TRANSCRIPT
ECC Personal Hygiene: Bathroom Skills and Complex Learners
3/10/25

>>Lynne: This idea for this Coffee Hour today came about from a conference we were doing on the topic of behavior. And potty training, toilet training came up as it related to our kids with complex needs and their need for safety. We're going to talk a little bit about that. Lisa comes to this topic from the perspective of an occupational therapist. I come from the perspective of like a classroom teacher or TVI. And so I think together, hopefully we'll have some tips and tricks for y'all to think about. So the first thing that we want to talk about was typical children. Typical learners. Lisa has done some research on this but I just randomly Googled it earlier today, what are the signs that a child's ready to be potty trained. And some things showed up that really made me think about our kids with their complex needs and maybe other etiologies such as communication. So one of the signs that a typical child is ready to learn to be toilet trained is can follow multi-step directions. One other thing is communicating to you, communicating their feelings that they feel the need to go to the restroom. And also I thought this was really interesting. The child's interested in when you go to the bathroom. So that comes in with that kind of imitation and they want to know what you're doing. So just those three things -- and there are several others off the bat. You know, they highlight why a lot of times we have such difficulty teaching these kids. Something that we all take for granted as a normal part in human development. So I'm going to hand it over to you, Lisa, to get more about that. 


>>Lisa: It seems people start potty training a little bit differently, depending on the student, the child, and the family. Even the culture. But I read a lot about near 18 months all the way up to 3 years, sometimes as a starting time. The idea with 3 years or between the ages of 3 and 4 is like Lynne said. Now you have someone who can multi-step and talk to you more about the steps. Sometimes parents have to wait until there's some bowel and bladder control they achieved through diet, drinking, and movement. Sometimes our students aren't feeling the need, the urgency in the body. Like, when does the bladder feel full or the bowel. They might be missing that cue. And with incidental learning it's so great. Our eyes are always on, our ears are always on. But if our learning is through our hands, then we have to kind of turn it on with our mind. And learning through the fingers is sequential. Learning through touch is sequential rather than whole picture. And harder to do. And you have to keep your attention on your hands, which is super difficult to do when the whole skin is involved. And so using the toilet learning is so sensory that it's like a whole body experience. If you have somebody with sensory imbalances, it can be pretty tough. You can definitely do it but you can just see some behaviors, some fear, some rejection of using the toilet. But it can definitely be done. 

>>Lynne: Okay. So, you know, we talked about a few of these already but what's the impact of sensory impairments on a child -- around the topic of potty training. And the first one is that lack of incidental learning and imitation. They never see anyone go to the bathroom or use the restroom. It probably doesn't even enter a parent's head to take them with them and tactually show them what they're doing. They're sitting on this thing. They might never know a toilet is in the bathroom. Their experience of a bathroom might be washing their hands or standing on a stool to get their hair brushed. Because sometimes parents don't even, you know, they don't change their kids, necessarily in the restroom. It's easier to just maybe spread something on the floor or, you know, a low table or something like that. And so they don't have that automatic, you know, they say 75% of what we learn as a sighted person is through incidental learning. And, you know, for a kid with a visual impairment, that's flipped. And so really very small amount of learning takes place incidentally. A large amount takes place with direct teaching or direct contact. And so that imitation piece is gone, whereas kids with vision, you know, they're learning about potting all the time, right? But they don't start just cold when our kids do. So a lot of our kids have communication difficulties. And so the question of why should I do this pops up. Do they know that other people use the toilet? You know, why should they have to do it when they already have a system in place? And we're going to talk about that a little bit more. What is the reasoning behind it? You know, they don't have the language to explain to them anything. You know, why do I need to be changed at all? It doesn't bother me so why is it bothering you? And also there can often be a lack of consistency between home and school. Parents might have a routine or a way that they do things at home. The school maybe can't do that thing. Maybe they can't lay the kid out in a blanket on the floor. The school has to follow certain procedures. And then all of a sudden you're introducing maybe all these environments that are totally foreign to the child. And so that can evoke some fear and resistance. 

