Greatest Hits - Gotta Go: Toilet Training Children with Down Syndrome

This summer, we're revisiting some of Hina and Marla's greatest hits from the first 10 seasons of The LowDOWN. On Season 3, Episode 6 of The LowDOWN: A Down Syndrome Podcast, Occupational Therapist Hina Mahmood gives us the lowdown on toilet training children with Down syndrome.

Transcript

The purpose of this episode is to explore common health and wellbeing, strengths and challenges for people with down syndrome. The content discussed here is not meant as a substitution for direct medical care with relevant professionals. Rather, we hope to share new and little known information so that families and supporters can be well informed when accessing medical care. Your child or student's medical or educational professionals may have recommended different practices or procedures that are specific to them. Do not modify or change your child or student's treatment or therapy plan without consulting with your care provider. Today on The Lowdown A Down Syndrome Podcast. Occupational therapist Hina Mahmud gives us the lowdown on toilet training children with Down's syndrome. Over to you, Hina. Thanks, Jodie. Hi there. I'm Marla Folden, SLP and cohost of The Lowdown podcast. And with me here is Hina Mahmoud M.OT, co-host and all round lovely human being. Hi, Hina. Hi, Marla. How are you? Oh, I am doing great. How are you doing? I'm good. Yeah. I'm happy to be back on as a guest this time again. I know, prizes in store for everybody. Yeah. We are back today with an episode about toilet training. Oh, yeah. Big topic. Big topic for sure. Um, and before we continue on with our episode, we would love for you to hit that subscribe button and leave a review of our podcast on whatever platform you use. Um, remember to check out our episode pages. We put stuff in there. Cool stuff that's either resources that are relevant and our guests will often also add resources as well. And you can follow the BSF at desforges and on Instagram and Twitter by following at Canada. Do it today. You got it. Um, back onto toileting. So toilet training is a major milestone for any person and represents growing independent skills. And it's also often fraught with resistance. And it can be a really long process. And I've just potty trained my own toddler at home and it was really quite the experience. Yeah, it's definitely an adventure of its own kind, for sure. How has your experience been? Well, I wanted it to be done. I didn't necessarily want it doing it. Yeah, exactly. Yeah. Um, yeah, it took longer than I thought. Um, messier than I thought. Um, but I'm also still really glad that it's done. Yeah. Like, other parents can relate to that one. Oh, for sure. And I and I think it's like, you know, it's kind of comforting to know that, okay, if a typically developing kiddo can have challenges. And of course, you know, our individuals with down syndrome are going to have challenges too. So, so many things are so similar amongst amongst both kind of types of kids for anybody. Challenges, messes, resistance. Lots of no mommies. Oh yeah. That know lots of things. Mhm. So today I thought we would take a look at sort of there's lots of methods. So we're going to take a look at different methods that are out there. And Hannah and I will chat about what works for kids with down syndrome and what doesn't, because not everything is going to work for any given kid. And kids with down syndrome are included in that. I also want to talk about pitfalls to avoid because there's several of those. Yeah. Yeah, absolutely. Yeah, there's lots of things and there's so many methods that we'll get into it. We'll chat about it. Yeah. And Hannah, just so that everyone who's listening knows it has done really extensive work on toilet training for people with down syndrome. She's given lots of community presentations in person and online, and she gives 1 to 1 support to families in direct therapy and toilet training and independence. With this routine, I would say for you, is probably in the top ten areas of things that you work on, am I right? Absolutely. And I, I also, and it's not only for younger kids. I've had quite a few clients that are older, um, you know, pre-teens or even teenagers that are having some challenges. So it is like many other things, a skill that we can work on across the lifespan. Oh, sure. And it's not, it's not. Yeah. It's not a one and done. It's not a oh no. Yeah. It's you're somewhere along the on the path. Absolutely. We'll get into it. Yes. Exactly. I'm so glad to pick your brain on this one. Yeah that parents listening are either doing the mental like phew. Glad that's over. Or cringing that it's still going on. I've been there. Yeah. Or daunted by the thought of even starting it. And I've been there too. I'm just not even wanting to go there. Really. And I do want to make it clear that people with down syndrome are capable of using the toilet. Absolutely. Degrees of independence. But definitely it's not something that's not achievable for our group of students and population. And we're just going to talk about that process today of how do we get there? For those of you who are joining us for the first time ever, we have a tradition of asking secret questions of our guests to help listeners get to know them a bit. Now, Hannah's been a guest here before, so this time I'm changing it up. Oh, fill in the blank questions. Watch out! Hannah. Here we go. Okay, excellent. All right, so, Hannah, can you fill in the blank? The most annoying sound in the world is. Oh, man. Um, Based off like a gut reaction, I would say I for me personally, the sounds of chewing like loud chewing or like loud slurping and drinking, I have a visceral reaction I can't like. I have to remove myself from the situation when I'm when I'm sitting next to anybody eating very loudly. So I would have to say the most annoying sound is loud chewing and or drinking for me. Yep. Fair enough. Yeah. It's a it's a thing to guys. It's a really. Well, yes, exactly. It's a thing like there's an actual term for it. I think it's called misophonia. So there are people like me in the world that also find similar noises annoying. So I'm not the only one. Oh, definitely. Yeah. Um, question number two. The best view from my neighborhood can be found. Oh, that's a good question. Um, so I live in the North Burnaby area, and, um, I recently discovered the beautiful views atop Burnaby Mountain, um, especially around sunset time, because it's kind of facing west so you can see the sun setting. It's amazing. I love it. Yeah. It's gorgeous. You get for people who are not from the Lower Mainland, you see the whole of downtown mountains on Vancouver Island. Oh, stunning. Yeah, with some water in between. It's just. Yeah. It's beautiful. Lovely. All right. Question number three. A well organized office is. Wow. You do know me really well. Um, a well organized office is my idea of heaven. I, for my coworkers and a lot of people that know me, I am. I love to organize. It is where my happy place is. Give me a messy room and I will take care of it and be the happiest to do it. So. Oh, yeah. Yeah. Oh, yeah. No. Everyone in our office building looks at Hannah's office as like, the gold standard of what beautiful office could be. And almost none of us get there. But we all know where to look. Where to look. Yeah, exactly. Yeah. If you can't get there, just let me to come. Let me come and help you. And I'll be happy to help you get there. It's my pleasure, believe me. Oh, man. Um. Number four, hot sauce is essential. It's essential. I am a spicy food eater. I've grown up that way. And, um. I mean, I'm the kind of person that finds spicy salmon rolls. Not spicy enough, so. So I'm like, give me. Give me some sriracha. I'm not a, uh. I'm not a one brand hot sauce person. I like all kinds, so. But it is definitely an essential staple to have. Um, just add some pizzazz. Mhm. Absolutely. And number five, this is a trickier one. The best part of working with families is oh that's such a good question. Yeah. You know I think recently I've been thinking about this, um, you know, we're kind of living in a pandemic age at the moment, and a lot of our DS services have been transferred to a service model. And I love when I'm doing sessions with the parents, with their kids, and then that moment when parents kind of recognize, oh, you know, like you're making progress because we're doing it every week and the parent can themselves see the progress happening. So I just kind of love that, that recognition. I'd love it when my clients know that they've learned something. That's the confidence boost. But when the parents or even sometimes I mean having sessions at home, the siblings will pop in and they'll, you know, encourage their, their, um, brother and or sister with, with down syndrome to, you know, do things and cheer them on. So as stressful as tele service can be for