Monday, April 20, 2015

Heart of an OT?

Dear Melissa,
What's the heart of a good Pediatric OT? 

A common mantra I enjoy is "when you love your job, you never work a day in your life!"  I admit it, I am an Occupational Therapist (OT) that loves the job and I am not alone. What is the heart of a good pediatric OT? He or she has to LOVE their job.That's it! It's simple. However, a more illuminating question might be,"why do you love your job?" In the spirit of recognizing OT month, I reached out to several of my fellow Children's Therapy TEAM OT's to ask this question. They shared the following responses: 

“I love the connections I build with people and helping them reach their own personal goals…whether it be learning to tie shoes, or motor planning to salute a scout leader.”
-Katie Gehrki

"I love being an OT because I love watching kiddos discover and use their unique strengths to develop self-esteem while reaching their goals in therapy and beyond." 
-Bridget Glynn

“I love being able to combine my creativity skills with my understanding of science...child development and brain functioning. Relying on these skills lets me be innovative and helps my kiddos have fun and make great progress.” 
-Allison Schmitz

“I love being an OT because I love working on skills that kids use in their everyday lives!  Plus, we get to have the most fun.”  
-Dana Tolle

“I love being able to help give children the tools to succeed in their daily lives. I love the pride and smile on their face when they meet a goal. And, I love that OT's have a client centered, holistic approach that puts emphasis on working with the families, teachers, and other individuals who impact the child’s life.”  
-Kelly Yates 

“I love seeing the excitement for the parents and kids as they master new skills that they have worked so hard to achieve. Focusing on the child’s ‘occupation’ allows her to succeed with life changing skills.”  
-Kati Bullington

So let me summarize why we LOVE being pediatric occupational therapists, while of course putting in my own two cents!

It Works!  
We wouldn't do this if we didn't see progress. We know how hard our kiddos struggle to meet their goals, and I can’t tell you how many times I have smiled for a full week when a child has met a much anticipated milestone!

Medicine + Creativity = Win, Win.  
Most of us love science and medicine. But we also love problem-solving and creativity. This allows us to live in the best of both worlds!

Um…my “office furniture” consists of a ball pit, trampoline, swings, and a wicked-cool light room. My “office supplies” include play-dough, scooter boards, UNO cards, and glitter glue. Best workplace ever?  Yes, I think so! Take of tour of my clinic and see for yourself. 

It takes a village…
Yes, we are problem solvers, but we are not egotistical problem solvers.  Parents, grandparents, extended family, doctors, other therapists, teachers, even the martial arts instructor…all of these people are in my client’s “village”.  I love having input from all of these loving, caring adults in order to help my kiddo meet his fullest potential. 

Practice, practice, practice. 
I am a mama of 2 young children. I love that I have “work kiddos” that are the same ages as my “biological kiddos”.  Now, I am sure that my biological kiddos hate it, but I have the unique opportunity to practice therapy techniques all day long at work, then all day/weekend long at home. Cool therapy techniques, games, books, TV shows, crafts, books, etc. I am constantly passing these ideas back and forth between my two worlds and I love it!

Do you love being a pediatric OT?  
Are you a parent/child who loves your pediatric OT? Please share! 

Monday, April 13, 2015

ADHD Diet & Supplements

Dear Melissa,
My 7 year old son was diagnosed with ADHD, but I don’t want to give him prescription medications to treat it. I have started giving him the supplement from the local natural food market and have taken sugar and red dye out of his diet. What else should I do to treat ADHD “naturally”?

I am asked this question frequently. It is very common for a parent to tell me that they have changed their child’s diet and started them on a natural supplement from the local natural market. However, frequently the parent does not actually know what is in the new supplement. I commend you if you do know what the supplement is made of, you have talked to your child's pediatrician and you understand how the supplement and special diet may interact with your child's body. 

A word of caution
A couple weeks ago, I went to a natural market myself and tried to read the labels of several "natural" supplements. I wanted to better understand what my patients were taking. I couldn't discern heads from tails! This is concerning because certain herbs interact negatively with traditional medications. For example, Ginko biloba should not be taken with aspirin, anticoagulants, or antidepressants (ref: Like I always say, psychedelic mushrooms and marijuana are “all natural” but you wouldn’t want to give them to your child!

