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

Difficulties with toileting may show up in a variety of ways. In some cases, the child or young person may be incontinent (ie. unable to control their bladder and wetting themselves). Other problems may include difficulty with physically getting to the toilet in time, managing clothing and needing supervision and/or help with wiping. Children who use a wheelchair may face environmental limitations such as poor access to toilets, a lack of circulation space in the bathroom, or they may need help to transfer from their wheelchair onto the toilet.

When to see a doctor?

If there are concerns regarding toileting, please discuss this with your child's rehabilitation doctor, clinical nurse consultant and the occupational therapist from your child's rehabilitation team. A team approach is necessary to ensure all factors are considered before introducing a treatment plan.

Assessment would involve an evaluation of the following:

• a child's living and school environment - their access to a toilet, the need for rails or other modifications and their need for supervision for safety
• a child's motor skills - assessment of their ability to perform all the necessary movements to be able to use the toilet. This includes balance, arm and hand movements and the ability to manage clothing
• frequency - how often the child needs to go to the toilet, and the need for prompting (such as a toilet timing program)

What is the treatment?

A knowledge of the child or young person's self care abilities before the brain injury is necessary so the treatment program can be targeted at the appropriate level for the child. 

While the child or young person is in the early stages of recovery (and may be confused and easy to distract) it is useful to develop regular toileting times to promote continence. As children and young people recover, it is important to encourage them to take increasing responsibility for their own self-care. The degree of independence expected will depend on their previous level of functioning and any residual physical or cognitive difficulties.

Intervention to promote independence may include:

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

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