The Functional Skills for Kids series written by occupational and physical therapy bloggers on developing 12 functional skills for children continues today with the topic of toilet training. Each month throughout 2016, we will discuss the development of one functional skill in children addressing the many components of that skill. The ability to complete the functional task of toilet training requires the biological ability/awareness to void in addition to fine motor skills, sensory processing skills and gross motor skills. First and foremost, success with toilet training requires that the child is physically and emotionally ready, not a specific age.
GROSS MOTOR SKILLS AND TOILET TRAINING
In order for a child to be completely independent and physically ready when using the toilet, it requires a significant amount of higher level gross motor skills. When discussing early toilet training with adult assistance, a child needs to be able to complete the following skills: maintain postural control to sit upright, sufficient balance to sit and to weight shift, reach for toilet paper and coordinate wiping. For boys, sufficient trunk control and balance skills are necessary to stand in front of the toilet or urinal. As toilet training progresses children are expected to complete more of the bathroom routine independently. This increase in independence requires even higher level gross motor skills. Using task analysis, the ability to use the bathroom independently, without adult assistance, can be broken down into smaller steps.
Step 1: Entering the bathroom –
Can the child get the door open? This requires muscle strength, coordination and fine motor skills to turn the door knob. The child needs to be coordinate walking and holding the door open at the same time.
Can the child get into the bathroom independently? The child must be able to walk or crawl, with or without assistive devices, into the bathroom, including stepping over any thresholds, moving around obstacles or changing surfaces (ie carpet to tile).
Step 2: Removing clothing –
Can the child remove the proper clothing? Around 26+ months and child can undress with adult assistance. Around 30+ months children may be able to independently pull their pants down from the waist to the floor which requires the ability to squat (Furano, 2014).
Can the child unfasten clothing? Fine motor skills are required to be able to unzip, unsnap and unbutton clothing. Gross motor skills are needed to maintain balance and postural stability while the child uses his/her hands to unfasten the clothes.
Step 3: Getting on the toilet or potty seat –
Can the child transfer onto the toilet or potty seat without assistance? A child needs to transfer from standing, rotate the trunk and slowly lower into a seated position for a potty on the floor. To transfer to the regular height toilet, the child may need to step up on a stool, rotate the trunk and sit on the toilet seat.
Step 4: Sitting on the toilet seat –
Can the child maintain independent sitting on the toilet? Significant balance skills are required to sit upright (especially if the feet are not supported).
Step 5: Wiping clean –
Can the child maintain his/her balance while reaching for toilet paper? Can the child weight shift side to side or forwards to wipe the area clean? Can the child reach around the body to clean the area?
Step 6: Getting off the toilet or potty -
Can the child transfer from sitting to standing without assistance? Can the child step down from a step stool if present?
Step 7: Getting dressed –
Can the child pull up his/her pants? Around 26+ months, some children are able to independently pull up their pants from the ankles to the waist (Furano, 2014).
Step 8: Exiting the bathroom –
Can the child open the door to exit the bathroom? Some doors open in and some open out therefore the child will need to have the coordination and strength to exit the bathroom independently.
The previous steps include the gross motor skills necessary, but children also need a significant amount of motor planning and body awareness to carry out the entire routine. Toileting is a multiple step activity that poses motor planning challenges. A child may need to react and move to avoid obstacles in the bathroom. A new motor plan is necessary every time a child uses a different potty, toilet or bathroom.
DEFICITS IN GROSS MOTOR SKILLS AND THE EFFECTS ON TOILET TRAINING
If a child exhibits decreased gross motor skills, the child may be at risk for injury in the bathroom. When standing to remove clothing, children will frequently lose their balance when first learning this skill. Bathroom floors can be wet making it easy for children to slip.
Balance skills and postural control deficits could result in the child falling off the toilet or the potty seat when reaching for toilet paper or wiping. Providing a feeling of stability on the toilet is extremely important. If children are well positioned, relaxed and balanced in sitting, the abdominal muscles will relax helping the body to void (Lee, 2002). When a child is working hard to balance and sit upright on the toilet, he/she may not be able to focus on going to the bathroom. When necessary, a child may need an adapted toilet seat to help provide stability.