Mixed Review on "All Natural" Treatments 
There is quite a bit of research on this topic. The following are some “all natural” treatments for ADHD which actually do have some research behind them (with both positive and negative results).
  1. Artificial Colors: Mixed Reviews. A few years ago, the United Kingdom and European Union restricted the use of artificial food colorings. Of particular concern are certain red and yellow dyes. Much of this debate started in the 1970’s with the publishing of Dr. Ben F. Feingold's Why Your Child Is Hyperactive. This book touted that half of children on his specialized diet showed improvement. However, the American Academy of Pediatrics3, 4 reports recent studies that “only approximately 2% of children with ADHD on the Feingold diet have shown consistent behavioral improvement when these food dyes are eliminated." 
  2. Sugar/Artificial Sweeteners: Probably No Effect. Once more, many studies have looked at the relationship between sugar (both real and artificial) and hyperactivity in both ADHD and neurotypical children. The result? No evidence that sweeteners affect hyperactivity. Furthermore, it is hypothesized that it is actually the lack of structure in the child’s overall household which allows for more sugar, or possibly the sugary event (birthday party anyone?), that causes the increase in hyperactivity rather than the actual sugar/artificial sugar ingestion. 
  3. Omega-3 Fatty Acids: Probably Help. 4 Omega-3 Fatty Acids are important for brain health. So it makes since to study the relationship between fatty acids and hyperactivity/impulsivity. The jury is still out on supplementing with Omega-3 Fatty Acids, but the American Academy of Pediatrics states that adding them to your child’s diet is “a reasonable approach” (reference:
  4. Megavitamin Therapy: Possibly dangerous. 7 – Some people think that ADHD is caused by deficiencies in the way the body absorbs certain vitamins & minerals. However, studies have shown that megadoses of vitamins can actually cause permanent liver damage. You can have too much of a good thing when it comes to vitamins. 

My Recommendations
When trying to follow the research and try a more natural approach, I recommend the following: 
  1. Connect with your Pediatrician. Discuss ALL treatment options, diet changes, and supplements with your child’s pediatrician! Again, some treatments can actually have negative effects on your child. 
  2. Embrace a whole-food type of diet and leave processed foods behind. In general, this seems to be the overall nutritional recommendation given by many physicians.8 This means a diet which focuses primarily on fruits & vegetables, adds some fish and other lean protein, and reduces processed foods as much as possible. 
  3. Work WITH your child’s “village”. This means the pediatrician, behavioral therapist, occupational therapist, teacher, grandparents, coaches, aunts/uncles… The research clearly shows that a multidisciplinary approach creates the best outcomes. Whether your child ultimately needs prescription medication or not, the bottom line is to make sure that the ADHD symptoms are treated in order to help your child be his best!

Have you tried any of the above treatments?  
Which combination worked best for your child? Please share!

1. ADHD Treatment: Where do you start? Children's Therapy TEAM Monday's with Melissa Blog, posted February, 2015.
2. Alternatives to Prescription Medications for Treatment of ADHD, Children's Therapy TEAM Monday's with Melissa Blog, posted April 6, 2015.
3. A Research Model for Investigating the Effects of Artificial Food Colorings on Children With ADHD, Pediatrics, American Academy of Pediatrics, Vol. 127, June 1, 2011.
4. The Diet Factor in Attention Deficit/Hyperactivity Disorder, Pediatrics, American Academy of Pediatrics, Vol. 129, February 1, 2012.
5. Relative Effects of Drugs and Diet on Hyperactive Behaviors: An Experimental Study, Pediatrics, American Academy of Pediatrics, Vol. 61, June 1, 1978.
6. ADHD Diets, WebMD, Accessed January 2015.
7. Your Child's Diet: A Cause or a Cure of ADHD, American Academy of Pediatrics,, updated May, 2013, accessed February, 2015.
8. What does the research say about the relationship between food additives and ADHD? John E. Huxsah, Mayo Clinic, updated October, 2014, accessed February, 2015.

