Many people with autism, developmental delays, or other disabilities have touched, played with, or even eaten their feces (poop) at some point. Parents, caregivers, and teachers may find the problem very upsetting and hard to deal with. Here are some things to think about, and some strategies you can try.
Medical Considerations
Research shows that children with constipation and other gastrointestinal health issues are much more likely to smear feces. This is especially true for children who are non-speaking, and may not have another way to show their caring adults that they are uncomfortable. If your child has autism, they have a much higher likelihood of having digestive problems. Work with your child’s primary care physician and consider working with a pediatric dietitian to make sure your child’s body is healthy and comfortable.
Sensory Considerations
Some people crave lots of sensory information. The smell and feel of feces gives a lot of sensory feedback. For these people, offer a time when they are invited to touch and smell intense textures and scents, such as slime or water bead play, and offer lots of other sensory information like swinging, bouncing, and tickling throughout the day to “fill them up” with sensory information. Do not make your child clean up the feces because that tends to reinforce that play feeling.
Other people are overresponsive to sensory information. The smell and feeling of feces in their pants after they soil is very upsetting, and they may try to get the feces out, and then smear it around to get rid of it. If this is describes your child, make sure you are changing them very quickly after they stool, and getting their skin very clean and dry each time you change them.
Seeking Connection
It is natural that the caregivers would have a strong and emotional reaction to seeing and smelling poop. Sometimes children connect fecal smearing with a long opportunity to connect with a parent or caregiver while they get cleaned up. They may also register that parent’s strong emotions in that moment as a positive: “mom has a lot of feelings towards me right now!” Make sure that when you approach your child to clean up, that you are calm, and not reactive. You may have to take a break away from the poop first, take a few slow breaths, or drink some water to calm down. You can also wear a surgical mask, gloves, and cover your hair with a bandana before cleaning up your child so they can’t get poop in your hair or on your hands.
Boredom
Some children will play with their poop if left alone with a poop for a period of time. This happens often when someone first wakes up, and might be very relaxed and by him/herself. Make sure you know when your child tends to poop, and stay close to them at that time. If your child is willing to sit on the toilet, this is a great time to practice. If they are not, you can simply make sure that an adult is nearby, or watching (using a video monitor, etc.). If this happens in bed, try using back-zip pajamas, which cannot be undone by the person wearing them.
Limited Skills & Knowledge
Your child has watched you take off their diaper each time they poop, and knows that poop is supposed to come out after they make it. They may be trying to be helpful. Give your child social stories or video models explaining that when we poop, we do not play with it; we wait for an adult to help us, or we go get help. Remember that your child may need another way to tell you when they’ve pooped. Make sure your child has a way to communicate, such as a speech generating device (BIGmac or similar), that enables them to say they need help. Make sure you, the adult, are modeling using this, too. Finally, give your child a job in the hygiene process so they know where they fit in and how they get to help.
Line Modin, Ida Skytte Jakobsen, Marianne Skytte Jakobsen
Abstract
Aim: Constipation studies have only evaluated behavioural difficulties in children with faecal incontinence. This study evaluated changes in behavioural difficulties in childhood with functional constipation (FC) with and without faecal incontinence, based on treatment outcomes.
Methods: Children aged five to 16 years who fulfilled the Rome III criteria for FC received conventional treatment. The Strength and Difficulties Questionnaire was completed at inclusion and at the 12-month follow-up.
Results: We included 116 children. The behaviour scores decreased in successfully treated boys (10.3 versus 7.9; p < 0.001) and girls (10.0 versus 7.4; p = 0.0001) with and without faecal incontinence. There was no decrease in the behaviour scores in children with unsuccessful outcomes. Unsuccessfully treated boys had significantly higher behaviour scores than successfully treated boys at inclusion (13.2 versus 10.3; p = 0.006) and after 12 months (11.4 versus 7.9; p = 0.02). No difference was found between unsuccessfully treated and successfully treated girls at inclusion (10.5 versus 10.0; p = 0.77) or after 12 months (10.3 versus 7.4; p = 0.18).
Conclusion: Our findings indicate that conventional treatment of FC had a positive impact on behavioural difficulties in constipated children with and without faecal incontinence. This study highlights the importance of proactive detection and treatment of FC in paediatric patients.
