Global’s Webinar Series Recap


 SPRING 2017

Potty Time! A Journey to Successful Toilet Training

What You Need to Know



Dr. Patel joined the Sie Center for Down Syndrome at Children’s Hospital Colorado as Director of Psychology in November of 2012. She has 7 years of experience as a licensed psychologist specializing in treatment planning, diagnostic evaluation, and intervention. In her current role in the Sie Center, Dr. Patel is responsible for management of all referrals for psychological treatment and evaluation. This webinar will help participants navigate the complex journey of potty training. Potential medical, behavioral, and environmental factors that can impact successful toilet training will be discussed. Strategies and visual supports to overcome these challenges will also be provided.


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1. At what age are most kids with DS ready for potty training? Our urologist made it sound like the “window” for potty training was much later than for children without DS. – Colorado

a. Readiness for toilet training can vary just as much in children with Down syndrome as it can in all other kids. They may not be as ready to start toilet training because of physical limitations or refusal behaviors, etc., but that does not mean you can’t start the toilet training process around the same time as with all other kids. The key is making sure that you are not forcing them to sit on the potty or begin toilet training. There is minimal research on the age at which children with Down syndrome are fully toilet trained (some research indicates between ages 5-7), but that doesn’t mean that you can’t start much sooner.

2. What are some suggestions for nighttime potty training a child who must use a cpap machine to sleep? I do not necessarily need tips on how to teach our son to take on and off the cpap mask. I am just wondering if you have worked or looked closely at dealing with cpap and nighttime potty training. – Pennsylvania

a. I apologize, but I’m not sure I understand the question. There is not much research on toilet training in Down syndrome in general, and I don’t know about any correlations between apnea and nighttime toilet training.

3. She will go to the potty when I take her, but how do I encourage her to prompt me? At length, we discuss this with her. She’s only done it a couple of times. She is good with routine, but many times I take her, she likely really doesn’t need to go. We do it out of an abundance of caution and the she is irritated that I didn’t trust her answer. She is 4. – Florida

a. Some of this will naturally occur as your child becomes more confident and comfortable with going to the bathroom. One way to start encouraging going on her own is to use a potty watch to cue her to go, rather than an adult. Of course, you would need to feel confident that your child would leave an activity to go when cued by the watch. The other thing that I have used is rewarding times when your child is dry or when they ask to go (if they are doing so infrequently). So intermittently throughout the day, between times that you take her, reward her for still being dry. A social story can also help to teach her that she can ask to go.

4. Is there a printed program/curriculum that can be provided to school for best results? – Florida

a. Not one that I know of. Typically, the plan that I outlined in the handout from the webinar is the one that I encourage folks to use and then to just make sure that you are consistent with your approach in both settings. Of course you will also have to troubleshoot, as each child is different.

5. She seems fascinated with touching herself as she voids. I have been reluctant to discourage because I presume with time she will be less fascinated. Is there a downside at the age of 4? – Florida

a. You don’t want her to develop a bad habit with touching her privates when she is going to the bathroom, as sometimes it can become harder to break. I would give her a fidget toy or something to occupy her hands to deter touching her privates during voiding.

6. Suggestions for combatting night time peeing? – New York

a. Stop all liquid intake about an hour before bedtime.
b. Make sure that you develop a routine of going to the bathroom as the last thing before going to bed
c. Determine if your child is waking up when they are wet at night or if they sleep through it. If they are waking up and wanting to be changed, track when that occurs and set your alarm just before that time. Take your child to the bathroom when your alarm sounds. Make sure that you don’t do anything to activate the child (turning on bright lights, talking to the child, making it fun) and then return to bed right after. This can help the child learn the routine of getting up and going at night if necessary. Some kids stay in deep sleep and this can be challenging, but a good start.

