Toilet Training, Part 2

Down Syndrome Center at Children’s Hospital of Pittsburgh of UPMC

Dr. Vellody continues the topic of Toilet Training in Down syndrome. Today's podcast focuses on problems that can arise during toilet training and ways to address those problems.

Released: 5/5/14


Hello everyone and welcome back for the next Down Syndrome Center of Western Pennsylvania podcast. I’m your host, Dr. Kishore Vellody. You’ll recall in the last podcast, we went through some basics of toilet training. If you haven’t heard that podcast yet, you should probably listen to that one first because it will give some important background for this podcast. Today, we are going to be discussing toilet training problems that can arise. Unfortunately, not all children potty train successfully in a day or two. For many children, it takes ongoing effort and practice as well as some potential behavioral challenges that may come up! After today’s podcast, I hope that you will have some tools to address many of these issues.

The first and most common problem in toilet training any child is stool withholding behavior leading to constipation. Children can withhold stools far longer and more effectively than they can withhold urine. As the stools are held longer in the colon, more water is extracted from it and becomes harder. A harder stool becomes more painful to pass which then makes the child want to withhold the stool even more. If this cycle is not prevented, it can become very significant. In children with Down syndrome, their ability to distend their colons seems to be even greater than with other kids. So they deal with stool withholding behavior and constipation quite frequently during the toilet training process. You may notice that they seem to be straining and often that straining is not to pass the stool but actually to hold it in. When they do pass the stools, they may have several hard balls of stool that are passed in a day or they may even have a large, “toilet clogging” stool every few days. Both of these stooling patterns are indicative of constipation. To make things even worse, constipation can functionally compress the urinary bladder making it impossible for the children to hold their urine effectively either. So constipation can make it impossible to toilet train at all! This is why we pay so much attention to constipation in clinic because it can impact the child’s ability to toilet train at all.

For more information on constipation and its management, listen to our previous podcast on this topic. However, I think it is important for us to touch on a few things here. The stools need to be especially soft and non-painful during the time of active toilet training. The best way to do this is by introducing healthy dietary changes. Dietary fiber with increased water intake is key. Fruits, veggies, cereals, etc., are excellent ways to do this. However, for many children with Down syndrome, dietary changes can be difficult. In those situations, a stool softener like Miralax can be very effective if used correctly.

Ok. So the next issue to talk about is the child who refuses to sit on the toilet at all or for a long enough time. The first thing to be sure of is that the toilet seat is not too high or too wide. The toilet can be a scary thing for a small child who may worry that they won’t be able to get off by themselves or that they might fall in and get flushed down that little hole in the bottom! Make sure that you use either a child sized potty seat or an adapter seat that fits on a regular toilet but makes the seat smaller. If they are going to sit on the regular toilet, find a small stool for them to rest their feet on.

If you’ve made sure that all the proper … seating arrangements … have been made and your child still refuses to use the toilet, you need to make sure that the proper motivation is present. You see, many children will not toilet train to please their parents. You may try by saying “It’ll make Mommy so happy if you sit on the toilet. Won’t you do that for me?” But that sweet adorable child who always wanted to make you happy somehow gets replaced by this child who finds it much more fun to watch Mom or Dad get red faced and frustrated! However, children will toilet train to get their own reward that makes themselves happy. It’s just a matter of changing how we reward them. One way to do that is to have a reward jar in the bathroom. If you child doesn’t have any dental or weight concerns, an M&M or jelly bean dispenser in the bathroom can be a good motivator. If they sit on the toilet and try to pass urine or stool, they get a single M&M reward. Another option would be if they have a favorite game to play on an iPad or other portable game system. Then that game should be made available in the bathroom when they sit on the toilet. But the only way for this motivation to work is if they ONLY get the reward when they sit on the toilet. It won’t work if they know they’ll get their reward no matter what. It can only be given when they do the desired behavior of sitting on the toilet. Finally, if they actually pass urine or stool on the toilet, try to think of an even bigger reward that they can get. With this subtle change in approach, toilet training becomes more about your child’s self motivation rather than them trying to please you and that becomes a much more effective method of toilet training.