>>Lisa: I know we're going to talk about vision diagnoses with ONH, I have had two students, one is in college now, who literally just held it throughout day until they could get home, which is just shocking to me. And very difficult. And these are students who can talk to you about it. They just literally are overwhelmed in some of the restrooms on our campus due to the dryers or due to the automatic flush, that they're literally just holding it until they get home. That sounds so hard. 

>>Lynne: All right. So we're going to talk about that a little bit more. So when we talk about eye conditions such as optic nerve hypoplasia, a lot of times these guys will be autistic tendencies or be labeled with autism. Once again, these kids, one of the hallmarks of kids with ONH with hormone aspects are rigidity. They like things to be the same. Things that are not the same can cause great distress and upset. By the time they come to your classroom, they have a routine for going to the bathroom, whatever it is. And probably, if they're in a Pull-Up or a diaper, that's a routine that they have. And they might not even understand, you know, so why are you changing this routine? It works for them. And so trying to break someone out of an established routine, any established routine with ONH is super, super difficult. Then there's some of this hormone involvement. I know Lisa is going to talk in more depth about that. But specifically the ONH if they have involvement. Everything in your body almost is controlled by a hormone, which is crazy, when you go to research it. Going to the bathroom is no different. You have a hormone to urinate and a hormone that makes you defecate. And you have hormones that make you not do either of those things. So if their hormone levels are messed up, you know, for urination they may have the diabetes insipitus where they are driven to drink water. In excess. You have to measure their water. 

>>Lisa: Because they literally don't have a feeling of a quenched thirst. They literally don't get that feedback. 

>>Lynne: Right. The hormone that regulates the level of water in the bloodstream is, you know, dysfunction and so then you may get bet wetting and the kid might be 15 or whatever. They can't help it. It's not a behavior that they can control. And then just on the other side of the coin, they may have chronic constipation and all the difficulties that come with that. And so once hormones get in the mix, you're dealing with a whole different animal, kind of, when you talk about potty training. 

>>Lisa: Yeah. And you mentioned constipation. So if you have students who are constipated or children, family members who are constipated, you might need a doctor to help you tease that out to sort of find out what's happening in the body. Because that can really throw people off. And so if someone has had a painful bowel movement they can be very afraid of going into the restroom and having a bowel movement. I also was looking at some sensory information related to ONH and autism and I couldn't really find numbers. But like Temple Grandin says most people with autism will have a sensory imbalance of some sort of another. Looking at ONH, it looks like about 36 or so percent of those guys will ultimately be diagnosed with autism. So there's a ton of overlap there. Oh, and I have a student who that doesn't have issues around toilet training but she literally had -- because with ONH you have hyperpituitarism where the hormones are all jumbled and mixed up. She is in our exit program, a young adult, but she is suddenly having bladder control problems. And it's definitely, in her case, hormone related. She was able to get some help and get to the doctor. But out in the middle of nowhere in Texas, it's really hard to find an endocrinologist. She had lost some prior care and was having to restart care, physicians and stuff, and it's really hard to get to some of these specialists so it might just take a little while. 

>>Lynne: And y'all feel free to type any questions or comments or observations or stories in the chat, and Kaycee will let us know that they're there. 

