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Toilet Training Children with Moderate-Severe Disability

Toilet Training Children with Moderate-Severe Disability. Lisa Samson-Fang MD University of Utah and Salt Lake City School District. Objectives. Background/ literature Practical programming Supportive equipment Adolescent issues. Case I 5 year old autism no functional verbalizations

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Toilet Training Children with Moderate-Severe Disability

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  1. Toilet Training Children with Moderate-Severe Disability • Lisa Samson-Fang MD • University of Utah and Salt Lake City School District

  2. Objectives • Background/ literature • Practical programming • Supportive equipment • Adolescent issues

  3. Case I 5 year old autism no functional verbalizations assistance for ADLs. finger feeds. Social quotient (Vineland Social Matuirty Scale) 0.36. Case II 7 year old total body involved CP cognitive impairments Communication: differential cries and eye gaze. Can This Child Be Toilet Trained?

  4. Is this an important goal? • Impacts on • independence • caregivers

  5. Impacts In the institutional setting. • Incontinence reduced • Decreased linen usage • Work load minimally decreased. Therapeutic vs. Custodial role • Positive impacts in other areas of self care Not studied in the home or school setting.

  6. Important? • Removes negative impacts on social interactions • Increased freedom in more environments • Privacy

  7. Who’s Job Is It??

  8. The child with disability Not just an adaptation of the process used for “the typical toddler”

  9. Cognitive Impairments Understanding goal Attention Initiation Impulse control Generalization

  10. Birth Cohort Follow-up Wendt et al. • Information available on 105 of 132 individuals with mental retardation. • Bowel continence. • 70% by age 7 and 80% by age 20. • Bladder continence. • 63% by age seven, 83% by age 20.

  11. Autism • Social motivation • Language • Sequencing/attending • Routine changes • The diaper is a routine • Sensory • Sensation – function • Sensory overload • Enjoyment of product

  12. Overall results Training required urine 1.6 yrs bowel 2.1 years Start at 4-5 years 95% successfully trained 78% self initiated Common issues Regression Night incontinence Constipation Behavioral concerns Survey of Parents Dalrymple et al.

  13. Cerebral Palsy • Motor Issues • Mobility • Safety • Upper extremity function • Medical issues • Chronic constipation • Neurogenic bladder

  14. Population n = 27 2.5 - 4 years old Results 6 dry at entry 7 immediately dry 12 achieved 2 wet Factors in success Higher expectations Routine Shared aim w/ peers More appropriate toilets Access to PT/OT advice Preschool children with CP Shaw

  15. CP: Neurogenic Bladder McNeal et.al. 30% prevalence of symptoms • Enuresis • Stress incontinence • Urgency • Frequency • Dribbling • Difficulty urinating • History of a UTI.

  16. Urologic Findings Decter etal. • Referred population for symptoms • Significant findings - 86% • Uninhibited contractions • Detrusor-sphincter dyssynergia • Small capacity bladder • Bladder hypertonia • Periodic relaxation of the external sphincter • Improved w/ treatment - 78%

  17. Constipation • Bowel training • difficult • unpleasant. • Affects bladder • Lower volume • Uninhibited contractions • Optimize treatment • Monitor for recurrence

  18. Multi-modal Treatment Nickel and Desch • Positioning and seating • Behavioral issues • Dietary changes • Cleanout procedure • Maintenance medications • Emptying program

  19. Note: The behavioral protocols discussed are not intended for the achievement of continence in individuals who lack bowel and bladder control (e.g., individuals with spinal cord lesions).

  20. The Literature • Populations: • Cognitive disability, autism, physical disability • Settings: • Institutional, school, home • Designs: • Case studies/ small cohorts

  21. The Literature • Methods: • Timed and Regular • Group vs. Individual • Goal: • Trained vs. Conditioned • Degree of independence • Attainment of “sub-skills” • Generalize to other situations

  22. Most Replicated Azrin and Foxx • Induce frequency • Timed toilet sitting • Positive reinforcement • Dry pants checks • Minimal assistance/prompt for dressing/ faded • Modeling • Pants and potty alarm devices • Verbal reprimand-cleanliness training

  23. Individualized regular potting Monitor child’s rhythms Toilet when high probability Stimulus to void is full bladder Arbitrary timed potting: Set schedule Stimulus to void is toileting routine Comparing Methods Smith

  24. Comparing Methods

  25. Frequent potting (q15minutes faded to q 2 hours over 1 month) Praise, liquid rewards Brief reprimand and simple correction Self initiation not a goal 4 children 4.5 hours / day No equipment Otherwise no change in classroom routine Preschool Setting Richmond

  26. Weekly Accident Rates

  27. Is continuity important Dunlap et.al. • 3 children with Autism (5-7 yrs) • 1 new to toileting, 2 w/ 2 years of no success • Baseline training program in 1 environment vs. training in ALL environments.

  28. Results

  29. Alarms

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