our parents, um, I found that it's so rewarding to see everybody in that child's immediate circle see the successes. So I just loved that part of collaborating with everyone's involved. Absolutely. And I would totally agree with you that having a family recognize the growth and the learning that's been happening, and then to really understand, like and it can keep happening and we can keep making progress towards these things. And all of this hard work you've been doing is, you know, paying off and your kids getting skills. Yeah. That is that feeling is everything. Exactly. Yeah. And it's just. Yeah. And I have seen so much progress over these last few months of tele service with some of our students. So it's pretty cool to see that happen. Yeah. Yeah. And you know, to me, that's been a really pleasant surprise. Yeah. The fact that I was really skeptical about how telehealth could work for our group of students. Mhm. And, you know, I didn't check my expectations. Exactly. And honestly, I've had some parents say that it's going so well and that they're really enjoying doing it with their kids. Yeah. And that they are like you know what, we're just going to take a break from school and I'm going to, you know, either homeschool or just like, you know, work more on these things at home because they're really getting into it. So it's kind of cool to see that too. Absolutely. Yeah. Yeah. All right. Let's dive into potty training. All right. Let's do it. This is one of those demonstrable skills that require so much from a person in terms of their physical ability, their sensory awareness, their cognition. And I would even say their social skills. Can you talk about what happens from a physiological perspective when we're going from not toilet trained to toilet trained. Mhm. Absolutely. So there are a few things we need to take into account from a physiological perspective. We know that individuals with down syndrome have low tone weak muscles, shorter arms. And all of this can really impact toilet training. So you know the low tone can make it difficult to sense bladder and bowel fullness. Um, the weak muscles can make it difficult to sit on the toilet with stability, and the shorter arms can make it difficult to wipe. So there are some of those very like core physical issues with down syndrome that can impact toilet training. But on a on a bigger level, um, and whenever I do toileting presentations, I definitely make it a point to let parents know that they have to think about some of the medical things that are going on that affect the physiology of toileting. And we know that our individuals with down syndrome definitely have multiple medical challenges throughout their lifespan. So this is why toileting can kind of be that roller coaster where it's going really well. And then it goes off. So sure. Um, there's I want to talk a little bit about just two of the big ones. So constipation is a huge, huge, huge physiological consideration. Um, many of our individuals with down syndrome suffer from chronic constipation. And this can definitely delay toilet training. People with lower muscle tone are generally at a higher risk for developing constipation. So I mean, not only is it uncomfortable and painful, um, chronic constipation can actually, you know, stretch out the colon, um, which would make it even harder for them to know when they have to poop, because the sensory receptors are, are kind of not working the way they should. Um, and it can actually take up to a year for it to return back to its original shape. Um, and for them to be able to recognize those signals again. So. Wow. That's a huge, huge component. Um, and definitely something when a kiddo is having trouble with toileting, I get parents to look at that first. And honestly, 90% of the time they're like, yep, yeah, they have constipation. So then we go off of that side road and um, and kind of work on that. How would how would a family know that? What would be the signs that constipation is in the mix? So, uh, infrequent bowel movements, Um, if, uh, if one thing is that I mean, you know, it's an at first and very painful experience to poop. So if they're sitting on the toilet, um, you know, and they're straining really hard when nothing's happening, um, you look at their water and dietary intake, um, that can be an indication that if they're not pooping and then their diet isn't really conducive to pooping, then, you know, um, I think talking to your pediatrician sometimes getting ultrasound or x rays to see where things are, um, in terms of the intestines and the colon. Um, so there's definitely some, uh, if they do poop, if it's in a certain shape that's really rock hard, that's an indication of constipation. So, I mean, majority of our people with down syndrome, you know, don't drink enough water. They really do spend a lot of their life dehydrated. So constipation is kind of just a given for most kids. Um, but the other thing about it is that that's stressful and painful experience can then create that memory long term, and then they're not going to even want to go to the bathroom. So if, you know, if their only memory of going to the toilet is pain, then they're never going to want to go there again. Mhm. Yeah. And we should point out too that, you know in other episodes we've talked about making long term memories for people with down syndrome and how that can be a little bit more difficult. Sort of the exception to that rule is highly emotionally salient things. Yes. So stressful events are often remembered immediately and for a very, very long time. And I mean, talking about, you know, other things too, like the death of a pet or a family member, but any instance of pain, you know, getting your blood drawn if that's traumatic. Yeah. Going to the toilet, if that's traumatic. Yeah. Our students do remember those things. Absolutely. So we can't just kind of brush it under the rug and be like, they won't. You know. That'll be fine. It will not be fine. Exactly. And toileting is such a like a, you know, a primary urge that we have as humans. So it's if there's anything that indicates an adverse experience leading to that, then it's a very hard thing to come back from. So, um, definitely constipation. I cannot say it enough. It's something that we need to need to look at. Um, the second physiological issue is bladder issues. So which can also impact toilet training for many of our individuals with down syndrome. Um, they may have issues with the bladder not emptying normally. Um, and this also is linked to constipation because a full colon and a stretched out colon can put pressure on the bladder. So this can really cause irregular urination and just other issues. Um, you know, some of them may have an underactive or an overactive bladder. Um, and as I mentioned, sometimes the muscles that control the urine flow do not relax fully. So this results in incomplete emptying. I've had so many parents say, well, they sat on the toilet. They peed for about a minute, then they were done. And then they got up and then peed again on the floor. So, you know, and we can talk a little bit about what the reasons are for that a little bit later. But it's definitely, um, I've had parents that have gone to their pediatrician to get a referral to a urologist. Um, because it is a known issue in individuals with down syndrome. I just want parents to kind of have it on their checklist of things to think about if they're having issues with urination and irregular urination or, you know, right, that kind of stuff. So, so something to I mean, if families don't have access to, let's say, urologist. Um, and they do know that their child is constipated. And there's also bladder challenges. The first approach is to see if you can manage the constipation a little better and see if the bladder issues might go away. Absolutely. You got it. Yeah, that would be nice. Yeah, we all see, you know, too many specialists anyway. Exactly. It's really stressful to go and do that. But yeah, being able to sort of manage some of those. So is is the constipation. Is it usually require medication or is it a hydration issue. Um, honestly, 99% of the time diet and hydration can can take care of it. I mean, there are instances where if it's become, um, too chronic, then you may need external help, like some form of a laxative. Um, uh, you know, I've had experience with clients where they need enemas at some times, but but that's not the case for most of our most of our kiddos. I think just a high fiber diet and lots of water. The water thing. I can't stress enough because I notice so many of our individuals not drinking enough water. And I mean, there's reasons for that. It's not, you know, from a sensory perspective, water doesn't have flavor. It doesn't, you know, make an impact on the tongue like a juice or something else will. But it also has those hydration properties that we really do need. So then we try to