7. I believe a common strategy with typically developing kids is to move them into cloth underwear. As the sensation of being wet is unpleasant, the child will learn to avoid becoming wet (i.e., learn to hold their urine). My child does appear to be disturbed by this sensation, however, so I’m not sure how to incentivize or motivate a desire to hold urine in the bladder. Any suggestions? Would cloth transfers be better at this than regular cloth undies? – Nevada

a. Many people put children in underwear or cloth diapers because they think that this will be a deterrent to going. If a child does not seem to care if they go in their diaper, they often times won’t care if they go in their underwear. I say that you should hold off on underwear until you have developed consistency with dryness for a few weeks at a time. That will help ensure that parents can stay on the journey for toilet training and prevent longer term frustrations with their child. This child may be on a peeing schedule for longer than other children who may be more motivated.

8. While my son is doing well with the urination part of pottying (he’s at 1 hour+ between toiletings), he refuses to go poop. Early on, he would poop just fine on the toilet when he was brought there by mom or dad. Recently however, he has stopped going poop when brought to the toilet; even when caught in the middle or preliminary stages of pooping elsewhere and then brought immediately to the toilet. What may have changed that is now inhibiting his ability to poop on the toilet, even while he is making such great progress on the urination side of potty training? – Nevada

a. I always try to eliminate any medical reasons that a child may be withholding their poop, like constipation. Sometimes, if diet has changed or if a child is just backed up, they may start withholding their stool because of how difficult it feels to eliminate it. I would make sure that you use lots of praise, cheering and rewarding for pooping in the toilet. Make sure that you are having your child sit with knees above the waist, perhaps using a stool to create the ideal position for eliminating. Talk to your PCP if constipation is the issue. Remember that just because a child has soft stools, doesn’t mean they don’t have additional stool that may be harder. A PCP can help you evaluate for that.

9. My son is doing pretty well at home. He is now going for about 1 hour+ between toiletings. At school, however, they can’t get him to move past the 15-minute mark. At school, he is in his diaper and pants at all times that he isn’t going to the bathroom. At home, we allow him to run around without a diaper or pants. Could this be the difference in success that we’re seeing at home vs. at school? If so, how do we start to translate the success he’s having without diapers/pants into successes while wearing diapers/pants? – Nevada

a. I would wonder if he is producing something every 15 minutes. If he is, I wonder if he is forcing it out, making it more difficult for him to actually hold the urine compared to at home. It could be that your son has developed a habit with going to the bathroom in his diaper, because that is what he has done for years. I don’t typically suggest underwear, but I wonder if the feel of that would help to create a new routine. I think step one is to decide why the school feels that they have to take him every 15 minutes. He should be able to stay dry for longer than 15 minutes even with the difference of wearing a diaper versus nothing.

10. What do you think of “trainers” panties?

a. Wait on underwear until you have a few weeks of consistency with staying dry (with occasional accidents). Trainers are great for kids that are developmentally able to pull them up and down. This is a nice way to work towards independence. I don’t think that they would feel that much different than a pull up or diaper, so don’t think that it is helpful from that standpoint.

11. Our child knows what the potty is for, but when she feels her need she immediately starts, so she cannot hold it and go to the potty most of the time. She’s almost 3. What can I do to facilitate her?

a. Start with the 3 days of 15 minute diaper checks to determine how long she is able to hold it. Taking her on a schedule will help her to make an association to peeing in the potty and being able to have success with going. That will increase motivation to do this. She may also just not have the muscle tone to hold it yet, but the data will help you to get her going in the potty more consistently and then you can build on that.

12. She’s at day care 3 times a week, for the whole day. Do you recommend to keep her completely at home while potty training happens?

a. Depends on the daycare. If the daycare is willing to follow the plan that you come up with consistently, then I don’t think that it is a problem to have her in both settings.

