Toileting without Tears Presented by: Cheryl Guy, PT Supported by: Laurie Anton OTR, Susan Clark, PT MSHA Tammy Eiseman, OTR and Kristin Newer OTR

RCS OT-PT Webpage: http://www.rochester.k12.mi.us/pages/5604/ot-and-pt-occupational-and-physical-therapy District Info (purple tab) on RCS web page>Curriculum and Instruction>Special Education on the bottom of the page

Toileting Without Tears “The Big Bowl Game” Why I’m presenting: “My Career is Going Down the Drain” How do we define incontinence: “Gotta Go!” ___________________________________ What are we actually doing when we toilet train: “Sit and Relax” _____________________ Instructional Theory for toilet training vs. Results Theory: “Know Your Roll” The Potty Journey: Judith Coucouvanis

How do we know when a child is ready: “I’m a Big Girl Now” * Instructional_________________________ * Results – only time will tell; good indicators 1._________________________________ 2._________________________________ 3._________________________________ Handouts: “The Paper Work”

General Toileting Rules Take child to restroom every two hours. Follow established routine. Each time you start the routine, explain the routine to the child and describe what will be expected of him. Toileting is not the time for reading, singing, talking etc. The environment should remain calm and quiet. Discussions should not take place. Simple directions and simple reinforcements are all that should be spoken at this time. Keep things very matter of fact.

cont… Child should identify (or be told) if he is wet/dry. He should not be punished or reprimanded for being wet/soiled. He should, however, be reminded that he needs to void in the toilet, not in his pants. If he is dry, he should be told he’s done a good job staying dry and now can go potty in the toilet. Proceed through the established routine giving hand over hand assistance as necessary to complete each step. Give simple praise (“good job”) when child completes each step even if assistance was needed.

cont… Tell the child the number of minutes he needs to sit on the toilet each time. Generally 2-3 minutes; less (30-60 seconds) for very young children. Never longer than 10 minutes. Use a visual timer or your watch to document elapsed time. If using your watch, give the child one minute updates. You may need to avert eye contact to decrease interaction with the child while he is sitting on the toilet.

cont… If child voids during the allotted time, when he is done voiding, ask if he is done or if he needs more time. If he needs more time, give him established increments of time and ask again. Don’t overly react if child voids in the toilet; it will stop the stream. A mere smile and “good job” when the stream stops is sufficient. Save your “party” until the child has completed the entire routine.

cont… If child has not voided in the allotted time, tell him time is up and ask him if he is done or if he needs more time. Prior to leaving the restroom, the child is informed that in two hours he will return to the restroom and his job is to stay clean and dry until that time.

Toileting Rules for Students with Compliance Issues Take student to restroom every two hours. Follow established routine. When you first start the routine, explain the routine to the student and describe what will be expected of him.

cont… Toileting is not the time for reading, singing, talking etc. The environment should remain calm and quiet. Discussions should not take place. Simple directions and simple reinforcements are all that should be spoken at this time. Student should not be punished or reprimanded for being wet/soiled. He should, however, be reminded that he needs to void in the toilet, not in his pants.

cont… Document number of verbal cues required for each step of the routine 0-3. If a third cue is required, physical assistance is given to complete the activity. Use a simple verbal reinforcer (i.e.; “good choice”, “nice job” etc) when student complies with the activity asked of him; even if done with assistance.

cont… Document time student sits on the toilet. Start at 35 seconds and increase by 5 seconds each trip to the restroom until student is sitting on the toilet 3 minutes. Tell the student the number of seconds he needs to sit on the toilet each time. If necessary, give him physical assistance to remain sitting. Count out loud the number of seconds student is to sit on the toilet.

cont… When student sits up to 3 minutes on a toilet, a timer can then be used as long as student continues to sit appropriately on the toilet. If student is not successful sitting with the timer, revert to counting aloud. If student voids during the allotted time, when he is done voiding, ask if he is done or if he needs more time. If he needs more time, continue counting where you left off. If student has not voided in the allotted time, tell him you are done counting and ask him if he is done or if he needs more time.

cont… If student complies with established routine (even if physical assistance is necessary) he earns a sticker. Sticker chart is taken home each Friday afternoon. Prior to leaving the restroom, the student is informed that in two hours he will return to the restroom and his job is to stay clean and dry until that time.

cont… Students who demonstrate a pattern of being wet or soiled must wear protective garments (diaper, pull up, Depends etc). Students must remain dry and clean for 15 consecutive school days before protective garments can be discontinued.

