Regression & Troubleshooting

Regression

If your child’s progress begins to slip backwards or even stalls altogether, don’t be alarmed. Some regression is not unusual. Consider whether there have been any recent changes for either or both of you such as holiday activities, job change, moving, or absence of a familiar person at school or at home. The stress of such changes can negatively impact your child’s toilet training progress. As you attempt to identify what is causing the regression, you may need to back up to a point in the toilet training process where your child was being successful. However, returning to the use of diapers is not recommended. That may confuse your child and further impede progress with the training process.

In addition to looking for any recent changes, consider also any possible physical causes for the regression such as painful urination or bowel movements. Recent illness or medication changes as well as changes in diet or sleep habits can result in regression. Consult with your child’s physician if your child has any unusual physical symptoms.

If your child experiences a setback, you may feel discouraged or even angry. Remain calm and keep the ultimate goal in mind. Provide emotional support to your child as well as any visuals he may need to understand what has changed. Consult with your child’s teacher and speech-language pathologist about any pictures and/or social stories that may help your child.

For additional ideas, see Part 13: Refusal to Participate in Toilet Training.

Troubleshooting Toilet Training

1. Fear of entering the bathroom

If the child covers his ears upon entering, he may be overwhelmed by noises including a fan or flushing. This behavior can be especially frustrating when the child cannot verbalize why he is anxious. Sometimes his non-verbal behaviors can offer clues as to what he fears in the bathroom. Additionally, if the child fears going in the bathroom because is too cold, try slippers, socks, or a rug.

More Solutions:

• Don’t rush the child. Encourage him to enter the bathroom for more neutral and brief events such as to place towels, wipes, or soap on the counter
• Move certain fun activities to the bathroom
• Set up a tray for the child to use for coloring, writing, reading, and/or playing.
• Pair entering and using the bathroom with calming music and other pleasant experiences
• Provide towels, toys, other toileting items that include favorites characters
• Use positive reinforcement for entering the bathroom

NOTE: With all of these steps you are shaping the behavior. You can deal later with removing some of the objects and supports as the child becomes more comfortable with spending more time in the bathroom.

2. Resistance to and fear of sitting on the toilet

Some children may develop a fear or intolerance of sitting on the toilet. A number of factors might explain this reaction to sitting on the toilet. The seat itself might be uncomfortable; the child might feel unstable on the seat; he may have a fear of the swirling water when flushing; or, he may have a fear of falling in.

Solutions:

• Don’t force the child to sit on the toilet seat because this may reinforce or worsen his fear and make him even more determined to refuse to sit.
• Start by practicing sitting on the toilet fully clothed or on your lap with the lid closed; gradually move toward having child remove clothing and sitting on the toilet seat.
• Use a doll to demonstrate sitting on the toilet.
• Use adaptive equipment to sit such as a potty chair to start. These are usually sized for smaller bodies and sit on the floor, are often colorful and fun, and often have removable seats that can eventually be placed on the toilet. A potty chair can also make voiding less scary if the child is frightened of something “falling” from his body.
• Use a cue or distractor (e.g., a timer or a book or song signaling the end of sitting when it is over) to help the child know how long he needs to sit on the toilet.
• Use a small table or tray that fits over the child’s lap while sitting on the toilet to provide stability and support as well as to move his attention toward pleasant and preferred activities.
• Provide a stool under the child’s feet so his feet are not dangling and he feels more stable.
• If the child has low muscle tone, consult with his occupational therapist and/or physical therapist regarding adaptive equipment to use to support sitting on the toilet.
• If you child has a negative reaction to the coldness of the toilet seat, try adjusting the room temperature and/or installing a padded seat that does not get as cold.

3. Flushing the toilet

Flushing can be an exciting aspect of the toileting routine for some children or a frightening one to others. One child may repeatedly flush the toilet. This may be due to the child’s lack of understanding of expected behavior or he enjoys the sounds and the movement of the water during flushing. Another child may refuse to flush the toilet because he is fearful of the swirling water and the sounds during flushing. That child may need additional emotional support and teaching to learn to tolerate the sights and sounds of flushing.