Picky eating is a challenge for many parents. It can feel twice as tricky when you’re trying to improve your child’s digestion and elimination through diet. This video by Vermont Continence Project nutrition consultant, Kelli Borgman, RD, and OT consultant, Chayah Lichtig, OTR, offers practical everyday suggestions for broadening your child’s diet and improving the mealtime experience for your family.
Hello, my name is Kelli Borgman. I’m a dietitian consultant with the Vermont Continence Project. Our topic today in this video will address how to help the picky eater to develop a diet that supports healthier elimination. I’m going to begin talking about the parent child feeding relationship and Chayah Lichtig will take over the the second part to talk about mealtimes, supports and communication.
When it comes to figuring out how to support your picky or extremely picky eater, I encourage parents and caregivers to slow things down a bit and take a closer look at the different areas of the parent child feeding relationship that might need to shift or change. This can happen in two different ways, either offering more support when it’s needed or requested by your child, and giving space for autonomy to increase confidence in order to expand skill and variety. When your child is ready.
But of course this is easier said than done. In real life. How do we as parents know moment to moment, meal to meal, when to step back and when to intervene? On many busy days, it may not feel like we have a choice in the matter, or we just don’t have time or capacity to set up an ideal situation. And just to be clear, things don’t need to be ideal every day for them to make progress. But in general, there’s got to be some ground rules to start from, especially when stress or refusals are happening or there’s worry about nutrients or growth.
This is where a division of responsibility comes into play. It’s a starting place to start thinking about how to have healthy boundaries with your child around food and eating. The Division of Responsibility is a model of feeding developed by a person named Ellyn Satter, who’s a dietitian and family therapist. The model basically breaks down the balance of what the child is responsible for at meal times versus the adult. It talks about the adult being in charge of the what, when and where of feeding, and the child is responsible for deciding if they want to eat and if so, how much. The model offers distinct roles which allows each individual to do their own job. The parent does not have to get involved with pressure, bribing or other creative ways they can think of to try and make their child eat.
When your child decides how much food is the right amount for them at that moment in time, they can build confidence and communication with their own bodies. This positively affects their long term relationship to food and taking care of their bodies. It’s the child’s job to tune into what their body is telling them.
There is a very important “and” to briefly mentioned in addition to considering the division of responsibility, when kids have current medical concerns or a history of intensive or frequent medical intervention or there are signs of neurodivergence or sensory processing differences, adaptations or more supports may be needed beyond this model and in words, the parent may need to rebalance their expectations around what they want their child to eat versus their what they’re actually eating, and take a different approach to routines and boundaries when it comes to the what, where and when. For example, neurodivergent kids often need to see more of their comfort foods on their plate than other kids to feel safe and relaxed when eating. Sometimes when eating has been challenging, kids tune out their hunger signals and try to avoid eating or want to be distracted or get up from the table. So supports that might work for that child may be taking special care to be sure the mealtime space is suitable suited for them. They have a comfortable and supportive seating situation. Visual and sound input is considered, for example, sometimes changing the lighting or adding music or eating in a quiet, quieter place can be helpful. Or the child is offered a high calorie drink like milk or a nutritional shake at the end of mealtime. If they need support to get the nutrients their bodies need to play, grow and learn, then absolutely accommodations and supports to the basic division of responsibility should be considered.
So just to review in a little more detail what the foundational roles are per the division of responsibility for each person. The child’s role is to eat what they are able to when they’re able to, to eat the amount they need, to learn to eat the foods their family generally eats, to grow at a predictable pace, and to learn behaviors and communication that gets their needs met at mealtimes. or helps in that. So being clear, positive, polite are some of the basics.
The parent or caregiver role is to buy and prepare the food, offer meals and snacks at regular intervals to create pleasant mealtime, expectations and routines (So what we expect to everyone to do and how we talk about it), to be considerate means acknowledging and taking into account your child’s needs and feelings without going overboard and giving too much attention, which is more like catering, and avoiding controlling their body size basically means avoiding portion control or overriding their decision about if or how much they choose to eat.
And of course, kids in certain scenarios, growth scenarios like tube feeding or low growth need different accommodations. Just wanted to mention that.
