Sensory Integration in ADL Series (SCAN) – Topic – Toilet Training

Hi All,

sharing details of another session which my wife attended , it was organized by SCAN group. The session details are:

Session Name: Workshop on Sensory Issues relating to ADL (Activities of Daily Living) Training – Toilet Training
Date: 17th September 2019
Timing: 10 am to 12:30 pm
Venue: Mitr, T-18/2, Coastal Road, Kalakshetra Colony, Besant Nagar, Chennai – 90
Charges: 150 Rs per Person ( Refreshments were provided)
About the Speaker: Mrs.Lalitha Sridhar is a rehabilitation consultant and developmental therapist specializing in sensory integration and neuro developmental therapy. She is an educator and counselor for children with development / special needs and their parents. Lalitha has over 30 yrs of experiences in India and abroad. She has worked with children across all age groups, from early intervention to vocational training and has been providing programs across age groups. Her core areas of work are assessment, intervention and developing holistic programs for children with special needs. She has worked with parents in guiding, training and empowering them in their journey.

This session was part of the ongoing Sensory Integration ADL Workshop/Training series, i.e. Feeding > Toilet Training > Sleeping > Communication > Behaviour. Today the area covered was TOILET TRAINING.

RHYTHM

She provided the analogy of sun rising at the fixed time and after 12 hours, it sets at the fixed time day in and out, which is the natural rhythm. This rhythm does not change, similarly our body has a Rhythm. Most of us abuse the rhythm by sleeping or waking up at irregular time intervals, consuming food at odd hours, eating food without boundaries etc. All internal organs has to work together for us to be in an optimum functioning level. There will be no rhythm, when your internal systems are in disharmony. Making our body work in a rhythmical way improves the cognitive ability which results in understanding of instructions provided to the child.

Our Rhythm should be: Sleep > Wake Up > Breakfast > Lunch > Snack > Dinner > Sleep.

Another example given is, when you go for a social event (reception or get together or party) previous night, had a great time and enjoyed the food on that night, next day morning how do you feel yourself??? Most likely we are less energetic, we may not consume breakfast immediately, all this happens because your rhythm has gone for a toss. It is well and good to enjoy yourself now and then, however don’t make it as a habit on a daily basis. Similarly a child can have an odd day out where a rhythm might have been missed, however please ensure that does not happen more frequently.

Opt for Time range, if fixed time is difficult:

Rhythm is very difficult maintain due to practical difficulties, but if you ensure discipline on this aspect, your will see improvements in your child without a doubt. For parents who cannot stick to a fixed time schedule for their kids, you can follow a time range instead of a fixed time. i.e. If you want the kid to wake up by 8 am, don’t focus on 8 pm, keep a range of time like 7 am to 9 am, within which try to wake the kid up.

Advantages of following the Rhythm:

1) For children in 0-7 age range, if we are able to maintain the rhythm, if will help the children to function effectively at the Optimum level.
2) Sense organs will be awake and the children will be 100% ready to receive external inputs.

Drawbacks of not following the Rhythm:

1) Without rhythm, if you train your child in an restricted environment (therapy center), it will not result in a productive outcome. It may help your child in learning few activities, which will not help in the child’s development.
2) Say for instance if you are skipping a meal, starving your body of food and over compensating in your next meal, you are compromising on the blood sugar levels, causing a health condition.

HEALTHY BALANCE SHEET

The components of a healthy balance sheet are: 1) Good diet/Food 2) Proper Toileting 3) Good Sleep

DEVELOPMENTAL PATTERN

Phase 1 – 0 to 7 Years = At this phase only Physical growth happens

Phase 2 – 7-14 Years = At this phase it helps in emotional and Physical Growth

Phase 3 – 14 to 21 Years = At this phase, adolescence and emotional maturity gets consolidated. Emotionally they have a different perception on everything.

Our Developmental Scale:

She asked audience to rate the level of there self development. Most of them mentioned values like, 60, 70, 75 etc., no one mentioned 100%. No one was confident enough to say that they are 100% developed because we also have delays and lag. She mentioned that the remaining undeveloped % is what makes us different. Even in that 75% which we considered as grown and developed, we would be strong on different domains and not everyone has the same strengths or weaknesses.

When your child is not developed fully, we begin to send them to school where he is mixed with other children who are developed at different levels, and prioritized learning of ABCD and 1234. We do not have the patience to wait for it. We do not recognize or observe other forms of development, we are measuring it only with the ability to sing a rhymes, write abcd etc ..
Few of us are Visual Learners, few are Auditory learners, so every one does not understand everything at the same phase.