If your child is fearful of flushing:

• Reduce the noise level when flushing and/or the view of the swirling water, have your child put the seat down first
• Pair preferred and comforting activities with the sights and sounds of flushing
• Prepare him by saying, “Ready, set, flush!”; play background music, or sing a “flushing” song
• Include “flush” on the visual schedule for using the toilet
• Help your child learn to better tolerate flushing noises by taping the flushing sounds and playing back the tape at neutral times allowing your child to control the volume
• Move this part of the routine to the end. After washing and drying hands, open the door, quickly flush and exit the bathroom

For some children, the flushing noise in the bathroom creates a sensory overload that is frightening. Solutions include:

• Mark a safe spot on the floor that is a safe distance away from the toilet. Before you flush, have your child move to the mark. Gradually move the mark closer to the toilet as he gets more comfortable.
• Provide a warning cue such as “Ready, set, flush”.
• Make an audiotape of the flushing sound for your child to listen and to control the volume as he becomes accustomed to the sound.
• Change the sequence so that flushing follows washing and drying hands to allow for a quick exit immediately after.
• Consider introducing flushing after other steps have been mastered; until then, the adult would do the flushing after the toilet trip.

For a child who repeatedly flushes the toilet:

• Review the steps of the toileting routine before entering the bathroom.
• Use the picture schedule to show him when it is time to flush.
• Continue to use the picture schedule once in the bathroom to cue your child as he progresses through each step.
• Have a “finished” envelope into which the child places the picture of each step as it is completed. Once a picture is in the envelope it is finished.

4. Hand washing

Washing hands with soap and water is an important part of the toileting routine. Some children enjoy hand washing and may even resist moving on from the pleasant sensations of water, soap, bubbles, etc. associated with this step. Other children may be less tolerant of the hand washing steps and materials due to sensory issues around touch, smell, or noise. Or, they may have a lack of understanding about the steps involved.

For those children who engage in excessive hand washing, the use of a visual timer may be helpful. Providing colorful and/or soft-textured towels that the child finds pleasing may help to move the routine along. You can also sing a “handwashing” song that includes turning off the water and drying hands as the conclusion. (e.g., “This is the way we wash our hands, turn off the water, dry our hands…when we use the potty”) Or, use a favorite song to be sung only when the water is on. When the song is finished, the water gets turned off, and the child moves on to the next step of drying hands.

For those children who resist some or all of the components of a hand washing routine, the following suggestions may help:

• Provide a visual cue of the steps in the toilet training routine to the child while he is in the bathroom; include a picture of “wash hands”. You may have to break down the hand washing step into even smaller steps. These steps may include:
• Turn on the water
• Put soap on hands
• Rub hands together, front and back
• Rinse hands in the water
• Turn off the water
• Dry hands with a towel
• Use soap, cloths, and/or towels that have textures and smells tolerated by the child. Some children may prefer bar soap to liquid; others want a paper towel versus a terry towel.
• Provide modeling of hand washing and physical assistance to the child, if needed.
• Make use of a social story with pictures that teaches the steps, including what comes immediately before and after hand washing.
• If the child consistently refuses water and soap, use hand sanitizer, sanitizing wipes or cloths to clean hands.
• Provide a pleasant experience with lotions or other reward upon completion of hand washing.

5. Playing with the water

Some children enjoy the feel and sound of water play and try to play with the water in the toilet and/or the sink during the toileting routine. To discourage water play in the toilet, close the lid on the toilet as soon as the child stands up. Limit time spent using the water in the sink by using a timer and/or singing a hand washing song. Include turning off the faucet as part of finishing the song. You can also create a “finished “ envelope for the child to put the picture for each step of the routine as he completes it, including the hand washing step. Once the picture is in the envelope, that step is finished. Provide opportunities for water play at other times on the daily schedule; use the picture schedule to show your child when he does get to play in the water

6. Hiding when having a bowel movement

Many children learn to use the toilet to urinate first but have a more difficult time learning to defecate in the toilet. It is not unusual as a child becomes increasingly aware of the need to poop that he may try to find a private place to do this. Afterwards, he may even then tell an adult, “I pooped”.

One solution may be to begin by encouraging your child to “hide” in the bathroom when he has to poop. Then gradually have him sit on the toilet with the lid down when he does this. All undressing, cleanup, and redressing should also occur in the bathroom as much as possible.

As you detect your child’s elimination patterns and can identify the occasions when he is most likely to have a bowel movement, try to have him sit on the toilet as he does for urinating. He is not likely to be able to resist the urge to poop as he also urinates. Provide positive praise for all attempts and success.

