, it quickly becomes part of the child’s daily routine.

Along the way, more by good luck than expectation, you may be able to ‘catch’ a wee or a poo. This should be responded to with lots of praise so that the child understands that this is a good thing to do!

Once a routine has been established, the child has some awareness and understanding regarding wees and poos and of what is expected and there are no major disruptions, such as starting nursery, moving house etc, then that is the time to remove the nappy and put a formal toilet training programme in place. This ideally should be when they are two to two and a half and no later than about age 3 years.

Parents should ask for help, sooner rather than later, if things are not going according to plan. The formal toilet training process should only take a couple of weeks at the very most. All the background work, such as potty/toilet sitting, awareness of wee and poos etc, would have been done previously.

More information about toilet training children with additional needs

For further information and advice regarding all aspects of toilet training look at the Bladder & Bowel UK website resources page or contact us via our confidential helpline 0161 214 4591 or on email bbuk@disabledliving.co.uk.

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Toilet training is an area of child development that worries many parents. It is not helped when there is conflicting information given by other parents, relatives, healthcare professionals and others. If your child has additional needs, or differences in development then toilet training becomes even more challenging.

Why might children with autism struggle with toilet training?

Communication differences:

Children who are on the autistic spectrum often have difficulties with understanding words, with non-verbal communication (picking up cues from facial expressions and body language) and with expressing their needs (saying what they want, feel or need).

This means that they may struggle with:

• Understanding the words for toileting and so may not understand what is expected of them.
• They may not have or be able to say the words to let others know that they need to wee or poo.
• May interpret language literally and therefore be confused by some of the expressions we use to describe weeing (passing urine) or pooing (opening bowels). E.g. going to the toilet is literally about going to a place. It does not describe doing a wee or poo.

Using picture cue cards and social stories may help overcome these issues

Social interaction differences:

Children who are on the autistic spectrum may not understand expected behaviour and may have difficulties with relationships.

Because of this they may:

• Not be interested in being the same as, or doing the same things as others
• They may not learn by imitating other people, in the way that many children do
• They may not be concerned about being wet or soiled

Using rewards to motivate may help. Discuss appropriate rewards with your child’s healthcare professionals. These should be something small that your child is interested in and which can be provided as soon as they have done what is expected of them.

Imagination differences:

Children who are on the autistic spectrum may not use imaginary or social play, they may be rigid in their thinking and struggle to understand what comes next, which means that they struggle if their  familiar routines are changed.

This means that they:

• May assume that you know when they need help and not realise that they need to tell you.
• Changes in their routines are very confusing for them and may make them fearful or anxious.
• They may struggle to transfer knowledge: if they learn to do something in one. place they may not realise that they should do the same thing in other places e.g. if they learn to use the toilet at home, they may not realise they should do so at school as well.

Making changes slowly and gradually, with the support of picture cues or social stories may help them to feel safe and accept the changes better.

Sensory issues

Many children who are on the autistic spectrum have sensory problems. They may:

• be more sensitive than other children, or be less sensitive. They may have a mixture of increased sensitivity in some areas and reduced sensitivity in others
• have difficulty filtering sensory information that occurs at the same time. Most of us can ‘switch off’ to some information that we don’t need e.g. if there are lots of background noises when we are having a conversation, we can concentrate on the words being said to us and ignore the other noises. Children who are not able to filter information cannot ignore all the other noises, but also sights, sounds, smells etc. that are going on at the same time.

Try to think about how the toilet environment affects your child with their sensory need and try to make adjustments to help them. Your child’s occupational therapist may be able to make some suggestions.

How do these affect toilet training?

To be able to use the toilet appropriately and successfully we need to learn a series of skills, but learning these can be more difficult if children are on the autistic spectrum.  Causes of the difficulties will vary according to how the autism affects them. Success with toilet training involves working out what is causing issues for the child and making changes to reduce the effect of the issues.

What can help?

Starting work on the skills for toilet training early is often successful as there has been less time for rigid behaviours and thought processes to become established.