Monday, April 6, 2015

Alternatives to Prescription Medications for Treatment of ADHD

credit: Envato Images
Dear Melissa,
My daughter is 7, and her teacher was concerned about her inability to focus in the classroom and generally “not meeting her potential”. I had my daughter evaluated by a child psychiatrist, and the doctor gave her a diagnosis of ADHD. I really don’t want to put her on medication at such a young age. Are there any non-prescription interventions that are proven to help?

I have frequently heard this question from parents. Often parents come and have their child evaluated for occupational therapy because the child is struggling in school, and they want to start the ball rolling to build success...even before the child has a diagnosis of ADHD.  Actually it is not uncommon at all for the psychiatrist to have me, as the OT, provide input from my treatment sessions with the child in order to help the psychiatrist gain a complete picture of the child in multiple settings and make a more accurate diagnosis. 

Prescription medications ARE a fantastic tool for treating ADHD. However, many parents, for various reasons, really want to avoid medications for ADHD. My personal philosophy is that ADHD needs to be treated. Period. No kid wants to be “that kid” who is bouncing off the walls and gets in trouble for not focusing, even when she is trying her best. BUT, I personally don’t like how medication is seen as the first line of defense. I want to see SOMETHING else tried first before we give medication to a young child. Below I have listed some options that are proven to generally help children with ADHD and other mental health disorders. 

Rule out other medical diagnoses.  This should always be first on the list.  Poor attention can be the result of many other medical diagnoses including depression, anxiety, learning disabilities, Autism, dyslexia, visual/hearing problems, insomnia, etc.  All the ADHD treatment/medication in the world won’t do your child a lick of good if there is an untreated underlying cause.  Working with your child’s pediatrician is your best source for ruling out other causes of poor attention. 

Occupational/behavioral therapy.  A therapist who specializes in ADHD and other mental health disorders can work with your child and your family to help find the right techniques to reduce impulsivity, improve social skills, improve listening skills/following directions, and learn to refocus attention.  In addition, occupational therapists can evaluate your child for any developmental “splinter skills” which may have not yet been met as a result of poor attention (ex. handwriting skills, auditory processing skills, self-care skills such as tying shoes, etc). 

Reduce/Eliminate Electronics.  Many years ago, there was a fantastic pediatric neurologist in the area who used to say, “Before you drug, UNPLUG!”  And this was in the days before smart phones and iPads!  Before she would prescribe ADHD medication for a child, the neurologist would require that the child eliminate all TV/video games/computer time for SIX WEEKS.  Research shows that children with more screen time earlier in life have more attention difficulties later in life. In addition, children with more screen time have more sleep problems, which also contributes to poor attention. 

Exercise.  Elementary schools are cutting recess and PE time right and left.  Fortunately, our teachers are finding ways to incorporate brief bursts of exercise into the classroom day to help their children focus. They know it works. For example, one study in Missouri compared three elementary schools using an ABC exercise program with two other schools not using it. Among the findings: Schools that adopted the exercise program for most of the academic year had a 33% decline in ADHD medications used by its students. That compared with a smaller, 7% decline in medication use in the schools not using the program. The side effect? More physically-fit children! Count me in!

Parenting techniques. A study published by the American Academy of Pediatrics in January 2013 showed that Parenting Behavior Training (PBT) was BETTER at improving symptoms of ADHD in preschool children than medication.  In general, children with ADHD (as well as most children) respond well to clear boundaries and structure.  Again, this is where an occupational therapist or behavioral therapist can help recommend techniques which work best for YOUR family. 

Diet. This one is a bit more controversial.  The CDC reports that there is NO link between sugar, artificial sweeteners, food additives (dyes, etc) and ADHD.  However, can it hurt to feed a child more whole foods, more fruits and vegetables, and less processed foods?  Simply go back to the food your grandma ate? Sounds good to me! Personally, if I eat fast food, I can feel my brain just turn down the fire power. That may be fine for a lazy Saturday, but not a great idea for a Monday night when homework needs to get done! Again, the biggest side effect is a child with a healthier diet. It can’t hurt!

Although I think occupational therapy is a valuable tool for treating ADHD, it is not the only option for a first treatment (as you can see above). Maybe the alternative treatment is not 100% effective, but it may help reduce the amount of medication a child may require. Unfortunately, in the American healthcare system (for ALL diagnoses), we are quick to offer pills, but very slow to try other treatments such as diet, lifestyle change, and exercise. In reality, many of these non-pharmaceutical practices actually work BETTER than pills. 