7. Lack of awareness of wetness

If your child is wearing diapers, he is not likely to feel the wetness after he has voided because the diaper is designed to wick away any wetness into the padding and away from the skin. Underpants do not hold urine or waste well and enable the child to feel the wetness of the clothing. Admittedly, these accidents result in time-consuming clean up of the child, clothing, and the area where the accident occurred. But, accidents help your child to understand the difference between wet and dry. One solution is to wear a diaper or plastic pants outside of the underpants to eliminate the need for extensive cleanup but still give the child the opportunity to sense when his underpants are wet and/or soiled. Change your child as soon as you know he is wet so that he does not become accustomed to being wet.

For children with severe intellectual disabilities or children who are hyposensitive to tactile sensations and may not be aware of or bothered by wet underpants, a wetness detecting monitor/alarm can be used.

8. Fecal smearing

As a child acquires increasing awareness that he has soiled himself – either in a diaper or underwear, he may touch the feces and even smear himself, his clothing, or even furniture and walls, simply out of curiosity. Most children respond positively to a calm and matter-of-fact approach to teaching them not to touch feces and to eventually eliminate in the toilet followed by wiping appropriately. However, some children continue to touch and smear their feces which can be a very challenging behavior to address. While this behavior is socially offensive and upsetting to others, it also presents some significant health risks. Understanding the reason your child is engaging in this behavior will help you decide how to best intervene. Motivations to engage in smearing fecal matter can range from attention seeking purposes to serving a sensory input need. In some cases, there can be several motivations for the child to engage in this behavior.

Your child may not understand the process of wiping. In addition to teaching wiping using a “hand over hand” approach, you may need to develop a social story and other visual supports to give the child the information he needs. If the child resists wiping, the toilet paper may be too harsh or otherwise intolerable. In this instance, using wet wipes may be an alternative. You may also want to consult with your child’s pediatrician to rule out physical causes for the smearing. The child may be experiencing pain or irritation that leads to digging and smearing feces.

Some children smear feces for sensory reasons. They may enjoy the feeling of smearing. In this case, try replacing the behavior with activities such as finger painting and playing with play dough while also making use of the visuals and social story to teach the child that “I poop in the toilet” and that “I wipe with toilet paper”. A child may enjoy the attention and the water play in the bath that often follows a smearing incident. As with accidents, the adult should remain calm and neutral, quickly clean up, avoiding shame and embarrassment as much as possible, and providing the child with the information he needs to eliminate in the toilet and to clean up without smearting. Provide opportunities for water play at other times on the daily schedule, making sure it does not immediately follow a toilet trip.

Whenever your child successfully follows the toileting sequence without smearing as well as when he engages in the replacement behaviors (i.e., play dough, finger paint, water play), provide positive praise. When you reward the desired behaviors, you are helping your child to learn which behaviors bring him positive attention and rewards.

In some cases, clothing that limits access can be used to prevent fecal smearing especially at night time. Some special needs clothing manufacturers offer products that inhibit access. A one-piece triathlon suit may be useful as well as more affordable. For a younger child, you can also cut the feet off of one-piece footed pajamas and put them on with the zipper in the back instead of in the front. Keep in mind that clothing that inhibits access will not solve the problem without teaching and rewarding the expected behavior in the daytime.

9. Tantrum behaviors

Tantrums can be challenging and dangerous, especially in the bathroom. And, the parent’s frustration is compounded when he cannot identify what is bothering the child and decide how to best intervene to help him calm down. A tantrum is a form of communication. The child may be frustrated, angry, disappointed, or confused and is expressing his feelings in a way that has worked for him in the past.

Try to prevent a tantrum before it starts by identifying and controlling for possible triggers such as tiredness, fear of the bathroom, or a change in routine. Use the visual schedule of the child’s daily activities to prepare him for a change. Your child may respond to a “safety plan” that visually represents for him the ways he can keep his body calm when feeling overwhelmed (such as “slowly count to ten “ or “squeeze my hands”). Read this article about the Sanctuary Model for more information on creating a safety plan.

If a tantrum occurs:

• Move the child to a safe area
• Ignore the temper tantrum and never give the child what he is tantrumming for as long as he is still having a tantrum. Do not talk to your child and use only the amount of physical contact necessary to assure your child’s safety. Make all your actions appear to be matter-of-fact. Treat the tantrum with as little attention as possible
• Wait for the child to regain control – this can be a very frustrating and a lengthy process. Of course you would need to intervene if your child is not safe
• When the tantrum stops (in the beginning, this may take a long time), wait a few moments, and then praise your child for the next appropriate behavior