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Sensory Processing Toileting and Toilet Training -‐ Negotiating the issue at school
www.pandatherapy.com.au
Who are we?
Lewina Schrale (PT)
Fiona O’Keeffe (OT)
The Mystery of Sensory Processing
Sensory processing is a neurological process that enables us to effectively use the information we gather from our environment and our own bodies.
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SP in the developing child
Sensory processing enables children to selectively attend to stimuli and filter out what is irrelevant to them.
Sensory processing -‐ * It supports exploration of their environment * It helps them to regulate their emotions * It helps them to organise their behaviour
History
“Sensory integration sorts, orders and eventually puts all of the individual sensory inputs together into a whole brain function. When the functions of the brain are whole and balanced, body movements are highly adaptive, learning is easy and good behavior is a natural outcome.” Jean Ayres 1979
The Senses
* Sight – Visual system * Hearing – Auditory System * Taste – Gustatory sytem * Smell – Olfactory system * Touch – Tactile system * Body and position – Proprioceptive * Head movement and gravity -‐ Vestibular system (essential for balance)
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Different processing systems
Discriminative Evaluative Wilbarger and Frick 2008
The Arousal Curve
Kimball 1999
Sensory Processing Patterns
* We all have patterns of processing that vary * Your pattern is not a disorder unless if interferes with your ability to participate in life * The ‘Sensory Profile™’ can help to identify patterns which are significantly different to standardized norms
Winnie Dunn
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Dunn believes that pronounced patterns of sensory processing are characteristics which do not need to be fixed, so much as they need to be managed, and understood.
Dunn’s SP Theory
Seekers * High threshold – need a lot of stimulation for it to register * Always want more, looking for novelty, get bored quickly * Self regulate by actively looking for what their brain needs
Dunn’s Four Patterns of SP
Avoiders * Low threshold – will register very small amounts of input * Actively self regulate by avoiding, which is adaptive for them, and should be respected * Want more the same and nothing more * Anything different is a threat * Good at routines, rules, organisation, predictability
Dunn’s Four Patterns of SP
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Sensors * Low thresholds – will register small amounts of input and can find it scary * They are passive – so don’t actively avoid, but like to stick to things that work for them * Will notice small changes and want it the same * Will have precise ideas about how they want to handle each situation
Dunn’s Four Patterns of SP
Bystanders * High thresholds – need a lot of input for them to notice and register it * Don’t know what they are missing, poor at routines * Easy going and can focus even in busy situations because they don’t register extraneous input * Disorganised -‐ don’t notice where they put things can never find their things
Dunn’s Four Patterns of SP
In an age matched study of 281 3-‐6 year olds with an ASD, 83.6 % of children with ASD were found to have definite differences on the Short Sensory Profile, compared to 3.2% in the typically developing group.
Sensory Processing and ASDs
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* Loads of theories – limited evidence that support specific prescriptive interventions * There is improvement or adaptions over time but life long patterns persist * Build on student’s strengths * Accept significant differences and allow for them * Structure the environment to make it less noxious for this student
What can be done
Toilet training might be delayed due to a particular sensory processing pattern, sensitivities, environmental challenges, communication needs, atypical behaviours and reliance on routines.
Implications for Toilet Training
Environmental strategies
* Can toilet be adapted to address child’s sensitivities? We can all relate to * Clean vs smelly * Warm vs cold * Private vs people every where and looking under
door
* Footstool/rail if needed * Disabled toilet??
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Communication strategies
* Visuals * Visual schedules * Signs * Reduce need for child to have to jump through extra hoops – e.g. asking teacher to go , if it’s not a safety issue * Independent access – lots of kids hate being taken to the toilet by someone else
Behavioural strategies-‐ rewards
* Bribery, rewards, positive reinforcement * Virtually essential as inherent rewards can be non existent for the child
* Must be something the child REALLY wants – no matter how unusual * Must not be given at any other times * Can be random * Can vary – lucky dip * Can just be praise, high 5 etc.
Behavioural strategies-‐ successive approximation
* Reward behaviours that are a successive approximation towards the one you want – i.e. wee in toilet * Reward each small step towards the end goal, such as: * Going into the bathroom when other students go to
wash hands * Touching water * Washing own hands * Sitting on toilet with nappy on * Sitting on toilet at nappy change time before new nappy
put on
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Behavioural strategies-‐Desensitisation
* When irrational fear exists, reward small steps towards the situation which elicits the fear and pair this with activities, sensations and experiences the child really likes * Use routines to build acceptance of new skills, such as sitting on the toilet every day before the bath * Always try new things when the child is as calm as possible and back off when distress appears * Never push into melt down territory with toileting
Common sensory challenges
* Hypersensitivities * Nappy addiction-‐ means change as well decreased deep pressure * Difficulty perceiving need to go when distracted by other things which just may be classroom, but especially can involve technology * Holding on because things are different
Toileting students with an Autism
Spectrum Disorder
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Why do we toilet in schools?
