Thursday, May 29, 2008

Trouble-shooting specific toilet training problems

Once a visually supported transition and sequencing system has been established, we continue to use a problem-solving approach to troubleshooting details. Whenever the child has a problem with any step of the process, we think about (1) what his perspective might be and (2) how we can simplify and/or clarify through visual structure. Examples follow:

Resists sitting on the toilet

* allow to sit without removing clothes
* allow to sit with toilet covered (cardboard under the seat, gradually cutting larger hole, or towel under the seat, gradually removed)
* use potty seat on the floor rather than up high
* if strategies are helpful for sitting in other places, use in this setting also (timers, screens, picture cues, etc.)
* take turns sitting, or use doll for model
* sit together
* add physical support
* help him understand how long to sit (sing potty song, length of 1 song on tape player, set timer 1 minute, etc.)
* as he gradually begins to tolerate sitting, provide with entertainment

Afraid of flushing

* don't flush until there is something to flush
* start flush with child away from toilet, perhaps standing at the door (might mark the spot with a carpetsquare and gradually get closer to the toilet)
* give advance warning of flush, setting up flushing cue system, such as "ready, set, go"
* allow him to flush

Overly interested in flushing

* physically cover toilet handle to remove from sight
* give something else to hold and manipulate
* use visual sequence to show when to flush (after replacing clothing, for example)
* when time to flush, give child a sticker that matches to a sticker on toilet handle

Playing in water

* give him a toy with a water feature as distraction, such as a tornado tube, glitter tube, etc.
* use a padded lap desk while seated
* cover the seat until ready to use
* put a visual cue of where to stand

Playing with toilet paper

* remove it if a big problem, use Kleenex instead
* roll out amount ahead of time
* give visual cue for how much, such as putting a clothespin on where to tear, or making a tape line on the wall for where to stop

Resists being cleaned

* try different materials (wet wipes, cloth, sponge)
* consider temperature of above material
* take turns with doll

Bad aim

* supply a "target" in the water, such as a Cheerio
* larger target as toilet insert
* (contact papered or laminated cardboard with target drawn on it), gradually moved down add food coloring in the water to draw attention

Retaining when diaper is removed

* cut out bottom of diapers gradually, while allowing child to wear altered diaper to sit on the toilet
* use doll to provide visual model
* increase fluids and fiber in diet
* may need to enlist doctor if serious bowel withholding, may give stool softener

These ideas are not intended to be an inclusive list of steps to take to teach a child to use the toilet. They are, however, illustrative of the problem-solving approach needed and the effort to provide visual cues to increase understanding, cooperation, and motivation.

V. Communication System

Another important step in teaching independent toileting is to plan for a way for the child to initiate the toilet sequence. At first trips to the bathroom may be initiated by an adult directing the child to a transition object or schedule. However, eventually the child will need a way to independently communicate his need to go. Even though he may begin to spontaneously go into a familiar and available bathroom, he needs to learn a concrete way to communicate this need so that he will be able to request when a toilet is not immediately available.

As always, the first step in designing a goal is assessment. Is the child currently signaling in any way that he needs to go to the bathroom, or is he totally reliant on an adult initiating the sequence? If there are behavioral signals that you as an adult observer can "read", these signals can show you the "teachable moments" when you can help the child learn to use a systematic communication tool. Is he able to use objects, pictures, or words to communicate in other settings?

Many children first learn to use expressively the same tool that the adult has used to teach him about going to the toilet. For example, if Mom has been giving him an empty "baby-wipe" box to mean it is time to transition into the bathroom to be changed, the child might begin to use this same box to let Mom know he needs to be changed. Or, if a photograph of the toilet has been used on the child's schedule to tell him when it is time to sit on the toilet, the same photograph will make a meaningful expressive communication tool.

A child who is sometimes able to verbally say "bathroom" may not always able to pull this word up at the appropriate time. When he is tired, in a new place, with a new person, with too many people, catching a cold, upset for any reason -- his higher-level verbal skills may fail him. A child who shows this inconsistency will also be helped by a visual support that (1) helps cue the word he is looking for and (2) serves as a back-up system when he cannot use verbal language.

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