Sensory Processing refers to how the nervous system detects, regulates, interprets and responds to sensory information. Sensory Processing is an important factor in considering a child’s attention, memory, behavior, and function (Ahn, Miller, Milberger, & McIntosh, 2004; Gardner &Johnson, 2013). A child’s brain needs to be able to register sensory information from the environment and react appropriately to it. If a child has difficulty regulating and processing sensory information, they may have Sensory Processing Disorder.
Sensory Processing Disorder is a neurological disorder in which the sensory information that a child perceives results in abnormal responses. Children who have difficulty processing sensory information often have inconsistent responses because they have a hard time discriminating between which sensory information is important and which can be ignored.
It is important to note that many children (and adults for that matter) have difficulty with processing certain types of sensory input. Typical things such as disliking certain smells or textures, feeling seasick on rides, or preferring certain foods do not necessarily mean that a child has sensory processing disorder. They may simply still be learning to process certain sensory stimuli.
There are eight sensory systems in our bodies:
• Tactile System (touch)
• Vestibular System (balance)
• Proprioceptive System (position in space)
• Olfactory System (smell)
• Visual System (sight)
• Auditory System (hearing)
• Gustatory System (taste)
• Interoceptive System (internal body awareness)
Interoception is our ability to sense what is going on inside our bodies internally. It includes sensations such as thirst, hunger, fatigue, pain, breathe, itchiness, nausea, temperature, etc. It also includes our sense of if we have a full bladder or bowel, and if we have “released” it. (Garland, 2014).
An explanation of the sensory systems related to toileting
The proprioceptive, vestibular, and touch senses are primary influences on the integration of our senses. The interoceptive sense also plays a crucial role in developing the foundational body awareness needed to function as a child.
When a child is unable to integrate and react to sensory information appropriately, the child will not interact with his environment in a functional manner. He may have exaggerated responses to typical noises or sensations or withdraw from certain stimuli. The child cannot consistently process sensory information, so their responses will be inconsistent, too.
If the child has decreased body awareness, they may demonstrate an inefficient grading of force or movement. For a boy, this may mean they have difficulty using the right amount of force when holding or aiming the penis. This might result in a child pressing so hard that it’s difficult to pee, holding too tightly, or having difficulty holding steady.
Our vestibular system helps us to maintain our balance. The fluid in our inner ear moves as our head moves, sending messages to our brain about where our body is in space (Abraham, 2002). Some children with vestibular dysfunction present with “gravitational insecurity”, which makes them seek a secure position during activities. They may dislike swings, being picked up, or participating in activities in which they are not in control of their body in space. These children might be fearful when attempting to sit on a “grown-up” toilet where their bottom is unsupported because they feel like they may fall.
Children with vestibular, tactile, and proprioception difficulties may have difficulty with eye-hand coordination and depth perception. It may be difficult for them to aim appropriately or estimate where to stand.
Many children with sensory processing difficulties have auditory sensitivities that interfere with toilet training. Think of the loud echoes, flushing toilet, the hand dryers, etc. Noises that are simply loud to an adult can be piercing to a child with auditory sensitivities.
Tactile sensitivities can interfere with toileting, too! Children may dislike the sensation of pooping, wiping, or even sitting on a hard seat. If they are under-responsive to touch, they may not realize that they aren’t covering their hand properly with the toilet paper, they aren’t wiping well enough to clean themselves, or that they’ve soiled their clothing.
Sensory processing and body awareness needed for toilet training
When our body is able to receive and interpret the signals from our skin, muscles, and joints, we are able to feel and know what our body is doing without looking at it. When a child has poor body awareness, it can lead to difficulty coordinating their body to do all of the components that are involved in toileting.
It is not automatic to feel the urge to go and just go to the bathroom. Each step of the task must be thought out and carefully performed, so it is important to be patient. It’s hard to know what to do if you can’t feel what you are supposed to feel!
Typically, toddlers and preschoolers spend a lot of time learning the “ins and outs” of toileting. Children are expected to be toileting independently before entering nursery school. Children with difficulties modulating sensory input find potty training to be a much bigger challenge than a typical child. The bathroom can be an overstimulating environment, so asking a child with sensory integration difficulties to focus on the task at hand (ie; peeing or pooping) is a challenge if they are overwhelmed with fear or anxiety about other sensory signals they are receiving. Problems with toileting and sensory processing might include (but not be limited to):
Toileting and sensory processing related to poor interoception
• May be unaware that his bowel or bladder is full.
• Feels that they need to go, but not be able to discriminate whether they need to urinate OR have a bowel movement.
• Unable to “push” in order to go; don’t understand how to make those muscles work
• Cannot feel that they have had an accident or that their clothes are soiled.
• Unable to bend and reach behind them to properly wipe
Toileting and sensory processing related to sensory defensiveness
• Dislikes the feeling of “peeing” or “pooping” and withholds.
• Fearful of falling in a regular sized toilet
• Dislikes the feeling of wiping or being wiped.