If a child has a significant gross motor skill delay requiring the use of a wheelchair or assistive device, the bathroom environment can be crucial to complete independence. Bathrooms in the home can be too small to accommodate equipment. Public restrooms pose challenges in terms of which way the child has to approach the toilet (left or right side), doors opening in or out, toilet paper out of reach, different heights of toilets, etc.
GROSS MOTOR ACTIVITY SUGGESTIONS TO HELP WITH TOILET TRAINING
Gross motor activities that will improve balance, postural control, muscle strength and coordination are beneficial when it comes to developing independence with toileting. Here are 5 suggested activities:
- Weight shifting while sitting on a bench – This activity will allow children practice time without the stressors of being in the bathroom. Children can reach for toys outside their base of support and weight shift to the right or left. Practice reaching forward for toys to encourage maintaining balance while leaning over in order to wipe.
- Squatting activities – Position toys so the child has to squat down to retrieve objects.
- Trunk rotation activities – Any crossing midline activities encourage trunk rotation. For example, try digging in the dirt or sand. The child can sit down, kneel or squat. Place a bucket on one side of the child and the shovel on the other side. Have the child dig and then rotate to place the dirt in the bucket. Do not let the child switch hands with the shovel when going to put the dirt in the bucket.
- Balance activities in standing – Practice maintaining balance while on one foot which is required to step up/down on a small step stool. This can be very simple activities such as stepping on and off a curb outdoors, playing games in standing with one foot elevated on a small block or walking along a balance beam.
- Motor planning activities – Practice following multiple step motor commands in different environments. Obstacles courses are great fun. Try setting up an obstacle course that includes stepping up and down, kicking a ball and bouncing on a small ball. All of these activities work on skills involved in toilet training!
MODIFICATIONS TO HELP WITH GROSS MOTOR SKILLS AND TOILET TRAINING
If a child has delays in gross motor skills that are effecting toilet training, you may need to modify the environment. Here are a few tips:
- The child can sit down to unfasten clothing.Use a potty seat on the floor for little ones. This eliminates the ability to step onto a stool and sitting balance is easier to maintain. It provides a stable base of support for the trunk to remain upright.
- When using a regular size toilet seat, use a toilet seat insert ring with handles on it. The child can hold on to the handles to assist with sitting balance. Make sure a step stool is available to provide a stable base of support.
- Place grab bars near the toilet to help with sitting balance and transfers.
- If the child uses any assistive devices or a wheelchair, make sure that the bathroom is accessible. Can the child fit through the doorway and move throughout the bathroom with the assistive devices?
- Position the toilet paper close to the toilet. This will decrease the amount of weight shifting necessary to reach for the toilet paper.
- If necessary, provide adaptive seating on top of the toilet to allow a child to relax completely while trying to void. There are adapted seats available that mount onto the toilet, over the toilet or a free standing commode style. Regardless, usually the child should be positioned slightly forward positioning of the upper body with the knees slightly higher than the hips to help encourage bowel and bladder elimination (Noble, 2014).
Potty Training, Toileting and Fine Motor Considerations | The Inspired Treehouse
Gross Motor Skills and Toilet Training | Your Therapy Source
Toileting and Sensory Processing | Miss Jaime OT
Potty Training with Attention and Behavior Problems | Sugar Aunts
Modifications For Potty Training | Therapy Fun Zone
Preparing Your Child & Environment for Potty Training | Growing Hands-On Kids
Potty Training Instruction Tips |Kids Play Space
Teaching Concepts for Potty Training Through Play |Your Kids OT
Furano et al and Parks, S (2014). HELP® Checklist 0-3 Birth to Three Years. VORT Corporation.
Lee DF, Ryan S, Polgar JM, et al. (2002) “Consumer-based approaches used in the development of an adaptive toileting system for children with positioning problems.” Physical and Occupational Therapy in Pediatrics. 2002; 22(1):5-24.
Noble, Elena MPT. (2014) Achieving Optimal Toilet Positioning for People with Disabilities. Retrieved on 2/16/16 at http://www.rifton.com/adaptive-mobility-blog/blog-posts/2014/february/optimal-toilet-positioning-special-needs