Toilet training is a significant milestone in a child’s development, and moving from nappies to using the toilet can be an exciting, confusing or even a scary experience for children and their parents. This is even more true for children with developmental delays or disabilities and their parents may feel a lot of pressure to have their child toilet trained by a certain age – an Occupational Therapist who is experienced in working with children can help when more support is needed for a child to learn how to use the toilet.
Occupational Therapist’s are allied health professionals who support individuals with their ‘occupations’ (the things they need or want to do as part of their day to day life). They can assess and address environmental barriers, skills of the individuals, or components of the task to support their independence. Occupational Therapists are able to support children to develop their skills in using the toilet. When OTs begin working with a child on their toileting goals, they use a holistic viewpoint to guide the therapy intervention, and use a combination of parent coaching, environmental modifications and play based intervention to support the child to learn.
Occupational Therapists collaborate with other allied health and health professionals, specifically, children’s pelvic floor Physiotherapists, General Practitioners, and continence Nurses, where the child’s toileting barriers require support from these professionals.
The Development of Toileting Skills
By age two, many children are able to indicate that their nappies are wet or soiled, be able to hold their bladder for longer periods before releasing a larger amount of urine (rather than frequent small amounts), as well as be able to sit in an upright position on the toilet or potty. These are all skills that indicate a child may be ready to start learning how to use the toilet. Between the ages of 2 and 3, we see a lot more development in independence in toilet skills, and at this age most children will achieve bladder and bowel control during the day and at rest times. Bowel control typically develops more quickly than bladder control. Usually children start toileting training on a potty, however some skip this and will begin straight away on the toilet with added equipment such as steps, toileting surrounds or toilet seats. By age 3, many children will be able to manage their clothing for toileting by themself, get on and off the potty or toilet
independently, tell an adult they ‘need to go,’ and do most steps of toileting by themselves but need support for some aspects – like remembering to flush!
Tips for Toilet Training at Home
Before embarking on the toilet training journey, there are many things parents can do to help their children learn about the toilet, feel safe in this environment, and set up healthy habits that can make the process go more smoothly. Starting these by age two is generally recommended to pave the way for successful toileting.
Food and exercise has an impact on our bladder and bowels, and can impact the ease of toilet training. Drinking lots of water each day will help young children’s bladders learn the sensation of ‘needing to go.’ When the walls of the muscular bladder are stretched, the brain is notified that the bladder is full – this is called a stretch reflex. Regular emptying and filling of the bladder helps children to tune into this sensation. Water, fruits, and vegetables also help to keep bowel movements soft, and avoid constipation. Children learn the sensation of needing to poo through a stretch reflex in the bowel; when the bowel is continually stretched from constipation, the stretch reflex doesn’t work effectively, and children can lose the feeling that they need to go until such time the bowel has had sufficient time to shrink and heal. Furthermore, it can hurt children to pass a bowel movement when constipated, and they may learn to avoid poo-ing (associating it with pain) which can worsen constipation.
Using the toilet can be very intimidating for many children – it is a big noisy thing, and children can feel unsure about what will happen to them when they use it. Having an ‘open door policy’ where children can see their family using the toilet, as well as using lots of language around using the toilet – poo, wee, wipe, need to go – can help demystify the process so it is less scary. Using imaginative play, and acting out going to the toilet with toys can also help children with their learning in a fun way.
Giving children choice and control is another great and easy strategy to pave the way for toilet training – children could be involved in choosing their own underwear for when they begin wearing these, or be involved in choosing how they would like to decorate their toilet room (such as to put stickers on the wall), or choose if they would like to read a book or blow bubbles while sitting on the toilet.
Parents may have a preference for using either potties or toilets for toilet training; either is okay, and parents can be led by their child’s preferences as well as their own. If using the toilet from the beginning, it is so important to set this up with equipment that allows the child to feel safe as well as be effectively supported to empty their bowel and bladder on the toilet. When a small child is sitting on a big toilet with their legs dangling, they may feel worried which will not help them relax to wee or poo, and this may build a negative association with using the toilet. Additionally, if they are needing to work hard to balance on the toilet, their deep postural muscles will impact the relaxing of their pelvic floor muscles, which can affect the full emptying of the bladder or bowel. If they are not completely emptying their bladder, there is a risk of developing urinary tract infections. If they are not completely emptying their bowels, there is a risk of developing constipation.
