Should I see a doctor? Which doctor should I see?

 

'A' is a 5 year old boy I see at the clinic. He is on the spectrum and is very proprioceptive and tactile seeking. 'A' is not completely toilet trained. He does not consistently indicate his need to use the toilet, and he has a tendency to dribble multiple times in a day, and sometimes hardly notices that he is wet. 'A' is also constipated most of the time as he holds himself  for days together to avoid going to the toilet for the 'big job', as he doesn't feel 'safe' sitting on the toilet.

'A' has been off therapy for over 3 months as they have moved out of town, and is yet to find a Therapy Centre in their immediate locality. A's mother called me one evening with concerns over his frequent accidents. "Who would you suggest I take 'A' to, a Nephrologist or a Urologist?", was her question.

(Names hidden to protect identity)

Before I go into what I told A's mother, let's first look at toilet training in general.

What is toilet training and why is it important?

'Toilet training' simply means, helping a child learn to use the toilet to stay clean and dry. A toilet-trained child knows when he needs to use the toilet and has learned to 'hold on' so he does not go in his clothing or on the floor until he gets to his Potty seat or toilet. A toilet-trained child will be able to indicate his/her needs to use the toilet, or (if he/she is physically able) go the the toilet on his/her own, manage clothing and maintain personal and toilet cleanliness.

Toilet training is important for the development of a child's independence and dignity. Children who are developmentally or physically challenged, are often late in learning to stay clean and dry. This may be partly due to their disabilities, or often due to lack of independent opportunity, training, and help that they need.

How do you know when to start?

The first step to a successful toilet training is readiness, from both the child and the carer. 

Is the child ready yet?

• Has he/she reached an appropriate age?
• Can he differentiate between wet and dry?
• Does the child, through facial expressions, gestures, pictures or words, indicate needing to go to the bathroom?
• Does he/ she completely empty their bladder when voiding and remain dry for at least one to one and a half hours during the day?
• Does his/her bowel movements follow a regular and predictable pattern?
• Is he/she able to walk to and from the bathroom independently and to pick up objects?
• Can he/ she sit on the toilet (or Potty chair) independently and comfortably for two to five minutes?
• Can he/she follow simple directions (eg. sit down)?

Is the parent (are you) ready yet?

• Are you able to dedicate time and effort to implement an effective program?
• Do your work schedules allow you the amount of time needed to take your child to the bathroom on a consistent schedule every day?
• Are you able to consistently be patient throughout the whole process, which I promise is not going to be a very easy task?

How do you go about it?

• Find out if he has any sensory problems that interfere with toileting, eg. fear of the 'flushing' sound, gravitational insecurity while sitting on the toilet, etc.
• Address his sensory needs (if any) before anything else.

Assuming that the child goes to playschool/nursery/school

• Collaborate with your child's teacher/therapist.
• Make sure he/she is consistently showing signs of readiness both at school and at home.
• Come up with a plan that is consistent with home and school
• Set a date to start.
• Resist the urge to put diapers back on for the child, because it is easier.
• Come up with a toilet schedule (your therapist will help you with this) and stick it it.
• Reinforce your child at every step.
• Make toileting a fun and safe experience. Provide a foot stool to rest his feet when sitting on the toilet. This would make him feel safe.

Always remember

• Help the child participate in all the steps involved in toileting and slowly wean off help as they progress.
• Provide support where necessary, eg. a foot stool to rest his feet rather than have them hanging down, something to hold on to like a grab bar when he is sitting on the toilet seat, wipes to clean himself or a towel to pat dry afterwards, etc.
• You have to be patient as it is most likely not to be a smooth ride!

When do you actually want to take your toddler, under toilet training, to see a doctor?

• The child hasn't had a bowel movement in 3 days.
• He/she strains when trying to pee or poop or has painful bowel movements.
• He /she says that peeing 'hurts' or 'burns'.
• He/she has sudden urges to pee and pees too often, or pees very seldom (every eight to nine hours).
• He/she uses the toilet regularly but still has wet pants.

Now what did I tell A's mother?

Like I mentioned 'A' is a child on the Autism Spectrum with no structural or physiological difficulties to his kidneys or bladder. Toilet training which was underway, was suddenly not consistently followed up when he had a break in therapy. Probably, the mother expected A to catch up on his own, as he had already come as far as going to the toilet when instructed. She overlooked the fact that he hadn't become consistent in indicating his need, and still hadn't mastered the activity.

She admitted to having been lax with his training, and I in turn, assured her that she doesn't need to see any specialist at this stage. We had a quick refresher of the toilet training program to make sure that the mother was clear of all the steps she had to follow.

Take a deep breath and remember: Toilet training is a developmental process, not a race! You will only reach there at your child's speed which again depends on your perseverance.