LALITHA’S FORMULA

40% from home training, 20 % from therapy and remaining 15% is form social interaction.
She spoke more on the 15% of the social interaction. How many of us are giving the child the opportunity to interact with the environment i.e. people or nature of situation or place ..?
Parents are denying social interaction, as it will put the child in a difficult situation, where he will not how to react to it, also at the time we are ashamed of exposing our kid in social environments to avoid remarks from strangers/bystanders. When you are ashamed of what is going to happen to your child, in the name of protection you are isolating the child, as a result the child never fits in the social environment. You as a parent are denying the 15% development for your child, you have to become strong and overcome the social stigma.
Even a typical child does mistakes, disobeys, throws tantrums etc. in social environments, instead of finding solutions if you began isolation, you are not denying the 15% of the development which is very crucial. If you start this habit from younger age, it will be easier to build on it, if you starter at a later stage, challenges will be there, we have to work on those, nothing is impossible it is only difficult.

Your Intervention program for the child should constitute only about this 75%, you will slowly achieve this. Without focusing on these areas, if you continue to work on therapies and other interventions, it will not yield any results. As most of the therapy programs work in isolated manner, the speech therapist ignores the sensory needs of the child, Occupational therapist ignores the prerequisite sensory requirements for speech … every one works on their own area, which is why you don’t see progress in spite of receiving therapy services. If you find an area that contributes to the development for the child, do not deny that to the child.

CHALLENGES IN TOILET TRAINING

• Where to pass
• Understanding
• Communicate
• How to do the Posture
• Washing and Cleaning
• I have to do now
• Body or Self awareness,
• New environmental changes,etc ..

CLASSIFICATION OF TOILETING

• Process
• Factors

TOILETING

Toileting refers to both urination and bowel. They compliment each other, so do not exclude one from another during your training phase, always focus on both.

COMPONENTS INVOLVED IN TOILETING

Similar to the feeding in toileting also we see Motor, Sensory and Emotional components are involved. You have to work on all of the three components irrespective of different age groups, however you change the ratio or weightage on the components.

For younger child (0-7), you give a lot of more attention to the motor component which gets higher weightage
For an middle aged child (7-14), you should provide equal weightage for all three components
For an older child (14-21), you should focus more on the Emotional component.

PRE-REQUISITES OF TOILET TRAINING

1. As a parent, it is extremely important for you to be relaxed. If you express anxiousness to the situation, you are actually passing it on to the child, the situation will never get better that way.

2. If you are not relaxed, do not do toilet training. A Child who clearly understands from your body language of what is about to happen, and his mind will be made up for non co-operation, i..e he will hold his muscles, which will give you NO RESULTS, irrespective of how much ever time you spend with the child.

3. Mild instrumental music helps in keeping the mind focused. The mild music should not increase the arousal, it should be some thing that will calm the child and make him sit.

BODY AWARENESS

Passing of stools and Urine involves bowel and bladder muscles. If you have to go to toilet, body awareness is the important aspect of it. Unlike feeding activity where your have motor activity involved outside, here every thing is internal to the body. For proper bowel movements we have to work on the muscles related to it. You need more input on the body awareness through internal senses. The Interceptors (i.e. Internal Receptors) which works on sending signals to and fro between the brain and organs, are responsible for body awareness.

TYPES OF FEELINGS

1) URGE

This is a feeling one would get when their bladder is full. There is nerve that is located at the bladder which is connected to the brain, this nerve sends signals to the brain when the bladder is full and its time to Urinate.
Followed by the Urge, process of defecation or passing of urine is focused. When the bladder is full, brain gets the signal, mind decides that it is time to go to toiler, begins to search for nearby toilet etc.

2) RELEASE BY CONTRACTING and RELAXING OF MUSCLES

After the urge, in order to pass the urine or stool, you need to relax and contract the muscles, which happens inside the body and you have no control over it.

3) FEELING OF EMPTINESS

Once you complete the urination or defecation, you should feel the sense of emptiness.

We have to work on all the above three areas, without which by sending kids to toilet alone will not make things work. The Systems are interrelated, i.e. for proper bowel movement, you need to have a properly digested food, for proper urination you need have adequate intake of water. For both of this to work, you should have adequate sleep which will make the organs work efficiently.

SENSORY PROCESSING

Sensory processing does the work of integrating all the senses.

1) Registration – Any information that flows from outside to inside and it goes to the brain

2) Modulation – The received information by the brain must be modulated, modulation refers to the required amount… not over not under…kids who does not have the modulation feel they are over stimulated

3) Planning – The brain has to decide what information it needs to take and what it should ignore to produce a response ..

