Toileting Regression (October 2013)

The Behavior Corner

I have recently gotten a few suggestions for a column on what to do when a child has a significant setback with toilet training.  A few parents have expressed frustration with children that had previously been completely toilet trained, in some cases for long periods of time but then started to have accidents at either home or school or both.

Although this can be a very upsetting and frustrating time for parents, caretakers, teachers and the students themselves there are some specific steps to take to get a child back on track.

See Your Pediatrician

Before anything else, please see a doctor to rule out any medical reason why this could be happening.  Because this is a bodily function and not just behavioral what seems like regression can really be caused by an underlying illness or condition.  Sometimes an untreated urinary tract infection or severe constipation or irregularity can be at the root of a temporary toileting setback.  These issues are not uncommon with children with special needs who can be finicky eaters.

Children may also show some toileting irregularities following an illness or as a result of antibiotics or other medications.  All vitamins or supplements that your child takes should be discuss with your doctors. They can impact on these bodily systems.  If your child takes regular medication it’s important to discuss these with your doctor or your treating psychiatrist to make sure that there are no side effects that may be playing a part in the toileting regression.

I cannot stress enough the importance of ruling out these possibilities. If the cause is an underlying medical reason, no further intervention is needed.

Go Back to the Beginning

If you have ruled out medical issues you will need to go back temporarily to a regular toileting schedule.  To determine the schedule, take notes on when the accidents happen and how frequent they are. In most cases a schedule of every hour will work but extreme cases may require you to schedule bathroom breaks every 45 minutes.

The key is to go back to the method that was successful for your child and focus on the positive.   Often times when children are experiencing toileting setbacks there is a tendency to correct and get upset. This comes across as punishment and can embarrass the child.  There can also be a tendency to argue with the child that he or she is a “big boy” or “big girl” and knows better.  Although I don’t ever advocate a punishing system, if your child had only one isolated accident this method would probably be effective.  However, if they are having significant toileting regression then this corrective approach is not likely to be effective as punishment programs are not opportunities for learning.

The goal of going back to a schedule is to reinforce appropriate toileting behavior. This is more than just using the toilet appropriately. It also reinforces a child’s desire to stay clean and dry in-between.  Putting a schedule in place allows you to reinforce proper behavior through the use of praise and tokens. It is much better to praise good behavior than reprimand inappropriate behavior.

Sometimes parents or teachers get frustrated with this advice as they see this as going backwards. “Why should I praise or reward him for staying dry for 45 minutes when he was fully trained six months ago?  He knows this already!”  The reason is because his or her current behavior does not demonstrate mastery of this skill so you need to go back to a level that allows you to reinforce it again.

The good news is that if this truly is a setback your child typically moves quickly through the schedule again and returns to full toilet control in a very short time.  After as short as two to three days of success you can lengthen your schedule until you are back to a normal child-initiated routine.  Just remember each child and every situation is different so it may take a bit longer for some.

As in the initial toilet training phase it is very important to be consistent with the schedule.  You will need to arrange your errands, therapies, trips and car rides around the schedule, at least for the first few days or week.

Reinforce All the Right Behaviors

It is also important to remember that toilet training is a two behavior goal.  You not only want your child to use the toilet for urination or defecation but you also want them to remain dry and clean in between.  This is an important distinction especially when dealing with children with underdeveloped language skills.

If you don’t remember to reinforce the need to stay dry between toilet use, then what often happens is your child will appropriately use the toilet but still have accidents. They may not realize they are supposed to exclusively urinate in the toilet.  To reinforce this, I recommend that at least once between scheduled bathroom breaks, check your child or ask them if they are clean and dry. If they are, enthusiastically praise them; don’t just do this on the way to the bathroom.  These are extra opportunities for reinforcing the actual target behaviors.

Avoid Pull Ups or Diapers

Although most parents are happy to stop spending countless hundreds of dollars on diapers and pull ups when toilet training is over they are often quick to reclaim them when there is a regression.  Try very hard not to go back as that typically confuses the child into thinking it’s ok to have accidents.  I know that it can be a laundry challenge or worse depending on the nature and location of your child’s accidents but if you avoid diapers or pull ups retraining will probably go faster.  If the child is experiencing toileting regression mainly at night consider using a pad under or over the sheets of the bed to make changing easier but keep them in underwear unless it is completely unavoidable.

Look for the Environmental Triggers

While you are returning to a schedule you also want to take very close note of the environmental changes that may have triggered this regression.  Was there a major transition in the home or school?  For example did the student change schools or teachers after a long time with one instructor?  Was there a death or serious illness in the immediate family?  Was there a birth of a sibling or a move to a new house?  These environmental changes can sometimes trigger toileting regression.

Some changes may seem like no big deal to you, but if your child is rigid or tied to routines, any change can be a major one.  Something as simple as moving to another bedroom in the house, getting a new bed, or changing nannies could spark a regression.  Although understanding the trigger won’t stop you from having to go back to a schedule, it may give you a better understanding of what is going on with your child so that you can provide supports for them.  This is especially true if your child has limited verbal skills.

The other reason this is important is because you may be able to take preventative measures the next time there is a major environmental change.  It is always better to be proactive rather than reactive.  While I am not suggesting that your child is always going to have toileting setbacks when there is a major life change, they may be prone to behavioral or emotional regression at these times. Being prepared and taking steps to limit the impact may help you in the future.

Try to Stay Calm and Find Positives

Few behavioral set backs frustrate parents more than toileting issues. Your best bet is to put a proactive plan in place and try not to get frustrated. Consistency is crucial here. In most cases the child will return to previous levels of training within a few weeks.  If it goes on longer, seek help from school or other professionals to determine other possible causes or intervention strategies.

Finally try to see what other positive behaviors or skills your child is exhibiting even in the midst of the toileting issue. They may have made gains in other skill areas that are being over shadowed by the toileting issue. It will do both you and your child good to focus on some of these other gains rather than just on this issue. Focusing on positives is better for all involved and will make the tedious nature of returning to a toileting schedule more tolerable for all involved.

Good luck!