Still not sure?  Next week I will dive into the more controversial area of specific diets and supplements for treatment of ADHD. Send in your questions now, and we will try to get them addressed!

ADHD Treatment: Where do you start? Monday's with Melissa Blog, posted February, 2015
Interventions for Preschool Children at High Risk for ADHD: A Comparative Effectiveness ReviewPediatrics, American Academy of Pediatrics, Vol. 131, May 1, 2013. 
A Research Model for Investigating the Effectsof Artificial Food Colorings on Children With ADHD, Pediatrics, American Academy of Pediatrics, Vol. 127, June 1, 2011.
Relative Effects of Drugs and Diet on Hyperactive Behaviors: An Experimental Study, Pediatrics, American Academy of Pediatrics, Vol. 61, June 1, 1978.
What is ADHDNational Institutes of Health, Accessed April, 2015. 
ADHD, Center for Disease Control & Prevention, Accessed April, 2015.
Why French Kids Don’t Have ADHD, Psychology Today, March 8, 2012.
Exercise Helps Children with ADHD in Study, Wall Street Journal, September, 2014.
Diagnosing ADHD in Children, American Academy of Pediatrics,, updated January 9, 2015. 

Monday, March 30, 2015

Rules of Engagement for Praising a Child with Autism

Dear Melissa,
What is the best way to tell my son with Autism that he is doing a good job?

If you read any parenting book or blog, one overwhelming truth comes out: one of the best ways to encourage positive behavior is to praise a child when he is being good.  This is true for children with Autism, this is true for children without Autism and this is true for your spouse as well! But news flash, in most cases, you have to speak differently to the child with ASD than you do with most other children. For example, those often posted "101 Ways to Praise a Child” are NOT how you praise children with Autism! I have had the fortune of supervising many OT interns over the years. Here I have seen firsthand how traditional praising that works for most children can backfire for children on the Autism Spectrum. 

Children with Autism have difficulties processing language and social interaction. This is the hallmark of the diagnosis. However, not all children with ASD are alike, just as not all “neurotypical” children are alike. But there are some general truths I have learned from over a decade of working with children with Autism. 

Praising a child in a variety of different ways is confusing.  

Children with ASD already have difficulties interpreting social cues and expressive language. Praising a child with ASD in 101 different ways requires him to decode the different types of praise 101 different times. Exhausting! That does not sound like a reward at all!

Consistent, predictable praise works wonders.
Consistency, consistency, consistency! Kiddos on the Autism Spectrum often repeat the same phrases over and over and watch the same movies repeatedly. The child who enjoys all of this repetition also enjoys it from you as well! For example, when a child with ASD brushes his teeth, he may expect that you sing the same song over and over. When he puts the puzzle piece in, he wants the same “good job” each time. One child I work with will even say the “good job” for me if I forget to say it after he completes a task well. 

Want to be a little bit more creative?  
You can spice things up a little bit by having 2-3 different phrases, but too many can quickly become overwhelming and less effective for a child with ASD. I personally use “Good job!”, “Whoohoo!” and a “Good job (name)” song. If the kiddo can handle a bit more, you can always add a qualifier to the “good job”.  For example: “Good job coloring”, or “Good job cleaning up”.  

Avoid too many words.

Don't use too many words in your attempt to praise your child. For example, you would NOT say “Johnny, I am so proud of you for brushing your teeth so nicely. See how shiny they are? You are such a big boy!”  This would be fantastic praise for a neurotypical child, but generally not appropriate for a child on the Autism Spectrum. Unless a child can speak back to you in several sentences strung together with emotions and abstracts thrown in, this is too much!

Try to ignore misbehavior. 
Responding to misbehavior with a simple “no no” or “ehh!” can really backfire. Just as the child with ASD may be motivated by immediate, consistent praise, he may also crave immediate words of reprimand. When you see a child misbehaving...then waiting for you to give the same verbal reprimand you offered last time...that is when you know you have entered a negative dance. If at all possible, keep quiet, avoid eye contact, and gently/silently redirect the child to the correct action. This one is particularly hard, but you can do it!   

