Potty Training with Attention and Behavior Problems

Teaching a child to potty train is a complex task. There are many components that can affect a child’s progression and retention of toileting independence. Parents often times seek out potty training help when they are working on building independence in this functional skill of childhood.  While there are many considerations that go into the developmental progression of independence, attention and behavior are key skills in function.

Today, I’m joining nine other Occupational Therapists and Physical Therapists in dissecting potty training and all things toileting.  From developmental stages of toileting to the fine motor considerations and potty training tools; we’re talking all things potty training from a therapist’s point of view.

Last month, the Functional Skills for Kids team covered Handwriting, and you can see all of the Handwriting concepts in one place here.

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Potty Training Tips and Help for kids with attention or behavior problems

Attention and Behavior considerations in Toileting and Potty Training the Child

Behavior and Potty Training

It is important to note that many times, behaviors that are seen with potty training are a result of potty training starting too soon.  When a child demonstrates behaviors, there is often times, a communication point that the child is trying to get across: Behaviors are many times just information. Other times, behaviors are normal development of a child’s cognitive and imagination.  Children who are potty training might refuse to take time to toilet, make urine or fecal messes on the floor intentionally, throw objects into the toilet, or refuse to use certain bathrooms, among many other behaviors.

It is important to take the behavior objectively and think about the behaviors as information. Information should be viewed objectively and without bias.  A behavior can be viewed as good or bad but in order to address the behavior, it is necessary to figure out the reason behind the behavior.  A child who has tantrums and hits an adult is considered to have bad behavior while a child who attends to a task is considered to have good behavior.  This bias is a perception of behavior.

There are many reasons behind behaviors related to potty training and the act of toileting.  Behaviors may be a result of:

  • Sensory concerns with steps of toileting
  • Fear of going into the bathroom
  • Anxiety as a result loud hand dryers or other sources of over-stimulation
  • Fear of self-flushing toilets
  • Uncertainty of the steps of toileting
  • Difficulty with fine motor or gross motor/positioning needs related to toileting
  • Constipation due to holding output or other physical discomfort
  • Cognitive delays limiting understanding of portions of the toileting process
  • Unfamiliarity with surroundings when using different bathrooms
  • Difficulty with the breakdown of a multiple step task such as clothing management, toileting, and hygiene
  • Inability to communicate effectively
  • Typical development of boundary pushing and expression of language and cognition

These types of difficulties can result in reactions that lead to frustration and tension between the child and adult.  It is important to remember the causes of behaviors throughout the potty training process.

Once there is a potential reason identified for the cause of behaviors related to toileting, examine the behaviors and consider the following questions:
  • What is the child getting or not getting from the behavior?
  • What makes the behavior stop?
  • What makes the behavior continue?
  • What are precursors to changes in the behavior?
  • Does the child withhold toileting breaks to avoid going into the bathroom?
  • Does the child demonstrate cognitive, communication, sensory, fine motor, or gross motor difficulties that might interfere with steps of the potty training process?

One tip to adjust the precursors to behaviors in toileting is to modify the task or simplify the steps that you are asking the child to complete.  Begin where the child is consistently successful. A child who’s anxiety of entering a bathroom prevents further progression of independence may begin with the child walking into the bathroom, and staying in the bathroom for a count of five.  Continue practicing this portion of potty training until there is success.  Then the child will be capable of moving on to other steps of toileting.  Gradual progression of potty training coincides with waiting to begin potty training until the child has shown readiness cues.  

Tips to help with behaviors related to potty training:
Aggressive behaviors might include shouting or physically hitting and might occur suddenly as a result of frustrations perceived by the child.  Other children might become upset in certain bathroom environments like public restrooms.  Still others might overly focus on certain details.  It is important to try and understand what is causing the child to become angry, upset, anxious, or agitated.  Take time to respond:

  • Think about the cause of the aggression or anxiety.
  • Focus on the child’s emotions.
  • Be positive and reassuring.
  • Provide reassurance through calm a voice and phrases.
  • Reduce noise and distractions to help the child relax.
  • Follow the child’s lead.
  • Realize that some behaviors can indicate that the child isn’t ready and they are communicating a lack of readiness through their behaviors.
  • Keep it simple: reduce verbal cues.
  • Boys can sit to pee at first until they get the hang of the physical act of awareness of the urge to urinate and clothing management.
  • Use the same gender roles to make learning easier.
  • Begin potty training when it works for your family time-wise: don’t start potty training during a vacation or when other changes are happening in the household.
  • Also accept that there will never be perfect timing to start potty training.

