By: Sam Develli, OTR/L

The previous blog provides information about the prerequisites and developmental stages of “potty training,” while also identifying potential challenges. Based on the area(s) of toileting impacted by limitations, specific approaches such as behavioral approaches, routines, or addressing weakness/decreased coordination can be employed by an occupational therapist to increase toileting independence. The occupational therapist can work with you to analyze the steps of the toileting routine, identify those that are causing challenges for your child and develop a unique approach for your child to ultimately increase independence.

Behavioral Approach

• Prerequisites include sitting independently, imitation, and staying dry for a few hours
• Include positive reinforcement and overcorrection for errors

Awareness & Initiation

• This is where the common suggestion to allow your child to go bare in your home is helpful, as this improves awareness (provided you don’t mind cleaning up some messes- pick up rugs for the time being).
• Interoception training (if cognitively ready and able)
• Wearing less absorbent materials (pull-ups or underwear)
• Timers (auditory or visual) to encourage frequent trying to establish habit
• Positive reinforcement can also assist with initiation and motivation to use the toilet

Sequencing

• Visual or written routines
• Video modeling
• Social stories
• Chaining: have child remember first step, then first & second, then first, second, and third (and so on).

Strength & Coordination

• Assistive devices
• Restructuring environment (i.e. where the toilet paper is in relation to the toilet, where the soap/hand towels are in relation to the sink, the flushing mechanism on the toilet, the light switch, throw rugs or other tripping hazards, visually distracting items in environment)
• Wearing clothing with less fasteners/different types of fasteners
• Using wipes instead of toilet paper
• Preparatory activities to strengthen muscles and develop motor coordination skills required when using the bathroom.

Limitations in Range of Motion & Postural Stability

• Toilet paper tongs or paper-holding devices if range of motion limitations but good postural stability
• Bidet
• Portable bidet
• Adaptive clothing to make changing easier
• Low toilet seat or squatty potty to allow feet to rest firmly on ground- aids abdominal muscles to effectively work during defecation
• Smaller toilet seat or reducer rings to decrease size of opening and increase sitting support
• Safety rails or grab bars around the toilet or on the wall, or a toilet chair that can roll in place on top of the toilet
• 3-in-1 commode if access to the bathroom is limited/impossible with mobility devices. These offer many types of modifications including adjustable legs, safety bars, angled legs to enhance stability, padded or adjustable back & head rests, seat reducer rings, seat belts, or adjustable footrests.

Sensory sensitivities

• Soothing music or calming scent in bathroom
• If your child is scared of the flush of a toilet (common with auditory sensitivities), try opening the door first to allow for an easy escape, and then flush.
• Headphones/earplugs
• Auditory desensitization with the help of an occupational therapist