To set up the toilet so a child feels safe and is well positioned for the toilet, their feet need to be flat using a non-slip footstool or step. This helps maintain proper alignment of the pelvis and spine, facilitating efficient bowel and bladder function. The child’s knees should be positioned slightly higher than their hips to encourage relaxation of the pelvic floor muscles and facilitate complete evacuation. Arm supports may also be beneficial for children who require additional stability or assistance with balance. The toilet ring of a typical toilet is too large for children, either a removable toilet ring or a family toilet seat (a 2 in 1 style toilet seat that is physically secured to the toilet, such as a LupiLu toilet seat) is necessary for the child to feel secure and balanced.
Challenges That May Arise During the Toilet Training Process
While toilet training is an important developmental milestone, it can present various challenges during this time of transition. Using a calm and consistent routine and approach will help many children progress through this period, although other children may need more help. Some of the most common challenges that may occur during toilet training include frequent accidents, refusing to wear underwear or to sit on the toilet, and withholding wee or poo. Where there is withholding or constipation occurring, collaborating with a health professional such as an Occupational Therapist is highly recommended to avoid health complications that could further setback toilet training.
What Can I Expect When Seeing an Occupational Therapist to Help my Child With Toilet Training?
An Occupational Therapist will begin the process by taking a thorough history with the parent or caregiver, to understand information such as relevant medical history, experiences to date with learning to use the toilet, what the toilet environment is like at home and daycare, and other areas of development such as muscle strength and tone, sensory processing, and fine motor skills. Another essential part of the therapy process is understanding the child’s current bowel and bladder habits, and this is done using a bladder-bowel diary which tracks frequency of bladder and bowel movements, as well as consistency of bowel movements using the ‘Bristol stool scale.’
Using this information, the Occupational Therapist can first determine if there is constipation present; parents are not always aware, especially if it is a milder occurrence, which can still negatively impact toilet training. If the Occupational Therapist holds any concerns regarding constipation, they will refer the child to their General Practitioner who may prescribe stool softener or laxatives. Often an initial dose is prescribed to clear the constipation, and from there a management dose is prescribed to prevent further constipation and to allow the bowel to shrink and heal. It is so important that the management protocol is adhered to, as further bouts of constipation will often impact sensation (the cue the child feels that they need to poo) and may cause pain, encouraging fear of toileting.
At this point the Occupational Therapist may also refer to other professionals, such as a pediatric continence nurse (who may be able to provide more detailed information regarding factors impacting continence, such as by performing bladder scans or urine analysis), or Pediatric pelvic floor Physiotherapists, where effective coordination of muscles seems to be impacting skill progression.
An Occupational Therapy intervention that is commonly used in toilet training is educating the child through the use of social stories and using their interests to aid motivation and engagement. Social stories help children by providing structure, guidance, and visuals to help the child better understand the sequences involved in the toileting process. Social stories also support the child by role modeling the skills required and breaking down the process, whilst keeping it fun and interactive. Social stories help provide an insight into what to expect and can improve their confidence when engaging in the skills themselves. Using children’s interests is a great way to promote engagement and attention, in the photo above you can see some of the visuals our Occupational Therapist has created to empower her client and provide excitement whilst learning new skills. Using interests and visuals is a huge motivator for the toilet training process.
What to Do if You Have Concerns Regarding Your Child’s Journey of Learning to Use the Toilet
Speaking with your child’s General Practitioner or Child Health Nurse is always a great place to start if you have any concerns regarding any area of your child’s development, including toilet training. Families are also able to self refer to see an Occupational Therapist at BillyLids Therapy.
Additional Resources
The following websites and resources have been included as further reading for toilet training for children.
Continence foundation of Australia
Provides locations of accessible toilets nationwide, a national continence hotline, and a range of in-depth information regarding continence including how to support children with disabilities to learn to use the toilet.
Website: Continence Foundation of Australia
Raising Children Network
A comprehensive online resource for Australian parents providing information on child development, health, and parenting strategies, including information on toilet training.
Website: Raising Children Network
The Mars Clinic
The Mars Clinic is a children’s Physiotherapy service based in South East Queensland, that is able to holistically assess pelvic floor, bladder and bowel functioning using highly specialised equipment. This website also provides links to contemporary research on children’s continence.
Website: Mars Clinic
Occupational Therapy interventions for feeding and toileting for children aged 0-5 years
This journal article is a systematic review of evidenced based interventions that Occupational Therapists use when working with children under the age of five years, to develop their independence with using the toilet. Journal: American Journal of Occupational Therapy.
Gronski, M. P. (2021). Occupational therapy interventions for feeding and toileting for children aged 0-5 years. American Journal of Occupational Therapy, 75(5), 7505390010.