To go into a little more detail about meals and snacks at regular intervals, the benefit of having a meal routine and a flexible routine is that it can really support the body’s regulation of hunger and fullness. There’s an entrainment and a natural, predictable ebb and flow throughout the day that can get established. It reduces the guesswork, since on challenging days with toileting or other issues, there may be barriers to communication between your child in their body or between your child and yourself. A flexible routine can also increase calorie intake and ensure they’re getting regular breaks from play and learning to really focus energy and eating.
Taking a look at when your child is naturally hungry is a good place to start. Noticing that the whole 24 hour cycle with elimination patterns in relation to when they eat and drink will also guide you on developing this routine. If a flexible routine is challenging for your family, using technology and visuals like app reminders and timers, meal planning apps and visual aids like schedules or menu boards may be helpful.
Offering balanced meals is key, so having a meal or snack plan that includes a starch or carbohydrate and some protein or fat will help with fullness and allow your child to take breaks from eating and avoid grazing and excessive drinking, which can make continence challenges worse.
Our overall goal as parents and caregivers is to help our child be more calm and emotionally prepared for the mealtime experience. Remember that mealtime is about much more than just calories. Instead of waiting for the moment that your child sits down and gives to your child in food and mealtime related activities, some of those might include choosing food together, even going to the grocery store together, preparing food together, setting the table, passing and serving food, watching others eat, talking about food, and participating in mealtime cleanup. You may notice that your child can participate in all of those activities without having done any eating themselves.
Most people benefit from knowing what to expect and knowing what’s expected of them. We suggest that adults create and follow some agreements about how mealtime and eating go. Most of these are useful whether your child is a picky eater or not. Some examples are start with an empty plate. An empty plate gives your child the opportunity to choose what and how much of each food they want. Optimally, people serve themselves, and this sometimes does need support, especially for younger kids. Model and teach passing. Passing food is a wonderful, low pressure way to get closer to a food when you may not be sure whether you want to eat it or even try it. Also, if you’re serving your child because they can’t serve themselves for some reason, keep the portions small. An over-full plate can be overwhelming, while a less full plate is an opportunity to finish your portion and ask for some more.
Remember the Division of Responsibility and how the parent gets to choose what food is offered? Well, we suggest including something your picky eater likes and will eat every time. This doesn’t mean catering to your child by offering exactly what they want each time, but making sure that they are welcome at the meal time. Parents and other family members should eat that food, too. We’re showing that we’re all willing to try a variety of foods. Finally, your child’s role in the Division of Responsibility needs to be honored. At any time, they are allowed to refuse any food that is offered to them.
The ways that parents talk about foods can really affect the way children see those foods, too, and how they see the relationship to those foods are really common. One that we see is that a child tries a food and doesn’t choose to have another bite. The parent says, “Oh, you didn’t like that”. Remember that there are lots of reasons your child may not might not go for that second bite. As Kelli described, they may not have been exposed to that food yet. And the flavors or textures may be unfamiliar. They might be full and yes, they might not really enjoy it.
Here are some alternative phrases you can try instead of “You don’t like it”. “That had an unexpected taste. Huh?” Or, “you’re not interested in eating more of that right now.” Or “one taste was enough for now, huh?”
If you think they might spit it or throw it, you can tell them where they can put it. For example, “you can put that on the corner of my plate”. Or “I like how you tried that food”.
Don’t forget that there are lots of things about and not about food that you can talk about during a meal. If you want to talk about a food, you could talk about it sensory characteristics. Is it warm? Is it mushy? Is it cold? Is it hard? Is it crunchy? You can share experiences about food like, “well, this apple is crunchy, but I ate an apple pie last week and that was soft and mushy”. You can ask questions about the food. “Hmm. Did you notice that some of the bites were kind of chewy and other bites were kind of mushy?” Or you can just share your own observations about the food.
And then there are so many other things you can talk about at the meal as well. Things like what was your favorite animal or game or what did you do outside today when you were at school? Games like Two Truths and a Lie or Thorn Rose, but are also a great way to catch up with your child about their day.
Ultimately, you’re still probably wondering how to expand the foods your child is trying and even eating on a regular basis. Just like with toilet teaching. Start with a little investigation. What are the characteristics of the food that your child likes right now? See if you can get specific. Does your child like sweet foods? Sour, spicy, very flavorful or bland? So they seem to go for warm or cool foods, or right in the middle, like room temperature.? If your child has very specific foods they eat, there may even be a specific shape that there may be a round cracker they eat regularly, but a square one with the same flavor is a no go.
