Hypothesis / aims of study
Toilet training children with special needs can be challenging and can result in long-term consequences for children and their families if inadequately addressed (1). Factors impacting the toilet training process in children with special needs include problems with communication, social interaction and processing sensory information (2). Additionally, families of children with special needs may delay toilet training and families and clinicians may not adequately deal with any toileting concerns due to more pressing medical, development and psychological concerns (1, 2). A paucity of data and research exists about how and when to effectively toilet train children with special needs to educate families and guide clinicians (3).
Some clinicians recommend using a “modelling method” for toilet training children with special needs. Modelling is a form of learning using pictures or stories teaching children to model appropriate behaviours. Many children with special needs are visual learners hence can benefit from this communication style to attain new skills including toileting (2).
Our multidisciplinary continence team decided to use a “Potty Monkey” toy to help toilet train children with special needs. “Potty Monkey” offers a fun, interactive and purposive approach to assist children with special needs who have failed to respond to standard toilet timing.
The “Potty Monkey” Study aims to explore the effectiveness of a “Potty Monkey” toy device for toilet training children with special needs who have not attained urinary continence and to document child and family attitudes to “Potty Monkey”.
Study design, materials and methods
A pilot study using a “Potty Monkey” to model timed voiding in children with special needs.
All the eligible children who enrolled in the study were given a “Potty Monkey” that came with a flushing toilet and a timer that could be set to alarm at 30 or 90-minute intervals. At the set times “Potty Monkey” spoke and expressed a desire to void, saying “I want to go potty” which it would repeat twice in an increasingly urgent tone “I really need to go potty. Come on, let’s go potty”. The child was encouraged to take the monkey and sit it on the monkey’s toilet. The monkey would express delight at being able to void (and laugh and say things like “great job”) and sing. The child could then flush the monkey’s toilet. If the monkey was not taken to the toilet by the third warning it said “oh no, I had an accident, please take me to the potty next time”. Parents were encouraged to take the child to the toilet at the same time as the monkey, providing modelling and positive reinforcement.
Over the course of six-month intervals we collected parental feedback and examined the experience of families using a “Potty Monkey” to toilet train their child.
Primary and secondary outcomes included: attainment of daytime continence, time to achieve continence, any improvements in baseline toileting, acceptability, adverse events, change in quality of life based on a modified (PinQ) (Paediatric Incontinence Questionnaire) score which is a validated continence specific quality of life score for children and additional parental feedback.
Statistical analysis explored factors associated with the outcome of objective improvement using chi-square tests and logistic regression.
Results
Of 21 children in our study, 15 were male. Age ranged four to 10 years (median 6.3 years). Descriptive statistics of the participants are outlined in Table 1.
Days that “Potty Monkey” was used ranged 0 to 156 (median 22 days). At six months, nine children had improved, five were unchanged and four were worse (three were unknown). Eight of the participants (38%) did not use “Potty Monkey” despite being given one. Treatment outcomes are represented in Table 2. Many families agreed treatment had been helpful (56%).
We examined associations between participant factors and treatment outcome and found no evidence for association between age, gender, days they used “Potty Monkey”, baseline ability to ‘take themselves to the toilet’ or PinQ scores and improvement in toileting.
The experience of families was ambivalent. 10 families reported “Potty Monkey” had been helpful however many complained it interfered with family schedules. Reasons for the child not responding positively were due to sensory issues, embarrassment and being developmentally not ready.
Child attitude to toilet training in general and to “Potty Monkey” specifically varied.
Interpretation of results
Although there was improvement in toileting for some children, with five children achieving daytime continence most or every day after being given access to “Potty Monkey” for six months, we were unable to identify factors associated with toilet training success.
Our study demonstrated the practical challenges of carrying out research among children with special needs. Busy family schedules combined with the health concerns and demands of caring for children with special needs made treatment adherence and data collection burdensome. Additionally, the aesthetic features of “Potty Monkey” which were unpleasant for some children with sensory issues and the lack of interest paid by most children to use (or persist in using) “Potty Monkey” caused difficulties in conducting our study.