Toileting and School
by Jodie Thompson
For children starting school for the first time or for those who are returning to school, it can be an anxious time whilst they settle into new routines, get to know their teachers and are making new friends. Many children who are quite sensitive to changes in their normal routines can find it difficult to adjust and adapt, often displaying some regression in their behaviours or skills they have acquired.
This includes their toileting behaviours and within their familiar, safe home environment that has readily accessible toilet facilities they may be fully continent. These skills however don’t always transfer well when they start at school due to some common reasons including :
- New environments and new distractions can reduce children’s awareness of when they need to use the toilet and so accidents can occur if they leave their run too late to use the toilet
- Children have a fear of missing out on playtime and will often forget to use the toilet during break times at school
- Some children don’t find use of the toilets a particularly pleasant experience at school and will avoid using them as much as possible which leads them to withhold their wee or poo and this can result in them having an accident when they just can’t hold it in anymore.
- The location of the toilets may be a distance away from the classroom and so for children who only recognize the message that they need to use the toilet at the very last minute can experience some leakage on the way there.
Depending on the child’s age, one of the most important ways to help children manage this is to be prompted by their teachers to use the toilet at regular intervals during the day, approximately every 1 ½ - 2 hours, often coinciding with breaktimes. There are also programmable vibrating alarm watches that are available that children can wear that can help to prompt them to use the toilet at different times.
Some children find the experience of using toilets when lots of other children around to be too overwhelming and would benefit from having the opportunity to access the toilets during class times when it is quieter versus in the busy break times. For children who are particularly sensitive with their toileting needs they may require some special access to a separate accessible toilet which is sometimes in a quieter area of the school to offer them some additional privacy.
There are continence products that are available on the market that are designed to support children’s continence needs which can be helpful during times of transition or change in their routines where ‘sneaky leaks’ can sometimes occur which required containment so that they are not embarrassed in front of their peers. Some children may still require the use of pullups but there are many different brands available of reusable incontinence underwear available on the market as well but ensuring that they have enough absorbency to contain any sneaky leaks is important when choosing the right one for your child. Absorbency of 100mls and over is usually enough depending on if they are only passing a small amount of wee into it versus a large amount. Having a change of clothes available in your child’s bag plus a discreet wet bag to also bring wet or soiled underwear or clothes home is important to support them.
What if my child isn’t toilet trained before they start school?
This is a concern that is regularly raised by parents of children that I see in my practice. I work with many children who have a Global Development Delay and may have Autism Spectrum Disorder or Attention Deficit Hyperactivity Disorder and other conditions that affect their cognitive or physical development that can have an impact on their skill development.
For many of these children they may not be toilet trained by the time they are legally required to attend school at age of 6. They may not have the awareness of their need to use the toilet or the control required to hold in or release wee and poo. This is not something that they have voluntary control over yet, but these skills will come with time, but it will be on their timeline and no one else’s. It is so important that we meet children WHERE THEY ARE AT, not where others think they should be with their skill development around toileting.
Many children may have previously had attempts made to help them toilet train before they were cognitively ready and had the skills to be able to learn the tasks of toileting which have subsequently traumatize them, undermined their confidence and left them with a sense of failure and a reluctance of wanting anything to do with the toilet. They may actively avoid using the toilet and for some children they start to withhold their urine and stools which only leads to the development of constipation and an increase in accidents.
Supporting children who experience incontinence by the time they reach school age requires a sensitive approach and should include a team of both health professionals and education staff to work collaboratively to work out a realistic toileting plan for each individual child, what support they require, the best products to meet their needs to maintain the children’s confidence and social continence.
Consultation should be sought from a Nurse Continence Specialist if your child is experiencing incontinence by the time they reach 5 years of age to screen them for any underlying bladder or bowel concerns and come up with a realistic plan of how to support your child as they transition to school. Children often require collaborations as well with Occupational Therapists, Physiotherapist, Dietitians, Psychologists and Behaviour Support Practitioners depending on their individual needs.
Bed Wetting and School
When children start back at school it is common to see a recurrence of bedwetting especially if the child has not long achieved dryness overnight. There are many contributing factors to this but common reasons include
- Increased levels of fatigue from full days at school that leads to deeper sleep overnight and lack of awareness of the sensation of when their bladder is full, so they miss their cues to get up to use the toilet
- Changes in routine and daytime toileting as well as eating habits can lead to constipation which can reduce the bladder’s ability to expand to hold the urine overnight if stools sitting low within the bowel are pressing on the bladder.
- If children are quite sensitive to changes in routine and their anxiety increases this can also lead to bedwetting as it impacts on their sleep quality.
- The use of some medications such as Catapres or Risperidone that help children to settle overnight can have a sedative effect and make it more difficult for them to recognize the feeling of a full bladder.
- Children who use drinking fluids as a way of helping to regulate as part of their sensory and emotional needs tend to consume more fluids later in the day which can lead to bedwetting again.
There are numerous disposable nappies or pullups available on the market that are suited to contain nighttime wetting as well as reusable discreet products which can be good for children who may be sensitive to the fact they still experience bedwetting and don’t want others to know, and these are products are good for taking on school camps, holidays or sleepovers at friends places.
Take Home Messages
Many children may not be toilet trained by the time they start at school despite the best efforts of their family and caregivers. The reasons for this can be varied but ultimately it is because the child has not reached a stage in their development that has formed the necessary connections in their brain that allow them to store urine in their bladder or bowel, release it on command and be able to identify the feeling of a full bladder or full bowel. If you can’t hold it in, then you’re not going to associate the feeling of fullness with needing to use the toilet.
It is important that we support children in their continence journeys by making the necessary environmental accommodations for them, use appropriate products to contain their wee and poo so they remain socially continent in front of others and involve the right professionals to help them with their skill development.
Remember we need to meet children WHERE THEY ARE AT with their continence journey and NOT WHERE OTHERS THINK THEY SHOULD BE!
This blog has been written by Jodie Thompson from Kids Collaborative a Nurse Continence Specialist based in Sydney, NSW Australia specializing in the care of children with complex needs including children who are neurodiverse and have rare conditions. The contents of this blog are subject to copyright and should not be reproduced without the permission of Jodie. To find your nearest Continence Nurse Specialist enquire at The Continence Foundation of Australia
Phone : 0435 126 972