“Pupils can’t learn if they don’t feel safe or if health problems are allowed to create barriers. And doing well in education is the most effective route for young people out of poverty and disaffection.” Every Child Matters: Change for Children in Schools, DfES, 2005
Children’s Rights 1. Be treated fairly no matter what 2. Have a say about decisions affecting you 3. Live and grow up healthy 4. Have people do what is best for you 5. -‐ 6. -‐
7. Privacy 8. -‐ 9. -‐
10. Be cared for and have a home 11. -‐
12. Help and protection if you need it
* 3x a day to 3x a week ✔ * Type 4 and 5 ✔ * Large bowel motions ✗ * Infrequent motions ✗ * Multiple small motions ✗ * Pain ✗ * Blood on the paper ✗ * With holding behaviour ✗ * Poor sensation ✗
Bowels – What’s‘Normal’?
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Bladders – What’s‘Normal’?
* Maturity @ 6 ✔ * Void 4-‐8 times a day ✔ * Bladder capacity - * Frequency ✗ * Urgency ✗ * Dribbling ✗ * Odour ✗ * Pain ✗ * Using abdominal pressure ✗
IF NOTHING ELSE PLEASE REMEMBER THIS POINT Wetting or soiling your pants outside home was rated by children as one of the worst things that could happen to them
IT IS NOT ON PURPOSE
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It is never too late! Everyone has a right to be continent
Toilet training children with Au2sm
* Considered to be hard to toilet train * Students with an ASD are extremely hard to treat once they have a toileting disorder * Difficult for parents because the usual strategies may not work * Usually gain control within 1 year of neurotypical peers * Every individual is unique
Toileting students with an ASD
Special considerations
* Nappy addiction is common * Sensory awareness and sensitivities * Anxiety and fears * Preference for routines and rituals * Limited learning through imitation * Poor motor planning * Reluctance to embrace change * Poor generalisation of skills to new situations * Importance of visual communication * Literal thinking
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What happens before school
* Introduce the toilet as early as possible to reduce chances of ‘nappy addiction’ * Introduce routine sits on the toilet, ideal time is when bath is running * Teach toileting routine, even if no results * Remember that after 4 or 5 years of practicing voiding in a nappy – it is a VERY hard habit to change!
Is this student ready?
Regardless of any interest from the child * Does the child stay dry for more than one hour? * Does the child do good volume wees? * Does the child have regular, so=, formed bowel mo2ons? * Does the child drink and eat appropriately in rela2on to toilet training? * Is the child 3?
Toileting readiness for students with an ASD
* Is there any interest or curiosity about the toilet? * Is there any change in behavior when the child is wet or soiled? * Is there any change in behavior in relation to toileting environment? * What functional communication is available to you to use with this student?
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Developing a toilet routine
* Every child and family is different * As a rule, teach using the toilet as an en2re rou2ne, not just siEng on the toilet * The toilet visits should be included in the child’s visual schedule for the day * The toilet rou2ne may be described in a picture strip
Getting started
* Set up schedule * Timed * Natural * Sort out communication * Record progress -‐ toileting diary or similar * Collaborate with family/staff * Be patient – reward yourself
* Never deprive fluids * Dressing * Flushing * Wash hands * Mistakes * To stand or to sit * Rewards * Literal learning
Important points!
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Fears can appear anytime!
Toilet refusers
* Very very common in children with an ASD * Preven2on beJer than cure * Get them happy with the toilet ASAP – before 3 * Change then as close as you can to the 2me that
they have voided, in or near the toilet/bathroom * Stand up changes can make this easier * The goal is for them to develop an associa2on with voiding
and the toilet – especially for poo * Ensure against too much holding with increased fluid intake
and prophylaxis for cons2pa2on
What can you do?
* Keep the child within their comfort zone * Give the child 2 choices -‐ e.g. you can have do poo in the toilet or you can do poo in the nappy in the bathroom * Reward any behaviour that is moving forward
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Bottom wiping
* ? Effective before 6 * They can’t see what they are doing * They can’t feel very well * Medications may make bowel motions sticky
Please help them * To prevent skin break down and infection * To reduce the times that they are smelly * Teach them wiping in other activities if appropriate
* It is never too late and children are never too old
* Toilet training a child with a disability can be hard work * Get extra help when you
need it * It is almost never the
child’s fault and they should never be punished
Point to remember!
* Victorian continence Resource Centre * Toilet tactics kit * One step at a time – Toilet training children with special needs * Visual supports * www.pandatherapy.com.au
Resources
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