• Prefers the parent to wipe them
• Does not like to wash their hands
• Takes off all their clothes to use toilet
• Avoids flushing the toilet
• Toileting and sensory processing issues related to poor registration or sensory input with a hyperactive or over-reactive response.
• The child is fearful of the sensations involved when they pee or poop.
• Reports that the act of “peeing” or “pooing” hurts terribly, crying, etc.
• Extreme reaction to the sound of the flush or the air dryer
• Gags, chokes at the smell of the poop
• Visually distracted by details in the bathroom, including lines in the tile, dust on the floor, etc.
Toileting and sensory processing related to sensory seeking
• Repetitively flushing the toilet
• Fecal smearing
• Repetitively having accidents in pants, enjoys the sensation
• Playing in the water
• Playing in the sink
• Asks to use the toilet in public constantly
Toileting and Sensory processing issues related to sensory avoiding
• Avoids wearing big girl or big boy underwear, prefers a diaper
• Will tell you when the diaper needs to be changed, doesn’t want a wet diaper
• Difficulty tolerating new bathrooms, public bathrooms, etc.
• Covers ears when flushing, air hand dryer goes on, etc.
• Holds nose for bowel movements
• Avoids using certain toilets with “hard” seats
• Avoids going into the bathroom, “sneaks off” to poop in diaper behind a couch, etc.
How to Help: Possible Modifcations and Strategies to help with Toileting.
• Try a 4 in 1 Stages Potty Seat which is closer to the ground and fits a smaller bottom. It also helps transition to using a grown up toilet
• Try fun potty seats like this Fire Truck Potty and Character Underwear underwear that are motivating!
• Try using flushable wipes and a Wipes Warmer to make the experience of wiping more enjoyable
* one consideration for this is that your child may begin to rely on it…. if you are out in public and don’t have warm wipes, will it be a problem? Take that into consideration before making it part of your routine. But if you are desperate, it’s worth a shot!
Sing Songs to make toilet training more fun:
• “Let it go! Let it go!”
• “Push it out, Push it out, WAY OUT!”
• “Pee Pee in the Potty, Pee Pee in the Potty!”
• “I just want to Potty all the time, Potty all the time, Potty all the time!”
• Use painter’s tape to make a line for boys to know where to stand
• Offer Toilet Targets or use this Bullseye Toilet Decal or use goldfish crackers or fruit loops (get the pee in the hole!)
• For children who aren’t sure if they have to pee OR poop, let them sit. It’s hard to tell which muscles are which.
• Provide an inviting environment depending on your child’s sensory needs:
• For a sensory seeker, bright lights, fun music and toys, alerting aromatherapy (peppermint and eucalyptus).
• For a sensory avoider, soft lighting (night lights) and music, calming aromatherapy (lavender and chamomile).
• Let your child leave the room before flushing if they are defensive, OR let your child choose if they flush or you do.
• Use earplugs to block the sounds, (especially in a public bathroom), OR keep post-its in your bag to put over the automatic sensor.
• Use a soft toilet seat.
• Keep a Potty Training Chart or offer Potty Reward Stickers for Boys or Girls
• Try a toileting schedule. Have your child sit on the toilet every 15 minutes for a few minutes. If they go, Wahoo! big Praise. If not, that’s ok, we’ll try again in 15 minutes.
• Provide a Kitchen Timer for set “potty” sitting times. Let your child set the timer so they are a part of the process.
• If your child is fearful of the sensation of pooping in the toilet, have them help you dump the poop from the diaper into the toilet and then flush it.
Toileting and sensory processing in children with special needs
Very often problems with potty-training, such as accidents, difficulty recognising if they have to go, struggles with hygiene, fear of flushing, and refusal to use the toilet are the result of an inefficient sensory processing system. It is important to note that children with developmental delays and other diagnosis may need more time to be trained. As parents and educators, it is essential to treat the process with patience. Your child has a lot of information and sensory signals to make sense of and every child has to go at their own pace. Do not feel the “peer pressure” from other parents that your child “should be” ready.
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Ahn, R., Miller, L., Milberger, S., & McIntosh, D. (2004). Prevalence of parents’ perceptions of sensory processing disorders among kindergarten children. American Journal of Occupational Therapy, 58, 287-293.
Crozier, S. C., Goodson, J. Z., Mackay, M. L., Synnes, A. R., Grunau, R. E., Miller, S. P., et al. (2015). Sensory processing patterns in children born very preterm. American Journal of Occupational Therapy, 70.
Daunhauer, L., Fidler, D., & Will, E. (March 2014). School function in students with down syndrome. American Journal of Occupational Therapy, 68(2):167-176.
Garland, T. (2014). Self-regulation interventions and strategies. Eau Claire, WI: PESI Publishing & Media. Shelly J. Lane, PhD, OTR/L, FOATA, Isabelle Beaudry-Bellefeuille, MScOT; Examining the Sensory Characteristics of Preschool Children With Retentive Fecal Incontinence. Am J Occup Ther 2015;69(Suppl. 1):6911500194p1. doi: 10.5014/ajot.2015.69S1-PO6099.