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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    

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