>>Lisa: So thinking about postural control. So there's a picture here under this toilet of a foot box. It's a really old foot box. But a while back we had a whole lot of foot boxes made -- this one is small -- for our elementary building. And we had bigger ones for our high school building. If somebody's feet are dangling, not supported, it's much, much harder to have a bowel movement. One of the books listed in your reference, toilet training for autistic and SEND, you almost can't have a bowel movement if you don't have a way to push through your feet. So be sure someone's steady on the toilet. And also if they have low tone, which is so common with optic nerve hypoplasia, they might be droopy or slide forward. You want to make sure someone is sitting safely on the toilet and there are inserts you can add that make the space smaller and put a bit of a cushion or a different feel than just a porcelain. Be sure somebody is sitting safely. We have -- you can't see them in the picture. We have grab bars to the right and behind that toilet, so someone can easily grab on, if they need to. Because if they're posturally don't have good posture control, a big part of it could be I slip or tip forward or slide backwards. Sensory defensiveness in toileting just makes a lot of sense. It's so loud in there. If it's the hand dryer or if it's the sinks, and the sinks might be automatic. And the toilets might be automatic. So there's sort of a lot happening in the sensory world in the restroom. The way I think of sensory defensiveness is I think to myself -- and restroom sounds are everyday sounds. I think to myself is this person afraid of everyday sounds that other students seem to be okay with? If someone is really auditory defensive, it's likely that the bathroom is a very scary-sounding space. Like Lynne mentioned earlier, literally the physiology of the body can be set on this is not safe. I'm not safe. 

>>Lynne: And since the primary need of your whole subconscious is to be safe, feeling that you're not safe, nothing can happen until you feel like you are safe. And so sometimes the bathroom can be a place that there's a lot of high emotions going on. 

>>Lisa: Yes. I think I talked to you, Lynne, about someone I helped with their bathroom routine who I know really well who is auditory and tactile defensive. And it was really tough. Even her knowing me for a long time, knowing my voice for a long time, and me trying to use the right cues, it was so stressful for her. So stressful for her. And I realize that she's coping with what I'm saying, like my instructions. I'm trying to be very minimum in her case because she's auditory defensive. I'm trying to use more touch cues and have her symbols ready. But I definitely talked too loud in the restroom. If I were to do that again, I would only whisper to her. She's also super loud in the restroom so the echoes are going bananas. But I definitely would whisper and have as little language as I could. And then also she was just so wound up and afraid that the walking of the next four steps towards the sink were almost too much. It wasn't that she was refusing to wash her hands, she literally couldn't move that way. And that just looked like sensory overload. 

>>Lynne: Okay. So we are going to propose that you guys create a bathroom routine with your kids that you're attempting to potty train. And so we have a little rationale about it. Why make a routine when you can just do it in five minutes? First of all, the routines allow for structure and that structure for you and the student. So if you create a routine, you know exactly what your part is and they know exactly what their part is. So it destresses the situation at the beginning, right? Because there's no confusion about what's going to happen. The routine, if it's done -- every time it's done in the same way, hopefully with the same communication, the student will learn to be able to anticipate what comes next. And being able to do what comes next by yourself builds that independence. But here I want to throw in just a caution. This is not specific to toilet training but it is specific to routines. So if you find yourself verbally prompting kids through routines, what you're really doing is you're teaching them that this is a routine between two people and that you have a turn. And your turn is to prompt them. And they can't take their turn until you do your turn. And so has anyone out there ever had a kid prompt you to prompt them? Let's go wash hands. You know, and then wait until you say "Let's go wash hands." So, you know, they're just learning what you're teaching and so by all that verbal prompting, you are teaching they can't do it unless you do it first. So just in general, throughout the whole school day and any kind of routine, I would really consider stop talking so much, try to use more tactile and object cues to signal what's coming next. 

>>Lisa: And timers. And timers. 

>>Lynne: Timers, yeah. But they're never going to be independent if they're always waiting for you to say your thing. So, that's just a side. But anticipation allows for independence. And in the bathroom is one of the most important places for independence because it equals privacy. Any time a child is in a vulnerable position, meaning they're in a state of undress, you know, those should be priority activities that you remove yourself from. Ultimately it's best if they have that privacy, just like we all have the privacy. We usually don't go in a bathroom stall with a bunch of people. Usually we're by ourselves in the bathroom. And so having a routine they can anticipate, the steps, they can learn how to do the steps independently. Ultimately, your goal is to remove the extra people out of that vulnerable situation. Routines reduce anxiety because you know what's going to happen and so all of that wondering and being escalated goes away. Also, if you create a bathroom routine, you can share it with the family. You can write it down and share it with the family. Probably, just like in any routine, the actual skills involved in going to the bathroom, sure, they're going to be taught but there's a bunch of other things that are going to be taught in a routine. Communication. You know, number one, that relationship. Things like asking for help. There's a whole bunch of stuff that you can add into a routine centered around going to the bathroom. Does anyone have any comments on that? 

