Question:

We have a 4th grade special ed. student who continues to soil his pants at school. Do you have a toileting program we could use for him? We have been working with this child since 1st. grade and it seems as though we start over each year. Thanks.

Answer:

Hi, I will need a lot more information before suggesting a/some "toileting programs" for this student. You describe him as a "special education" student but I do not know whether he might be learning disabled, mentally retarded or other health impaired (such as Cerebral Palsy). This is important in determining whether it is actually physically possible to toilet train him. If he is severely retarded then this may not be an option. Similarly with neurological difficulties it may not be possible to train him.

I am assuming that you are talking about "bowel" training rather than urine though certainly there are similarities. The sequence required for producing a bowel movement volitionally when needed is actually quite complex. It requires an intact gut sensory system and also the ability to initiate coordinated bowel contractions to move the waste out. Glitches in the neurological system such as lack of sensation (some spina-bifida children) of bowel fullness or lack of the nerves necessary to propel bowel contents down and out(a problem called Hirshsprung's Disease) can prevent bowel training.

It is these factors that make talking with the child's pediatrician or neurologist a necessity. Though it would be unlikely that these conditions had not been already discovered in a 4th grader, it is important to receive medical clearance on the situation to avoid putting both yourself and the student in an impossible situation.

Similarly psychological etiologies need to be considered. A behavioral approach to bowel training will not solve any underlying psychological issues but a psychological approach to the difficulties might solve the bowel training difficulties. Sometimes the condition is both behavioral and psychological. "Encopresis" is a condition common in young boys (1st or 2nd grade) where a child withholds stool until impacted and then further waste overflows around the impaction. This leads to "soiling". You mention that in your question and I wonder if that might be part of your students problem.

Again, this is a difficulty that needs medical attention. Often a good approach is reassuring the child and their parents (and ruling out the neurological difficulties mentioned above). Then the bowel can be cleaned out… some form of oral laxative is less invasive than enemas and usually does the trick. Since the bowel is often stretched and less effective than it would be, the stool should be kept soft and a positive behavioral approach using rewards, toileting after meals etc. can be instituted.

After the above possibilities have been ruled out, then a "toileting program" would certainly be indicated. I asked a colleague to forward me the recommendations and references that he uses in such situations. I've included below a sample recommendation page and a list of books and web sites. I hope that this is helpful.