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.
Hi, my name is Chayah Lichtig. I’m the director of the Vermont Continence Project and I’m a licensed occupational therapist. In this video, we are going to talk about taking bowel data to support continence.
So parents often wonder, what’s the purpose of taking this data? We’ll start with the fact bowel issues are the number one underlying cause of incontinence in kids. This is true for kids with disabilities and kids without. It’s true for kids who were continence and loss skills and for kids who have never been continent. It’s even true for kids who only have urine incontinence and no identified bowel issues. So we want to have concrete information about our child child’s bowel habits to support our conversations with our child’s physician school team and your child themselves.
So let’s start with something called the Bristol Stool chart. On the next slide, I’m going to share a picture of a one through seven scale that describes the consistency of stool. Doctors like it because it’s well agreed on. It’s easy to understand and it has some pretty clear visual representations. This is a picture of the Bristol Stool chart.
You will see that the numbers get higher as you go along. A lower number means a drier, harder stool consistency, and a higher number means a wetter, looser stool consistency. Let’s go through the seven numbers in order.
Type one is separate hard lumps. They may be difficult to pass or they may fall out.
Type two is sausage shaped, but dry and lumpy.
Type three is like a sausage, but with cracks on the surface.
Type four is super smooth and soft, like a snake or sausage.
Type five is soft blobs with clear edges. They pass easily.
Type six is fluffy, ragged pieces with soft edges almost liquidy.
And type seven is watery. No solid pieces entirely liquidy.
As you may have already learned from watching videos from our nurse consultant Kelly, you will know that numbers one and two are very strong signs of constipation. Numbers six and seven can also be common signs of constipation. Or they can be signs of other GI problems as well. The Bristol stool scale is a very important piece of data which your child’s doctor will probably ask about, but it’s also helpful to keep track of these other factors.
Frequency. One of the official criteria for constipation is how often your child has a complete bowel movement. Loss of small amounts of stool is not the same as a complete bowel movement. But you’ll also want to know and take track of how often they have small streaks, smears or pebbles size. Note If your child has very small or very large BMs regularly or on occasion, these can be signs that the muscles aren’t working well to push out through shape.
Are your child’s stools shaped like logs or balls? A ball shaped stool means that your child’s colon is very stretched out, allowing stool to collect in a lump rather than squeezed into a tight tube.
Mixed consistency. Does your child have BMs that are dry and hard like a two or three one day and a number six the next day? Or can you see a mix of consistencies in a single BM? These are also signs that GI function is not as smooth and consistent as it could be, and that things are not moving along as we might hope and expect.
Finally, if you are giving any medication at this time for your child’s GI system, please make a note of when and how much you give.
Parents often ask how long to take data That depends on how often your child is struggling and how much you know about their system. If your child has a BM every single day, not just a smear, 5 to 7 days of data is probably enough. If your child has very irregular stool patterns or goes infrequently, try to take data on at least seven complete bowel movements.
Many parents find, however, that once they start paying closer attention to their child’s stool habits, that they notice some of the concerns we’ve mentioned and they seek the support of their child’s PCP sooner. Overall, the goal is to get a clear picture of how your child’s system is working right now so you can make the right choices to help them.
How to take Data: In the resources connected to this video, we have a data sheet that you can use. It has a key that reminds you of all the points that I’ve mentioned in the previous slide. You are encouraged to print that out and use it. You can also use any notebook and pencil or the notes app on your phone or tablet. We find people are most likely to take data when they make it as easy as possible. So we suggest keeping that notebook or data sheet and a pen in whatever location your changing undergarments or disposing of stool.
Some parents don’t know what’s going on with their children’s bowel habits because some children change or use the toilet independently or they don’t want to talk about their stool habits. That’s okay. Some children can take their own data using our existing sheets. We’ve also included a simplified version of our data sheet where kids can circle the poo that looks the most like theirs. We find that children who are having accidents are really motivated to do something that is scientifically proven to help. With the right support, they’re often willing to try things that might feel sort of awkward or embarrassing. Explain to your child that most pee and poop accidents come from problems with poop and that this is the first step of treatment.
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.
To teach toileting, it’s helpful to know the basics of how we eliminate (pee and poop), and how we learn to do these things. We encourage every parent to watch this video.
Associated Resources:
“The Poo in You” (video): this simple video is helpful for both kids and adults to understand how digestion and elimination work, and what can stand in the way.
A full transcript of the video appears below.
Hello, my name is Kelly Savitri. I’m a nurse with the Vermont Continence Project. This short video is going to present some information about how our bodies eliminate waste, which is basically a polite way of saying pee and poop. I hope by the end of this video you will understand why this information is the foundation of helping our kids become successful with toilet learning.
The process of toilet learning starts when a person’s brain can recognize signals from the bladder and bowel, and then that person learns how to respond to those signals. So the first thing that we need to understand is how that process works in the body and where things can go wrong that make it difficult for someone to learn toileting skills.
First, let me explain how we create urine, or pee, and how we excrete it. Pee is produced in the kidneys. It travels down tubes called ureters and collects in the bladder. As the bladder fills, it stretches. Special nerves called stretch receptors in the bladder sense when it is full and send a message to the brain. We perceive this message as a feeling, which most of us learn to recognize as the need to pee.
Now we’ll talk about how the bowel works. Food enters the mouth and goes into the stomach where it gets broken up and mixed with our stomach acid and enzymes that allow us to digest it. At that point, it becomes liquid. And it stays liquid as it goes through a long, twisty tube called the small intestine. From there, it enters our large intestine, also called the bowel or colon, and it is still liquid. This liquid is what becomes poop. In the large intestine, water gets absorbed back into the body, so the poop moving through becomes more solid. The longer it stays in the bowel, the harder and drier it becomes. The last part of the colon is called the rectum. Just like the bladder, the rectum has stretch receptors. When the rectum fills with poop, it stretches. And those stretch receptors send a signal to the brain.