figure out a way with families on how to encourage kids to drink more water. Um, and if you need to add a couple of drops of flavoring, go for it. You know, so but water is for sure my number one thing. Please, please make sure that your kiddos drink enough water, make it a habit. And from the SLP side of things, water drinking is a hard one. Um, SLPs work on feeding sometimes, as do OTS, and water is the hardest. It's the thinnest liquid. It has no flavor. It doesn't have a smell. It doesn't have a smell. Yeah. So what we usually do is increase the sensory experience with water, either by making it really cold. Right? Body temperature. Water is the hardest thing. And you know, adults will notice it too, Like if you're ever going to spill water out of your mouth, it's when it's body temperature. Water. Yes. And that happens to our kids with down syndrome. And that's embarrassing. They don't want that. Yeah. So we make it really cold. Yep. Or we add some flavor to it. And the flavor doesn't have to be a prepackaged flavor, although it certainly can be. We make those little powder powders and crystals and things now. Yeah. Put a little bit of that in there. Or a slice of lemon peel. Fancy with that a berry frozen blueberries. It's bold and flavorful. Yeah. And usually I see when parents are able to do that and schools, the child's water intake increases quite a bit and it's easier and I like I would also recommend to parents to just, you know, join in with their kids. So I had one eight year old where they all got new water bottles. They made their son a part of the process of cutting up the lemons. What do you want to put in your water today? And oh, mommy has drunk this much water. You can have a visual chart so, you know, it's it's easier to do these kind of new things when you have somebody else doing them with you. I mean, I think that goes across the board for everybody. Like, if I want to start a new workout regime, if I have a friend or a family member doing it with me, then it's more fun. So if you have that, you know, that culture around the house and that environment where everyone's drinking water, you know, then it makes it a bit easier for our people to kind of follow through with it and get on board as well. Yeah. One of my favorite things to do, if we're if liquids are one of the goals in SLP, I will have, you know, my water bottle and my coffee cup on the table right next to the kids stuff. This is not in pandemic times, obviously. Yeah. Cheers. Yeah, we'll be playing our games and then we'll be like, oh, cheers. Drink them together. We'll both have a nice sip of water. Yeah, I think it's hilarious. And they feel super grown up. Yeah. And what do you know. They've drunk at least half their water bottle by the end. Exactly, exactly. Yeah, better to address it by addressing around it rather than standing over somebody and saying, drink this. Exactly. Yeah. Yeah, exactly. And then what you feel like doing for sure. And then we have to I mean, of course, there's that segment of our population that, you know, may have some physical issues with drinking and swallowing and stuff. So there's ways around that as well. But, um, you know, it's just something to kind of think about and really focus on because it makes such a huge impact not only with the constipation and the and the urination, but it helps with skin, it helps with alertness. You know, it just makes you an overall. I mean, 70% of our body is made of water. Yeah. So I think it's 70% don't quote me on that. But a huge percentage is made up of water, so we do need it. Um, and often a lot of us don't drink it enough. So. Yeah, sure. Um, let's move ahead a little bit here. Um, a lot of parents, myself included, do the potty training process because you go from these like super convenient diapers, which, you know, manage their own mess to heaps of laundry and cleaning up at home and on the go. And you're supposed to manage, you know, public washrooms and yikes, all of that. And building a potty training into your routine can can help tackle this aspect of training. So what do we do from a routine building perspective to get sort of get toilet training going? Yeah. So before we really talk about establishing routines, I think it's important to think about the skills that need to be in place to make the process a bit more successful. Um, and these behaviours or skills have come to be associated with developmental readiness in the research literature. But I tell parents that they're not all required to happen all at once. But these are definite considerations. Um, when you're thinking about, okay, am I ready to toilet train my kid? Um, so you look at some of the skills that your child may or may not have at that time. So let's think a little bit about the motor skills. You know, do they have the ability to get up and go to the bathroom. Can they walk to the bathroom. Um, can they pull their pants down to come, you know, pull their pants and underwear down? Can they stoop or sit independently on on the toilet seat? Can they sit for at least 5 to 10 minutes? Because you do need that extra time. Um, can they relax and eliminate, um, the waste? Can they actually bear down and push? Because even that, for our individuals with down syndrome can be a hard thing to teach. Like you have to really strain and push. What does that feel like? What does that look like? So we're considering motor skills. Um, then we're thinking communication skills. Uh, you know, like, are they able to communicate if their diaper is wet? So is that awareness there? Um, and the communication can take a variety of forms. You know, it could be sign language, it could be verbal, they could gesture, they can use visuals. It could be a combination of everything. Um, but I mean, with communication, I don't think it's always required. But if they're able to, it's a great way to kind of link the process. Sure. Um, and then we're thinking about their cognitive skills too. So are they able to follow directions because there's a lot of directions involved in toilet training? Tons. You know, do they have that awareness when they're soiled? Um, do they even have an interest in the bathroom routine? Some kids don't aren't even aware or don't even care about what happens in the bathroom. Um, do they understand from a behavioral perspective? Do they understand that if they do what you say, something good will happen? So it's that first then kind of connection like, oh, if you go to the potty, then you get this. Do they understand that in other contexts? What are their attention levels like. You know, can they sequence and plan. So Definitely a lot to think about from a cognitive perspective. And then the fourth area that I talk about with parents are the social emotional skills. And you did talk about how toileting does involve some social skills. Um, can they do they have that social relatedness piece? So can they imitate mom and dad, you know, their caregivers or siblings of going to the potty? Um, do they have that desire to be clean? You know, do they want their diaper changed quickly because it feels yucky on their on their body? Um, are they fearful of toileting? Um, you know, I've had some kids that have had some and constipation can be a reason there can be sensory reasons. Um, are they? And as a mom, you would appreciate this to Marla, but are they in that know phase like everything. No, no, no. You know, consider that a little bit. And then thinking about their learning style, you know, we know that our individuals with down syndrome are very strong visual learners. So once we have a really solid grasp on these pre toileting skills, we can use that knowledge to then build a routine. Sure. So you're saying it's it's way less about age and more about stage. And we need to see all of these things beforehand. So is it appropriate for parents to kind of I wouldn't say assess necessarily, but kind of assess and see like, okay, are we able to walk to the toilet? Can we get up there. Yeah. You know, are you paying attention to me when I go to the washroom? You know, are you grabbing at your diaper because you want it off? Because it's dirty? Yeah. Should parents be keeping track of all these little. Yeah, absolutely. And, I mean, and the thing is, like. Like I said, you don't have to have all of these things in place, but it's just some it's I would say that there are guidelines, you know, so just observe your child's behavior. Just see where they're at already. Um, I mean, I've had kids that I've started toilet training with that aren't independently able to get up onto the toilet yet, but that's fine. They've shown an interest. They can, you know, we'll talk a little bit about readiness later on, but, um, these are just skills, uh, to kind of look for and, um, you know, and if they can't get up onto the toilet yet, that's fine. You can help them get up there. And that's the thing with skills and