>>Lisa: We do have a book, it's in the references, for individuals with autism, it has really nice routines. Really nice routines. 

>>Kaycee: This is Kaycee. We didn't have any questions, we just had one comment from Linda saying she works with her classroom teachers daily. 

>>Lynne: That's amazing. Yeah, guys, if you're an itinerant, I would consider making the toilet training routine a priority, just because when that child is now a 25-year-old person, best-case scenario do not have someone in the bathroom with them. Even though now they're in second grade and adorable and cute. Sometimes it takes that long to teach stuff. So I would start soon. Okay. So this is a schedule. This is a sequence of activities for the toileting routine. So this is a Pull-Up and this person wears underwear over the Pull-Up. There's some toilet paper and this is a wash cloth for when they wash their hands. Uh-oh. So starting in a routine you have to start thinking about what's going to happen before the routine starts, the pre-bathroom routine. Objects or pictures. So how are you going to tell the student what's going to happen in this routine? So you could review this sequence of objects prior to even going to the bathroom, pick it up, and take it with you to the bathroom, and then go through it as you go through the routine in the bathroom. But somehow you need to tell the person what's going to happen. And then so when you think about the sequence of the routine, sure, we know the sequence of you go to the bathroom, wash your hands. What about before all of that? So a lot of times movement will make you more likely to have to use the restroom than just sitting for long periods of time. Do you think you're going to eat and then you're going to take a little walk around the school. And then you're going to go to the bathroom. Or you're going to eat and then they're going to get out of the wheelchair and be on the mat for a little bit and then they're going to go to the bathroom. Mixing in some movements between those two things might help your results. And then, you know, what goes in comes out, right? And so what does the child eat? We all know kids that just eat one or two things. Or they only eat like soft food. Or they're tube fed. And so as much as possible is there a way to work with the family -- and this would be a family deal -- of what kind of foods can they eat that might help the process of them learning to recognize the signals. Because if a kid is tube fed, probably not. You're probably not going to be able to -- just because that's the way it is. But could other things be added to the diet if they're not tube fed so that they maybe become more aware or they have more time to be aware that they have to go to the bathroom. Lisa, did you have anything else you wanted to say about that? 

>>Lisa: Not really. Both books have good recommendations to help you with trying to time when you would have to use the restroom. For example, for how much have you had to drink? And how much time goes by before you need to use the restroom? So trying to figure out eating, drinking, and the timing following to use the restroom. And, like Lynne said, movement. And for the most part -- there could be exceptions, like someone with optic nerve hypoplasia might be drinking too much water but broadly for the most part people don't drink enough water, including children. One of these authors, she talks about you're trying to add a little bit of water to the diet. And of course if it's about to be nighttime, you have to figure out do I need to say I'm going to stop drinking evening two or three hours before bed? So there's all these timing things. It helps to have a little schedule or a diary or something so you can kind of figure out what's the best schedule that fits the bowel and bladder functions. 

>>Lynne: And that would be a good thing to have taped up maybe in the bathroom wall so you can see a pattern. Typically we're creatures of habit and our body has patterns to everything. So, Lisa, what about kids, you know, I just bring this up because we all have them. Kids who just drink milk. Milk in and of itself is constipating, isn't it? 

>>Lisa: I think so and it has quite a bit of sugar in it, or lactose in it. Yeah, I think one of the things in these two books is a lot of times children are drinking juice or milk but not water. And so trying to add water in. And also trying to use added water to help you stimulate the need to go to the bathroom. Like, when the bladder begins to feel full. But, yeah, definitely I think maybe adding water or watering down juice, even -- that doesn't sound right for milk. It sounds terrible for milk. But both of these books kind of said the same thing. Children, all of us, actually, are on the side of not being hydrated enough. Just because we're toilet training, we don't want to remove anything to drink, we want to add water, if we can. 