Finally, texture is a really common category that people limit in their diet. Everyone knows someone who only mushy food or doesn’t like chewy meat or thick drinks. Our dietitian Kelli, describes food textures in detail in the video Constipation, management, food. So be sure to check that out.
Let’s give an example. Many children like cheese she uses salty and savory and soft cheeses are a soft cube texture, and they’re usually cool or maybe room temp, and they’re generally a yellow or white color. When working to expand variety, especially with the goal of improving nutrition. Think about going to a preferred foods neighbors. Neighbor foods aren’t exactly the same as preferred foods, but they don’t live all the way across town. For example, if your child likes Fruit Roll-Ups, maybe they would be interested in trying some dried mango. If your child likes cheese, why don’t you try something like a salty roasted potato, maybe dipped in a cheese sauce?
Also, don’t be afraid to play with flavor. Not every child who’s a picky eater dislikes flavor. For example, some picky eaters might really like something like Doritos. And you can widen your diet by diving into those flavors. For example, Doritos and chips and salsa are definitely neighbors, and nachos definitely live on the same street as Doritos, chips and salsa, even if they’re not next door neighbors. You can also try combinations of preferred foods like your child might like a crunchy pretzel, and they might also like a queso dip. And if you can combine them, you’re on your way to increasing your child’s flexibility with the foods they might be willing to try.
You also want to think about making micro changes over time. This means don’t change too many of the characteristics of a food that your child likes or don’t get a food that is too many differences away from foods that they prefer right now. We’re looking for just enough change that your child is willing to try it and hopefully accept it into their diet.
Picky eating can be a big challenge for parents and for families. We hope that the suggestions that we’ve made in these videos have been helpful for your picky eater. But if you’re finding that your child may be more described by the extreme picky eating category or your family is experiencing a lot of conflict and distress around food and meal time, we’d suggest finding some more targeted support for your child and for your family. One support we definitely suggest is a dietitian with a background in pediatrics. Also looking for an O.T. or a speech language pathologist with a background in feeding a mental health professional. With a background in feeding and attachment can be really helpful for working on the relationship between you and your child around mealtime. And finally, many regional hospitals do have intensive feeding teams who may be able to help you on your journey if some of those more local options are not enough or are not available.
Thank you for taking the time to watch this. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider.
Most parents know that their child’s diet plays a role in their elimination health and habits. What do you do if your child won’t eat those foods that help improve elimination? This video from Vermont Continence Project nutrition consultant, Kelli Borgman, RD, describes the things that stand in the way of children developing healthy eating habits. Watch this before Picky Eating and Continence Challenges, Part 2, where we suggest some ways you can adapt foods and mealtimes to help your picky eater.
A full transcript of the video appears below.
Hello, I’m Kelli Borgman. I’m a dietitian consultant with the Vermont Continence Project. In this video, I’m going to talk about picky eating as it relates to continence challenges, and a general framework to start thinking about how to best support your child.
Picky eating can be so challenging day to day, and both parents and kids can have a lot of worry, stress or strong reactions around it. It’s also quite a personal topic. Each child’s or family has their own story about how picky eating came to be an issue, how each family member is dealing with it and what’s being done about it, if anything, and how picky relating eating relates to the emotional and communication dynamics within the family system. Family cultural or personal beliefs and ethics about food and health all play a part too.
When a child continually refuses foods, you purchase and prepare with care, parents and caregivers feel frustrated, powerless, hopeless, or just annoyed. Sometimes it can come with a lot of shame or you feel like you’re a bad parent. This is made worse when parents and children have conflict about food and eating. So I really want to start off by saying there are no right answers and each child and parent needs personalized support. Please know it’s okay to put on the brakes and of trying to get your child to eat specific foods in a similar way to how you might be rethinking teaching, toileting.
Parents often wonder if their child’s picky eating is typical. Feeding therapists may describe children as being picky eaters or extremely picky eaters. So this is kind of a busy slide. But I wanted to give you some context for caregivers to know which category their child can fall in. I hope it will validate the experience you’re having and give some clarity on how to best support your child’s eating. So just to compare picky eating affects about half of children at some point. It starts around 15 to 18 months, once calorie needs decrease past infancy. Picky eaters do have favorite foods, which are often carbs. They drop new foods but are able to pick up new ones. They often will reintroduce dropped foods in time and over several days will eat foods from all food groups. They can be hesitant to accept new foods. They can accept varied textures, and they will often eat enough at school or daycare.
