The Toileting Journey

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.

A full transcript of the video appears below.

Hi, I am Chayah Lichtig, I am occupational therapy consultant and director of the Vermont Continence Project. And in this video we are going to explain what we mean when we use the terms toilet teaching and toilet learning, and we’re going to talk about the steps in the toilet learning process. I’ll lay out the roadmap for these steps that will get your child using the toilet hopefully with less stress and more success.

So a little bit about the word learning. Learning takes time and it takes teachers. Have you ever watched a child learn to read? Chances are they didn’t pick up a book the first day and read it flawlessly. They may have watched you reading for years first or sat there while you read books to them, they probably learned the alphabet first or maybe their name. They definitely didn’t read themselves “War and Peace” in bed that first night and that doesn’t mean that they weren’t learning enough or that you weren’t good at helping them or teaching them. Learning naturally takes time, support, and may happen in many small steps. Some people may need extra support from a teacher or a pair of glasses to make the words clear. So instead of thinking of this process as training, keep asking what parts of toilet learning have we got down and what parts still need help. Similarly, continence is learned. Continence is the process of learning to recognize sensations in your body and learning how to respond to them. If you’ve watched any of our videos about elimination yet, you know that your body has to learn to feel when you need to urinate or stool. You also have to learn what to do in response and how to do it. Peeing or pooping on command isn’t something we’re born doing and this doesn’t happen all at once. And also, if your child has any gastrointestinal, digestive or urinary health issues, those can block this learning entirely.

Toileting skills are also learned. This picture shows a parent sitting on a toilet with their child standing in front of them. The parent’s word bubble says, “Watch me pee, child, learn my ways, please.” And under the image it says, “Parenting is weird.” Well, for your child’s whole life they have probably been using a diaper or a pull-up to pee or poop. Then we change the expectation and tell them to use the toilet. Of course, that includes undressing, redressing, wiping, hand washing, not to mention pausing something else that’s probably a lot more fun than sitting on the toilet. For some children that change might be obvious and for others it might not. Whatever it is, remember that the way that our culture and/or your family toilets is not intuitive, it’s learned.

I like to think about the process of learning toileting in three phases. I’m going to go into detail about each one in the coming slides. I’ll mention how you know that you’re in that phase of teaching and what goals you’ll want to consider to progress from that phase. You’ll notice that I don’t mention durations or ages and that’s because this process is highly personal and we’d rather that you focus on what you see in front of you instead of deadlines.

Phase one is the getting started phase. You’re in this phase at any time that you’re just introducing toileting concepts to your child. If you haven’t worked closely with your child’s PCP to rule out or treat any medical concerns, you’re also in this phase. This is because healthy continence is very difficult when elimination isn’t addressed. If you have a lot of conflict with your child around toileting, we consider you to be in this phase because as we’ve discussed negative associations are one of the biggest barriers to children using the toilet consistently. Many people don’t understand why we use the term getting started when they’ve already been working with their child sometimes for years. Sometimes it’s helpful to think of this as getting restarted because we’re trying to try something new and starting a new process. I also like to think of this as being the ounce of prevention stage where we are focused on letting down pressure, creating positive associations, taking care of medical issues so that we can set the stage for easier success in the future. This is mostly the information that you’ll learn in units one through three.

The goals of the getting started phase are to make sure that you’ve taken the health data that you need and taken it to a doctor to discuss, that you’ve identified your child’s inchstones without trying to add or force any additional skills. That your child understands expectations like when and how long to sit, that you found rewards your child likes and you have an approach for how to give them. Your child allows hygiene and might even participate and your child might even practice sit.

Phase two is the first time that we’re actually encouraging your child to sit on the toilet. You’ll know you’re in phase two if your child may sit willingly but they can’t get urine or stool to come out or they may eliminate on the toilet but they’re also having accidents regularly.

The goals of phase two are that your child toilets with prompting and is often dry in between, that your child is sitting on the toilet when it’s time to stool, and that your child may sometimes self-initiate. Another important goal is that your child is using an appropriate position when they’re seated on the toilet and that they’re trying some breathing techniques. This is the domain of units four and five.

The third phase of toilet teaching and learning is the toward independence phase. You’ll know that you are in this phase if your child has had no backslide with medical issues for months or medical backslides have been handled effectively and quickly. Your child uses the toilet successfully about 75% of the time. Successful means that something comes out into the toilet and they’re dry and clean in between and your child is taking themselves to the bathroom sometimes. This is the domain of unit six of our content.

The goals of this phase and how you’ll know that you are stabilizing on this road towards independent continence is that your child has periods that they are dry every day and your child is self-initiating toileting. Self-initiating may not be that they are doing it only from body sensation, they may be using a watch or a timer or a schedule, but that they are participating in and initiating that process.

Presume competence and continence. Remember the learning to read example. Educators like to use the term presume competence. This means we start with the assumption that our student is able to learn what we’re teaching and that it’s our job to teach them in a way that fits them. It also means that all people want to learn. We like to say that we presume continence. This means that we believe that most people experiencing incontinence can gain skills and that people experiencing incontinence want to be continent.

We encourage you that no matter what kind of defiance or refusal your child shows that we can go on the assumption that it is supportive of their dignity and wellbeing and that they desire to be continent.

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.