Help & Support Professionals Children's Continence Pathway Toilet Readiness Assessment Instructions for the Toilet Readiness Assessment Download print-ready version of the Toilet Readiness Assessment Chart (PDF file) Has Bladder/Bowel Assessment Chart been completed? A baseline bladder/bowel assessment chart should be filled in when the child is first assessed. This should be repeated after any intervention e.g. treatment for constipation. Bladder: Interval between voids is at least 1½ hours Voiding frequency should be assessed in conjunction with an assessment of fluid intake – frequent voids can be caused by an excessive fluid intake, or inappropriate drinks. If the child is voiding more than once an hour check for constipation/UTI. Review fluid intake – concentrated urine can irritate the bladder. If child is over 5 years old and frequent voids persist in the absence of constipation/UTI and the child has an adequate fluid intake, consider treatment for overactive bladder. Bowels: Child passes soft stools between 3 times a day and 4 times a week If stool frequency is outside these parameters consider constipation +/- overflow. If frequent stools persist in the absence of constipation consider undiagnosed Coeliac disease/Cow’s Milk Protein allergy/absorption problem – refer to paediatrician. Toileting: Child can sit safely and comfortably on the potty/toilet for at least a minute Check posture - feet firmly supported, knees higher than hips. Consider aids – foot stool/children’s toilet seat/adapted toilet. Consider referral to OT for assessment. If child refuses to sit for at least a minute check suitable distractions such as toys/books provided. Check environment is acceptable to child – consider lighting/smells/sounds etc. Suggest regular toileting practice for short time, building up as tolerated by child. If the answer to these questions is YES, then the child is ready to commence toilet training. Use the completed Bladder/Bowel Assessment Chart to identify voiding frequency and likely bowel emptying times and plan a toileting programme accordingly e.g. if the child wees every 2 hours, then toilet them every 1½ hours. If a pattern of bowel actions occurs use that to guide toileting times – otherwise toilet child 20-30 minutes after meals (optimising the effect of the gastro-colic reflex) and before bed. Other things to consider: Awareness: Does the child give any indication of awareness of full bladder and/or bowels? Some children never show any signs of awareness; this is not an obstacle to toilet training. If there is obvious recognition of bladder/bowel emptying then the child is definitely ready to begin a toilet training programme. Recognising the sensation of wetting and associating it with voiding can be promoted by using washable rather than disposable nappies, wearing cotton pants under the nappy or putting folded kitchen paper inside the nappy. Communication: Has a means of communication been identified? If the child understands/uses speech then prompt the family to choose the terms they want to use for wee/poo/toilet etc and to use them whenever the child is changed or toileted. If the child uses symbols/pictures, then establish a system – start by showing the relevant image every time the child is changed or toileted. Suggest photographs of real toilets to prevent ambiguity; ensure more than one photo is used so the child does not limit themselves to one particular toilet! Participation: Does the child help pull pants and/or outer clothes up/down? Can the child wash and dry their hands with/without assistance? If the child is able to help adjust their own clothing they should be encouraged to do so. Handwashing, independent or assisted, should always be encouraged. Devising ways to promote the child’s independence, even in seemingly small ways, will help to engage them in the process. It will also provide opportunity for motivation such as reward systems, rewarding achievable goals. Behaviour: Is the child able to respond to commands? Do they usually respond appropriately to requests? If behaviour problems are likely to interfere with toileting programmes then these should be addressed in conjunction with everyone who cares for the child. Strategies for managing the child’s behaviour should be agreed and responses must always be consistent. Choose an achievable goal to work towards, and then plan small steps to gradually progress towards sitting on the toilet. Positive answers to any of these questions points towards readiness for toilet training. Negative answers are not necessarily obstacles though; toilet training should not be delayed until the child e.g. shows signs of awareness, as this may never happen - the child may however achieve continence with a regular, timed toileting programme. Some children do well with weeing in the potty or toilet but refuse to poo. Refer to ERIC's information sheet Children who will only poo in a nappy.