In comparison, extreme picky eaters impacts a smaller amount of children, and this is nondisabled children about 13%. It usually starts earlier than 15 months. They might have favorite foods, but there’s more rigidity in their choices. They drop foods but aren’t as able to pick up new ones. They won’t often reintroduce dropped foods, and over day’s time, they will avoid foods from certain food groups and not get the variety.
They generally have a fear of new foods or have food anxiety. They won’t often accept varied textures and will often struggle to eat enough at school or daycare. If you think your child falls into the picky eater category, there’s some great information in the video called Picky Eaters, Part Two about the parent child feeding relationship. That will likely be a great foundation to think about extremely picky eaters generally need more accommodation and support, so consider working with a pediatric feeding therapist and dietitian team. These are the kids that can have more severe malnutrition or at risk for longer term disordered eating patterns. Please note the data from these stats are commonly cited and accepted in the scientific literature. Of course, children don’t always neatly fall into one category or another and disabled or neurodivergent children are often underrepresented or not acknowledged. So it’s hard to apply this data to include all kids experience with picky eating or more extreme picky eating.
So when thinking of the long term nutrition goals related to GI health, we of course want to help support their GI tract to function optimally and optimally function functioning GI system is able to uptake the amount of nutrition they need to play, grow and learn. So for most kids this means working on increasing fiber, fluid, or variety, or a combination of these.
If your child’s daily eating choices don’t currently meet 100% of what the GI tract requires to function optimally, medications and supplements should be used to support each child’s body, mind and emotions where they are right now.
So what makes healthy, healthy relationship to food possible? Really, a more regulated nervous system stimulates appetite and allows more flexible thinking and openness to foods. The enteric nervous system, shown in a picture here, innervates the entire GI tract, and is the largest and most complex unit of the entire nervous system outside the brain. It’s all quite connected, literally. Appetite, curiosity, and interest in more quantity or variety will often dramatically increase when we think about nervous system balance and meeting their emotional needs at the table, too.
In my work with families over the years, I’ve noticed a common theme amongst the extreme picky eaters parents often report, and I can see during mealtime observations that children display lots of non-verbal and verbal communication that indicates they’re getting disregulated and upset. The causes of upset are usually what foods are offered or not offered, or the caregivers involvement in their mealtime.
Their sensory and nervous systems are ringing alarm bells that the situation isn’t comfortable or safe, or they have fears that their needs aren’t going to be met. So why do kids avoid healthy foods First, Kids, just like adults, use food for emotional comfort. There’s nothing pathological or wrong about this. This is human nature. So if emotional needs are perceived to be threatened or needs aren’t getting met, children will often revert to their comfort foods to regain that sense of calm and relax by filling their belly with foods or drinks that satisfy that sense of emotional safety or control and help them regulate their nervous systems.
Sometimes, especially at specific times of the day, such as lunchtime at school or at dinner, they might come to the table with a dysregulated nervous system already, or they perceive a threat to be coming. They might also be seeking comfort in a specific experience through their food, which is often the case. Like for the afternoon snack, they’ll be more rigid with their choices and behavior the more their nervous system is dysregulated. There are likely sensory needs and preferences they’re also turning into tuning in to. These sensory preferences are unique to your child, their natural likes and dislikes, what foods they’ve been exposed to so far, and in what frequency, as well as how comfortable they are with varied sensations. They also may have or have had in the past.
Oral motor skill difficulties:less processed foods are generally more challenging to eat. Fresh produce and whole grains are often presented in forms that are much harder to chew, and mixed texture foods are just more complicated for your mouth to manage. They naturally start to avoid what they’re not yet competent at, especially if the adults are around them, aren’t quite catching on to what a challenge it actually is for them. Imagine if you were continually offered whole apples when you actually have the ability for applesauce or offered steak when you’re really only able to handle meatloaf.
