Toilet Training Children with Special Needs
Determining Readiness
Child Readiness
- Diapers are typically dry for at least 2 hours.
- The child can feel the difference between being dry or wet/soiled. Sometimes the child has to be changed into regular underwear instead of absorbent diapers or pull-ups for a few days to assess this.
- The child is capable of delaying urination or stooling until reaching the potty, with help if needed.
- For some children, they are motivated to use the potty and help remove clothing when possible.
- The child displays no fears of being in, on, or around the bathroom. If fears exist, a behavioral desensitization program needs to be done first.
- All medical or physical barriers (e.g., constipation) have been addressed.
Lack of Readiness
Toilet Training Methods
Child-Oriented Approach
Behavioral (Operant Conditioning) Approach
Timer/Clock Training
Addressing Toilet Training Challenges
Medical/Physical
Children with cerebral palsy (CP) typically have several challenges that make toilet training more difficult; motor disabilities may require adaptive equipment or adult support to use the toilet. It is important that the child wear clothing that is easy to remove. Many children with CP have delayed or impaired bladder control and may need adult assistance in recognizing signs that they need to urinate (fidgeting or “potty dance,” for example). Constipation is also common in children with CP, and it is important that families work with their child’s doctor on optimal management of constipation prior to beginning toilet training. For these reasons, toilet training generally occurs later in children with CP than in typically-developing children. Despite these challenges, toilet training is achieved for many children with CP, especially when provided with appropriate adaptive equipment and developmental therapies. CP has detailed information about management, including therapies.
Children with neurogenic bladder due to spina bifida or other medical conditions often do not develop adequate bladder awareness to use the toilet to urinate. However, they can be taught to self-catheterize to independently CP, constipation is common, and regular soft bowel movements should be achieved prior to attempting toilet training for bowel movements. Constipation has in-depth treatment management information.
Developmental
Children with cognitive and communication delays generally demonstrate toilet training readiness later than children without delays and take longer to toilet train. Children with developmental delays benefit from a stepwise approach that teaches one skill at a time (sitting on the potty, pulling pants up and down, washing hands, etc.). Some of these skills can be taught even before a child develops bladder awareness and control. Visual schedules of the toileting routine are also helpful. Children with communication delays benefit from working with a speech-language pathologist to develop functional communication skills both in general and specifically around toileting.
Core communication, behavioral, and sensory differences in autism spectrum disorder can result in complex toilet training difficulties. Children with autism often have sensory sensitivities, and it is helpful to assess their sensory experiences around toileting if they are resistant to toilet training (see Sensory Differences below). Children with autism also may have significant difficulties with routine changes making the transition from diaper to toilet challenging and even distressing. Visual schedules, ample preparation (books and television programs about toileting, for example), and a gradual, stepwise approach can help children adjust. Behavioral, occupational, and/or speech therapy may be needed to help the child develop skills around restricted behavior, sensory sensitivities, and communication delays that interfere with toileting (see Behavioral Therapies (see MT providers [13]), Occupational Therapy (see MT providers [43]), and Speech - Language Pathologists (see MT providers [55])). Autism Spectrum Disorder has detailed information about management, including behavioral therapy.
Behavioral
Sensory Differences
Children with significant vision impairments do not use the visual tools and cues that are cornerstones for children without these impairments, such as visual observation of parent and sibling toileting behavior and toilet-themed picture books. They depend more on cognitive and communication skills for potty training and, as a result, often potty train later than children without vision impairments. These children benefit from supervised and narrated tactile exploration of the bathroom and toilet and initial guided support of the toileting process (pulling pants down, sitting on toilet, using toilet paper, pulling pants up, washing hands, etc.). A small potty on the floor is likely to be more accessible than a potty seat on the adult toilet, and it is important to keep the small potty in the same place in the bathroom so that the child can always locate it. Children’s audiobooks about toileting help support the learning process.
Children with hearing loss often toilet train at a similar age to children without hearing loss, using the same visual cues and then signing and gesturing to communicate. Children with hearing loss and co-occurring developmental or communication delays generally toilet train later and benefit from a stepwise approach (see Developmental section above). For detailed information about delays and other management information, see Hearing Loss and Deafness.