4) Response

If there is an issue with registration, modulation and planning, then definitely there will be issues in response.

BREAK THE GENERALISATION

You have to break the generalization from day one. For instance, a child can be fed by anybody and not by a particular person alone, a child can be fed anywhere and not in the same place/room. It is important to break the generalisation, because when one fine day you try to feed the child in a different place or by a different person, the child will not co-operate, also by breaking it, it will make the child to learn and adapt in the different environment. Understanding happens when generalisation happens. Only then kids will respond to questions like what is your name, what are you doing now etc. Involve more people, more practical experiences which will improve the kids in their responses, do not work on a separate world for them.

Don’t assume just because we are parents of the child, the child will do everything we like doing. You need not take the child to all the places for the sake of it. When you are going for social event, ensure you have some avenues where your child can be engaged or not, if no such avenues present you take his favorite toy or book so that he is engaged in his area of interest when you enjoy your area of interest. Every individual has their own identity, we have to respect it.

Do not break the rhythm, but you can break a routine once in a while. Exposing the child to different people and environment helps in development of the child.

SOCIAL STORIES

For any social outing, prepare your child. Preparation through social stories help. The basic components of social stories are:

1) The child should be the central character

2) Use Visual pictures, do not limit to auditory

3) Your social story should only have 4 parts in it,

• Who is this Character ?
• What we are going to do ?
• Who are all involved?
• What the child is expected to do?

4) Do not set the expectation i.e. don’t tell the child “If you behave ….”. A Child can behave positively or Negatively there, it it is positive you appreciate it, and if it is negative you ignore it. You will see the behaviour changes over a period of time. At the end give some reward to the child.

IMPACT OF POOR INTERCEPTION

If there is a poor interception in the body, we will see the following :

1) Unaware that the bowel and bladder is full..
2) Before completion the child will runaway
3) Feel the need to go, but unaware that they need to pass
4) unable to push i.e. lot of times you take them to the toilet, they are unable to push.      5) Unaware about their accidents

INDIAN TOILET vs WESTERN TOILET

Indian toilet is the best, as you have to sit in a squatting position where thighs pushes the intestine and gives the pressure on the bowel. Also in Indian toilet your body is rested, balanced, weight bearing on feet gives proprioception input to knees and hip, also you have give a holder for the child to hold on during toileting.
This is the natural way we have defecated years before, due to changes in life style, we are not following the same now, so this became an activity as part of child’s improvement plan.

For Western toilet users, the foot should not hang loose which gives the child a feel of insecurity, so you provide a bench where the kids can rest his feet during toileting. For body support, she also advice’s mother to hold the shoulder of the child, as child feels more secured with that person, the emotional component is taken care of along with the stability. If this is not possible, you can give arrange for a grab bar for the child to hold.

Initially when training for younger child, do not do it inside the toilet, get a potty and train them outside. Let them feel comfortable in sitting on the potty first and then decide on a schedule.

FACTORS PREVENTING CHILDREN FROM TOILETING

1) Wet bathrooms – Kids often does not like to step on to wet floor, they do not like the feel of it. Hence these kids will avoid getting in to a wet bathroom just to avoid the sensory stimulus it will give to them.

2) Flushing of toilet – There are two types of kids with different set of issues in flushing. Kids who are sensory seeking will keep on flushing the toilet, as they like the sound of it and wants more of it. Kids who are sensory avoiders, cannot tolerate the noise made by the flush, so they avoid getting in to the bathroom for the fear of the flushing sound.

3) Removal of Dress – Few kids often remove the entire pants in order pee, instead of dropping it few inches which is enough to pee, if they are unable to remove the entire pants/dress, they will not pee.

4) Smelly toilets – Unclean smelly toilets are a BIG NOOO for them to enter

5) Fear of falling from the toilet

6) Fear of falling in to the hole

7) Avoidance due to associated accidents – In the past, there might have been some accidents/incidents happened to the kid which may have been associated with the peeing activity. For example, a caretaker in the school might have either shouted at the kid or insulted the kid during the process of peeing, which will get registered in the kids mind. So the kid will think, that in order to avoid getting insulted by the caretaker, he should avoid going to the bathroom, so they will hold the pee and urinate in their pants.