Most kids that are picky eaters benefit from a flexible routine where they can generally feel safe and predictably get their needs met. There are a lot of challenging, competing time priorities for families and kids, so being able to slow down and really focus on a food routine can be challenging. Oftentimes we talk about eating together as a family and how great that is, but when kids are hungry and want food immediately during busy days, parents often focus on getting the child what they need quickly versus actually being able to sit down and eat with them. Meals can be fast paced and just feel more stressful for many reasons, which virtually eliminates curiosity and appetite for many children. Also, irregularly timed meals and snacks can cause extreme blood sugar, highs and lows. Even without diabetes, blood sugar lows can be felt as alarm bells to the nervous system, which can lead to eating processed foods and snacks that quickly calm the body and resolve the low blood sugar. They will get confirmation these foods feel good to their body and that the processed foods meet their safety and hangry needs for other kids or regularly timed meals and snacks means grazing or whatever or whatever kind of eating. When grazing occurs, the gut doesn’t get a chance to rest, and some rest between meals and snacks is optimal for the GI tract to move food efficiently through.
Foods offered at daycare or school can also be a big part of the picture for some kids. They can undereat at school or will only eat snacks or drink milk or juice. This may be partly due to nervous system dysregulation or because lower preference foods are being offered during meals. Some kids also start to associate eating with the urge to poop, which they’re usually trying to avoid at school. So this will lead the child right back into the constipation, carousel and undernutrition, which can lead to more extreme picky eating and a negative behavior loop or cycle being established.
So in summary, what makes eating healthy foods possible a healthy relationship to food, responsive and attuned caregivers who sense when their child is disregulated at a meal and try to learn why taking small steps at the right time. So when the child’s nervous system feels more safe and regulated, when you take those small steps, consider offering choices that match their dietary needs and sensory preference preferences, which we’ll talk more about in the next video.
And the last point is true. Treating GI distress and constipation adequately. Don’t underestimate how constipation and other GI issues can be the underlying cause of picky eating kids quickly learn to kind of sort of eat to avoid that discomfort. So recognizing and treating GI concerns adequately is key.
Thank you for taking the time to watch this. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider.
Lots of children refuse to sit on the toilet at some point. While our first step is always to let down the pressure and make sure we’re identifying and treating medical needs, we want to get back to the toilet at some point. How do we do it? Practice sits! This video explains a low-pressure way to help your child feel comfortable sitting on the toilet.
We might think of “toilet training” as one activity, but it’s actually made of lots of separate steps and skills! This video can help you figure out where to focus your attention and support your child with the skills they are working on right now.
Let’s talk about building your toilet time toolbox! There are lots of things you might want to have in the bathroom to make toileting more successful and enjoyable for you and your child.
Building your toileting toolbox is also a great activity to do with your child to prepare for a sitting schedule.
Popular toilet “training” models give the impression that many children can go from diapers to full continence independence in a few days. This is not the experience of many parents. This video explains the phases of the toilet teaching process, and can help you identify the right kinds of support to provide at different times in the toilet teaching journey.
Using rewards can be a great way to increase your child’s participation in toileting and continence. Many parents aren’t sure what to reward, or how. This video explains how to choose a good reward, how to give it, and what skills to reward. For more information on what to reward, check out our video about “Inchstones”.
A full transcript of the video appears below.
Hi, my name is Chayah Lichtig. I am the occupational therapy consultant and project director for the Vermont Continence Project. Today’s topic is “beyond the sticker chart: using rewards to teach toileting”. And that is exactly what we are going to talk about. Appropriate and creative ways to use rewards. While you are teaching toileting to your child.
So a comment that we get often is that people have been told that they’re not supposed to reward people for sitting on the toilet or other toileting related skills. And while there’s a certain logic to that, when you are thinking about a certain toddler or somebody else who might be motivated by toileting and learning new things about how their body is working, Unfortunately, not every toilet learner is motivated by toileting incontinence. This is especially true for our older toilet learners who may have months or even years years of frustrating, difficult experiences related to toileting and maybe have even internalized some shame or blame from the people around them about their continence challenges.
So having a reward when we are teaching toileting can create new excitement or a new commitment. And for someone who is maybe not feeling super excited about learning, toileting, having a reward can also clue a child into the most important skill in that moment, because that’s the skill that we are going to be offering. The reward for. It also has the benefit of helping us adults to remember what skill to focus on, because it’s the thing we’re rewarding and we can often remember to let a lot of other things go and let the pressure down around other aspects of the toileting experience, because they’re not the thing that we’re focused on in that moment.
