Most parents assume that toilet training a child with low tone (also called hypotonia) isn’t going to be easy. A child with low muscle tone often crawls later, walks later, and may speak later. But low tone can affect toilet training in ways both obvious and subtle. As an occupational therapist, I want to share an explanation of why one of the consequences of low muscle tone can make teaching this skill just as hard as teaching your child to walk independently. Hint: it isn’t something you can see, and it isn’t balance or stability. (both very important, but quite visible, consequences of low tone).
When muscles are not “sitting at the ready” for use as they are in normal tone, it takes more time, more stimulation, more effort or all three to get them to contract and tighten. But it also means that the receptors inside the muscles of the bladder, the rectum, and the abdomen are not firing as frequently or as strongly. The brain’s interpretation of a change from resting state to the stimulation of stretched receptors is known as proprioception. The special ed teachers I work with in Early intervention would call it “body awareness”. This internal awareness of a change in pressure within your bladder wall, in your rectum and against your pelvic wall is what compels you and I to get up and go to the bathroom. This is “interoception“, proprioception’s internal version. With low muscle tone, your toddler is honestly stating the truth when they tell you that they don’t feel like they have to “go” and then they pee on the floor right in front of you. They may have only a very weak sensation of fullness, or it may only be perceived a few moments before they really have to go. That is what lower proprioceptive registration is like. All of a sudden, the level of muscle receptor firing has reached a point where it is perceived. And now there is a puddle on your floor.
What can you do?
In previous posts I have mentioned that all the strategies to develop cooperation and frustration tolerance are keys to teaching a toddler anything at all. I go into more details about readiness in Low Tone and Toilet Training: The 4 Types of Toileting Readiness. When you are facing an issue where the feelings that you are trying to sensitize them to are fleeting and invisible, you are going to need them to be very highly motivated indeed. That means that you work on Happiest Toddler on the Block techniques such as patience stretching and “feeding the meter”. These create positive parenting interactions that help your toddler listen to you when you tell them it is potty time and then keep them on the toilet long enough to make things happen. If your toddler ignores your directions unless it is something he wants to do, and engages you in defiance games constantly just to see your reaction, you have some work to do regarding his behavior before toilet training is going to be successful.
Here are specific suggestions for toilet training the child with low muscle tone:
- They need stronger physical sensations at the time when you sit them down on the potty. A full bladder stretches, and that stretch of the muscle wall is what they don’t feel unless it is a profound stretch. That means that they should drink a larger amount of liquid at specific times, so that bladder is really full at a predictable time. Yes, it means that roaming the house with a sippy cup will not work for toilet training. A half-full bladder isn’t going to give enough sensory input but it will empty when they bend forward or squat. If you have done the patience stretching and feeding the meter techniques from Happiest Toddler on the Block, your toddler can handle the change in beverage scheduling and they will be fully hydrated at all times. They are just not drinking all day long. The same thing can be done with meals, allowing for small snacks but having real toddler-sized meals, not grazing throughout the day. Full colon= more contractions and more sensations. A diet with fiber makes the poop firmer, and therefore sensations in the colon are more obvious. A higher-fiber diet is a good way to prevent constipation as well. This is a summary of a recent comment from a parent that used these methods: She told me that using this strategy made her life so much less stressful when taking her daughter out of the house for preschool or appointments. She knew that her child had fully emptied her bladder and wouldn’t be taking a big drink again until lunch. She didn’t have to scout out bathrooms constantly and keep watching her daughter for little signs that she needed to “go”. Makes sense to me!
- Watch your child closely, and see what their current voiding/defecating schedule seems to be. Not every person is like clockwork, but you need to know when they are likely to go once you have the drinking and eating schedule down. What goes in will come out. Kidneys are more reliable than intestines. About 30-45 minutes after a big drink, that bladder should be filling up. For some children it can be 20-25 minutes. Then you know when to get them on the potty. There is no point in sitting there when they are close to empty. Everyone gets irritated. Is your child unwilling to drink enough? You may need to offer a better beverage, such as a yogurt drink or chocolate milk. Serve them with a “silly straw” and watch that drink disappear!
- These children just don’t have that much abdominal muscle tension to help with voiding, so the physical position they are in can help or hurt their efforts. Sitting with your knees lower than your hips and your body leaning back reduces the intra-abdominal pressure. You want to increase their ability to push gently, so sitting on a floor potty in a slightly flexed position can help them contract their abdominal muscles and push with their feet to get some pressure going. Heavy straining is not recommended and so do not demonstrate or encourage superhero-sized force. Read my post on selecting potty seats that help your child do the deal. Picking A Potty Seat For Toilet Training A Child With Low Tone
- Don’t distract them from the job at hand. You might not be comfortable with a long conversation about toilet activities, but if they are chatting about Thomas the Tank Engine while that pee is coming out, they have no idea how it happened or what it felt like just before the stream started. They missed out on becoming more aware of the sensory experience, and low muscle tone can make that sensation very fleeting and vague for them to begin with. If they arrived on the potty full and ready to do their thing, this doesn’t have to be an extended bathroom visit. This bathroom trip is all about the process of using the toilet, not a rehash of what they did at school that day.
- Last, and probably obvious to most parents, is that you cannot shame a child for not recognizing a sensation that is not easily perceived because of low muscle tone. They didn’t cause this issue, and once they are motivated to use the toilet, they would like to please you and feel proud of themselves too.
For more information about managing toilet training with low tone, take a look at these posts: Is Your Constipated Toddler Also Having Bladder Accidents? Here Are Three Possible Reasons Why and Can Your Special Needs Child Stay Dry at Night?
And if your child has hEDS too, read Why Your Kid With hEDS Doesn’t Seem to Know They Need the Potty… Right Now! and Can You Prevent Pelvic Floor Issues in A Hypermobile Child? .
If your child has mastered the potty seat but isn’t ready for the “big time”, read Low Tone and Toilet Training: Using The Adult Toilet for two pieces of equipment that can raise their game, and a few other strategies to help them make the switch to using an adult toilet.
Want a guide to toilet training?
I wrote two books for you!
They are both available on Amazon as PAPERBACKS, or on Your Therapy Source as printable e-books.
Here’s what parents are saying about The Practical Guide to Toilet Training the Child With Low Muscle Tone”:
“The Practical Guide has truly been heaven sent! Although my globally delayed 5-year old daughter understood the idea of toileting, this skill was certainly not mastered. Our consultations with Cathy and her guide on how to toilet train have given me the knowledge I’ve needed to understand low tone as a symptom that can be tackled. Morgan has made visible advances, and I am so encouraged and empowered because I know what piece we need to work on next. Thank you, Cathy, for writing this book!” Trish C, mother of Morgan, 5 years old
“I would often say to myself “Cathy has to put all of her accumulated wisdom down into a book”. I am happy to say-here it is! You will find no one with more creative and practical solutions. Her insights and ideas get the job done!” Laura D. H., mother of M., 4 years old
Cathy has been a “go-to’ in every area imaginable, from professional referrals to toilet training. I can’t say enough positive things about her. She has been so insightful and helpful on this journey.” Colleen S. mother of two special needs children
Need MORE than just toilet training advice?
I wrote TWO books for the parents and therapists of young children with hypermobility
Read my post The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today! to learn how The JointSmart Child: Living and Thriving With Hypermobility Volume One The Early Years and Volume Two: the School Years will help you with the practical aspects of raising a young hypermobile child, from selecting the best equipment to communicating with your child’s doctors! They are currently available on Amazon as PAPERBACKS as well as affordable digital downloads, and as printable downloads with a clickable table of contents on Your Therapy Source!
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