8) Visual Distraction – Kids focus on the minute details which are often not Visible / ignored by adults. A spider web, hint of dust is a strong visual distraction that could cause avoidance

9) Water Temperature – During winter/rainy season, the running water temperature is at the room temperature level, its off, which makes the kid uncomfortable

10) Hard seated toilet – It is very difficult for children to use hard seated toilets, which are typically found in western toilets

11) Peeing in Living room – Some kids avoid going to the toilet, but goes behind the couch to do the toileting or pee in the corner of the room

All the above factors are exhibited by the child when the sensory systems are not in order.

STRATEGIES for IMPROVING BLADDER CONTROL / URINATING

1.) The thumb rule is that, the amount of liquid that is consumed by the body, the is the amount of liquid that is urinated. We need to focus on regulating the intake of water, juice and other beverages.
From Waking up to mid day, half a liter or water consumption is enough
From Mid day to Evening, another half a liter
The volume depends on the age, it can go up as below:
For 0-7 years age, less than 1/2 a liter
For 7-14 years age, 1/2 liter can become 1 Liter
For 14-21 years age, 1 Liter can become more..

Kids will drink at two extremes, you will have kids who keeps drinking water for no reason, then you will have kids who does not drink water at all. Also there will be days, where the child will feel little more thirsty, don’t say that you will not give water , that day consider it as an expectation. Irrespective of whatever be the water requirement of the child, ensure that you spread it through out the day in regular intervals and not in big volumes at a single go. Also consider other liquid food items that are consumed like butter milk, rasam etc, when deciding on the water requirements for the child.

It is important to restrict liquid intake beyond 8ó clock because when we focus on toilet training, we also should address bed wetting. It is good if no liquids are consumed beyond 8 pm in the night, but due to circumstances if it is required to consumed, limit it. If you do any practice for 21 days, your body gets regulated .

2) The ideal frequency of putting the kid to urinate is 1:30 hours not less than that (i.e. every 90 minutes your kid should visit the toilet). Any thing less that that will be a very laborious process. Kids should sense the urge, kids should develop the control habit. There will be odd accidents that would happen, don’ pay much attention to it.

3) Initial stages, train the kid for the Half a day routine. Most kids spend their first half in school, so you only have the remaining day for training the child. It is also easier to train the kid for half a day, there will be very less accidents and also the child will learn when there he enjoys the success. Increase the hours gradually, i.e. from 90 minutes to 120 minutes intervals.

4) It is easier if you train your kid with a signage for washroom, which are widely used in public places like male/female etc, so that it becomes easier when you take your kid out.

5) Use single word commands, do not give detailed instructions that are overwhelming for the kid. Simply say, su su or su su time or go su su …

6) Ensure consistency is followed at regular intervals. Only when the you achieve 70% of success rate in day time, you can proceed for night time. Ensure the diaper is completely off during day and night.

7) If the kid is not urinating after 1:30 hours of time interval, you can stimulate it by opening the tap, the sound and visual of running water gives them the simulation to pee. Ensure that tap is at the distance, else kid will begin to play with water.

8) For Older children, practice it directly in the washroom, for younger children keep the potty outside and make them do it there.

9) For night training, ensure that you keep an alarm every 4 hours after the child goes to sleep. Take the child to the bathroom in the sleep stage, do not wake them up, as few kids are disruptive sleepers, it would be hard to put them back to sleep it waken up. You can try sprinking water on their private parts, which causes stimulation for them to pee. The waking up procedure is being followed since they are young, over the period there will be in a position to have a continuous sleep from 10 pm to 6 am with no su su breaks.

STRATEGIES for IMPROVING BOWEL MOVEMENT/ DEFECATING

1) Potty training should always be done in the morning. If the body is not accustomed to the rhythm of internal organs, you find another time frame that suites the child

2) To stimulate bowel movements, after the child wakes up, give them 30 mins of time, warm water can be provided and make the child to have some movement, before make him to sit on the Toilet. You might not see results earlier, but it will show up afterwards, if you are consistent. Once the change is achieved, it will be permanent.

3) Ensure that Toilet seat, the foot rest, the hand rest and the stability are in place.

4) Avoid too much visual distractions in the toilet.

5) Toileting is an act that involves lot of emotions, so suppress your emotion / anxiety/ hurriedness and do not pass it to the child. Even if the time taken for the process is more, sit with the child till it gets completed. You can strike a conversation during that time, as the kid movement is restricted.

6) Give the child a toy to hold, something soft to hold or squishy in nature. Sqeezing the toy relaxes them and it helps in pushing down the bowel

7) Irregular bowel movements are often caused due to inadequate digestion. Cut down on wheat, biscuits etc.