Next, we’re going to talk about how to use rewards throughout the toilet journey. So as you’ll remember, phase one is the getting started or the getting restarted phase. This is the phase before we are asking our child to use the toilet. This is our ounce of prevention stage. We may be offering a reward to our child for entering the bathroom. We may be offering our child a reward for changing in the bathroom. We may be offering them a reward for engaging in hygiene. For example, taking part in dressing, undressing or wiping. We may offer a reward for taking their medication and something you’ve learned about perhaps from another one of our videos. You may also be offering a reward for your child during practice sets, which are sitting on that closed toilet or a pants up toilet just to get used to the feeling of sitting there.
So phase two is what we call getting to the toilet or back to the toilet. And there are several things that you can reward in this phase that aren’t just whether or not your child successfully gets their PE or poop into the toilet. For example, you can reward for the duration of sitting in the case of urination when you’re just expecting that your child is going to pee. 1 to 3 minutes is plenty. And when you expect that a BM might be coming out, 3 to 5 is the maximum amount of time that your child should have to sit.
So you may also want to offer what’s called a differential reward. That means you offer one reward for your child sitting and a larger or additional reward for a successful pee or poop. Remember that if your child sits on the toilet and they do happen to pee into the toilet, we’re not going to tell them that they didn’t earn the reward if they didn’t sit for a full 3 minutes because they sat as long as they needed to to urinate successfully.
It’s also important to remember that in phase two, we are not trying to stay dry.You want to keep your Pull-Ups. This is really important because when your child is just starting to have new control and awareness of their body, if we are asking them to stay dry, we are often reinforcing withholding patterns that your child has just started to change in phase three toward independence. We will reward for each successful void or a BM in the toilet.
We will reward for self initiation. Even if your child misses. And when your child is well established in getting themselves to the toilet, that is when you could start to consider using a token system, which means using something that isn’t rewarding in and of itself. That works towards a bigger prize. For example, ten stickers equals a trip to McDonald’s. Or when you fill out this entire picture of a favorite toy, we will go to the store and buy that toy. But remember, especially at first, we want to be giving a reward every single time because we want to really, really encourage child to be as consistent and as excited as possible.
So you may be wondering what makes a good reward. The five principles for a good reward are that it is easy to give, that you can give it immediately, that it is inexpensive or even free, that it’s high preference for your child and that it is not offered at other times. So to illustrate this, I’ll give the example of one of my favorite rewards: chocolate.
So if someone were going to reward me with chocolate for doing something that they really want me to do for example, my job, they might do something like give me a chocolate each time I write an email. But unfortunately, if they needed to drive to a store every time they needed to get me a piece of chocolate, that wouldn’t be easy for them. And it would be really unlikely that I was going to get that chocolate every single time. So it needs to be easy to give.
It also needs to be something that they can give to me immediately. If I write my email and I get my chocolate 2 hours later, I might not make the connection that the chocolate is for making for writing the email.
It also should be a relatively inexpensive chocolate. So if you are buying fancy Belgian dark chocolate for me, I will surely appreciate it. But it might be hard for the person who’s giving me those rewards to sustain that over a long period of time because I write a lot of email.
It also has to be something that’s high preference. So if you picked out something I didn’t particularly like, like another kind of candy, I might not actually be motivated to complete that task. But give me a chocolate and pretty good chance that I am going to want to do the thing that you ask.
It also can’t be offered at other times. Yes, it’s great that I can get a chocolate for writing an email, but if there’s also chocolate sitting right next to me on my desk at all times or in my kitchen cabinet, and I really don’t want to write that email, it might be more likely just to go get the chocolate that I can get more easily. So to increase the excitement of getting that reward, I have to not get it at other times that we want to use rewards to increase a feeling of excitement and well-being around the skills that we want them to learn.
So we really want to do what we can to help a child meet their goals rather than making it really, really difficult for them. So we want to analyze the routine. As we’ve discussed in other videos. What are the interest stones that your child is working on right now and what are the next steps to learn? Those are the ones to reward for, not the way off in the distance ones, right? You may also want to give them a choice. What skill would you like to work on next?
It could be something like pulling up your pants. It could be working on wiping, it could be washing your hands, whichever step they choose. That gives them some agency and some power in the process. You also will want to represent the goal and the reward. You see on this slide, there’s a very simple image that has a picture of a toilet with a poo in it, and next to it is a picture of that candy that you’re going to give to that child.