Attention Considerations in Potty Training

Like the reasonings behind behaviors seen in potty training, children often times have a reason for inattention leading to poor carryover of skills or steps of toileting.  There are certain attention areas that should be achieved by children before attempting to begin potty training. A child should have an attention span that allows them to respond appropriately to verbal instructions when they are given one step verbal cues:

  • Sit down in a chair.
  • Stand up.
  • Walk to another room.
  • Imitate a parent in a simple motor task.
  • Point to body parts when asked.

If a child is not able to attend to these tasks, they may not be ready to begin attention.

Strategies for Helping with Challenging Behaviors and Attention Difficulties during Potty Training 

Tips and help for potty training with behaviors and attention problems like this key chain schedule.
Tips and help for potty training with behaviors and attention problems like this key chain schedule.

Potty Training Schedule

Visual Supports– These might include visual supports are schedules, dry erase boards, and timers.  A schedule can be as basic as a “first-then” cue or complex and including each step of the potty training process. I have created a customized schedule card that can be attached to a key chain and taken to various bathrooms during outings as well as used in the home. Use the steps printable to customize the schedule card to meet the needs of your child.  
How to make a customized potty training schedule for kids:

  • Print the schedule images. Cut out the pictures that work best for your child’s needs.  You can adjust the length or steps of the schedule based on your child.  Changes to potty training schedules should be practiced for at least two weeks before giving up on a specific technique or schedule.
  • Using card stock, cut a 2 1/2″ by 9″ length.  
  • Create  2 1/4″ x 2″ card stock squares for covers.  
  • Fold and tape the covers to the back of a 2″ square card stock.  This will hold the different steps of potty training.  
  • Create a small slit and attach a badge clip. Use this clip-on schedule by attaching to clothing or hang it in a bathroom.

Choices– Incorporate choices into the potty training process.  Choices might include: Do you want to use this restroom or that one?  Do you want to use the paper towel or the hand drier? Do you want to walk or hop into the bathroom?  Choices like these allow the child to feel in control of a situation that has to happen.  Toileting is a task that must occur and the choice that a child makes can sometimes be withholding toileting or purposefully urinating on the floor instead of in the toilet.  

Positive Reinforcement– Positive behaviors can be rewarded to provide feedback to the child with behaviors.  Feedback is the information about the outcome of a response. Internal feedback is the response of the sensory systems in respond to a task.  A child feels better after toileting.  External feedback comes from a source.  In potty training, external feedback might be visual cues or praise from a parent in response to completed tasks.  A reward system is another type of external feedback.  Feedback can be provided after every completed step of potty training, or it can be varied to transition to the end of tasks.  Feedback (like a small food reward) that is given after every step of potty training becomes a crutch.  Positive reinforcement should be transitioned to the end result of toileting, including hygiene, washing hands, and leaving the bathroom in order to help with skill retention.

Initially, a positive reinforcement such as a food or sticker reward should be given immediately after the child does the expected behavior. They can be given the reward every time they complete that part of potty training. Gradually you will increase the steps the child needs to accomplish before earning a reward. Parents should be specific with the behavior that is being reinforced. Say,“I like the way you are sitting on the toilet,” as they are given a tangible reinforcement. 

Reinforcer Chart– A child who is working on multiple steps of potty training or who has moved on from single step positive reinforcement can use a reinforcer chart to earn a small prize after multiple successful attempts at toileting.  The child might earn a toy from a prize bin or a small treat at a store.  This type of reinforcement builds delayed gratification.

Positive Communication- When behaviors arise during potty training, it is important to use effective communication and not respond with criticism to behaviors or inattention.  Also important is avoiding the term “good job” as a reward to accomplishing desired behaviors.  A child might not be successful but tried hard.  Other more appropriate terms include words or gestures for encouragement or suggestions for “next time”.

    Potty Training Tips to Help with Behavior and Attention Concerns:

  • Simplify when teaching new skills.  Break down tasks into smaller, obtainable steps to allow success.  Provide positive reinforcement to each step.  
  • Use stronger reinforcers for more difficult tasks.  This might include holding urine overnight for several nights or continuing potty training skills at different settings outside the home.  
  • Verbal cues are more difficult to fade than physical cues.  Limit the amount of verbal cues once a child has shown success with steps of potty training.  

Stop by and see what the rest of the Functional Skills for Kids team have to say about Potty Training:

Modifications For Potty Training  | Therapy Fun Zone

Warwick, T. (2013, February)Effective Strategies for Decreasing Challenging Behavior in Individuals with Autism Spectrum Disorders. OccupationalTherapy.com, Article 2174. 

Tips and help for potty training with behaviors and attention problems like this key chain schedule.
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