>>Lynne: Right. Guys, if you have kids who don't like to drink water, you can have a whole routine about water. Like you get some of those flavor packet things and you could have a whole routine about creating some delicious flavored water drink or maybe with some bubbles or all sorts of stuff. That would actually be a super fun routine. 

>>Lisa: Oh, my goodness. 

>>Lynne: Yeah. So now we're going to think about the space. We have our pre-bathroom routine now and now we're going to think about the actual bathroom. And so what does the bathroom bring to the equation? Well, first let's think of the auditory aspects of the bathroom. Some classrooms I have been in are very lucky to have like a bathroom attached to the classroom. A lot of them are not. And even if it's attached, sometimes it's pretty big with a couple of toilets in there. But usually the bathrooms are echo-y and they're loud. And so, you know, going back to the whole safety is primary. As we all know our kids are very sensitive to auditory sounds, especially unexpected sounds. If your bathroom has these doors, these doors bang unexpectedly. They create a big sound. So just the auditory aspects of the space can cause fear, can cause behavior, can cause a kid to not even want to be in there. Or if they have to be in there to get out of there as soon as possible. 

>>Lisa: I think with auditory, what you might see is someone really trying to cover their ears. Even though they're trying to get to the sink and use their hands and get ready to wash, they're honestly trying to block out sound or they might scream. Sometimes if somebody is auditory defensive, they get loud. But I have also had someone who was almost overstimulated by the sound environment. But his response was to slam the doors. Like I think he picked a big, loud noisy thing to do in there, and to flush the toilet over and over and over. And I think he was just using the sound but also overstimulated by it. 

>>Lynne: Uh-huh. Right. So I worked with a teacher that had a little girl, second-grader with ONH, academic Braille reader. This girl had some enthusiasms. She really, really liked the Braille semicolon, the feel of a Braille semicolon. Loved the semicolon. And she also was really intrigued with Clarisse. Anybody from the Dallas area know Clarisse Fox News at 5:00 news anchor. She really liked Clarisse. She also screamed every time someone used the hand dryer in her school. She stood there and screamed at the top of her lungs. She was terrified. But she also liked to play in the water at the sink. And so her teacher, who is brilliant -- Ruth, I hope you're watching -- wrote a social story for this little girl about the feisty little semicolon and Clarisse from Fox News at 51:00 were having a conversation about how not to be afraid in the bathroom. She just wrote this story that this little girl loved about, well, you know, if we only wash our hands quick and get out then we won't be scared by the hand dryer. I just thought it was brilliant. Thinking about creative ways to use the kid's interests into helping them deal with their emotions that they feel and the fear that they feel while not in the moment, not telling her it's okay. Nothing's happening, it's okay, when she's screaming. To her, she's being killed. Her subconscious knows no difference. So talking about it outside of the moment and here she is reading and she's having fun is a great way to kind of think about those strong emotions.

>>Lisa: And we do have a couple of students who will wear the sound dampening headphones when they go into the restroom, because it's so loud in there to them. And then I've made a lot of just digital recordings of various toilets. And then we just play with the recordings. We take them to a swing. We take them outside. We just talk about the sound a lot and play them over and over and over. And I've had students who like that part of it, like trying to get the recording part of it. So there is some hope for sure for desensitization to sound. There are some strategies that help. 

>>Lynne: Right. And so maybe as part of the bathroom routine your student would have some kind of recording device or whatever where they could listen to their favorite music while they go through some steps of the bathroom routine, or while they're sitting there, just to kind of block out that big, loud scariness of the echo-y sound. And if y'all have things that you've tried and have worked in the past, let us know about it. Okay. So tactilely, most bathrooms are tile. Tile and they are hard and they are cold. So tactilely it's not a real interesting or -- I don't know, welcoming spot. So is there any way you could make it more so. Would the school allow a little heater if it's cold in the bathroom? Or maybe a wall hanging by the kid. Or get one of those cushioned toilet seats, if possible. But just something to relieve the cold hardness of the porcelain. 