independence. Independence can vary. So, you know, they can maybe step onto the first step by themselves and then the rest. Mom and dad help. So you kind of have to look at it on a case by case basis. But generally this is these skills are good guidelines to kind of get you thinking, okay, I feel like he has this this and this in place. Let's try it. Okay. Yeah. And then, you know, it's also important to understand that all these skills involved, um, involved in a routine. So we have to think about some of the other things like hand washing is part of toileting. You know, dressing and undressing is part of toileting. Wiping. Um, as I mentioned, even accessing the toilet. So what kind of equipment, you know, do they need to navigate? And then of course, the sensory considerations of the bathroom environment as, as OTS, you know, we're we're taught to and we teach parents and caregivers this as well to break down a skill to its individual steps. So you really see what's involved. And then you begin your teaching in a more systematic way that is developmentally appropriate. Um, and many of these skills can even be established into routines that you're already doing. Right. So hand washing you don't have to. It doesn't have to be in the toilet in context yet. It could be before eating a meal, um, working on dressing and undressing every morning or at nighttime. Um, practicing wiping if they're not ready to practice wiping on the toilet, that's fine. Practice while you're playing with dolls. Um, one of my favorite things that kind of gets parents to cringe a little bit is I say, put some peanut butter on a doll's bum and practice wiping it. You know, it might turn you off a peanut butter, but it works beautifully because it really is a good visual and our kids understand that, you know, what is it to be clean? Sure. You know, work on their core strengths so that they can sit with a stable posture. So there's lots of things that you can work on, um, in a routine that you're already doing and that is already established in the home. And the last thing that I want to say probably is the most important one is I implore all parents, caregivers, educators, everybody that's working on toileting to keep whatever routine you have to keep it consistent. This is so important for toilet training. So often I see kids with one twirling routine at home and then a different toileting routine at school, and then maybe a third toileting routine at daycare. Or if they come to see me at dsph. So, I mean, this can make the process so difficult because it's really unfair of us to expect kids to do something as important and complicated as toileting one way at home with a different set of rules and expectations and a completely different way at school. So often we'll have meetings with the school, with the parent for toileting plans so that everybody's on the same page. So consistency is really important. And do you even make up some kind of document that says like here is exactly how we're going to absolutely all of the steps, because I think the point you're making really beautifully is toilet training is not just one skill. It's a good 15, 20 different skills. Yeah. And I really like what you said about trying to offload some of the skills onto other parts of the day while you're sort of getting ready to be toilet training. It just kind of makes the the actual toilet training piece a little bit simpler, because you know that your child has already worked on handwashing and they've already worked on getting dressed and undressed. Yeah. And, you know, it's kind of putting the puzzle pieces together as opposed to trying to tackle everything under the umbrella, which is overwhelming. Yeah, exactly. And I think that for I mean, and we can talk about this a little bit later when we talk about the actual, you know, how we actually start the process. But if you as a parent are not ready or if you feel like your child isn't ready or your life circumstances, I mean, especially now that we're in a pandemic, that maybe toilet training is just not your priority. That's fine. There's nothing wrong with that. But there are those other skills that you can work on still that don't require going into the bathroom and sitting on the toilet, because that alone, just getting your kid onto the toilet and peeing and pooping is a whole other ball of yarn. But all these external skills that are part of the routine can still be worked on. And then when it comes time, they've already learned them so they can they're just that more independent when they're in the bathroom, you know? And that's a really nice thing because then for families who, you know, want to be working towards toileting independence, they can feel like that's actually happening. Yeah I'm working on that. Yeah. Working on the skills around it, dressing, handwashing, all of these things. So if the actual pee and poo piece of it doesn't fit with your life because there's a pandemic and things are happening, you're moving whatever. Don't try toilet training when you're moving. Yeah. Yes. Don't recommend. No. Then you don't have to worry about that. Yeah. You're still working on the same overarching skill. Yes, exactly. I want to get into a little bit sort of the how on the people sitting on the toilet. So there's, there's a lot of quote unquote official ways to go about potty training with a lot of experts and self-proclaimed knowledgeable people saying things that are often really contradictory. And this is confusing for everyone. So some people say, you know, go every hour. Some people say, keep your kid naked all day. Some people say, load that kid up with fluids. Give them candy. So what approach do you take when you're helping a family with toilet training? Yes. Yeah. And you're absolutely right. There are hundreds of toileting programs out there. Everybody comes up with something new every day, and many of them will promise, but not always deliver. So the way we approach toilet training as OTS, and especially at the DSF, is keeping in mind the learning strengths of our individuals with down syndrome and taking more of a developmental approach. Um, you know, as OTS, we're looking at the person, the environment, and then the task at hand, in this case toileting. So we're more of a holistic approach, um, and especially with our population with down syndrome, because there are so many of those other things you kind of have to keep in mind, um, before we set up parents and Caregivers with Toileting Plan, um, we talk to them about whether they're ready and whether their kiddo is ready. So, you know, both parties have to be looked after. Um, now, again, these are just guidelines. Um, and not everything has to be in place. But again, like the skills, the readiness factors are also important to consider. So from your kiddos perspective, can they remain dry for or unsoiled for about one to 1.5 hours? Kind of gives you a bit of a time in between. You can think about if they're dry during naps. Do they wet their diaper less often? Are you seeing them do that little cute kid pee dance where their legs are kind of crossed and they're just like kind of hobbling because they have to pee? Do they have regular bowel movements? Again, that constipation thing to consider. Um, and even something as like if they're playing. Do they stop to go have a bowel movement. So this is gauging their awareness. This is gauging what their body is doing. So just some things to think about from a child readiness perspective. From a readiness perspective. Um, you know, you mentioned this. You have to be prepared for accidents and some messiness because unfortunately it's going to happen whether you have a typically developing kid or a kiddo with down syndrome. No major transitions. This is a huge one. So if you have a work thing going on, if you're moving, traveling, or if you have houseguests. Wrong time to do toileting because baby in the family. New baby in the family. Absolutely. That's a very good one. Yeah. Yep. Exactly. Pandemic. You know, lots of things are happening. Um, that I mean, are are individuals with down syndrome are so routine and structure oriented that any shift can make it difficult. So for a process as complicated as toileting, we kind of want to have a good chunk of time available with nothing happening. Um, so that time commitment, you know, could be two weeks. Could be a month. It depends. But it needs to be a consistent amount of time. Um, and then the other thing from a parent readiness perspective is that our other people in your child's life on board. So family members, teacher support workers, you know, whoever that they that they're seeing on a daily basis again, pre-COVID. Um, you know, everyone needs to be on the same page. The routine, again has to be consistent. So from a parent readiness perspective, those are some of the things to consider. Now what if you know your kid isn't ready or you as a parent are not