Tech Toilet Training – “Smart” Solutions for the Developmentally Delayed

Toilet training is a rite of passage for people, and for a majority of children is a trouble-free part of early childhood. However, for children with disabilities, mastering the skill of toilet training can be a long and arduous road. Current wirelessly connected technology offers promise to helping children with special needs achieve independent toilet training success. In this series we will build a technology solution with the goal of helping an older special needs child become fully independent in toilet training.

Our Personal Journey

Our daughter, we’ll call her “Jane”, is 12 years old with a rare chromosomal abnormality. For Jane, she presents both physical and mental delays and is still not fully toilet trained.

As a baby and young child, Jane was delayed in reaching milestones – sitting independently, crawling, walking, and talking. We introduced her to the potty as a toddler, but her high muscle tone and very limited attention span made sitting on the potty arduous, and with no interest shown in using the potty, we kept her in diapers past the toddler age. Once she entered school her teachers began working with her on “trip training,” and while she has been very successful at urinating when on the potty, she still will not indicate when she needs to go or if she has already gone. Jane’s particular chromosomal abnormality is quite rare, so we don’t have a lot of history from other children with her condition. Most are beyond their toddler years before they begin to have any success on the potty, but eventually those we know of have limited success with independent toileting.

Like most children with her condition, Jane deals with chronic constipation and takes laxatives periodically to help manage this condition. To date we have had no success with bowel movements on the toilet and because she does not indicate the need to go, or have a regular routine, we keep her in pullups.

Jane has no underlying physical gastrointestinal conditions outside of chronic constipation and we feel she is ready to achieve complete toileting independence. Our goal is to develop a technology solution that will help Jane once and for all become independently toilet trained.

A Brief History of Toilet Training

Toilet training has evolved over the years from the parent-led methods of the late 1800s to the child-led methods of today. Parents up until the late 1930s were advised to start babies as young as six months on heavy doses of laxatives for predictable pottying as a method of training. However as children moved from cloth diapers to disposable diapers (introduced in the 1930’s[2]), and aggressive parent-led training ceded way to child-led methods focusing more on the child’s readiness, full toilet training started being achieved at later ages. By the 1950s 95% of children were potty trained by 18 months of age.

Playtex Dryper- World’s First Hybrid Diaper 1950’s

The disposable diaper market is valued at $923 million in the U.S.[4] The average child will use more than 2,700 diapers in the first year of their life alone, which can add up to more than $550 (based on an average price of $0.20 per disposable diaper)[5]. While new diaper varieties like pullups are marketed as products to help ease children into full toilet training they may actually delay children learning to potty train until later in life. In 2007 Pampers introduced a disposable diaper for children weighing more than 41 pounds (typical for age 5)[6].

In 2014 Kimberly- Clark introduced the GoodNites TRU-FIT a cotton-blend underwear with disposable, absorbent inserts[7]. The product is aimed at the one in six children age 4 – 12 in the United States that still wets their beds. Today, in our disposable diaper-centric culture the average child is fully potty trained by 36 months; double the average age of a child being trained 65 years ago when cloth diapers were predominantly used[8].

Today’s Modern Approach to Toilet Training

A simple Internet search on toilet training can overwhelm a parent taking on the task of properly training a child to potty. Today’s approach is typically to begin toilet training when the child is both developmentally able and shows signs of readiness[11]. This approach was promoted by renowned pediatrician Dr. Benjamin Spock when in 1946 he encouraged parents to “leave bowel training almost entirely up to your baby…[who] will probably take himself to the toilet before he is two years old“[9].

In 2006 the University of Alberta conducted a comprehensive review of popular toilet training research to determine which methods universally were the most successful. The review concluded that one popular child-led approach popularized by Richard Foxx and Nathan Azrin had the most success. They developed a “four-step stimulus-control model”:

Increased fluid intake
Scheduled toilet training time
Positive reinforcing correct behavior
Over-correcting accidents (verbal reprimands or keeping positive enforcement away from the child)

The Foxx and Azrin model was also cited as the best method for toilet training children with disabilities.[10].

