Toileting is an essential part of daily life. How we complete this activity differs depending on our developmental stage and as we grow and mature, our abilities and needs change.

For children with disabilities and their families however, navigating these milestones can present challenges. This article will discuss the different developmental milestones and what would be expected in terms of toileting, the potential impact of developmental delay and possible strategies that could assist with maximising independence/autonomy.

Birth to toddler:

In these early months, toileting needs are primarily the responsibility of parents/carers with frequent nappy changes. Whilst they may begin to indicate when they need changing, infants require full assistance. At this developmental stage, it may not even be evident to parents that their child has additional needs and so toileting is managed with no evident difficulties or differences. As children transition into toddlers, they will typically start to become more inquisitive with toilet training, learning to recognise bodily cues, observing, and understanding toilet use and may become interested in sitting on a potty. They are also developing motor skills to manage clothing and hygiene routines such as handwashing. For children with developmental delays this may be more difficult, for example they may find sitting on the potty or manipulating clothing challenging, or they lack the sensory feedback (interoception) to know they need the toilet.

Small child sitting on toilet training seat.

Childhood:

During childhood, children typically gain more independence as they refine their skills and routines and are expected to be more proficient in using the toilet and associated tasks such as wiping and washing their hands. Peer influence – for example at school, and societal norms also play a role in shaping behaviours during this stage. For children with disabilities, achieving independence may require ongoing support and adaptations. For example, physical impairments might require equipment or adaptations and cognitive disabilities might require visual prompts or structured routines to reinforce behaviours. The child may still require assistance from parents and other adults that their peers no longer need and so emotionally they may start to recognise that they are different to their friends.

Adolescence:

The adolescent stage marks significant changes in physical and emotional development, and as such associated toileting and bathroom habits. Puberty brings hormonal changes and increased awareness of body image and privacy. Adolescents may take more interest in their appearance and therefore spend more time in the bathroom, incorporating skincare and other grooming activities. For girls, they also have to manage their menstrual hygiene. For adolescents with disabilities, puberty presents unique considerations. What can be a very personal and often emotionally challenging time may be much harder to communicate. For a young woman who does not have the motor skills to manage her own periods, it is important that this is done in a sensitive and appropriate way. Communication barriers or sensory sensitivities might also necessitate tailored support in understanding and managing personal care needs.

Adulthood:

As young people with disabilities move into adulthood, they may still require ongoing support with their toileting needs. Access to appropriate facilities at home and in the community (for example Changing Places) can help maintain dignity and support those caring for them.

Happy smiling disabled person in a wheelchair in a bathroom.


Supporting children with additional needs

When we are supporting children with additional needs it is important to understand the potential barriers to them being able to complete the tasks that they need to do. This could be because of their limited motor skills, reduced cognitive skills, sensory processing difficulties or challenges within the environment, usually a combination of the above. When thinking about toileting, how do we best approach this so we can maximise their ability to carry out this basic daily task with as much autonomy as possible? In addition to the suggestions below, Bowel and Bladder UK and Down Syndrome UK have some excellent resources to support with toilet training for children with additional needs.

  • Take an individualised approach: It is important to recognise that each child is unique, with specific strengths, challenges, and developmental trajectories. One size does not fit all and so toilet training strategies and interventions should be tailored to meet the child’s own needs, preferences, and abilities.
  • Consider readiness: It can be helpful to understand the child’s readiness for toilet training, taking into account their physical, cognitive, sensory, and emotional capabilities. Look for signs of readiness such as demonstrating awareness of bodily cues, showing interest in using the toilet, and exhibiting some degree of motor control. Not exhibiting readiness however should not be a barrier to trying things. June Rogers’ article is a useful read to help understand that we can still introduce things and provide the foundation, even if a child doesn’t appear ready.
  • Visual supports and social stories: Use visual supports such as social stories, or visual aids to explain the toilet training process and expectations to the child. Visual supports can help clarify steps, reduce anxiety, and facilitate understanding for children with communication difficulties or cognitive impairments.
  • Consistent routine and structure: For some children, having a consistent toilet training routine with predictable cues and prompts can help them anticipate and use the potty/toilet and in turn can help build skills and promote confidence in using the toilet more independently.
  • Sensory considerations: Be mindful of sensory sensitivities or aversions that may impact the child’s comfort and participation in toileting activities. Adjust the environment and sensory stimuli to accommodate the child’s sensory preferences and avoid triggers that may cause distress or resistance, for example the noise of the flush or the bright bathroom lights.
  • Adaptive equipment:  Much mainstream equipment can be used to support a child to help with their development around toileting skills. For example potties that have a wetness sensor that plays sounds, or booster seats for toilets. As the child grows they may benefit from rails or a wash dry toilet. Adaptations will provide support and assistance as needed, while also continuing to promote a level of independence in toileting skills.
  • Positive reinforcement and encouragement: Positive reinforcement strategies such as praise, rewards, or preferred activities to motivate and reinforce successful toileting behaviour. Children respond well to celebrating progress, no matter how small, and so provide encouragement and support even if experiencing setbacks.
  • Shared experiences: Ask other people in similar situations about their experiences and share your own. If you are a parent, can you seek advice from other parents? Or from a professional such as a nurse or occupational therapist? Bladder and Bowel UK has some excellent resources including a helpline for individual advice and signposting.
  • Patience and flexibility: Recognise that toilet training may take longer or require different approaches for children with developmental delays. Be patient, flexible, and persistent and adapt strategies as needed based on the child’s progress, feedback, and evolving needs.
  • Empowerment and dignity: Foster a sense of empowerment, autonomy, and dignity in the child’s toileting experiences. Respect the child’s choices, preferences, and boundaries, while providing guidance, support, and opportunities for skill-building and independence. This will become more important as the young person transitions into adolescent and adulthood where age appropriateness should be a core consideration.

In conclusion, as children move through their developmental milestones, we want them to be as autonomous and independent as possible. While disabilities and developmental delays can pose unique challenges, proactive support, person centred strategies, and inclusive environments can empower children and young people to work towards the goal of independence in toileting skills.


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