ready to tackle it totally fine. You know, there's lots of things you can still do in the meantime. Um, you know, you can introduce your kids to the bathroom and the toilet. You can read about it in books. There are lots of songs out there, just YouTube, Elmo, potty or potty songs, and you will be overwhelmed by the options that are available. So you're just kind of, you know, putting it in the, in their, um, psyche to be like, oh, this is the bathroom. This is where we go potty. I even encourage parents, if you're changing your kid's diaper, just do it in the bathroom so that they understand that that's where pee and poo go in the potty. Not in my room, not in the living room. If you can do it, that's a great way to introduce the toilet. Um, encourage those pre toileting skills. So hand washing. Great to start off if you're not ready for toileting. Um and then depending on your family dynamic and your comfort level, even having them observe parents or other siblings use the toilet because that's I mean, modeling, as I'm sure you know, Marla, that it's such a huge, powerful way for our kids to learn. So if you can model. Great. Another great. Honestly, say for my own kid, he is not going to like this when he's 16. But here we go. He made more progress in potty training when he realized that big kids at his daycare are doing this independently, and he was like, yeah, oh, absolutely. And he didn't really care that mom and dad were doing it per se. But if it's those motivating big kids, yeah, yeah, yeah. Peers are. Yeah. Peers are such good models for those kind of things. Right. Absolutely. I'm so happy you brought that up because that is a huge, huge reason why I think modeling is so important in a lot of things, um, that you're teaching our kids. So, I mean, now that we've kind of considered the readiness skills. So, I mean, and I'm just going to kind of give you a quick brief overview, because in our in the presentations I go into more detail. But for the actual training part, once the parents are like, okay, we're ready to go. What do we do first? So our general process is to work on trip training first. So we ask parents and caregivers and even school and support staff have been really on board with this recently. Um, to complete a toilet tracking sheet, um, that allows us to figure out a child's natural elimination pattern. Um, so we ask parents to keep track for a good chunk of the day, 3 to 5 days in a week of, you know, whether they're wet, dry poop. No poop, whatever. Um, and then what I do is I use that data to do some mathematical calculations. Um, and at the end of at the end of it, it kind of gives me an idea of how long a kid is able to stay dry. So once we figure that out, um, then we can go from there. So the toilet schedule really this. You know, once we actually schedule a trip train, it serves two purposes. First, the child will use the toilet during the times that they're more likely to pee. So that increases success. You know, you're kind of trying to build in that natural part of the routine. And then the other purpose is that it provides predictability, um, for this new behavioral expectation. Right. So it's decreasing that resistance, which is super important because we know that resistance will occur. Um, so the goal is to not only train the child, but also the body to go at about the same time every day. And honestly, this is something that doctors recommend for anybody. You know, they say if you poop at the same time every day, your body kind of gets used to it, and then you will find that you do need to go to the bathroom that time, generally every day. So why? Yeah. Constipated is such a bad thing. Because then it's not that regular ability is not there. Exactly. Just as a side note, say, if you know if parents are keeping track of things, let's say they're doing their data sheet 3 to 5 days and they're like, oh, some of these things are really not regular. This is a sign that potty training should not commence. Yes. Okay. Yes. Yeah, definitely. Yeah. And I've had that conversation with some parents recently where they're like, you know, we'll try bits and pieces, but we're not ready for the data part yet, and that's fine. That's fine. I mean, that's the thing. Like if if parents are this is a really good readiness check for me also for parents that if you if you don't really don't have the time to do a data tracking sheet, then you're not going to have time for the training yet. And that is 100% fine. There's nothing wrong with that. It's just a good gauge, you know? So because it does a lot of work. Absolutely. Exactly. Yeah. So it's a good gauge that okay. If you're not able to do the tracking sheet yet. Um, then let's just work on some of the other pre toileting skills. And then when you're ready we can go back to the tracking sheet. So I found I think it might be a bit helpful if I just give a quick example of how the tracking sheet works. So for example let's say after I do my mathematical calculations and I make it sound like it's this big thing, but it's really not. Um, let's say I find out that, you know, a kiddo is able to stay dry between pee and poo for about an hour. So then the goal is for parents to take them to the bathroom 15 to 20 minutes before that hour is up. So you're preemptively taking them to the bathroom so that by the time you get there, you're kind of hitting. You're meeting them at that point where they hopefully will need to pee or poo. The time for that. Exactly. Yeah. So this is why it's important to get consistent two to 3 to 5 days worth of data. So we can really see a pattern. Um, and that's kind of how the trip training process works. And then of course, we follow up with the parents and kind of adjust that according to whatever purpose we need to adjust it up. This sounds like a lot because it is a lot. Yes, and toilet training is just a lot in general. Do you recommend that parents, you know, life is busy and stuff? Do they put a reminder on their phone? Yes. Sort of 45 minute interval. Like how are we? Absolutely. A lot of pressure on the parents to make sure that this gets started and gets going. Exactly. And then I think the thing that I failed to mention is generally we ask them to check every 30 minutes. So that is a huge commitment. Um, so then and again that can be adjusted. It doesn't have to be. I mean, you could do instead of three full days, do five half days, so that at least from morning to afternoon you get you can do every 30 minutes. Um, so we can figure our way around that. But absolutely. Setting a reminder on your phone, um, for some of our older kids, if your kids are tolerant of wearing potty watches, it's kind of fun to get them involved because you can set, um, some potty watches to the 30, 60 or 90 minute intervals and then it rings and it kind of it's kind of cool. And the kids involved in the process. Um, but yeah, definitely. I say to parents, I know that it's a lot of work, but it gives me such valuable information that I promise you it's going to be worth it so that we can really properly go through the training process. Um, so yeah, I'm happy that you brought that up as well. Um, and then as, as OTS, we also while the toilet tracking sheet is happening and we're giving parents some time to complete that, then we look at the environment, the toileting environment. Um, this is crucial because the setup is, you know, just as if not more important than the actual schedule. So, you know, we need to ensure that the bathroom is set up with equipment that will not only make it easy to get on the toilet, but to also stay on the toilet. So whether you're using a ring reducer to make the toileting hole a bit smaller, um, it is very scary for our kids to sit on an adult sized toilet for the first time. For a lot of them, because it's yeah, a lot of them feel like they're going to fall in. And so and some of them do and it's and then. Yeah. And then you're definitely. Yes. Exactly. Then you're backtracking. Right. So um, I make it a point to, um, really stress, um, having their feet not dangling. So you need to have a step stool or something because that firm grounding on, uh, the floor or on a step stool not only provides them with stability and security, but it also helps them, um, you know, helps them, relaxes their pelvic floor so that they can actually push. So it's the same thing behind like the now popular, I don't know what they're called the squatty potty adults use. Right. Yes. Absolutely. Yeah. Yeah I mean any step stool will do. Squatty potties I feel like are unnecessarily expensive but you know but yeah if you want it. And then honestly, that 90 degree angle is good for everybody. I mean, doctors have said it straightens out your colon or your intestines so that everything can move through easily. So everyone should be at a 90 degree. Everyone should have a step stool if you don't have that first one. Right. And then certainly our