Try to ensure that your child is having fruit and vegetables every day and is drinking plenty of water based fluids, as far as their behaviours and habits allow. Fruit and vegetables help prevent constipation, which can delay toilet training. Good intake of water based fluids (about 1 ¼ litres a day for children aged 2-4 years and about 1 ¼ – 1 ½ litres per day for children aged 5-11 years) helps develop a healthy bladder as well as prevent constipation.

Where can I get more information and support for toilet training children with autism?

Bladder & Bowel UK have lots of information on toilet training children with additional needs including autism on their website at www.bbuk.org.uk/children-young-people/children- resources/ that is free to access and download.

For individual advice consult your child’s healthcare professional or contact the Bladder & Bowel UK confidential helpline at email: bbuk@disabledliving.co.uk or telephone 0161 214 4591.

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Things that help with toilet training are:

• Trying to encourage your child to drink plenty of water-based drinks (about a litre a day for children aged 2-3 years old) and try to make sure they have a healthy diet, including fruit and vegetables
• Changing children in the bathroom encourages them to associate wees and poos with toileting, particularly if any poos are tipped into the toilet.
• When children can stand up on their own, it is a good idea to change them in a standing position. This way they can be more involved in pulling their clothes up and down and with checking their nappy to see if it is wet or dry, soiled or clean.
• Making sure that everyone uses the same words for wee and poo, helps prevent confusion
• When children are able to sit independently, then they can start to sit on the potty or toilet. They should sit for a very short time to start with (maybe just a few seconds), but should be praised for doing so and can be involved in checking to see if there is any wee or poo there. To start with the children are learning to sit and any success is a bonus!  As they learn to sit, they can be encouraged to sit for a bit longer and then the number of episodes of sitting in a day can be gradually increased.

It is important to remember that any child can have a problem with their bladder and or bowels.

The most common problems are delayed toilet training, constipation, day time wetting and night time wetting.  If any of these occur in a child who has Down Syndrome they should be assessed and appropriate advice or treatment offered. If you have any concerns about these problems in a child with Down Syndrome, then talk to their GP or health visitor.

There is information and resources about children’s continence, including toilet training on the Bladder & Bowel UK website.

Bladder & Bowel UK also have a confidential helpline for parents, carers and professionals. You can send an email to: bladderandboweluk@disabledliving.co.uk or contact us by telephone on: 0161 214 4591.

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Often families are advised that they should not worry about toilet training until the child appears to be ready for this stage of learning. However, there is no clear definition of what is meant by ‘being ready’. There are some signs that are quoted, such as knowing when their nappy needs changing, asking to wear normal pants, or asking for the toilet. Children do not often reach this stage by themselves and many will not understand that they should be doing something different from what they have been doing since they were born. For many, signs of readiness for toilet training are not present until the children have actually started a toilet training programme.

What we suggest

At Bladder & Bowel UK, we suggest that toilet training should be started early for most children, including those with disabilities. To toilet train a child needs to learn a set of skills including communicating the need to go, managing their clothes and learning to sit on the toilet or potty. With appropriate support children can start to learn these skills from their second year. Toilet training does not necessarily get easier as children get older – it might get more difficult if they don’t see why they need to change something that is working well for them.

If toilet training is delayed, for whatever reason, children should be offered assessment to ensure that their bladder and bowel are healthy. Children with disabilities are more prone to constipation, which may in turn cause bladder problems. Without assessment these problems may be missed.

Further support

For children who need assistance with using the toilet or who need to be changed, there are disabled toilets in the community, which have more space, privacy and are quieter than public toilets. Most of these are part of the National Key Scheme and can be accessed independently by people with disabilities who have a RADAR key.  Keys can be purchased from Disability Rights UK. There are also toilets with adult-sized hoists and changing beds.  These are known as Changing Places. To see a full list of these visit their website.

Speak to your child’s health care professional if you are concerned about your child’s toilet training or would like support. There is also information about toilet training on the Bladder and Bowel UK website available here.

You may also contact our confidential helpline at email: bbuk@disabledliving.co.uk or on telephone number 0161 214 4591.

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