Having difficulties with bladder control is very common in young children. This is partly due to immature bladder function which will naturally improve with age, but control problems are more marked amongst children with physical and learning difficulties.

**If **your child’s cognitive skills are delayed in language and understanding, it is likely they will need a bit more time and patience to master toileting skills.

Some children are especially anxious about new routines or demands. They might need extra patience, planning and organisation. It will help if you use strategies you know will ease your child’s stress - for example, you could give them choices over aspects of the toileting routine. Ask them if they want to take a toy with them or take their pants off beforehand. You could also explain the process in advance, making it fun by including favourite toy animals or dolls in role-play.

**Body Awareness **– Some children have an over or underdeveloped sense of their body’s needs – such as the need to do a poo or a wee. If your child has reduced body awareness, they may not notice the discomfort of sitting in a wet nappy. Or, if they have heightened body awareness they may go to the toilet repetitively, even when they have little need to do so. You can model listening to your own body signals as well as incorporating body listening into stories and play to help the child build their skills.

**Physical difficulties** – If your child has continuing bladder difficulties they might have an underlying medical condition, such as an infection or abnormalities in their urinary system. Keep a record of the problems they are experiencing and when they occur, before consulting your doctor.

In New Zealand 15 percent of five-year-olds wet their beds regularly, as do five percent of 10-year-olds. It is generally not considered a concern until children are aged seven or older. For children with disabilities or who are neurodiverse, bedwetting can be more long-lasting and can get in the way of school camps and sleepovers. This can be upsetting for everyone.

### **Some tips that might help with bedwetting:**

You’re probably already doing these, but it might help to tick them off and know you’ve covered the basics.

- Keep your child’s fluid intake up during the day – aim for six to seven water-based drinks, at regular intervals during the day.
- Encourage your child to go to the toilet before going to sleep.
- Protect the mattress with a waterproof cover.
- Don’t pick your child up and take them to the toilet while sleeping – it is important they learn to wake up to bladder demands.
- Bed alarms are available which are triggered by moisture in the bed, which helps develop children’s awareness of a full bladder and the need to go to the toilet. Talk to your GP or needs assessor/navigator about a referral to an incontinence nurse.
- Celebrate and praise your child for their toileting wins. Never get angry or punish your child for toileting accidents.

### **Regression and Relapses**

Just when you think you’re over this stage in your child’s life - you find the bed wet again! Regressions and relapses happen. Take a deep breath and don’t panic. It might be a blip on the road to toileting success, or there may be something going on with your child that you need to know about. Remember, behaviour is communication, so find out what your child is trying to tell you.

Firstly, investigate if there are any health issues that are causing the problem – for example if your child has a urinary infection or is constipated this will lead to changes in their toileting behaviour. If all possible medical causes have been investigated and treated and the problem persists, look externally. Perhaps your child is stressed due to changes in the family environment – you’ve shifted house or had a relationship breakdown. The problem could be in their school environment – they don’t like their new teacher or have had a falling out with a friend.

Once you’ve identified the issue it will be easier to provide the calm and supportive environment your child needs.

### **Remember:**

There is usually a reason for children to act in a particular way. It’s our job as parents to figure out what that reason is and do what we can to fix the problem with the help of others.

Try not to let feelings of embarrassment get in the way of talking to other parents and people who can help, about your child’s toileting issues. You’re not alone - toileting issues can be so frustrating and be really hard to manage.

Believe in your child’s ability to learn and celebrate their achievements.



How do I stop my child wetting the bed?

bed wetting disability bed wetting and autism, ADHD and bedwetting, Disabled child bed wetting

Children with Down Syndrome face particular challenges when it comes to toileting. These can be physical, behavioural, and cognitive. But with a gradual, consistent approach, backed up by positive, creative encouragement, your child will get there.

Devising a toilet plan for your child requires parents to consider their particular strengths and challenges. Some of the more common challenges and strategies to overcome are listed below. For detailed advice on how to gather the data, create the plan and implement it, check out our other posts about toileting.