students absolutely are going to have more trouble with this. We know in advance exactly. They really need. Exactly. Yeah, they absolutely do. And then also while they're sitting on the toilet, they're moving around. They're trying to reach for the toilet paper or whatever. Having some form of a grab bar or and again, everyone's bathroom setup is different. So you might have a counter edge you can hold on to. You might need something, you know, that goes over the toilet, that like a frame that you can hold on to. But giving them that sense of security so that they're not feeling like they're literally going to fall off the toilet, because that is a very real fear in their minds. Right. Um, and then we need to also make sure that everything, you know, as OTS, we think accessibility all the time. so everything needs to be within reach. If you want them to be independent, you have to set up the environment for independence. So can they reach the toilet paper once they're done? Can they, you know, get up to the sink to get the soap and turn on the water, the towel, the light switch. So again, you have to think about when you go to the bathroom. All the steps that you go through from beginning to end. And independence will be when your kid can do most, if not all of them by themselves without you helping them. Right. So, um, and then the final thing about the toileting environment is the sensory aspect. So just kind of thinking about aversive sounds, smells like air freshener might be too much. Um, the exhaust might be too loud. The feeling of the soap or the towel might not be really, you know, what they feel like they can use. And then the visual stimuli. So all of these things with your OT you can think about And, um, and figure and there's lots of fun, cool, creative, DIY ways that we can do to adjust it. So yeah, I mean, it's a lot. I like how you're talking about minimizing the demands because it's such a demand heavy process. But from, you know, the SLP lens pilot training, it's not the time to have communication challenges, you know? So by putting everything in reach, you're going to reduce the chances that things are going to go wrong because the kid can't tell you that they need this or that or whatever, right? So we're just trying to make it as simple as possible. Really? Absolutely. Yeah. And then you're reducing frustration levels too, right. Like I mean, imagine if you're trying to get the toilet paper and it's just yeah, and you're going to fall off, then you're not going to want to try to reach for the toilet paper again the next time. So you're just increasing the chances of success the first time around as much as possible, so that they're motivated to go back. And it's like what our OTS as OTS, we call the just right challenge, right? Like you want to for them to learn, but not for it to not be as aversive so that they're not going to want to do it again. Sure. You know. So. Yeah. Yeah. Makes sense. You're trying to pave the way for future success. Not just this time. Exactly. That's 100%. You said it beautifully. Yeah. Um, let's. So a lot of the methods that are out there talk about this, like, go sit now, like we're gonna, you know, it's the time and your method is similar ish where you're going to be on a schedule. What do we do if the kid says no or that they don't have to or they don't and, you know, have to want to? It's a little bit of a toss up. Mhm. What do we do if they say no no no. Do you go with what they've just said or do we stick to the routine. Yeah. Um I mean I've never been a fan of forcing kids to do anything. Um, especially when it comes to toileting, this is an area where you do not want to have a power struggle like feeding. Toileting is that one area where a child still has that sense of control? Um, so we want to ensure that we approach that process carefully, because the last thing is, if you get into a power struggle, then they're not going to want to go. They're going to withhold. And then it's a cascade of other issues that can occur. Um, so now let's say if your kiddo is on a toileting schedule, say you have to take them to the bathroom every hour after all the calculations and everything, and they refuse because they're playing with their iPad, which is way more fun than having to go to the potty. Um, hear this all the time from a lot of our parents. Now, the goal will be to use some of those go to strategies that we know work well when teaching new skills to our kiddos with down syndrome. So for example, using visuals, you know, first let's go potty. Then you get something. Providing choice, I think, is one of the most powerful tools that anyone can use when working with kids with down syndrome. Um, and then presenting reinforcement and rewards. So these are some of the things to think about. Um, providing a controlled choice is one of my favorite ways to get them to go without seeming like you're making them do it. So, you know, like, let's go to the bathroom, then you can pick a prize from the surprise box, right? So you're in. Yes, I know iPad is really fun, but hey, let's go to the potty and then you can do this other thing. I find the surprise bag and surprise box is really great because, um, you just don't know what's going to be in there. It's going to be something different every time. So yeah, the novelty of it is kind of cool. Um, or sometimes I'll say, hey, do you want to run to the bathroom or hop or do you want to, you know, blow bubbles to the bathroom or sing songs? It works really well because you're still getting hopefully getting what you want at the end, but you're giving them some control as well, so, you know, make it fun. Honestly, toileting is one thing that if you can make it fun, like a lot of a lot of actually, we say this to our parents a lot, and they're probably sick and tired of hearing us saying it. But honestly, if you make it fun, they will follow through with it more often and it will save you a lot of headaches. So there's definite ways to, you know, I also advise parents, this is probably my other really important thing that I'm going to say today. Do not ask if your child needs to go to the bathroom because you know what they're going to say exactly. They're going to say no. So I always recommend to parents, teachers say, you know, tell your kids and your students that you're going to go to the bathroom, but you present it in a way that ensures follow through. So like, hey, it's time to go to the potty. But guess what? You know, when we're done, you get to come and play with this or whatever. Like even just how you present it can make a huge, huge difference. Absolutely. Yeah. I think what you just said, you probably don't even realize is you said time for, which is a little bit different than I want you to win at all costs are avoiding that I want you want situation. Yeah. You know, it's just it just appeared in the schedule. This is just. Yeah. That's just what the schedule says, you know. Yeah. Says it not me. Not exactly. Sure. Time for it. Yes. Right. So so happy you pointed that out. Yeah. That's I didn't realize that I said that, but. Absolutely. And this is a like a little tip that we tell parents when they say, well, they'll do it for you at, at OT or at SLP sessions, but not at home. And we're like, just use the schedule as this all magical being, being like, oh, the schedule says it. So you know, your phone timer or your or your phone timer. Yeah, exactly like you set up the timer. But timer. Yeah, exactly, exactly. And I mean, we'll talk a little bit about, um, some of the sensory aspects of toileting in a second in terms of interoception. But, you know, you also have to keep in mind that sometimes they say no because they may not know that they need to go. So you kind of have to give them that benefit of the doubt that maybe they don't feel that they need to go yet. So. So they might be saying no because of that, not because they don't want to stop playing. So kind of have to really gauge the situation that maybe their bladder isn't full enough to feel the pee yet. Um, so they're saying, no, I don't need to go. So that's why I always say asking is a bit tricky, because they may not know themselves if they need to go or not. Yeah. And it shouldn't be a question. Yeah. Yeah. Let's talk about interoception. So how does toilet training overlap with interception? Sure. So, um, going to for our listeners that may not have had an opportunity to listen to the first episode or the first season when I was talking about OT and sensory stuff. Um, do a quick little refresher on sensory processing and down syndrome. So, you know, we know our five basic senses sight, touch, taste, smell, and hearing. So we know all we know what's involved. But there are three additional sensory components that we have to consider, especially for our individuals with down syndrome, because they definitely have challenges in all of these areas. So the first, the