Parenting a child on the Autism Spectrum offers a whole new set of challenges. But with shoulders to lean on, some extra patience and a few tricks in your bag, you can do it! 

What do you find most difficult about parenting a child with Autism?  
What tricks have worked for you and your family?  Please share!

Autism Spectrum Disorders,, accessed February 2015.
Behavior & Discipline Issues for Children with Autism Spectrum Disorders, Super Nanny (June 25, 2014), accessed February 2015.  
Helping Children with Autism,, accessed February 2015. 
Tips for Parenting a child with Autism, WebMD, accessed February 2015. 

Monday, March 23, 2015

Potty Training Wisdom: Constipation

image credit: Envato
I have received many questions over the years concerning difficulties with helping children have bowel moments in the toilet. The concerns often sound something like this:

Our son still refuses to have a bowel movement in the toilet. When we put him in underpants, he will either simply use the underpants for a bowel movement, or “hold it” and become horribly constipated.

Though I have seen issues surrounding bowel movements with many “typically” developing children, boys with Autism tend to have particular difficulty with this aspect of toilet training. A study published in Pediatrics (February 2014) found that children with ASD have four times more GI distress (constipation, diarrhea, & abdominal pain) than “neurotypical” children. No wonder it can be so tricky for these kiddos! It has been my experience that little boys will often find success with urinating in the toilet, but many of them have a whole new set of troubles when it comes to bowel movements including:
  • Withholding bowel movements and becoming constipated.
  • Requesting that the caregiver change him into a diaper so that he can have a bowel movement.
  • Only having bowel movements at night when they are changed from underpants into a pull-up. 
  • Not caring if they have a bowel movement “accident” in their underpants. 

This area of difficulty is SO common, and it seems that the reason for it is often multi-factorial including: 
  • Fear of sitting on a standard toilet/potty seat.
  • Fear of pain associated with previous bouts of constipation.
  • Difficulty with wiping after bowel movements.
  • Difficulty with managing clothing before and after bowel movements.
  • Not wanting to take the additional time required to sit on the toilet.

So...with this many different factors playing into the problem, there are many different ways to address the issue. As with most problems with raising children, it is often best to attack this predicament from several different angles. Here are a few ideas:

Adjust your child's diet
Sometimes simply adding lots of water, juice, and fresh fruits is enough to prevent bouts of constipation.

Add fiber supplements or laxatives 
Work with your pediatrician to make sure that your child does not become constipated. This may include adding fiber supplements or laxatives.

Develop a strong association between the bathroom and bowel movements 
 Allow the child to be changed into a diaper for bowel movements if the child requests this.  However, encourage him to go into the bathroom to have the bowel movement in the diaper. This will help him associate that THIS is the room where people go potty. 

Normalize this aspect of everyday life 
Use social stories, books, and TV shows to help your child understand that “everybody poops”.  It's normal and not something to be scared of or ashamed of. In my house, after this particular developmental learning stage passed, we then firmly established a new set of ground rules revolving around one idea: “We only talk about poop in the bathroom!”

Reward every step
Take baby steps toward sitting on the toilet with rewards for every step of the way:
  • Sit on toilet with clothes on (and even while holding a grown up's hand if this is still scary).
  • Sit on toilet with underpants only.
  • Sit on toilet with bare bottom.
  • Sit on toilet using a timer for longer periods of time (start with a few seconds, then work up to a few minutes).
  • Sit on toilet several times per day, particularly after meals, to help encourage accidental success.

 Learn More
Consider attending the March 26, 2015 talk:
Toilet Training Children with Autism at the University of Arkansas, Fayetteville. 

Elizabeth Pantley's Potty Training Tips - Part 2: Poo Problems! (updated 2014). Super Nanny, retrieved February 2015 from
Gastrointestinal Symptoms in Autism Spectrum Disorder: A Meta-analysis (2014). McElhanon, B., McCracken, C., Karpen, S., Sharp, W. Pediatrics, American Academy of Pediatrics, retrieved February 2015 from 
Gastro woes more common in kids with Autism: Review (2014). Brenda Goodman. Autism Spectrum Disorder Health Center, retrieved February 2015 from
Toilet Training Children with Special Needs (2014). American Academy of Pediatrics, retrieved February, 2015 from
Toilet Training. (2010). University of Michigan Resources on Child Development and Behavior Resources, compiled by Kyla Boyse and Kate Fitzgerald. Retrieved February 2014 from

Did your child have difficulties with toilet training?  
What solutions do you have to share?  We would love to hear from you!

