An Occupational Therapist’s Guide to Potty Training

James Gilmour by James Gilmour Additional Needs

James Gilmour

James Gilmour

James graduated from University of Ulster in 2016 with a BSc in Occupational Therapy. Before joining Leckey in 2017, James worked in the NHS Paedia...

An Occupational Therapist’s Guide to Potty Training

(This is part one of a two-part blog series)

Is it time to change the way we potty train?

Potty training is one of the first and important steps towards building independence. As a social and developmental milestone, it is quite unique as it relies upon a parent or carer to both instigate the training process and provide ongoing support. Yet for children with a physical or Neuro-disability, the approach is often haphazard. Why is this so?

Potty training has evolved, devolved and evolved again countless times over the years, and across the world. In many cultures, training begins as early as one year old, however, in the Western world the age has more than nearly doubled in the last 60 years from 18 months to three years old. Modern lifestyles, the shift in social expectations, changes in work-life balance as well as the introduction of disposable nappies have all influenced this remarkable rise.

While delaying potty training for typically developing children may cause little harm, the impact of delaying or completely overlooking training for children with disabilities, can lead to serious problems such as constipation, urinary tract infections and urge incontinence. Constipation alone is estimated to affect 1 in 3 children and often requires acute medical attention in children with disabilities; never mind the often-neglected impact on mental health, family participation and quality of life.

Training the bladder and bowel is important for both physical and physiological development. In simplistic terms, the muscles surrounding these organs operate much like any other muscle in our body. If the muscle is unused, it becomes weak and functions poorly. By training and strengthening the muscle, the function improves.

So, why is it so often overlooked and what influences whether, and indeed when, a child with a disability is potty trained? Is it their mobility, their communication, their learning ability, or even the age that their siblings or peers were trained?

The reality is a mix of these factors. Ironically (and I can vouch for my own professional experience here), while there is a wide range of resources to support toileting, such as advice on diet, equipment and undressing/dressing, there is very little specific guidance on potty training and often no single healthcare profession takes the lead in providing support.

Why is this? Well, this is largely down to potty training being perceived as a parental responsibility. Recent research challenges this thinking as it reveals that not only is potty training a complex neurological process, but that a team-based approach greatly aids success. Much potty-training advice leads you to believe that there is a ‘lightbulb’ moment when everything seems to fall into place. Yet this is not the case. It takes millions and millions of neural pathways linking up and working together before this happens. Evidence supports the understanding that several core regions of the brain, relating to the sensory interpretation, muscle control, social awareness and understanding, are responsible for continence.

For children with a physical or neuro-disability it is likely that at least one of these regions will be impaired. However, this should not necessarily limit the child’s potential to toilet train as we can maximise the child’s neuroplasticity (the brain’s ability to reorganise and form new synaptic connections) to develop potty-training skills. Over the past 2 years, I have had the good fortune to support families in applying principles of neuroplasticity to potty train their children. It has been rewarding to see how by understanding the child’s impairment and applying new strategies, success is achievable with a positive and transformative change in the life of the child and their family.

In part 2 (coming soon) I will explore how applying neuroplasticity to potty training is the key to success.

James Gilmour, Occupational Therapist

References

Fowler, C.J. and Griffiths, D.J. 2010. A decade of functional brain imaging applied to bladder control Neurology and Urodynamics, 29, pp. 49-55.

Fowler, C.J. and Griffiths, D.J. 2010. A decade of functional brain imaging applied to bladder control Neurology and Urodynamics, 29, pp. 49-55.

Franco, I. 2011. The central nervous system and its role in bowel and bladder control. Current Urology Reports, 12, pp. 153-157.

Malykhina, A.P. 2017. How the brain controls urination. eLIFE Sciences, DOI: https://doi.org/10.7554/elife.33219

Millard, E., Benore, E. and Mosher, K. 2013. A Multidisciplinary Functional Toileting Pathway for Children with Cerebral Palsy: Preliminary Analysis. Clinical Practice in Pediatric Psychology, 1(1), pp. 81-88.

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