By: Sam Develli, OTR/L
Independent toileting or ‘potty training’ is often a source of fear and anxiety for any parent who has this important task looming. However, once it’s achieved, it’s often forgotten how vital independence in this activity is to our daily lives. It becomes a rote task that we think nothing more of, until something goes awry or you are faced with a difficult case of ‘potty training’.
Independence in toileting is often a prerequisite for participation in many community activities, including daycare, school, and recreational opportunities. With the added financial implications of diaper use and the space/time constraints of carrying around a diaper bag and change of clothes, successful ‘potty training’ is often one of those tasks that is vital to family cohesion and decreased stress.
Toileting, however, is a very complex task that requires a keen analysis of the task demands, a child’s capabilities and the environmental context on developing these vital performance skills and patterns (Case-Smith & O’Brien, 2015). It’s important to understand the prerequisite skills needed prior to successful ‘potty training’ to ease the physical and psychological strains posed by a difficulty in this area.
Prerequisites to Toileting Independence
A child must be physically and psychologically ready for toileting independence. Additionally, they must possess the underlying necessary skills and patterns to achieve this milestone. Here are some of the prerequisite skills that are needed to achieve full independence in toileting:
- Physiologically ready: demonstrate predictable pattern of urine and feces elimination
- A newborn voids reflexively and involuntarily. Maturation of the spinal cord in the low back enables bowel and bladder control to enable a child to learn to control sphincter reflexes for volitional holding. This typically occurs at 1 year for bowel control and 1 ½ years for bladder control.
- Psychologically ready: can recognize and identify when they are wet/dry and require a diaper change
- Neurologically ready: can recognize the internal body signals that it’s time to use the restroom, a function of interoception (our often forgotten and misunderstood sense)
- Occupationally ready: manage clothing & fasteners, clean thoroughly after toileting, wash & dry hands thoroughly
- Strength & stability ready: able to get on and off the toilet, remain stable while seated on toilet
Developmental Sequence of Toileting
*on average, girls are typically ready for and toilet trained 2.5 months earlier than boys*
- 1 year: volitional holding of bowels, indicates discomfort when wet/soiled
- 2 years: stays dry for 2+ hours, flushes toilet independently, achieves regulated toileting with occasional daytime accidents (32-35 months)
- 3 years: go to bathroom independently, can seat self on toilet
- 4-5 years: full independence in all aspects of toileting (includes getting on/off toilet, wiping, managing clothing, tearing toilet paper, and washing/drying hands)
- 5 years: most children will wake up dry at night, tells someone when they need to go to the bathroom, wipes urine & washes hands independently.
Limitations in Toileting
Limitations in strength, endurance, range of motion, postural stability, or dexterity may delay toileting independence.
Strength & Endurance: Reduced strength or endurance may result in difficulties with sitting down and getting up from the toilet.
Range of Motion: Wiping after bowel movements requires significant range of motion in the shoulder, arm, wrist, and fingers in addition to postural stability during rotation. Adequate wiping can be impacted when a child cannot turn their palm upward, bend their wrist, rotate their arm/shoulder inward, or extend arm fully.
Postural Stability: Unstable posture results in difficulty with relaxing and maintaining a ‘bearing down’ position in order to empty the bowels. Increased extensor tone can also impact ability to remain seated while using the toilet.
Dexterity: Decreased fine motor dexterity may result in difficulties with manipulating fasteners and ripping toilet paper. Intellectual or developmental limitations may also impact the motor planning or the complex cognitive skills required for toileting independence.
Awareness: Not recognizing the internal signs that you need to go or need for increased signals to become aware can result in reduced time to make it to the restroom or accidents.
Initiation: While your child may internally recognize the signs that they need to go, they may struggle independently initiating this task. This may include failure to notify an adult or not going into the bathroom at home when they need to go. This may occur more often when your child is engrossed in an enjoyable activity due to a combination of a lack of awareness and a reduced desire to stop what they are doing to ‘take care of business’
Sequencing & Memory: While your child might be able to make it to the toilet, they may struggle once they get there with the steps required for independent toileting. Since toileting isn’t just one task but a pattern of tasks that mostly need to be initiated in order, cognitive or motor planning difficulties with sequencing can result in your child just not knowing what to do next.
Dexterity: Along with sequencing and the physical ability to utilize fine motor dexterity, children with cognitive limitations often have difficulty motor planning the minute movements of the fingers and wrist to manipulate small objects such as buttons, zippers, scrubbing hands, or ripping toilet paper.
Fear/Sensitivity: Some children experience enhanced fear or anxiety due to sensory sensitivities surrounding bathroom use. These may include oversensitivity to smells, sound, or tactile feel of urination/defecation (less startling in diaper).