Monday, March 16, 2015

Potty Training Wisdom: 7 Day Challenge

image credit: Envato
Dear Melissa,
My 4-year-old daughter has Autism. She will sit in her potty chair several times a day when I take her, and she even occasionally uses the potty. I think we are ready to actually start potty training. Now what?

Congratulations on all of your hard for the hard part! Again, potty training was my LEAST favorite part of being a mommy, so I have read many different books and sought lots of advice on this matter. I have listed three approaches below. The third, a modified version of the first two approaches, is a "Seven Day Challenge" and has been my go-to approach for my own children. 
The Gradual Approach
The gradual approach involves having the child wear pull-ups or training pants while you take her to the bathroom frequently throughout the day for several weeks. This approach has its benefits in that you don’t have to worry about your child having “accidents” either in your home or in public. The downside of this approach is that it often takes much longer for a child to become ready for big-kid underpants. In addition, pull-ups are so absorbent that children often can’t feel the difference when they do have an accident. 

The "All-In" Approach
For this method, you take the child to the store, ask her to pick out her favorite big-kid underpants (I suggest buying a lot!), and then she NEVER goes back into diapers/pull-ups. First, you start off by taking the child to the toilet every 20 minutes and gradually move to every hour over the next several days. If a child has an accident, you do NOT shame the child.  You are matter-of-fact about it being her accident (just as if she had spilled milk), and you ask her to clean it up. This approach means changing clothes and cleaning the floor if necessary. You can certainly help, but ultimately it is her responsibility.

The 7-Day Challenge Using an Adapted Approach 
Personally, I used the "all in" approach for my own children, largely because it was what their school required. However, I modified the approach a bit and allowed my kids to wear pull-ups at nap and bedtime, and they still turned out OK. I suggest using this technique for one week. Hang in there for the full 7 days! It is really awful the first few days. However, if you see NO improvement by day 7, the child may just not be ready yet. That’s OK. Go back to the readiness tips from last week’s blog and try again in a couple months

7 Tips to considers:
1. Don’t switch back and forth between diapers and pull-ups. This confuses the child and they can’t remember if they need to use a diaper or run to the toilet. 
2. Provide lots of positive role models. If everyone feels comfortable, allow older siblings to take the younger child to the bathroom, read books about “big kids” using the toilet, etc. 
3. Bribery works!  Keep lots of tiny treats on hand for success.  Think M&M’s, stickers, hand stamps, etc. Young children need immediate positive reinforcement rather than more extended behavior charts. However, they can save up their immediate rewards of stickers for larger prizes. 
4. Use easy clothing. Avoid buttons and zippers on pants during this time.  In addition, clothing that is slightly too big is even easier to manage. 
5. Do not reduce fluid intake. Rather encourage her to drink lots of water. This will create more opportunities for successful use of the toilet. 
6. Don’t hesitate to help.  Although the goal is independence, don’t hesitate to help your child when it comes to learning proper hygiene and proper cleanliness techniques. 
7. Praise, praise, praise! I know it often doesn't seem like it, but young children really DO want to please their parents! The more you praise small successes (even simply sitting on the potty), the more likely your child is to cooperate. 

As always, talk to your child’s therapists, pediatrician, and teachers to determine the best approach for YOUR child. In addition, your child’s speech therapist has the “magic fairy dust” of social stories. These fantastic stories help a child know what to expect with toilet training and make the whole process less intimidating. 

Learn More
Consider attending the March 26, 2015 talk:
Toilet Training Children with Autism at the University of Arkansas, Fayetteville. 

Establishing Toileting Routines for Children. (2014). American Occupational Therapy Association, developed by Jay Doll, Bonnie Riley. Retrieved February, 2015 from
Toilet Training Children with Special Needs (2014). American Academy of Pediatrics, retrieved February, 2015 from
Toilet Training. (2010). University of Michigan Resources on Child Development and Behavior Resources, compiled by Kyla Boyse and Kate Fitzgerald. Retrieved February 2014 from

What has worked with toilet training your child? 
Did you use the gradual approach, or go cold turkey?  I would love to hear your ideas.

