Toiletting

Disclaimer: This information sheet is for education purposes only. Please consult with your doctor or other health professional to make sure this information is right for your child.

Children/young people who have had a brain injury may have difficulties with toiletting as a result of balance/coordination problems, changes in sensation and awareness, decreased control of their hands or poor planning skills. The child/young person may be unaware of body signals (such as the need to empty his/her bladder) or may not remember how to respond to these signals.

Difficulties with toiletting may present in a variety of ways. In some cases, the child/young person may display incontinence. Other problems may include: difficulty with physically getting to the toilet in time, managing clothing, safety factors and requiring supervision/assistance with wiping. Children who are using a wheelchair may confront environmental limitations such as poor access or lack of circulation space in the bathroom, or they may require assistance to transfer to the toilet.

Who can help?

If there are concerns regarding toiletting, please discuss this with the Rehabilitation Doctor, Clinical Nurse Consultant and the Occupational Therapist from the Brain Injury Team. A team approach to the assessment of the problem is necessary to ensure that all

factors are considered prior to introducing a treatment plan.

Assessment would involve an evaluation of the following:

• Environment- access to the toilet, the need for rails or other modifications; need for supervision for safety.
• Motor Skills- assess ability to perform all the necessary movements to be able to use the toilet. This includes balance, arm and hand movements and the ability to manage clothing.
• Frequency- assess how often the child needs to go to the toilet, and if they need prompting such as a toilet timing program.

What is the treatment?

A knowledge of the child/young person's self-care abilities prior to the acquired brain injury is necessary so that appropriate tasks can be chosen to incorporate into the treatment program.

Whilst the child/young person is in the early stages of recovery (and may be confused and highly distractable) it will be necessary to develop routines so that the child/young person uses the toilet regularly as this will help to promote continence. As children/young people recover, it is important to encourage them to take increasing responsibility for their own self-care. The degree of independence expected will depend on the pre-traumatic level of functioning and the residual physical and cognitive difficulties.

Intervention to promote independence may include:

• Repetition and use of training strategies such as backward/reverse chaining. (In reverse chaining the child/young person is trained to relearn how to accomplish an activity beginning with the final step and progressing backward until all steps are learnt.)
• Use of prompt sheets and sometimes photos. These may have pictures/words to help the child/young person remember the sequence of the task.
• Use of adaptive equipment may be necessary to accommodate for physical changes. This may include equipment such as toilet surrounds or commodes, or may be modifications to clothing to allow the children to more easily prepare themselves for toiletting (for example elastic-waisted pants). Changes to the bathroom itself are often required, especially when the child is using a wheelchair. Ask the child's occupational therapist for advice.

Rehabilitation Department The Children's Hospital at Westmead Cnr Hawkesbury Rd & Hainsworth St, Westmead Locked Bag 4001, Westmead, 2145 Tel: (02) 9845 2132 - Fax: (02) 9845 0685 http://www.chw.edu.au/rehabilitation/