For more hints and practical ideas check out June Rogers talk or have a look at our booklet One Step At A Time (call us for a copy on 9816 8266).

For those who missed June's lecture, on this page you will find the major points and outline of the presentation given in August 2005.

Bio of June Rogers MBE

June is employed as Director of PromoCon based at the Disabled Living Centre in Manchester, UK and is seconded part time to Liverpool PCT as a Specialist Paediatric Continence Advisor with responsibility for developing an Integrated Continence Service. June previously worked for Knowsley PCT where she was responsible for the development of a nurse led paediatric continence promotion service.

What are the issues?

• Lack of appropriate specialist health professionals
• Tradition custom and practice
• Perception of 'free nappy' service
• Difficulties in formal assessment
• Lack of robust data
• Children often 'labelled' inappropriately

Normal bladder filling and emptying cycle - from about 3 yrs of age

• Bladder fills with urine (takes around 2 hrs)
• At certain point child feels need to wee
• Child holds on until potty/toilet reached
• Then bladder empties with combination of sphincter relaxation/bladder contraction
• Urine flow continues until the bladder is empty
• Bladder refills and cycle starts again (Berk and Friman 1990)

Developing control

• Sphincter control normally follows a set pattern:
1. Control of bowel asleep
2. Control of bowel awake
3. Control of bladder awake
4. Control of bladder asleep

Level of development required for independent toilet training

• Physiological maturation - ability to sit/walk/dress
• External feedback
- understands/responds to instructions
• Internal feedback
- self esteem/motivation
- desire to imitate/identify with peers
-self determination and independence
(Brazelton 1962)

Toileting 'Time table'

• 15mths
- point to wet clothing/self made puddles. Will use same word/sound for urine/faeces
• 18-24mths
- reports soiled nappies, separate word for urine / faeces
• 2yrs
- occasionally announce need to PU
• 3 yrs - Able to delay urination for some time
• 4 yrs - Will use toilet appropriately, awareness of privacy, will close toilet door
(MacKieth 1973)

Facts and Figures (newspaper cutting 2002)

No sign of nappy sales drying up

 

Many a new mum has felt the disapproval of their own mothers over the question of when to toilet train a toddler. Some grannies talk about infants who could control their bodily functions before they could crawl, but these claims are based on fact.
A study by the American Academy of Paediatrics showed that in 1961, ninety percent of children were out of nappies by two and a half, compared with 22 per cent in 1997. But while grannies might criticize modern parenting, nappy makers certainly do not.
Faced with a declining birth rate, the longer our offspring remain packed-up, the better for sales. In toilet training guide, Kimberly-Clark, makers of Huggies nappies, recommends waiting until the child shows it is ready, then switching to trainer pants. These innovations, along with new products such as swim nappies, may explain why sales have not fallen as drastically as the birth rate. But market value has tumbled during the past ten years due to supermarket price wars. Only five percent of mothers use terry or reusable nappies, saving about #350 over two and a half years.

Rachel Unsworth Source MINTEL: ABSORBENT HYGIENE PRODUCTS MANUFACTURES ASSOCIATION:THE DERBY REAL NAPPY PROJECT NATIONAL STATISTICS 

There are several rules to be learned!

The child has to:
• Recognise the need to pass urine
• Perceive the signal correctly
• Postpone micturition until appropriate receptacle is reached

Also...
• Boys have to learn to stand to pass urine
• Recognise that a urinal is OK to use but a bidet is not!
• Boys can pass urine in front of other boys but not in front of girls!
• You have to go behind a shut door to open your bowels

And...
The child has to be able to:
• open doors
• manage clothing, including zips and buttons
• use toilet paper appropriately
• flush the toilet
• wash and dry their hands

Children with Down's Syndrome - acquisition of bowel and bladder control
• National study to identify age at which children with Down's syndrome became toilet trained.

Rogers J (1998) Lessons in control. Nursing times,94:6,66-67
[15] Age achieved night time bowel control
[16] Age achieved day time bowel control
[17] Age achieved day time bladder control
[19] Age achieved night time bladder control

Toilet Training

• 'Acquisition of continence skills in children with mild learning disability appears to be little different from that of the general population.' (von Wendt et al 1990)
• 'Problems described...interpreted as 'challenging behaviour'. (Smith et al 2000)

Toilet training children with 'special needs'

• 'Behavioural training procedures have been effective in establishing toileting skills...' (McCartney 1990)
• ...'even for those with profound learning disabilities.' (Smith et al 2000)

Health professionals need to:

• not presume all wetting /soiling is due to the child's 'disability'
• carry out thorough assessment
• exclude underlying pathology
• implement treatment programmes as appropriate
• monitor/evaluate progress

General continence assessment

• General medical history - ? Medication
• Surgical history ?
• relevant family history
• age appropriate milestones
• dipstick urine
• baseline input /output chart
• exclude constipation
• discuss diet/fluid intake

Toilet skills assessment - check list

• Bladder function
• bowel function
• ability to sit
• any indication of awareness
• any dressing/undressing skills
• any appropriate use of potty/toilet
• any behavioural problems
• response to basic commands

Getting children ready

• In order for a child to be toilet trained they need a bladder that can hold on to urine for at least 1-2 hours
• They need a bowel that is not constipated or have toddler diarrhoea
• They need to be able to sit on a potty/toilet for up to 5 mins
• They need to have some awareness of wees and poos!

Raising awareness

• Modern disposable nappies contain 'super absorbency' - child never feels wet
• child needs to be aware of what wee is!
• place disposable non-absorbent liner in nappy
• check nappy every hour and record wet/dry
• involve child in checking
• toileting programme developed from findings

"He'll only poo in a nappy!"

• Reassure family that it is a common problem
• Importance of early intervention
for children with 'special needs'
• Low key 'matter of fact' approach
• Exclude any underlying problem

Behavioural Approach

• Non-confrontational approach
• Meet child 'half-way'
• Nappies to be kept in bathroom
• Child to stay in toilet area
• Nappy removed once bowels opened
• Work towards sitting on toilet
• Work towards removing nappy

Toilet training programme development

Questions to ask:
• What achievements are expected ?
• What is the level of development?
• What skills does the child already have?
• What prompts may be needed ?

Toilet training programmes

• Remove nappy!
• Timed /scheduled toileting
• Behavioural programmes -
- basic reward programmes
-positive reinforcement
- 'shaping'
- 'chaining'

Making toilet training fun!

• Positive reinforcement
• Incentive charts /stickers
• jigsaw pieces
• musical potties / toilet bowl inserts
• food colouring in cistern
• floating objects to aim at
• peer competition

Facilitating Toilet training

• Positive family support
• provision of appropriate products washable pants / pads (not nappies!)
• written information
• 'talk about' pictures for child
• toileting aids -wetting alarms etc
• ongoing assessment/programme adjustment

Findings

• "...children acquire continence faster than adults..." (Smith and Smith 1997)
• "those...are less likely to acquire bowel and bladder control spontaneously..." (Smith and Smith 1998)
• "...systematic appropriate toilet training could improve those figures markedly." (von Wendt 1990)