8) It is important to eat the food in a proper manner for a better bowel movement. Food must be consumed by Biting and chewing and should not be swallowed. Also avoid feeding mashed foods to the kids, it will train your kids digestive system to expect for mashed foods all the time. Be consistent in the texture/form of the food provided so that internal organs work effectively, don’t experiment too much on this.

9) The food given to the child should contain a mix of Carbohydrates, Pulses and Fiber. Don’t stick to rice based food all the time.

10) One can try providing Kottai Thiratchai (which looks like size of dates) which can be purchased from traditional medical shop (Nattu marunthu kadai). In the night, put 2 grapes in the water and soak it and in the morning, you squeeze the grapes and provide the extracted juice to the child. It makes the stools mode softer and the passage of stools becomes easier

EXERCISES FOR BOWEL MOVEMENT

1) Squat to stand

2) Sit to stand

3) Duck walking

4) Sitting on the spot position

5) Churning (Rolling the stomach)

6) Pelvic Bridging … Lie down and lift the hip from the floor ….

7) Bend your legs keep it apart and place a ball or some thing and ask the kid to squeeze.

You can do these exercises in the evening / morning .

OTHER TIPS / RESPONSE TO PARENTS QUERIES

1) Some parent ask suggestions / references for an OT (Occupational Therapy), for which she responded to take up the home program for the children and try it out yourself. Then move to an OT for issues which cannot achieve by yourself in the home program. Combination of proper diet, home program and Rhythm in daily routines helps a in building a strong foundation for the child, after which if you opt for an OT program it will be beneficial for the child.

2) One of the parent asked what to do, if the child is not wanting to eat. She suggested to find reasons why, as one cannot rule out the fact that kid is hungry, which is evident. When some thing which is very natural to the body does not happen, it means there is an Alteration of rhythm that might have taken place, which needs to be addressed.

3) The important part of toileting is the bowel, if the bowel movements are not proper, it impacts on cognition as a result there will be No focus, No attention, No memory, No sitting, No comprehending, No Completion happens

4) Don’t opt for IQ test for kids between the age group of 0-7 it will provide a false reading only. Instead you can go for DQ.

5) A parent mentioned that his child goes to the toilet in middle of a meal, for which she responded, this might have been caused due to improper digestion or setting of bowel movements in the child.

6) Any activity in therapy or which you give at home, should should make the child process an information and convert it to an activity, start with simple and then move to complex. If the child is not feeling the sense of completion, it will continue to pass to the later stage of life. It is the sense of completion which sends the signals from Organ to brain and vice versa.

7) Her advice to all parents is to work on their ADL Skills in order to see developments in their cognitive skills.

8) She mentioned that, it is extremely easier for her to simply provide tips and activities, however i wanted you to know why we are doing it so that you would be able to judge and decide on which activity suits your kid. If you understand your child, you would be able to solve the problems. Instead of giving a fish, to teach fishing is lot more important to her.

9) A parent asked that her child was suddenly regressed back to old habits for no reason, for which she responded when there is a change in the environment, child go back a step instead of progressing forward which is not a regression. Try limiting your instructions given to the kid for toileting, we call it as “Keyword with pointing”. You simply say “su su” or “ka ka” with finger pointing towards bathroom. By giving too many instructions,
focus and the attention gets dispersed. Also it is perfectly normal if a child skips a milestone, kids without prompting or communicating the need for toileting, they go to the bathroom by themselves.

10) Don’t do things with kids that are so boring, because the kid is unable to communicate to you that is is boring, instead he is communicating through behaviours, whereas we are not understanding those signals appropriately and force the kid to do the same thing.

11) She mentioned about IBS – Irritable Bowel Syndrome and Constipation. For down syndrome children, they do not have control on their bowels, it passes out without their knowledge or its gets struck there due to constipation, both are equally bad.

12) GFCF diet is still under research, she will not recommend for 0-7 age groups, it will cause issues due to lack of nutrients

13) For kids who remove the complete dress for toileting, she suggested to do it as a play outside the bathroom first before trying it in the bathroom. Train him for removing half way down, half way up, sitting and standing.

14) Children often prefer diapers because of the tactile input it gives to them. Instead of diaper, opt for underpants which are 1 size smaller than your child’s current size. so that child will get the tactile input required. It also avoids fidgeting with their private parts.

No personal feedback on this, as i did not attend it myself. My wife felt satisfied with the information shared in the session.

I thank Scan for organizing this session and looking forward for the upcoming sessions.

Regards,
Saranya and Karthik
karthiksaranyaparents@gmail.com