Children with sensory sensitivities (common in autism spectrum disorder and also occurs in children without autism) are often sensitive to many aspects of the toileting process (toilet flushing, bathroom odors, the sensation of clothing, etc.). These sensitivities may manifest as anxiety around toileting, tantrums, and toilet training resistance. Caregivers should evaluate their child in the toilet environment to identify sensory-related triggers. For some children sensitive to toilet-flushing sounds, being allowed to flush the toilet without any expectations to use it can be a low-pressure way to help the child adjust to this sound. Other children benefit from noise-blocking headphones. Frequent practice in pulling up and down pants may exacerbate sensitivities to fabrics; soft, elastic waist sweatpants can help (and are generally easier to manipulate for all children). Consultation with an occupational therapist can be very helpful in evaluating and managing sensory sensitivities around toileting.
School Considerations
Referral/Subspecialist Collaborations
Refer for assistive equipment and communication programming needed to accompany the toilet training program. These consultations can be obtained through the school services, but, on occasion, private consultation may have to be arranged if the school lacks adequate resources. Once continence is achieved, consultations for additional or updated equipment, training to enhance independence as the child matures, or teaching optimal transfer techniques for parents may be helpful.
Refer for concerns related to delays in language skills that impact communication around toileting. Speech-language pathologists can provide therapy to build functional communication skills and, if needed, augmentative or alternative communication strategies.
Refer for behavioral desensitization if a child displays fear of being in, on, or around the bathroom or otherwise demonstrates persistent resistance to toilet training that does not respond to supportive behavior strategies outlined above.
Refer for concerns about unaddressed medical or urological issues that may impede toilet training when a child is otherwise ready for this process.
Refer if a child needs additional specialized evaluation or support in managing effective stooling.
Resources
Information & Support
The following have diagnosis and management information for clinicians:
- Constipation
- Autism Spectrum Disorder
- Cerebral Palsy
- Intellectual Disability & Global Developmental Delay
Toilet Training for Individuals with Autism or Other Developmental Issues: Second Edition
How to gauge readiness, overcome fear of the bathroom, teach how to use toilet paper, flush and wash up and deal with toileting in unfamiliar environments. by Maria Wheeler, Carol Stock Kranowitz (Oct 1, 2012).
For Professionals
Incontinence Issues among Students with Disabilities (Council for Exceptional Children)
A practical guide for teachers of children with special health care needs that includes terminology, schedules, and the practical
skills that need to be addressed for toilet training; by Clarke LS, Embury DC, and Bauer A (2014).
For Parents and Patients
Toilet Training Children with Special Needs (AAP)
An excellent resource for toilet training children with sensory disorders, behavioral disorders, autism, spina bifida, cerebral
palsy, intellectual disability, and developmental disorders; American Academy of Pediatrics.
Toilet Training (healthychildren.org)
Extensive information about potty training that addresses problematic behaviors, readiness, choosing a potty, cognitive and
emotional issues; from the American Academy of Pediatrics.
Bedwetting (healthychildren.org)
How to manage bedwetting and recognize signs of a medical problem; from the American Academy of Pediatrics.
Toilet Training for Children with a Disability (Continence Foundation of Australia)
How-to video for toilet training children with disabilities at home featuring an Australian occupational therapist and toilet
training consultant (8½ minutes).
Patient Education
Bedwetting Brochure (AAP)
Explains the causes of nighttime bedwetting and provides techniques to help parents manage the condition until it is outgrown.
Also provides signs of a possible medical problem; available for a fee from the American Academy of Pediatrics.
Toilet Training Brochure (AAP)
Details a step-by-step training program for potty training (not focused on children with special health care needs); available
for a fee from the American Academy of Pediatrics.
Toilet Training Resistance: Daytime Wetting & Soiling (Contemporary Pediatrics) ( 248 KB)
A printable handout for families with tips for helping the child to overcome hurdles in potty training.
Toilet Training your Child: The Basics (Contemporary Pediatrics) ( 375 KB)
A printable handout about potty training using the Barton Schmitt developmental approach; includes “the bare-bottom weekend”
and other helpful information (not focused on children with special health care needs).
Tools
Potty Tracking Chart (AAP) ( 96 KB)
A simple, printable chart to count potty times each day for a week; from the American Academy of Pediatrics.