Some other tips to help your child reach their goal are to offer different forms of prompting. Remember that the goal is toileting and continence, not compliance. So we don’t want to have to get into a battle with our child to do the thing that helps them to get the reward. We also want to make sure that this schedule is predictable, right? Again, the goal is toileting and continence, not to be able to guess what’s coming next in their day. So something like a simple visual schedule that shows where in the routine of your day toileting usually falls can help a lot of kids to feel a sense of understanding and a sense of agency when it comes to toileting and finally make time concepts visible.
So as we’ve talked about in other videos, while some children may understand the concept of saying we’re going to sit for a minute, that is pretty abstract and we will be way better off and help a lot more kids if we show them the time using any kind of sound timer, kitchen timer, or perhaps a visual timer app, anything that relies on more of a pizza pie instead of counting down numbers.
Thank you so much for taking the time to watch this video. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care professional.
When parents start their work with us, they often ask how to “jumpstart” the toilet teaching process. In this video, we explain why less pressure, not more, may help you and your child get started stronger and with less conflict.
Associated Resources:
We know it might not make a lot of sense to “lower the bar” with your child around toilet use right now.
Take a look at this list of Steps to Toileting Participation to think of some low-or-no stress ways your child can be a part of the toilet-learning process.
If you are getting into power struggles with your child, check out our Prompt Hierarchy to consider how you can decrease the pressure put on your child.
A full transcript of the video appears below.
Hi, I’m Tammy Willey, family resource consultant with the Vermont Continence Project.
And I’m Chayah Lichtig, Director and Occupational Therapy consultant with the Vermont Continence Project. So we’re going to talk to you in this video about how to relate to your child and their continence as you’re stepping into this program. For example, hey, Tammy, why did the chicken cross the road?
I don’t know why, Chayah?
Because the rooster farted.
Good one, good one, Chayah. Okay, I’ve got one. And why did Tigger stick his head in the toilet?
Why?
He was looking for Pooh.
Oh, that’s a good one.
Yeah, but in all seriousness maybe you’ve been asking yourself why is this toileting thing taking so long?
That is a question we get a lot. You’re not alone. We find that parents, and even well-meaning, well-informed providers are often missing some key piece of information about a child’s health, development or learning needs that’s made it hard for them to really get toileting.
So what’s the next step, Chayah?
Hm, well, we have two goals at the beginning of this process. Number one, to better understand the reasons for your child’s incontinence. This is most of what we discuss in the first two units. Goal number two is to create new positive associations with toileting. This is actually the harder part for most parents. It means taking your foot off the gas and decreasing the pressure on our kids’ continence and toilet use.
Okay, so how do we take our foot off the gas and maintain momentum? I mean, shouldn’t we take it up a notch and be more assertive to move things along?
There are a lot of reasons that a parent might want to pull back on their focus on toileting incontinence with their child for a moment. So parents and children often get into difficult dynamics around participating in toileting. In this process, you may have to ask your child to do things they’ve never done before and you’re going to need them to be on board. You’re probably also tired of doing the same thing but without any change or improvement. Instead, we hope you’ll devote that time and energy to learning about the signs that we’re going to teach.
Tired, frustrated, overwhelmed. Tell me more, Chayah.
We recommend a positive approach that decreases the pressure for everyone involved. We suggest that you step back on direct prompting in terms of sitting on and using the toilet, also, hygiene and dressing. Help your child more and decrease asking them to sit on the toilet. Decrease expectations of them being dry and clean. This means let their natural patterns emerge at least for a few days while you gather data.
So it sounds like you are suggesting that parents build their toolbox.
Yes, in the coming videos, we’re going to give you a lot of information that will help you have a clearer picture of your child’s skills and needs related to continence. We’re going to focus heavily on health questions because almost all people referred to the Continence Project have a health concern that affects their continence. Tammy, can you offer any advice or suggestions for what a parent can do or tell themselves in a moment of change and challenge with their child?
Yeah, I think a little reflection can help us shift our perspective. I think ask yourself how do you want your child to remember toilet learning? How do you want them to feel about it? And what do you want your role as teacher to look like? I think the goal is to not engage in huge power struggles in this, around this process. Am I right, Chayah?
I agree with that completely.
So Chayah, ready for another poop joke?
No, they stink.
Yes, that was perfect. Thank you so much for taking the time to watch this video. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare professional.