>>Lisa: And I do have one student who I did a toilet routine with him for like two school years. And the temperature of the water was hugely important to him. And not even easy to really recreate because our sinks are so funny. Some are press and stay on for a certain amount of time. That's hugely important to him. And I knew that from mom telling me he'll put his hands in warm water but not cold water. Sometimes people's clothing is kind of a tactile issue. Sometimes kids are uncomfortable with the clothing around their waist. Sometimes the toilet paper doesn't feel right or doesn't feel like home, or paper towels are really hard. There's also a lot of touch issues in the restroom, for sure. 

>>Lynne: Right. And another one is the smell. Most restrooms are very antiseptic smelling. Some might have that pink thing that they put in there that smells horrible. And so is there any way you can make it smell a little better? Like get one of those aromatherapy things with some essential oil or something to reduce the kind of clinical smell of the bathroom. We're going to talk a little bit more about that too. And then we have visual. Most bathrooms are lit by really bright fluorescent lighting and there's a lot of glare. If your kid has vision and they walk into this space, is it painful? Do they have photophobia? Does it make them want to turn around and run away? Is there any way you can use ambient light or string Christmas lights to make it more visually appealing? And then the last thing about the space I want to touch upon is this emotional memory thing. Guys, if you're looking at this picture -- let's see, how can I say it? Give me some adjectives that would describe this picture. 

>>Lisa: It definitely looks like not home. So a medical office. 

>>Kaycee: We've got people coming in the chat saying cold, clinical, institutional. 

>>Lynne: Great. Guys, we all have memories of past events and things shape us and affect us as we go on through life. And so if a kid walks in and doesn't have a lot of visual information and goes into a bathroom and it smells antiseptic and it's hard and cold and echo-y, might it spark memories of a past hospital visit or, you know, urgent care, something like that. Outpatient surgery. I mean, a lot of our kids have had so much medical intervention and it can be so traumatic, especially if they don't have the language, they can't anticipate what's happening. They don't know what's going on. So just, you know, step back and give them kind of, you know, the courtesy of maybe they're carrying this baggage. Maybe it is a really scary space to them. They don't know what you're doing, especially if they're new to you or you're in a public bathroom somewhere that they've never been before. They may have these kind of emotional reactions just to the space, just because of memories of events that may or may not happen in a bathroom. 

>>Kaycee: This is Kaycee. We have a couple more things come in the chat. Somebody said it feels scary. Somebody else said intimidating. And then someone shared that the toilet may represent -- there may be a fear associated with the toilet due to it being like a hole they can fall in. They can feel that way about it. 

>>Lynne: Yeah, exactly. And so when Lisa was talking earlier about that postural safety, if they feel like they're going to fall in the toilet, you know, let's face it, most of these toilets are those huge industrial kind that are oblong and if your legs don't reach the floor -- like my granddaughter gets on one and she's holding herself up. I need to get Lisa to make me a box. But, yeah, that whole fear and what's in there. We don't usually let kids explore what's in that big hole they're perched over. That's more unknown and the more unknown things are, the more scary they are to all of us. 

>>Lisa: Yes. You know, with vision, with vision and hearing, we all have our own favorite bathrooms at our jobs or wherever. But we have all the expectations of what this will sound like, maybe even smell like, just by vision. Right? I don't have to anticipate what it will sound like because I'm familiar with toilets through vision and memory, building memory. But if you don't have vision and you haven't built these memories, it does sound really scary. Or maybe your memories are poor ones because it wasn't a pleasant experience. 