Monday, March 9, 2015

Potty Training Wisdom: Readiness

 credit: Envato Images
Dear Melissa,
My 3-year-old daughter, who has Autism, has recently been removing her diaper. Does this mean she is ready for potty training?

I will admit that toilet training was my least favorite part of being a mommy!  Some children are independent and literally tell you, the parent, when it is time to lose the diapers. Other children are more subtle. There are a wide variety of factors involved with determining when a child is ready for toilet training. In sharing my insight I reiterate my stance - you can’t force children to eat, sleep or potty. But, there is a lot you can do to support your child during their journey to becoming ready to toilet train. 

As parents, if we are unable to answer "yes" to a majority of the questions below, then toilet training will likely end up being a frustrating failure for both the parent and the child. Below I have listed five common readiness indicators that I recommend parents consider.

5 Common Readiness Indicators
1) Verbal skills: 
  • Does the child have some way (either verbally or non-verbally) to tell you that she needs to use the bathroom?
2) Motor coordination skills: 
  • Does the child have the ability to manage simple clothing, wipe after voiding, flush the toilet, and wash her hands independently? 
  • Can the child control her sphincter muscles for voiding?  
  • Can she climb onto the toilet/potty chair independently?
3)  Cognitive skills: 
  • Does the child understand the cause and effect of voiding and soiled clothing?  
  • Does the child have the capacity to sequence the steps of toileting?
4) Sensory processing skills: 
  • Can the child tolerate the sounds of the flushing toilet, running water, and echoing bathroom?  
  • Can the child feel the difference between wet/dry?  
  • Is the child able to tolerate the sometimes scary sensation of sitting on a toilet (vs. a solid chair seat)?
5) Emotional skills: 
  • Does the child have any desire to wear “big kid underpants”?  
  • Is she in a phase where she is fighting you tooth and nail and saying “no” to everything you say? 
Again, regardless of your child’s chronological age, these are the precursor steps for toilet training. This is where many parents understandably despair. We often feel like toilet training is an all-or-nothing deal. BUT IT’S NOT! There are many, many actions you can take to encourage toilet training readiness and help set your child up for success.

Ways to Encourage Readiness
Change diapers in the bathroom. This encourages her to associate voiding with THIS room in the house, rather than elsewhere.

Wash hands in the bathroom. All toddlers need more practice washing their hands. I love them to pieces, but our toddlers can be like little Petri dishes!  Also, washing hands in the bathroom helps the child to integrate the sensory input piece of the process – stepping on a stool, splashing water, echoing bathroom, you get the idea. 

Practice dressing. Even if you are placing your hands over your child’s hands to help her pull her pants up and down, this begins the motor planning process. 

Establish routine. This will assist with the emotional/behavioral piece. If we are going into the bathroom at regular intervals in the day for diaper changes, then it will eventually become just as easy to use the toilet during these times. 

Sit on the potty. Listen to music, sing songs, read books, keep your clothes on, whatever.  Just help the child get used to sitting on the toilet or potty chair in a “no pressure” situation. 

Establish “potty time”. If your child is comfortable and ready, begin a routine of sitting (bare bottom) on the toilet several times a day. The times for best success are generally when first waking in the morning or after nap, after meals, and before bath time. 

Praise like crazy! If the child “accidentally” uses the potty correctly, then YES, singing and dancing are required. Party hats and confetti are strongly encouraged. 

Next week I'll dive into different techniques for toilet training once your child is developmentally ready. 

Learn More
Consider attending the March 26, 2015 talk:
at the University of Arkansas, Fayetteville. 

Establishing Toileting Routines for Children. (2014). American Occupational Therapy Association, developed by Jay Doll, Bonnie Riley. Retrieved February, 2015 from
Toilet Training Children with Special Needs (2014). American Academy of Pediatrics, retrieved February, 2015 from
Toilet Training. (2010). University of Michigan Resources on Child Development and Behavior Resources, compiled by Kyla Boyse and Kate Fitzgerald. Retrieved February 2014 from