the sixth one I'll say is proprioception. So that's your body awareness that you get from, you know, the receptors on your muscles and joints. So that tells you where your body is in space. So if we take that to toileting, your proprioceptive sense tells you, oh, my feet are firmly planted on the stool. Now I feel secure or my bum is firmly planted on the seat. You know, sitting. So I now feel secure. So that's your body awareness. The seventh sense is vestibular. So that's your sense of movement. So that kind of helps you gauge your balance while you're sitting on the toilet while you're moving to reach for the toilet paper. So it's kind of helping you, um, address your balance concerns and then sort of like the point where you feel like you're going to fall, that is your vestibular sense. Like, I can go this far if I reach for. Exactly. That's. Absolutely. You got it? Yeah. Um, and then our eighth sense is interoception. Um, and this is a huge one. So this refers to your, um, body's ability to perceive and understand your internal sensations. So hunger, thirst, um, feeling hot or cold, pain, fatigue, and, of course, the need to go to the bathroom. So if you understand what you are feeling inside, then you can act to meet that need effectively. So, you know, research indicates that 49% of school aged kids with down syndrome experience sensory processing challenges. So that's a huge, huge, huge number. Um, and interoception is a major area of difficulty that can impact, you know, feeding, uh, temperature and pain regulation and of course, toileting. So because of that weak interoceptive system, it is difficult for them to feel the sensation of the bladder or bowel fullness, sometimes until it is too late. So you and I might have that feeling. Oh, I kind of need to go pee, but I can maybe wait another hour, you know? But for a lot of our kiddos, it has to be like full, almost to the point where it's too late before it registers in their system that, oh, now I really got to go pee. Yeah. So weak. Interoception can also make it really difficult to fully empty the bladder. So as I was talking about earlier, um, you know that bladder emptying is a huge issue. So they might go to the they might go pee from a really full bladder and then but there's still some left, but they can't really gauge. Oh, I still have some more left that I need to sit on the bathroom longer. So, you know, and then they get up and then they pee again two minutes later in their pull ups. So that whole interoceptive piece is super important To not only help with training, but also understanding why they can't tell you if they need to go pee or poo. Um, why? Sometimes they're having accidents irregularly because they're not fully emptying in the toilet. Um, so anytime you're kind of like questioning, just think of that piece rather than jumping to they're doing this on purpose. Exactly how annoying exactly it is, because it's like, um, and we like, just got the new pull up on and now we need to do another one. Exactly. Yeah. Um, that is irritating for sure. Yeah, but it is not necessarily on purpose. Yeah. It's happening. Yeah, 100%. What are some signs that toilet training is going in the right direction? What are we looking for progress wise? Yeah. So that's a really good question. I, I think how we define going well is dependent for each individual kiddo. Um, so for some families, you know, if a child is able to enter the bathroom and just sit on the toilet without anxiety, big success. While for another family, going well could mean that their kiddo is following through with trip training, going to the bathroom when it's time with no protest going well. And then there are some families who would define going well as their child, just communicating and initiating the need to go to the bathroom. So it's really different. Um, from my perspective, any step towards independence is an indicator that it's going well, no matter how big or small. So if they learned how to reach over and pull down the toilet paper to the appropriate amount and not, you know, all of it, all of it, um, is an indicator that it's going well, you know, because there's so many steps involved in the toilet routine, there's so many opportunities for success. And to label something going well. So I don't know if that kind of answers the question the way you wanted to, but I feel like it is dependent on each kid's goal. And, you know, that is the silver lining of working on a process that is so complicated. There's actually so many little areas then where you can be making progress in games. Exactly. Not thinking about, you know what I think a lot of parents rightfully think is the final outcome of yeah, I don't have to think about it anymore because my kid does it all on their own. Yeah. Um, there's many, many, many, many, many steps. Yeah. And, and I think as our it's our job as OTS and even I mean, if you can find some great examples being as an SLP to point out the successes to parents, sometimes I feel like you're right. They kind of think of them going to the bathroom by themselves without me doing anything is success, and it absolutely is. It is like a hallelujah moment for sure. But sometimes I'm like, hey, did you just see that? You know, your daughter or son just, um, I don't know, like, pulled down their pants on their own and got up on the toilet. That's pretty great. You know, I had a mom tell me that, uh, her her kiddo just took to the step stool for the toilet by himself and just got up there, and he's only three. And I was like, that's amazing. Yes. When he sat down on the toilet, he freaked out. But that's fine. We got him halfway. Now let's move on to how we can make him comfortable sitting on the toilet. So sometimes I think in a very busy, stressful parent life, we have to kind of find those moments to be like, hey, we actually did that. That's pretty cool. You couldn't do that last time. Yeah. You know. Yeah. Um, yeah. So a related question, and I think it's going to be a related answer, is sort of how long do we expect this process to take? You know, there are methods out there that claim you're going to be done in one day. Yes. Exactly. Unlikely. Yes. Yeah. And then how long are we talking? Really? For sure. And again, I will use my go to. It all depends on the person and and the routine that the parent and caregiver has put in place. You know, all things being equal. And I think you had said this earlier in the episode. All things being equal, there's no reason why a kiddo with down syndrome can't follow roughly the same trajectory as their sibling, or a typical peer with respect to toilet training. Um, you know, it could be two weeks for some. It could be six weeks or maybe a couple of months. It just depends. Um, but one thing to keep in mind for our individuals with down syndrome is that they, they, because of those medical challenges that they experience throughout their lifespan, it can easily curtail the toileting process. So if they have surgery, a new medication, or honestly, even something as having a stomach bug or flu can cause a major setback. So, you know, I mean, Covid has been a huge example of how I've had so many calls and emails from parents being like toileting regression, like, what do I do? They were trained and now they can't do it 100% expected. It does happen. Regression definitely happens back and forth with our kids with down syndrome, and I'm sure to some degree with typical kids too. Um, you know, and the important thing is that it can't be overcome. We might just need to go back a couple of steps and kind of use our process again and reintroduce. So, you know, and I, I never want parents to feel like if there's a setback, it that's just where it's going to be. It's very stressful because I can imagine, you know, they're trained, you know, you're all done. Hands you know hands clean. We're good. But then Covid and now we're back to square one. Yeah. So so yeah. So it's different for each person. Um, I'm going to talk a little bit more about Self-initiating. So this is the goal that a lot of parents think about when they think about potty training, which is like my kid is taking taken themselves there. So why is this so difficult? And what can parents or caregivers do to sort of help their child learn this? Yeah. Um, so many kids with down syndrome will naturally transition into self-initiation, especially if that trip training routine is kept consistent across all environments. Um, and everything is kind of done as consistently as possible in terms of rewards and, you know, all that stuff. However, some will have difficulty and that is, you know, um, fully expected. Uh, one thing I want parents to understand is that you can't expect self-initiation at too early of an age. I've had some parents say, well, he's three, but he's not really initiating. They're not going to they need to be taught how to self initiate. They need to be made to