Toilet Training Challenges for Special Needs Children

Special Needs children can be difficult to toilet train. These children can often present physical, mental, emotional, communication and medical obstacles to toilet training. Some barriers include chronic constipation, the in-ability to manage clothes or detect the need to go. The Centers for Disease Control and Prevention (CDC) found that children with Autism are 3.5 times more likely to suffer chronic diarrhea or constipation than are their normally developing peers[13]. In these cases other factors need to be considered such as diet modifications including increasing fiber and water intake or encouraging more physical movement to help promote bowel movements. Additional considerations also need to be made for physical limitations such as wearing easy to manage clothes for children with limited movement or making their toileting area more accessible. In these cases intervention methods have been utilized and even workshops are set up to help parents and caregivers manage toilet training a difficult child.

High-Tech Tools to Help Toilet Training

Potty Time - Two Little Hands Productions — Potty Time – Two Little Hands Productions

Technology has also helped in the area of toilet training. Smartphone and tablet apps like “Potty Time” allow parents to schedule times to use the potty, provide reward systems and show videos to entertain the child while on the potty. YouTube videos also have both parenting advice as well as teaching tools for children including modeling the proper behavior like the “Wonkidos Going Potty” video or Sesame Street’s “Elmo’s Potty Time” video with over 5 million views. These tools help parents organize the process and also entertain kids.

The Quick Trainer consists of an iOS device, Bluetooth transmitter and disposable sensor.

Technology also extends off-screen and also can include personal sensors to alert the child or the parent or caregiver when an accident has occurred. Researchers at University of Rochester have developed the “Quick Trainer” that combines a wearable sensor pad, Bluetooth technology, an iPhone and accompanying app to help toilet train an intellectually disabled children[14]. In their experiments initial results show a lot of promise. An 11 year-old female child with severe intellectual disability began using the toilet without accidents after 40 days and a 15 year old boy with the same condition needed only 26 days. Both had histories of repeated, unsuccessful training attempts and were using disposable pull-ups before using the Quick Trainer. Other similar solutions have appeared on crowd-funding sites like the “SiempreSecos (always dry)”[15] which is a discrete reusable moisture detection device that goes into the diaper and a bracelet worn by a parent that vibrates when urine is present on the device in the diaper. A non-connected solution available today is the Tinkletoonz “Sensor” which is placed in a diaper and will play music when moisture is detected[16].

Conceptualizing a Solution for Jane

Considering Jane’s chronic constipation, and her lack of proper communication to let us know when she needs to go, we will have to consider changes to her diet, physical activity as well as a method to alert both her and either us as her parents or her teachers when she should attempt to go. Also, Jane works with a large team of people in various settings including home, school, church and therapy centers so we have to ensure that her teachers, service providers and “buddies” all work in the same manner for Jane’s success. Finally, we need to track data including toilet readiness, trials, successes, diet, exercise and sleep to ensure we are measuring success.

At this point, here is the solution we plan to build for Jane:

A Connected Fitness Band: A Fitbit bracelet that has a vibrating alarm to alert Jane when it is time to go potty. Additionally we can track movement, sleep, water intake and diet.
Text Message Alerts: Text messages to notify parents and Jane’s larger team of when she needs to try toileting.
A Toilet Training App: The app will be used by Jane’s team to record data as well as access social stories, entertainment (such as videos to show Jane while on the potty), timers and possible rewards for Jane.
Back-End Management and Reporting: Systems used to pull in all the data sources to monitor success as well as modify Jane’s toileting schedule to real-time statistics.

In Part 2 of this series we will show you how we built this solution for Jane and present some early results. In the meantime, if you have any high-tech solutions that you have used for toilet training, we would love to hear from you by commenting below.

References:

[2] http://en.wikipedia.org/wiki/Diaper

[3] http://priceonomics.com/the-evolution-of-potty-training/

[4] http://www.statista.com/statistics/342999/us-supermarkets-diapers-dollar-sales/

[5] http://www.investopedia.com/articles/pf/08/budgeting-for-baby.asp#ixzz3WqPebsPv

[6] http://www.motherjones.com/environment/2008/04/brief-history-disposable-diaper

[7] http://www.marketwatch.com/story/goodnites-brand-launches-goodnites-tru-fit-underwear-2014-07-16

[8] http://www.med.umich.edu/yourchild/topics/toilet.htm

[9] http://priceonomics.com/the-evolution-of-potty-training/

[10] http://archive.ahrq.gov/downloads/pub/evidence/pdf/toilettraining/toilettr.pdf

[11] http://www.childrensomaha.org/documents/Potty%20Training.pdf

[12] http://www.childrensomaha.org/documents/Potty%20Training.pdf