13. Suggestions on how to determine when my nonverbal child is ready to potty train? – Colorado

a. Start with the 3 days of 15 minute diaper checks. This will help you to determine if your child can actually hold it for long enough and in a pattern to start on a timed schedule for going to the bathroom. Teach your child the sign for “potty” and always sign “potty” when you are taking your child on a schedule. This will help you to create an association between the sign and what it means. Make sure their behavior is not resistant to going, as this may indicate that they are not ready or they don’t understand what that means. Modeling going to the potty can help with this too. Remember that behaviors are just as much communication as words are.

14. I try to take my son to potty anyways, every 2 to 3 hours. Is he ever going to tell me that wet diapers are uncomfortable? – Texas

a. That is child specific. Some children will eventually show that they are uncomfortable. These are the kids that tend to become toilet trained in the traditional fashion, where they will ask to go as they get in the new routine. Some children just aren’t deterred from going in their pull up/diaper/underwear, because they don’t appreciate the social pressures of not being toilet trained and don’t care about how it feels. This doesn’t mean that they can’t be toilet trained on a schedule though.

15. Our daughter had Hirschprung’s Disease which was repaired with a pull through procedure when she was 5 days old. Any thoughts on what we can expect in terms of toilet training; in particular the difference between training her to potty in the toilet versus pooping? – Colorado

a. There shouldn’t be much of a difference with potty training for peeing. Pooping depends on whether the surgery will help with feeling the sensation of needing to go. Even then, many kids poop around the same time of day, so you can proactively do sits on the toilet just before those times.

16. What is the best way to help a child with DS and sleep apnea become nighttime trained when daytime is schedule trained? – Texas

a. Stop all liquid intake about an hour before bedtime.
b. Make sure that you develop a routine of going to the bathroom as the last thing before going to bed
c. Determine if your child is waking up when they are wet at night or if they sleep through it. If they are waking up and wanting to be changed, track when that occurs and set your alarm just before that time. Take your child to the bathroom when your alarm sounds. Make sure that you don’t do anything to activate the child (turning on bright lights, talking to the child, making it fun) and then return to bed right after. This can help the child learn the routine of getting up and going at night if necessary. Some kids stay in deep sleep and this can be challenging, but a good start.

17. Is scheduling the best way to answer a bladder held for too many hours or are there other solutions that put the responsibility more on the (older) child? – Texas

a. Starting out with schedules is a great start. I sometimes will use a visual roadmap to show that if a child holds it, they will not be able to go back to their preferred activity, while if they take a break and go to the bathroom, they get to continue engaging in a preferred activity.

18. How should we best handle accidents at school when child was accident free for several months? What might cause it? – Texas

a. Lots of things can cause children to slide back. It can be related to changes in routine, school feeling that they don’t need to cue as often or changing their way of asking, stress, etc. I would ask the school team what they have noticed happens (in detail) when the accidents occur. Depending on age, some children become way more focused and engaged in school and exploring their environment as a natural developmental growth, so don’t want to move away from that activity to go potty. I would ask more detailed questions about when it occurs, what language they are using to cue going, and if your child needs to be back on a schedule for a while.

19. What tips can you recommend to teach wiping (front and back)? My daughter is having a hard time reaching back as well as understanding that she has to clean thoroughly. – Florida & California

a. I have children practice on “wiping” on a sheet of paper. Use a laminated piece of paper with a circle in the middle. Place peanut butter or chocolate in the circle and practice having her wipe front to back. Once she gets good at that, then you can fasten the laminated paper to the back of her pants and have her practice that way. There are also tools that can help children with shorter arms reach to the back. Use a wet wipe followed by toilet paper.

20. What are some strategies for when a child shows signs of regression? – Michigan

a. I start with putting them back on a schedule and using a motivator to get them to go. I always get curious about what is causing a child to regress and then try to proactively address whatever the cause is.

21. We’ve got ahold on urinating. What are some strategies for stool training? – Michigan

a. Track when stooling typically happens and then proactively have the child sit during the time when they would naturally produce something. You may also have to teach the child how to push out the poop, so that they don’t just sit on the toilet without trying. You can also make sure that your child is around you during times when they typically go poop during the day so that if you see them showing signs of going, you can cue them to sit on the potty.