Potty Tracking Chart in Spanish (AAP) ( 86 KB)
A simple, printable chart to count potty times each day for a week; from the American Academy of Pediatrics.
Services for Patients & Families in Montana (MT)
Service Categories | # of providers* in: | MT | NW | Other states (4) (show) | | NM | NV | RI | UT |
---|---|---|---|---|---|---|---|---|---|
Behavioral Therapies | 13 | 40 | 25 | 25 | 32 | ||||
Occupational Therapy | 43 | 38 | 27 | 15 | 38 | ||||
Pediatric Gastroenterology | 15 | 1 | 1 | 6 | 19 | 4 | |||
Pediatric Urology | 5 | 13 | 1 | 2 | |||||
Physical Therapy | 48 | 33 | 30 | 5 | 51 | ||||
Speech - Language Pathologists | 55 | 4 | 4 | 29 | 29 | 71 |
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Helpful Articles
Foxx RM, Azrin NH.
Dry pants: a rapid method of toilet training children.
Behav Res Ther.
1973;11(4):435-42.
PubMed abstract
The original and most replicated rapid toilet training program (not specific to CYSHCN). More modern practice often removes
the negative reinforcement from this program.
Warzak WJ, Forcino SS, Sanberg SA, Gross AC.
Advancing Continence in Typically Developing Children: Adapting the Procedures of Foxx and Azrin for Primary Care.
J Dev Behav Pediatr.
2016;37(1):83-7.
PubMed abstract
A review of adapted rapid toilet training approaches based on the original Foxx and Azrin procedure in typically developing
children.
Klassen TP, Kiddoo D, Lang ME, Friesen C, Russell K, Spooner C, Vandermeer B.
The effectiveness of different methods of toilet training for bowel and bladder control.
Evid Rep Technol Assess (Full Rep).
2006(147):1-57.
PubMed abstract
A review of studies examining effectiveness of primarily 2 different methods of toilet training for children with diverse
health care needs. Demonstrates the effectiveness of both the Azrin and Fox model and other approaches that differ from toilet
training of typically developing children.
Levato LE, Aponte CA, Wilkins J, Travis R, Aiello R, Zanibbi K, Loring WA, Butter E, Smith T, Mruzek DW.
Use of urine alarms in toilet training children with intellectual and developmental disabilities: A review.
Res Dev Disabil.
2016;53-54:232-41.
PubMed abstract
A review of studies investigating the use of daytime wetting alarms to help children with intellectual and developmental disabilities.
Macias MM, Roberts KM, Saylor CF, Fussell JJ.
Toileting concerns, parenting stress, and behavior problems in children with special health care needs.
Clin Pediatr (Phila).
2006;45(5):415-22.
PubMed abstract
Emphasizes the importance of medical home providers in assessing and intervening to help families with toilet training their
child with special health care needs.
Kroeger K, Sorensen R.
A parent training model for toilet training children with autism.
J Intellect Disabil Res.
2010;54(6):556-67.
PubMed abstract
Discusses a rapid training method for parents to use to toilet train children with autism within a few days.
Wright AJ, Fletcher O, Scrutton D, Baird G.
Bladder and bowel continence in bilateral cerebral palsy: A population study.
J Pediatr Urol.
2016;12(6):383.e1-383.e8.
PubMed abstract
This study describes the age of achieving day and night continence relative to the degree of motor and intellectual impairment
in children with bilateral CP.
Zickler CF, Richardson V.
Achieving continence in children with neurogenic bowel and bladder.
J Pediatr Health Care.
2004;18(6):276-83.
PubMed abstract
Detailed material on caring for and achieving continence for children with neurogenic bowel and bladder in a variety of settings.
Written from a nursing perspective.
Page Bibliography
Azrin NH, Foxx RM.
A rapid method of toilet training the institutionalized retarded.
J Appl Behav Anal.
1971;4(2):89-99.
PubMed abstract / Full Text
Brazelton TB.
A child-oriented approach to toilet training.
Pediatrics.
1962;29:121-8.
PubMed abstract
Kroeger K, Sorensen R.
A parent training model for toilet training children with autism.
J Intellect Disabil Res.
2010;54(6):556-67.
PubMed abstract
Discusses a rapid training method for parents to use to toilet train children with autism within a few days.