### **Common Physical challenges:**
- Delays in motor control and gross motor skill development.
- Low muscle tone.
- Constipation due to medical conditions.
- Constipation due to physical inactivity or dietary issues.
- Celiac disease.
- Difficulties with sitting on the toilet seat and wiping, due to shorter stature and shorter arms.
- Delays in fine motor skills – e.g., ability to undo buttons and zips.

### **These tips might help...**
- Be patient and allow for your child to take longer to reach physical milestones.
- Short stature and limbs can be accommodated by adjusting the toileting environment based on an occupational therapist’s recommendations – for example, installing a bar that helps your child with stability and balance. A foot stool will also help.
- To allow for difficulties with fine motor skills put your child in looser clothing and use pants with elastic bands. Wet wipes may be easier to use than toilet paper.
- For constipation caused by medical conditions consult your doctor.
- For constipation caused by dietary issues, consult a dietician, but also make sure your child is well-hydrated and encourage a varied diet.
- Encourage your child to be physically active – make sure they have physical activity breaks throughout the day and incorporate physical tasks into ordinary activities – such as pushing the shopping cart. Being physically active is important for building muscle tone as well as preventing constipation.
- Celiac disease – act on the advice of medical experts.

### **Common Behavioural challenges can include:**

-   Attention span and impulse control difficulties
-   Anxiety over mastering the different steps required for toilet training.
-   Sensory issues
-   Reluctance to change routines.
-   Compliance issues

### **Some tips that might help...**

-   If your child’s low attention span makes toileting difficult, make it an activity they enjoy, such as looking at a book, or playing with a designated ‘toilet toy’. And remember to lavish them with praise for every achievement!
-   If your child seems anxious about toilet training, break it down into smaller steps, and explain what you’re doing and why. Again, praise and reassure them as much as possible.
-   Some children with Down Syndrome have sensory difficulties. If your child does not realise when they are wet or dry, help them to notice the difference. Some children are overly sensitive to certain sounds, smells and sensations. Notice if anything is bothering your child in the toilet, then do what you can to eliminate it, or decrease its effect.
-   If your child is reluctant to change routines, introduce the new routine very slowly. It can be motivating to give them more control with the new routine. Make sure your new routine is more fun than the old one, so if you’re fading out ‘nappy-changing’ make sure it’s as boring and unstimulating as possible!
-   If your child is being particularly non-compliant about toileting, find out what’s behind the behaviour. It may be due to some of the reasons above, they have sensory issues or are constipated which makes it painful to poo. Once you know the reason you can figure out how to solve it.

### **Common Cognitive challenges:**

-   Communication difficulties
-   Difficulties with transferring skills from one context to another
-   Difficulties understanding why and when the toilet should be used.

### **These tips might help...**

-   Remember behaviour is communication. If your child is non-verbal, become attuned to their facial expressions, gestures and whether they show distress or pleasure when on the toilet, use picture cards or sign language, if they are appropriate.
-   Creating a visual schedule, which shows what activities can be done where, will help your child understand how to transfer a skill from one context to the next.
-   Talk your child through what is happening to their body and why, when they’re in the toilet. Engage their curiosity and show them how impressed you are with their achievements.

It can be a good idea to start toilet training around the same time as typically developing children age – that is, between eighteen months and three years of age. But you’re the parent - you know best. In order to start toilet training, a child needs to be able to sit safely and independently on a toilet. Don’t worry if they don’t haven’t passed all the ‘readiness milestones’ too much.

Remember, your child is an individual, so you will know best what motivates them and how to overcome their specific challenges.

Toileting is a complex issue and** IHC Library** and **Awhi Nga Matua** have produced a series on toileting issues. 
For more information give the library a call on** 0800 442 442**, or **email: librarian@ihc.org.nz**.




How to help children with Down Syndrome use the toilet 

Down syndrome toilet training, down syndrome toileting

Using a toilet is a skill almost all children can acquire. But some disabled and neurodivergent children may need more support and practice to get there. They may never get there, but if you’re on this journey - these tips might help/

The three key stages are the same as they are for all children – **Preparation**, **Practice**, and **Persistence**.