Again, we perceive this signal as a sensation. And it is that sensation that most of us learn to recognize as the feeling that we need to poop. There’s a little ring of muscle at the bottom of the rectum called the anal sphincter. The anal sphincter is a muscle that we can tighten to keep poop in or we can relax to let poop out.
There is also a group of muscles in our pelvis that we call the pelvic floor. Those muscles help us control when pee and poop comes out. While there are many muscles working in many different ways, a simple way to say it is that we contract the muscles to keep pee and poop in, and we relax them to let it out.
So what could go wrong with these systems? For most children, the answer is constipation. Many parents are surprised to hear that their child might be constipated, because constipation can be sneaky and can present in unique ways, especially in children. At the Continence Project, we have worked with hundreds of families and consulted with many pediatricians and specialists, and we have found that when a child is really struggling with incontinence, despite their parent trying all the conventional strategies, there’s almost always an issue related to constipation that needs to be addressed. This is true for typically developing children, as well as those with developmental delays or other identified diagnoses.
I’m going to talk much more in depth about constipation in upcoming videos, but for right now, I’m going to give you the quick summary of how chronic constipation affects a person’s ability to gain toileting skills. In this graphic, the yellow part of the cycle represents the mental and emotional effects of constipation that influence a child’s behavior. And the green cycle represents the physical changes that happen in a child’s body that make it difficult for a child to effectively recognize their body signals and respond to them. For today, I’m going to focus on the green part of the cycle, but I want you to know that we will talk about the yellow part of the cycle in future videos.
First, let’s define what we mean by constipation. Remember how the last part of the bowel stretches when it is full of poop, and then it goes back to its normal size when it empties? Constipation is what happens when the rectum does not fully empty. Usually, for adults, this is a short-term situation that resolves when a person eventually has a complete bowel movement. In children, we often observe that an episode of constipation can trigger an ongoing cycle where they might be able to pass some poop on a regular basis, but the bowel never fully empties, so the rectum becomes stretched out.
We use the term constipation a lot because that is the word that your healthcare provider is most likely going to use. But sometimes it is confusing because people think of constipation as a situation when no poop at all is coming out. We often hear parents say, “How could my child be constipated? I’m cleaning up poop all day long.” In this situation, it’s more helpful to think of it as incomplete evacuation. Even if your child has frequent bowel movements, they might still be experiencing the effects of an overstretched rectum because the bowel is never really fully emptying, and some stool is being left behind.
There are a lot of muscles involved in the digestive process. The whole digestive tract from the mouth to the anus has muscles that help move the food, and subsequent poop, through the digestive system. When someone has constipation, or incomplete evacuations, the muscles of the rectum are stretched out for a long time. Then they become weak and ineffective. That means that the longer constipation, or incomplete evacuation, goes on, the more difficult it is for the body to effectively push poop out. Remember how stretch receptors give you the urge to pee or poop? For those receptors to work, the bowel needs to go back to its empty state every time. When the bowel stays stretched out for a long time, those receptors stop talking to your brain. This is true even if some poop comes out. Remember, you can’t learn to respond to a signal that you don’t feel. So making sure that the bowel is fully emptying on a regular basis is our first and most important step in addressing incontinence.
Also, remember the muscles of the pelvic floor and anal sphincter? Those muscles can also be affected by the pressure of an overfull rectum constantly pressing on them, or from long-term withholding. So sometimes those muscles need retraining, as well as time to regain their normal function. In our psychographic, we call this situation ineffective or incomplete voiding and defecation.
Finally, remember how the poop is liquid when it enters the bowel, and it gets harder and drier the longer it stays there? Sometimes the hard, dry poop gets stuck in the rectum, causing an impaction. Eventually, the liquid poop starts to sneak around the impaction and leak out. This amount can be large or small. It often appears as streaks or smears in a person’s underwear because small amounts of liquid or solid stool comes out when the person passes gas. They may also have large bowel accidents. Often this is mistaken as diarrhea, but it’s actually a complication of long-term constipation called encopresis. In this situation, stool leaks out involuntarily, and a child often cannot even feel it. You might be wondering how incomplete evacuation affects urine incontinence.
We tend to think of the bowel and bladder as two separate systems, but they’re connected in some very important ways. The signals from the stretch receptors in the bladder travel the same nerve pathways as the receptors in the bowel. When the signals from the bowel are interrupted by incomplete elimination, the signals from the bladder can get messed up too. This usually shows up as a child either not recognizing that they need to pee, or not identifying it until it is extremely urgent, and they can’t get to the toilet in time. Also, the overly full rectum can press on the bladder, creating less space for the bladder to expand. This usually shows up as a child having lots of small pees frequently throughout the day.
The most important thing to understand is that this process is cyclical. When a child’s stretch receptors and muscles of the digestive system and pelvic floor become compromised because of constipation or incomplete evacuation, it slows down their elimination and makes it harder for them to poop, causing more constipation.
Don’t worry, we’re going to talk much more about how to identify whether constipation or incomplete evacuation is a factor in your child’s difficulty with toilet learning and what to do about it. In the next video, called Taking Bowel Data, my colleague will explain how to record the size, frequency, and consistency of your child’s bowel movements so that you can have an informed conversation with your child’s healthcare provider.
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 healthcare provider.
The Toilet-Teaching Video Series is a six-unit process that leads you through the process of teaching toileting to children and youth with challenging incontinence needs. This video explains the sequence of the videos.