>>Lynne: Okay. So the next step would be the clothing. You know, there's a little bit of back and forth about the diaper versus the Pull-Up. Maybe not now but, you know, Pull-Ups are relatively new. Yeah, I'm that old. When Pull-Ups are new and Medicaid would only pay for diapers. I don't know if that's the case anymore. But we had these teenage kids in diapers. And you can't -- back then, in my experience -- it's almost impossible to manipulate a diaper as if it were underwear. I always encourage people, if at all possible, even if the kid will never be toilet trained, to always change them sitting on the toilet, if you can. If they can bear any weight on their legs, if they're in a wheelchair, just help them up and swivel, pivot, and then sit them on the toilet, and use Pull-Ups. Just because, for one, I think it gives them more dignity. We all do that and it also gives them a way to participate. Because you can push down and pull up a Pull-Up. But you can't do that -- you can't put a diaper on yourself, right? And so there's no way that they can participate in that process. And, you know, also think about some classrooms have those changing tables where they'll lay the child on it. That is a super vulnerable position to be in, guys. When you're not dressed and, you know, we don't need to be doing that if we can possibly help it. And I get there's some kids that have absolutely no control over their body and you use a lift and, okay, you have to do what you have to do. But if at all possible, especially if your goal is that they would be more independent in the bathroom, to move to a Pull-Up. Because it is more of like what we use. And then, Lisa, you were talking to me about some kind of underwear that's like a Pull-Up but you can wash it? 

>>Lisa: Yeah, they're kind of expensive but there's a brand named Knicks and I'm sure there are others, but they are underwear that can absorb for incontinence. They get washed in the wash. They're different from a Pull-Up but they're cloth. And they're kind of expensive. 

>>Lynne: Do they go to adult sizes? 

>>Lisa: Yeah. And then the clothing thing here, this little guy, this picture, he's so adorable. He's looking and managing his buttons. Using his vision. So if somebody hasn't really mastered fasteners yet, you don't want to add fasteners to the clothing management, necessarily. You can still practice fasteners outside of that routine. And then the other thing is sometimes people are dressing for, like, cuteness or style, which is great. But if you're wearing a really tight yoga pant or leggings or something that's hard to maneuver up and down, I do just ask parents to go ahead and switch to something looser. You can still be super stylish. And in this case of this student, she started wearing almost large-sized yoga pants so they were still the texture she wanted, but it was just bigger sizes. We had the ability to move it up and down. 

>>Lynne: At the very beginning, when kids finally realize what their body sensations are telling them, it's immediate. If they feel like, oh, I have to go to the bathroom, they have to go now. So you don't want to spend a bunch of time manipulating clothing and the child will fail. And it's not their fault. It's because of the clothing. 

>>Lisa: I had a little guy -- miss him so much -- but he wore jeans with a zipper, snap, and a belt. And we definitely practiced all of that. For going into the restroom, I would get that ready for him, just because, like Lynne said, he was in a hurry. He was on a mission. 

>>Lynne: Okay. And now we think about the actual toilet itself. How long to sit is probably pretty individualized. You know, I remember having a kid that I wrote an IEP goal that they would sit for two seconds. And maybe at the beginning, that's all you're going to get. And that's great. Just, you know, pull the pants down, sit down, stand up, pull them up again. Okay. That's the first step and if that's the first step, fine. And you don't want to leave kids on there forever where they forget why they're there and, you know, what they're supposed to be doing. And because there's nothing for them to do, they kind of slip off in their own little world and then you're going to have to try to get them back out of that, which is going to be difficult. So that's an individual group decision. 

>>Lisa: One of the books in the references says you probably need to sit a couple of minutes to have a bowel movement, be able to sit a little while for a bowel movement. Maybe not urinating but you have to sit a little bit for a bowel movement. She mentions at least two minutes. It's this book. And the acronym SEND is special education needs and disabilities. I just didn't know that. But she says you need to be able to sit a couple of minutes in order to push and have a bowel movement. 

