Toilet Training, Part 1

Down Syndrome Center at UPMC Children’s Hospital of Pittsburgh

In this podcast, Dr. Vellody discusses assessing for toilet training readiness and general concepts of toilet training.

Released: 4/3/14


Hello everyone and welcome to the next Down Syndrome Center of Western Pennsylvania podcast. I’m your host, Dr. Kishore Vellody. Well, I hope everyone enjoyed the month of March as much as I did. March is a great month to raise awareness for Down syndrome, and I hope everyone enjoyed World Down Syndrome day on March 21.

Well, today’s episode is going to be a little different than our previous episodes. It will be just me today discussing on a topic that we discuss A LOT during my clinic visits … and that’s toilet training! Toilet training is universal. All cultures and all people must teach their children how to control their bowel and bladder habits. Unfortunately for many people, it can be a very frustrating and difficult time … both for the parent and for the child! I hope that after listening to this podcast today, we can help reduce some of those issues by explaining some of the techniques that we can use. Most of these techniques are universal but we will also discuss some specifics as it pertains to children with Down syndrome.

The first question we usually get is “when do I start toilet training?” In the typical population, we would typically give an age of 18 months to 2.5 years and say that’s the time to start. However, in a child with Down syndrome, age alone is not enough. First of all, there is a wide range of developmental abilities in children with Down syndrome. Some kids with Down syndrome pick up toilet training just like any other child, and some kids with Down syndrome take a little while longer for a lot of different reasons. The average age for toilet training for kids with Down syndrome is 3.5 to 4 years old. That means there are kids taking much longer than that to average out the kids who are training much earlier. I think the most important answer to that question of when to start is “it depends but patience is key!” If you’re a parent of a child with Down syndrome, you’ve probably heard that phrase before and will hear it many more times in the future!

Let’s talk about some signs that your child will give to let you know that it’s time to start toilet training. You will need to start paying attention to these signs because they are often easily missed. The first thing most parents notice is some control of “the plumbing.” There will be longer times of them holding their urine. The diaper may be staying drier for longer periods during the daytime. For example, you might typically change a diaper every 2 hours but find that they are dry at the typical time of changing. The child may even wake up from naps dry. These are all signs that they are beginning to be able to establish bladder control. As this progresses, the child may actually begin to prefer a dry diaper and start to indicate when the diaper is wet by acting uncomfortable or pulling on the diaper.

With regards to bowel control, you might start to notice that the bowel movements are happening at a similar time each day. This is important to keep track of because it will help with the toilet training. Your child might also begin to find a particular part of your home to pass stools into his diaper. Parents often interpret this as “hiding” while passing the stool but it is a good sign that they are learning to prefer certain locations to have bowel movements. The key will be to convince them that the toilet is the best place to have those bowel movements … but we’ll talk about that later in this podcast!

A very important part in assessing readiness for toilet training, especially for children with Down syndrome or any other type of developmental issue, is to make sure that they have the proper developmental skills to potty train. They need to be able to walk and climb onto the toilet or potty seat. They need to be able to follow sequential directions like “ok, go to the bathroom, take off your pants, and get on the toilet.” They also need to have enough communication skills to indicate their toileting needs. It does not necessarily have to be verbal communications Sign language or picture cards are just as effective. Once they get onto the toilet, it’s important for them to have a developmental level to be able to sit on the toilet for a few minutes without getting distracted and wanting to come off. A younger child might not like the “boring bathroom” when there’s more fun things to do!

Now, taking a step away from the readiness of the child, the parents also have to be ready for toilet training. While the toilet training process may be a weekend job for a typically developing child, for a child with Down syndrome, it can be a much longer process. I cannot stress enough that the toilet training process cannot be done in a high stress environment the week before Kindergarten begins. It also can’t be on a weekend packed with soccer games and ballet recitals. No, the process requires the parent and the child’s schedule to be open and free, especially in the early stages.

Ok, well, you probably wouldn’t be listening to this podcast if you didn’t think your child was ready for toilet training. So let’s get to the heart of the issue. But…surprise! Toilet training does not start with anything your child is doing for themselves in the bathroom! It starts with observation. If your family dynamic allows, let your child come with you while you use the bathroom. If it is not too uncomfortable, explain to them that you are putting your “pee-pee” or “poo-poo” in the toilet. The more that they see the natural process of using the toilet, the more interested they will become in doing it themselves.

The next step is the beginning of letting your child take ownership of their toilet training. You want to take them with you to the store and let them pick out their own child-sized potty or character themed toilet seat. It’s also a good time for them to pick out and purchase their own “big boy or big girl” underwear. When you get home, let the potty seat be a new toy for them. Show them how they can put their teddy bears, dolls, or action figures on the potty so that they can use their imaginations while Spider-Man and Dora do their business. At the same time, pick up some books about toilet training to read to your child. As the child learns that Elmo goes on the potty and that the flushing noise that accompanies those books are not scary, it will help them in their own toilet training.

Now, we’re finally here. You’ve got a child who’s ready and you’ve got all the gear you need for success. It’s time to begin the process of formal toilet training. First thing in the morning, take them into the bathroom and take off the wet diaper. Have them sit on the toilet or child-sized potty. They may not be able to sit long and they may not pass anything into the toilet at first. That’s okay. Next, it’s time to get rid of the diaper. I would suggest putting them in their character themed underwear and see how they do. Say things like, “You don’t want to get Dora wet with pee. That will make her so sad.” If you don’t think they’re ready to go straight to underwear yet, you can use pull-ups for a brief period but try to change to underwear as soon as possible. The pull-ups tend to be so absorbent that there’s not much of an incentive to stay dry since they can’t always feel when they start getting wet. If pull-ups are used, just remember to change them frequently so that they remain fully dry. Whatever you choose, stay away from diapers because it is far to cumbersome to take them off and put a new one on during the toilet training.

The next step is crucial in toilet training, especially in children with Down syndrome who tend to be very routine oriented. In the weeks coming up to the toilet training, it’s a good idea to get a sense of how often they use their diaper. If it seems like the diaper is wet every hour or so, then try to place them on the toilet every 30-45 minutes. While they’re sitting on the toilet, give them a favorite book or toy to occupy them and allow more time for that accidental urine or stool passage. If they sit for a good period of time, given them some type of praise/reward. Eventually, they will accidentally pass urine or stool into the toilet and then it’s time for celebration! You’ll want to repeat the sitting process all throughout the coming days. As they start to understand the concept, you can try to space out the timing to hourly or every 90 minute toilet sitting. Keep at it and expect some accidents, but if you keep to a schedule, your child will have a greater chance of succeeding quickly. If you try to wait for them to notify you that it’s time to go, you will probably be waiting for a long time for successful toilet training! So use that schedule and adjust that time frame as needed so they can start to have some successes on the toilet. They’ll get to see Mom and Dad get excited and want to do it some more!

Well, in a perfect world, this would be the end of the toilet training podcast. The reality is that most kids, especially kids with Down syndrome, will have some hiccups along the road when it comes to toilet training. In the interest of time, what I’m going to do is end this podcast now. In the next podcast, we’ll talk about some typical problems that we can run into with toilet training and ways to get around those problems. Until next time, stay tuned and tell all your friends to come and listen to these podcasts and let us know how we’re doing at Thanks again. We’ll talk to you later. Bye bye.

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