22. Would you recommend the use of a potty watch? – Michigan

a. Potty watches are nice for getting children to become more independent with going on a schedule. The trick is making sure that your child is motivated to go and doesn’t just ignore the watch going off. They are also good for children who don’t always feel the sensation of needing to go. It just keeps them on a schedule.

23. Any specific tips to help our 4 ½-year-old tell us before he has a bowel movement? Cognitively, he understands and does well with voiding, but we are really struggling with getting him to tell us before he has a bowel movement. – Indiana

a. I would use a social story to help him start paying attention to the sensation he feels when he needs to go. Social stories are a great way to explain the sensation. As weird as this may sound, modeling is also great. When you are going, talk about how your tummy is rumbling and your bottom is feeling different. Then explain how you push the poop out (Sorry for the details ☺)

24. In your experience, do intense 3-5 day “boot camp” type of potty training strategies work for children with DS? – Indiana

a. In my experience they do not. I feel like they create a negative association and a negative relationship with going potty. I feel that children with Down syndrome experience the frustration and then remember the frustration so much that even when you are done with the 3-5 day boot camp, they are resistant to going then. This is not true for every child, but I like to keep things positively associated.

25. My son is 3 ½ years old and time trained for peeing, but he will not hold his pooping. We have been working on this for 4-5 months now. What could be the reason? – Massachusetts

a. I don’t know if your child has normal stools or soft stools, but soft stools can sometimes be difficult to hold or to feel that it is coming. Does your child have celiac? Has there been concern about this? I would look at diet too.

26. I have a 5 year old son whom I regularly take to the toilet (every 1-2 hours) and he poops in the toilet and sometimes pees. But I find that he most frequently pees in his pull up. He never tells me that he has to go to the toilet and I wonder how we can make him care and tell us that he has to pee. – New York

a. It is difficult to teach him to care. You may need to use external motivators or rewards to encourage him to tell you that he needs to go. The reward would be given when he asks to go and produces something, rather than when you prompt him to go.

27. Neurological reason? How do I best address issues of night wetting that persist in my 9 year old that is day trained? – Texas

a. Typically children who have a hard time staying dry at night at this age could be just sleeping so deeply that they don’t wake up when they feel their body needing to go. There are potty alarms (underwear that have an alarm on them that goes off when a person starts to pee in their underwear at night) that could be helpful in training your child to wake up and go in the potty. Typically when the alarm goes off, it causes the person to kind of “tense up” and hold it until they get to the potty.

28. In a classroom where parents have no attempt to train 8-12 year olds, what can a teacher do? – Texas

a. I would be curious about what the parent’s motivation is to not toilet train their child. Sometimes you may be surprised why they aren’t investing time in this (it could be that they have other pressing medical priorities that they don’t feel like they can do it, they don’t know how to start, etc.).

29. My daughter sits for 30 minutes every night to make a bowel movement. Do I need to change this and how? – Texas

a. If it is working and your child is not resisting, I say stay the course. I don’t know if you are having her do a preferred activity while sitting on the toilet, but I typically have the child just sit without something for entertainment (unless they are at a stage of refusing to sit) so that the focus stays on going potty.

30. I just thought about potty training my daughter a month ago. My only question, am I starting too early? She will be 2 years old in 2 months. I just want to have a no pressure approach right now. – Mississippi

a. You are appropriately thinking about a no pressure approach. I don’t think it is a bad idea to get a child in the routine of sitting on the toilet at this age, as long as they aren’t resisting. You can also have them watch you go, put a potty in the bathroom that the child can independently sit on (even if they are clothed), and create a positive relationship with the potty. You don’t have to worry about success at this point, unless you really think she is ready. Taking her on a schedule, after doing the three days of tracking can help you make sure that you aren’t taking her so often that she gets upset about it.


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