>>Lynne: Okay. And then we have the kids that like to play in the water. If they do explore what's in the big hole and they find out, oh, it's water. So they're sitting on it and they get their hands underneath them playing in that water, if the they like to do that, you know, I would give them other ways to play in water while they're sitting there. So maybe have a little small table with a bucket with some warm water. Probably playing in water may make it easier for them to go to the bathroom. Sometimes people will turn on the faucet just so they can hear the sound of the water too. But that tends to maybe give a little kickstart. You have to decide about wiping. Are you going to use toilet paper? Are you going to use wipes? Are they going to do a portion of it? Are you going to do a portion? You know, what's the routine. What do they do at home? I mean, some families have bidets and the kid doesn't need to use anything. That's perfectly valid. If you have a kid that doesn't have good control of their hands, maybe a bidet is something you want to ask the family to try. 

>>Lisa: We did have a family ask me to help their son with wiping and I had a brilliant intern at the time. And he has the use of one hand but the other hand is not very easy for him to control. So he's essentially low vision and one hand for wiping. For some reason I was thinking he should do it like I do, you know, wrapping the hand or whatever. But I had this intern who was a dream and they came up with a basketball game. And he used a roll of toilet paper and he would just say pull and squish, pull and squish. We decided he needed to pull and squish three times to have enough in his hand. And he would just throw it, initially. Then we took the whole game in the bathroom. He's a brilliant student and he did really great. I think we hadn't really conceptualized how to teach it to him. 

>>Lynne: That sounds fun. And then flushing. A big toilet thing, flushing. Flushing may be painful and scary and if it's painful and scary, maybe that's your turn. So you're going to flush after they maybe leave the room. And that's fine. Or, you know, maybe the flushing is fun and they want to flush and flush and flush and flush. So then it's like maybe you can negotiate how many times can you flush today. And let's count together. And then you could make a book. You could make a book about toilets. And one of the things is they flush, except when you read the book together, you make the flushing sound, which is even funnier. And then you get the kid's interest from this inanimate object to you. That's the communication piece that can be the start of a back and forth to where you're the fun, interesting thing, not this thing that makes this noise. You make the noise, you're fun and interesting and you can play. Then it turns into kind of a play interaction, which is what we all should strive for for everything. I know we only have a few minutes left. So we're going to talk about the sink. You know, this is another step of the routine with substeps. So who's going to do the water? Are they going to do it or are you going to do it? Are you both going to do it? Are you going to use soap? Or not use the sink at all and use hand sanitizer. I'm not a big proponent long term. It's not good for your skin. And rinsing. How long are you going to rinse? Are you going to do something like count Mississippis. Are you going to have a hand-washing song that you sing together while you do it? Or you could sing it together, record it, and then the student can just play it so you don't have to be there, if they can be independent. Are they going to use towels? Are there hand dryers? And the trash should ultimately be the last step. And it should be somewhere by the door. Somewhere by the exit because exiting the bathroom is the end of the bathroom routine. So think about if a kid is prompt dependent in the bathroom, is this idea of backward chaining. That's where you start with the last step of the routine, in this case it would be the throwing of the paper towel in the trash. And your expectation is that they will do that themselves. They will do that without a prompt or help. And so if you can, you know, do that and teach them that. Then you go backwards one more step. Okay, now my goal is they will pull the paper towel out of the thing, also without a prompt. Also without help. And so slowly go backwards through this whole routine and try to introduce independence as much as you possibly can. And here again infuse fun and interests. Have songs. Celebrate stuff. Make it fun. You know, it doesn't have to be cold and awful and clinical. It's something we all do, like everybody poops. Isn't there a little kid book called Everybody Poops? It may have been an awful thing in this kid's past but you get to, as their teacher, change all that and make it more of a relaxing, pleasurable, sensory activity. All right. I think we have like a minute. Does anyone have any questions or anything you'd like to ask Lisa, specifically? 

>>Kaycee: While people are typing, we did have a comment in the chat about those underwear that you were talking about. Was it the Nix? 

>>Lisa: NIX? 

>>Kaycee: That they were created for menstrual cycles. 

>>Lisa: This second book in the reference is about someone who is a little bit older and scheduled their habit training. She does talk about that idea too. In this case she knows that her daughter won't feel the urgency of either I'm ready to use the restroom, I feel it in my bladder or bowels. She's schedule training, and that's great too.