### **Preparation - First Steps**

**Feelings** - Before beginning, parents should check in on their own feelings and motivation. For a successful outcome, it is important that parents do not feel anxious or pressured by friends and relatives. If you _do _feel this way, your child will know it and will likely push back, becoming uncooperative and stressed themselves. Keep positive and support your child even when it gets really hard. Celebrate each achievement, no matter how small. The toileting journey should be fun and stress-free.

**Support –** Getting your child toilet-trained is not a one-person job, you are going to need the support of your partner, other family members and any people involved in their care. If your child is already at school, contact their teacher and teacher aide if they have one and any other relevant teaching staff. You do not want your child to receive confusing or inconsistent messages about how and when to go to the toilet, so make sure everyone in your toilet team is on the same page before you begin.

**Timing **- Figure out the best time to start toilet training. For best results, choose a time when neither you or your child are likely to be stressed or busy with other concerns. This means avoiding significant times of change, such as moving house or schools, or bringing home your newborn baby. The Christmas holidays might seem ideal, but don’t start until the festivities are over, you’ve had a chance to recover, and your house is calm.

### **Gathering the data**

Take note of your child’s peeing and pooing behaviour over a few days and see what patterns emerge. For example, record how long after drinking they pee, what time of day they usually poo, how many times a day they poo, how long the average time between pees is, etc. You will use this information to devise a plan that will be your roadmap.

### **Practice**

The key to a successful toilet plan is to work around your child’s specific needs and routines and getting their buy-in to this new adventure. Explaining how our bodies get rid of the food we don’t need through poo and wee might help. Make sure they know it’s a sign our bodies are healthy and working well. Congratulate them if they successfully get all of their pee (or most of it) or a poo into the toilet.

### **Other key factors to your toilet plan:**

**Consistent language** including sign-language, that everyone in your toilet team will use for toileting activities helps a great deal. Try to use factual and accurate language if you feel comfortable.

**Break down the process into easy-to-manage steps. **As time goes by your child will be able to manage more and more of these steps by themselves, such as pulling down their trousers. It doesn’t matter if their mastery of each step does not happen in chronological order.

**Decide _how_ your child will be prompted** to go to the toilet if they don’t ‘feel’ the need to go. Will it be a visual or verbal cue?

**Decide _when_ your child should be prompted **to go to the toilet. For example, twenty minutes after meals, before leaving the house, going to bed, or after they’ve had some water or juice.

**Decide _how long_ they should sit on the toilet for**, and_ **what toilet specific activities **_**can happen** - singing a favourite song, using an ipad or phone, reading a book, playing with their designated toilet toy.

**Put your child in easy to remove clothing. **Try to avoid zips, buttons or hooks. Track pants are ideal. One-piece outfits and overalls can be tricky.

**Gather any aids they need **such as a child-friendly toilet seat, foot stool, or a specially installed bar**. **Make sure they’re set-up and ready.

As with any journey, there is always potential to get stalled or waylaid. Try to stay positive.

If you are making steady progress through making your child’s toileting journey enjoyable and consistent, now is the time to fade out. As your child gets accustomed to their new toileting routine, tell them as they are in the final stages of toileting (pulling up their trousers or washing their hands) that you’ll see them when they’re finished in the kitchen or wherever. Gradually you can remove yourself from the process all together and let your child enjoy their new independence.

### **Top tips to remember**:

- Your child may take longer to master the toileting process – so be patient and positive and don’t try to rush it.
- Never force your child to go to the toilet – physically or verbally.
- Even if you are feeling frustrated, don’t let your child know. Remember, they are doing their best.
- Focus on one stage at a time and be enthusiastic about the process - celebrate flushing a poo down the toilet, for example.
- Make sure your child has everything they need to feel comfortable and happy sitting on the toilet.

For more books on getting your child toilet-trained, contact the[ **IHC Library**](https://ihc.org.nz/library-page)** on 0800 442 442, or email: librarian@ihc.org.nz**. **[Join here.](https://community.awhingamatua.org.nz/)**


A toilet roll that has a sign attached that says "Don't Panic"

How do I “toilet train” my child?