Toileting Schedule Log

Progress/Sticker Chart Bathroom Monitoring Monday Tuesday Wednesday Thursday Friday 8:30   10:30 12:30 2:30

Toileting Routine Wall Poster

Assistance Monitoring

Least Independent to Most Independent Types of Prompts Least Independent to Most Independent Physical Assistance: Hand over hand helping the student perform the task. (i.e.. Zipping) Modeling: Demonstrating the task (i.e.. washing hands) 3. Gestural: Pointing towards the next step (i.e.. pointing to the diaper door) Positional: Placing near the child the materials needed to perform the next task (i.e. toilet paper) Visual: written words, pictures or symbols o the tasks (i.e.. Strip of entire routine on wall) Verbal Cues: Hints to progressing to or performing the next task (i.e.: “What’s next?”, “Now what?”)

Picture Prompts

Tips on how to help your child be more independent: “That was Easy” - Clothing choices; Avoid 1._________________ 2._________________ 3._________________ 4._________________ - Diapers that attach on the side can be easily pulled up if they are put in place while child is sitting on the toilet after his allotted sit time. - Toilet that fits/supports them; feet supported on the floor. Need to be able to relax. - Supplies they can reach and stored in the same place. - Put cotton underwear inside diaper to give child the sensation of being wet. Do this ONLY at home, not at school.

Odds and Ends - Ability to stay dry may fluctuate: don’t be discouraged - Age modifications for language, physical ability - Appropriate language - Physical and cognitive limitations - Reinforcements: __________________________

“Would you please show me?” Video demonstration: “Would you please show me?”

Questions and Answers Please feel free to leave at any time

Answer Key to Handouts   Why I’m presenting: “My Career is Going Down the Drain”    How do we define incontinence: “Gotta Go!” Voiding occurs in places other than the toilet What are we actually doing when we toilet train: “Sit and Relax” Teaching a self care routine Teaching the bladder sphincter to hold and then relax Instructional Theory for toilet training vs. Results Theory: “Know Your Roll” The Potty Journey: Judith Coucouvanis

How do we know when a child is ready: “I’m a Big Girl Now” Instructional- Can stand up Results- only time will tell; good indicators… When they are dry for prolonged periods When they can identify if they are wet/dry When they can give some indication if they have voided or need to void Handouts: “The Paper Work” Toileting rules Log for results Log for stickers etc Actual steps Tips on how to help your child be more independent: “That was Easy” Clothing choices; Avoid Tight clothes Buttons, snaps, zippers Low hanging shirts Onesies

Diapers that attach on the side can be easily pulled up if they are put in place while child is sitting on the toilet after his allotted sit time. Toilet that fits/supports them; feet supported on the floor. Need to be able to relax Supplies they can reach and stored in the same place Put cotton underwear inside diaper to give child the sensation of being wet. Odds and Ends: Ability to stay dry may fluctuate; don’t be discouraged Age modifications Language Physical ability Appropriate language Physical and cognitive limitations Reinforcements: For staying dry For participating in/completing the routine For voiding RCS OT-PT Webpage: http://www.rochester.k12.mi.us/pages/5604/ot-and-pt-occupational-and-physical-therapy   District Info (purple tab) on RCS web page>Curriculum and Instruction>Special Education on the bottom of the page or email: cguy@rochester.k12.mi.us

Evaluation Please complete the evaluation form and place in box at the sign in table as you exit.

“Would you please show me more?” Video demonstrations: “Would you please show me more?”

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