In any method that you choose to help your child to toilet train, it is very important to remember that most children with Down syndrome are visual learners. Using more abstract verbal motivator like “if and then” statements may not work very well. For example, saying “if you sit on the toilet, then you will get to watch Dora. If you don’t, then there won’t be Dora today” may not be very effective. Instead of doing it that way, use a sticker chart which can be a very effective visual motivating tool. Start off by making 3 square boxes in a row on a blank piece of paper. In the 3rd box, put a picture of Dora. You can do this by hand or use a word processor or spreadsheet program. Then hang the paper up on the wall in the bathroom with some tape and have stickers available in the bathroom. Every time they sit on the toilet, they get to put a sticker in one of the blank boxes. When the 3rd sticker is placed on top of Dora, they get to watch 5 minutes of a Dora episode. Keep going with this method for a while. Once they seem to understand the concept, you can gradually add more boxes before they get the reward. Once again, the key is that they do not get the prize unless they do the required behavior. At first this will be just to sit on the toilet. After they are getting better at toilet training, it can be a sticker only for actually using the toilet.

So this is a good time to talk about the next issue that can arise. Some children will sit on the toilet but just refuse to use it. Try using the sticker chart motivation we just talked about. Also remember about the stool withholding behaviors and constipation that can present like this. More often than we might think, there can actually be a fear of releasing their urine or stool into the toilet. They might not be able to verbalize it, but they might be scared that a part of them will be lost into the great watery abyss! Overcoming this fear can take some imagination. You could tell your child grand stories of the adventures their stool will go on. Maybe there’s a “poopy party” underneath your house and they’re just waiting for your child’s stool to come join them! You could put a few drops of food coloring in the toilet and have them guess what color the water will be after they use the toilet. For boys, you can make urinating more fun by putting some Cheerios in the toilet and having them aim for those floating objects. Just get those creative juices flowing and see what you come up with!

Ok, well, another common issue that we hear about is that a child will not notify before they have to use the bathroom. They may say after they have already had an accident, but they don’t seem to notify before they have to go. A very important point to be aware of is that this notification skill happens tends to happen much later in children with Down syndrome than in other children. As we talked about in the last podcast, scheduled toilet sitting is the key in toilet training in Down syndrome. As the children get older, they will develop the ability to notify prior to needing to use the toilet, but many of them continue to have scheduled sitting behaviors that they may not even be aware of. They may say something like “every day after breakfast, I go to the bathroom.” This schedule can be so rigid that if they went just 10 minutes earlier to the bathroom, they may go again because “that’s what I always do.” So use the schedule to your advantage. I can’t tell you how many times I’ve heard that from parents that their children with Down syndrome seem to be potty trained at school but not at home. It is because the school naturally is more rigid in it’s schedule, and that schedule includes the same times for bathroom every day. It’s perfect for scheduled oriented kids! Plan the scheduled sitting around events that happen at pretty much the same time each day (before breakfast, after lunch, at bath time, etc.). You could try to set a timer that beeps every 1-2 hours. Just set it for a time frame that you know they can hold their urine. When the timer goes off, they have to drop everything and go to the toilet. You will want to combine this with a sticker or other reward method like we talked about earlier so that they are self-motivated to respond to the timer. It should never become a battle. You want them to look forward to and be motivated for their scheduled time on the toilet.

The final thing I wanted to bring up is related to this issue and may be the most important thing to get from this podcast. Many parents will tell me that despite trying “everything” their child becomes afraid of the bathroom and toilet. This may get to the point where they will refuse even to enter the bathroom let alone sit on the toilet. This is a situation to avoid at all costs! Toilet training should remain fun for the child at all times. Even if there are accidents, there should never be punishment or fear during toilet training. If the stress level is getting too high, take a few weeks off and try again! If the stress level is getting too high, it’s always better to take a break from toilet training and come back to it in a few days than to get to a emotional standoff. So, how should you respond to accidents? Just use gentle correction. Say, “ “Uh, oh. Looks like you’re wet. Go on up and find a new underwear. Then come on back down and we need to clean up the mess.”

Well, this ends our podcasts on toilet training. Of course, every child is different and can pose different challenges. I know this first hand having helped toilet train my four kids! However, if you apply some of these concepts that we’ve talked about in the last 2 podcasts, you should have some insights into toilet training that you may not have had before. But, if there are still difficulties, give your pediatrician’s office a call. If needed, we can also try to troubleshoot with you and make sure there are no medical concerns. Thanks for listening today. Here’s hoping for some dry diapers this summer! Bye!

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