understand what that means, what that looks like and what that feels like. So I think one of the biggest reasons why self initiating is difficult is because of that interoception piece. So if they aren't able to attend to those internal signals, um, or those signals are not registering, then it will be really difficult for them to not only recognize that they need to go to the bathroom, but it will be hard for them to communicate and act on that need. So you ask, you know, how do we teach them? So in order for them to learn how to self initiate, we as the parent caregiver, therapist, educator have to help them learn to pay attention to their own signals and connect that signal with the need to go to the bathroom. So, for example, I say to parents, you know, if you see your kid doing that little pee dance, being like, oh, I see you. Oh, you're doing the pee dance. Good job. Like, let's go to the bathroom. So immediately they're like, oh, so the pee dance means potty time, you know? Um, a lot of our kids hide every time a kid is hiding under my table or under a chair. I know it's potty time. Um, you know, that's very common. Um, so if that's if you're seeing that happening, you're like, oh, you know, it looks like you might need to go to the potty. Let's go. Good job telling me. Or if they're looking that distressed look on their face when they're like, oh, I really gotta go pee. I just don't know how to tell you. I don't know what this feeling means, you know? Or their legs are crossed in an awkward way. Um, and honestly, many parents. Marla, I'm sure you can speak to this as well. You kind of know when your kid needs to go to the bathroom. You can tell parents telling me they have a look in their eyes, they have a look, or they get suddenly still when they were suddenly monkeying around. Exactly, exactly. There's this kind of like dazed moment where you're like, oh, things are happening. They're exactly at that point. Yeah. Too late. Really? Um, but if you start putting the words with it. Yes. Then exactly is this the child usually is going to get some inkling of this before it's happening. Yeah. And you just need to pair it with the concept. Exactly. Yeah. I mean, as parents, you're are already attending to these cues. So as soon as you see your child displaying the signal, it's time to be like, okay, let's go to the bathroom. And you're right. Labeling that signal is also important. And then reinforcing please, please, please reinforce, I say, because self-initiation is such a difficult thing to learn, I always advise parents to ensure that those reinforcers that you're using during the training stage, if not like, continue to use them during the self-initiation part. And perhaps it's more important in the self-initiation part than even in the training part. So keep those reinforcers coming. Whatever, in whichever way, whether it's social, whether it's a reward, you know, just making that connection like, oh, I see you're you're hiding under the chair. That means you need to go to the potty. Good job telling mom let's go or dad. So making that connection for them. Um, and if if they're not displaying signals, then there's definitely ways that we can figure out a way to help them. Like, you make the trip training time a little bit longer on the toilet, or there's lots of other ways to do it. But for most parents, this works quite well by just looking for the signals and making that connection. Um, ah, I think that's fantastic. I was going to talk a little bit about visuals. So as therapists, we love visuals for our students. And I know that there are several that are useful in potty training. So a little bit about what you use and what you like. Yeah. So absolutely, we know that our individuals with down syndrome are strong visual learners. Um, and it's a really important strategy to help them learn skills across all areas, especially toileting. So some of the ones that I love to use are a very simple first then strip. So first potty, then it could be, you know, um, whatever however you want to, um, give them the option of a toy or, you know, you get to pick an activity or you get a prize from the prize box however you want to use it. Social stories are really great to explain expectations around the toileting routine. So I love those and visual sequence strips. So as we mentioned earlier, each of the toileting skills has numerous steps. So even like just, you know, getting onto the potty has a whole bunch of steps. Pulling the pants down, putting your underwear down, sitting this, this and that. So if you can have a visual strip on the on the door of your bathroom or in front of the toilet and your kiddo goes in there by themself, looks at the visuals, follows the instructions, does the whole thing by themselves. That is an independence done. So sequence strips are great to teach any skill really toothbrushing hand-washing everything. So those are kind of like my top three. And then sometimes, depending on the kid, I'll recommend they use like a reward chart or like a visual tracking chart of how they're doing, whether it's skill based or frequency based, in terms of how how often they go to the bathroom. So this way the kids can kind of see a visual representation of their own progress, which is kind of fun. You can use stickers. You know, there's a bajillion Paw Patrol potty charts out there that you can print out so they can be customized. So definitely, because we know visuals are a strength, let's use these. And they do help quite a bit. And even a visual timer, that's another thing. So if you want your kid to sit on the toilet for five ten minutes, a visual timer is great to kind of help them gauge that that amount of time that they have to sit, and there's apps and things for that we can put it in. Absolutely. Yes. For sure. Yeah. Yeah. I like what you were saying about the sequence strips. Um, because it does that thing that we were talking about before, which is reducing the cognitive demand. Now, you don't have to remember. Yeah. All of these steps, you being the child in the and you don't have to remember all of the steps because you can kind of refer to this checklist of, here's what's going to happen next. Yeah. And we use those all the time when a skill is like maybe halfway there where some things are getting remembered, but some things are getting missed. And this is just the reminder which you know, is a neutral thing. It's not mom and dad or teacher nagging. Exactly. Let's do this. Exactly. It's a way for the child to be in control and independent with it. Yeah. Yeah, exactly. And then a lot of the times, if parents are comfortable with it, um, if we can use the kids themselves in the visual sequence, doing all the steps makes it even more meaningful. So, you know. So that's another way to go as well. Yeah. Yeah. Do you. So last question here. Do you have any books that you recommend, either for grown ups or for children that talk about this training process? Yeah. So there has actually been um, there's a great book that just recently got released, um, called and it's by Terry Katz and Leena Patel called Potty Time for kids with Down Syndrome, and we'll put a link on our episode page on where you can get that. Uh, we have some great resources on our website at. Um, one especially that I created to help with Covid regression. So parents that are experiencing toileting regression during Covid, um, my OT colleague at DSF and I, um, do toileting presentations at least once a year, and we're due for another one soon. So definitely, you know, look to our social media and to our website for information. Um, what I talked about today is a very brief intro. So we definitely go into more detail and detailed strategies and equipment during the presentation. And at the end of the day, you're always welcome to contact me through my email Hannah at org if you ever need any information or resources. Fantastic. Well, thank you so much for giving this sort of intro. I think if nothing else, it gives families, the uninitiated families. Yeah, the scope of what potty training involves, which is a lot of things. Yeah. And it kind of gives you gives you the groundwork for where to go next and how to start. Yeah, absolutely. I'm really happy that I was able to do this, because I know toileting is such a huge thing that parents are concerned about, especially for a lot of our like, pre-K kids that are, you know, ready to go to kindergarten, but not fully yet. Um, and just for the parents listening out there, you know, my take home message is just wait until you and and your kiddo is ready to, you know, have a good, solid plan. Take it slow. Make it fun. Um, you know, consistency is really important. And just have and just be patient. It's it's a hard process for everybody. So just take your time with it. And don't be hard on yourself if it's not working the first time around. Sure. Yeah. Well thank you, Hina Thank you so much.