Toileting/Bathroom Hygiene
Bathroom routines are such an essential part of our daily lives. It is typically the first thing we do in the morning and the last thing we do each night.
“Trauma as well as developmental delays can cause significant delay in mastery over toileting and toilet hygiene.”
Tactile (Touch)
Tactile input is not limited to just items that we touch with our hands. Tactile input includes any sensation related to another object (soft/hard, wet/dry, cold/hot, etc.). Children that struggle with age-appropriate toileting hygiene might struggle with the tactile input in their inguinal area. This can cause difficulty with ensuring that they have fully wiped (pee or poo) as well as determining if they have dried themselves off efficiently after bathing.
They might also struggle with tactile processing on their hands. For example, when you are wearing gloves you struggle with identifying what objects are in your hand. If a child struggles with tactile input they might be able to wipe appropriately as they might not be able to tell the difference when their wipe is wet or has come in contact with bodily fluids.
Vestibular (Head/Body Positioning)
Vestibular input is the ability to identify what position your body is in. This does not require any input from your visual system. For example, if you are on a roller coaster and you close your eyes you are still able to determine if you have gone upside down, sideways, etc.
Vestibular input can be a very alerting input. The turning and tilting of our head this required during toileting hygiene can be distressing. Difficulty with vestibular processing can be seen as distress with simple things such as being picked up, riding in the car, and evening tilting your head back.
Proprioception (Body Awareness)
Proprioception is the sensory skill of knowing where your body is specifically located. For example, have you ever had a doctor ask you to touch your nose? He is looking at your ability to coordinate muscle movements based on the input that your proprioceptive system has received. For a child difficultly with proprioceptive input can look like frequently bumping into others and “ping-ponging” off the walls.
Therefore, if a child struggles with proprioceptive input, they might not be able to locate their inguinal area without relying on their visual system to compensate for this deficit. These children might benefit from a visual demonstration of their inguinal and peri-anal anatomy.
Stereognosis
Stereognosis is the perception of being able to identify what you are holding/touching without looking at it. For example, if you have a pocket of change and I said to pull out one quarter you have the ability to identify and pull out the coin without ever looking at your pocket.
Difficulty with Stereognosis can impair a child’s ability to dress themselves as they struggle with identifying what they are holding and when they are reaching for various items (toilet paper, wipes, clothing, etc).
Reflex Integration
God designed our bodies with protective mechanisms called primitive reflexes. Theses reflexes were designed to help protect our helpless bodies during infancy. However, they are meant to become integrated via exposure to a variety of sensory inputs (tactile, vestibular, proprioceptive, etc).
Children that have experienced trauma typically have not had the opportunity to go through age-appropriate developmental play. Therefore, their overall developmental and reflex integration has been delayed.
These reflexes can become a nuisance as child get older as they can make bilateral coordination (using both hands at the same time) and midline crossing (reaching over your body) very difficult. If your child has an intact ATNR, STNR, Moro, or Landau this can make the motor coordination very difficult for your child to be able to wipe themselves. (If your child is struggling in this area it is recommended for your child to receive assistance from an occupational therapist).
Motor Planning/Coordination
Motor Planning is the skill of making the motor plan of exactly where, how fast, and when our certain muscles should be triggered into making a coordinated movement. Motor coordination involves interpreting various sensory systems in a way that allows us to make calculated and specific movements for variety of purposes (balancing, playing catch, etc).
This is commonly known as “muscle memory”. Building muscle memory requires frequent and precisely repetitive practice. For example, a marching band won’t be able to memorize the correct steps if they only practice them one time or if the only time they practiced it was the “wrong way”.
For females it is particularly important that they are taught to wipe front to back. If they aren’t ever taught or explain the importance of this motor plan it is unreasonable for us to assume that they will obtain this skill on their own.
To practice this skill you can do various activities to increase their motor plan to reach and wipe in that direction (see below).
Multi-Sensory/Executive Functioning
Multi-sensory input is the ability to interpret many sensory systems and sort them based on importance. Then you are able to analyze your accuracy and come up with a problem solving strategy to increase such accuracy.
Not only does this require a lot of sensory processing skills, this also requires years to obtain. A toddler (2-4) does not have the physiological brain capacity in order to think abstractly. At 5 years-old this skill begins to emerge.
Additional Tips
Poor use of toilet paper? Teach your child to only use the amount of toilet paper that stretches from their wrist to their elbow. You might need to also teach them to flush between wipes to help avoid a clogged toilet. It is also important to teach your child to fold the paper instead of wadding it up. This will help with tactile and proprioception input to encourage good accuracy with wiping.
If your child struggles with the sequencing required for toileting you can find a visual bathroom routine below that you can print and laminate for your convenience.
Squatty Potty and Children attachment while help your child have good range of motion with their legs and appropriate positioning to increase available surface area to clean. (See below)
Provide visualizations by practice wiping. This can be a simulation with a doll (Nutella for poo, lemonade for pee) or even wiping off counters. This is a great way to teach thoroughness.
Just as a parent would not want to wipe their infant with toilet paper, your child might need toilet hygiene wipes to increase their accuracy with wiping. In a sensory perspective the wet/cold input that the wipe provides might encourage full coverage when wiping.
If you have tried everything with no avail, you might look into a bidet! You can even try a portable, cheap, refillable peri-bottle before making the investment and installment.
Witch Hazel is a hypoallergenic and sanitary product made from a Witch Hazel plant. Witch Hazel has a cleansing and astringent property that provides a tingling sensation when applied to the sink. This can help increase a child’s tactile awareness in their inguinal area. Furthermore, if your child suffers from chronic UTIs your child might benefit from the anti-itch and anti-inflammatory properties that Witch Hazel provides.
Practice crossing midline (front and back) activities such as:
Pulling sticky notes off the back of a chair
Putting on a belt
Locating small items in their back pocket
Locate items under your seat while remaining seated
CORE -consistency, observation, repetition, and encouragement are necessary in helping your child understand and master the steps involved in potty training.
Final Reminder! Potty training takes an average of a quarter to half a year to master. Even after then, it is best to do random checks on their methods and accuracy of wiping.