Toilet training disabled children, toileting and autism, toilet training Autistic, ADHD, Autism, disabled, disability, PDA

According to Autism UK, **Pathological Demand Avoidance syndrome (PDA)** is a profile that describes children and adults whose main characteristic is to avoid everyday demands and expectations to an extreme extent

Many parents and teachers find that some of the recommended strategies used with autistic children are not effective for a child with a PDA profile. So here are some tips specifically for children with PDA to help with toileting.

Children with PDA find certain situations, such as toileting, extremely stressful and will often do whatever they can to avoid them. Behaviours may include hiding under tables or in cupboards, going limp, crying, verbal withdrawal, and hitting, kicking and screaming.

Compliance difficulties may arise because your child simply doesn’t understand what to do, or the task is too complicated. Or perhaps in a world where adults control everything like how and when to pee is something a child _can_ control.

To avoid your toilet becoming a battleground:

- Try to ignore negative behaviours and see them as signs of distress. Respond calmly and matter-of-factly. Even better, with humour!
- Break the toileting process into more manageable steps your child.
- Choose your battles – don’t sweat the small stuff.
- Don’t demand compliance – be prepared to negotiate.
- Provide options – being able to choose between one activity or item empowers children and reduces their anxiety.
- Be creative, and flexible in your approach – use role play and bring your child’s favourite toys into the mix. Keep it fun.
- If your child is very anxious, let them withdraw to a safe place until they’re calmer.

Often children with PDA learn to be more compliant at school – don’t take it personally, this more likely indicates they can express their anxiety where they feel safe and secure - at home.

## **Top tips to remember**:

- Your child may take longer to master the toileting process – so be patient and positive and don’t try to rush it.
- Never force your child to go to the toilet – physically or verbally.
- Even if you are feeling frustrated, don’t let your child know. Remember, they are doing their best.
- Focus on one stage at a time and be enthusiastic about the process - celebrate flushing a poo down the toilet, for example.
- Make sure your child has everything they need to feel comfortable and happy sitting on the toilet.

For more books on getting your child toilet-trained, contact the[ **IHC Library**](https://ihc.org.nz/library-page)** on 0800 442 442, or email: librarian@ihc.org.nz**. 


Emily Writes

Pathological Demand Avoidance syndrome (PDA) and toileting

How do I toilet train my PDA child? Pathological demand avoidance and toileting and toilet training.

Bowel and Bladder Assessment Pack, Toileting Assessment for Children and Adolescents, Children's Bristol Stool Form Scale, Toileting Success for Children with Disabilities, Continence Assessment for Special Needs Children, Comprehensive Toileting Assessment, Autism and Complex Needs Toileting, Incontinence Assessment, Monitoring Charts for Toileting Success, Action Plan for Continence, Managing Bowel and Bladder Issues, Impact of Incontinence on Children

Bowel and bladder assessment pack : - a guide for carers and professionals helping children and young people with a learning disability, physical disability, autism of complex needs to be successful with toileting - Charmaine Champ

a guide for carers and professionals helping children and young people with a learning disability, physical disability, autism of complex needs to be successful with toileting

"Some children and teenagers with a learning disability, physical disability, autism or complex needs remain incontinent of the bowel and bladder. This has a serious impact on their self-esteem, social and play activities. For parents and carers at home or in school there are added time pressures, increased physical demands and very significant costs. With her understanding of the many factors that can hinder toileting success at any age, Charmaine Champ has developed the Bowel & Bladder Assessment Pack. This enables a comprehensive whole-child assessment, gathering all relevant information and ensuring all aspects of a child's continence needs are considered and addressed." - BOOK JACKET

Bowel and bladder assessment pack :

Bowel and bladder assessment pack : a guide for carers and professionals helping children and young people with a learning disability, physical disability, autism of complex needs to be successful with toileting

Bowel and bladder assessment pack : a guide for carers and professionals helping children and young people with a learning disability, physical disability, autism of complex needs to be successful with toileting

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