How schools can support children who have toileting issues
For a number of reasons, children may enter the school population either not toilet trained or having specific bladder and bowel needs that require intervention during the school day. Schools need to develop policies and guidelines regarding good practice for the safety and wellbeing of both staff and children with such issues. They should ensure that individual health care plans are drawn up for each child and that any staff involved undertake child-specific training.
The School’s Admissions Code (Department for Education, 2012) states that admissions authorities must not discriminate against or disadvantage disabled children or those with SEN. This is in line with the Equality Act 2010. This states that a person has a disability if s/he has a physical or mental impairment which has a substantial and long-term adverse effect on that person’s ability to carry out day-to-day activities. Therefore, it is unacceptable to refuse admission to school to children who are delayed in achieving continence.
What specific continence procedures may need to be undertaken in school?
A number of children may start school in nappies with delayed toilet training. It is important that support is given to enable the child to undertake an appropriate toilet training programme.
Management of bowel problems
Soiling problems can be particularly difficult to manage in school. However, it is important to understand that the soiling often happens outside the child’s control. Indeed, the child may be unaware that it has happened. These children need to be treated sympathetically and schools must ensure that the child has easy access to a toilet that affords privacy, to help prevent any associated bullying.
Children who have neurological problems such as spina bifida may well need specific interventions to enable them to achieve continence and maintain healthy bladders and kidneys. In this case, they may require a procedure called clean intermittent catheterisation (CIC) which enables the child’s bladder to be emptied. This involves inserting a catheter into the child’s bladder via the urethra or an opening on the child’s tummy called a Mitrofanoff. This is a procedure that most children will learn to do for themselves but while they are learning, they will require help and support.
A stoma is an artificial opening in the body and is commonly made to allow for the emptying of faeces (poo) although it can also be made for urine. In most cases, the school care involved in supporting a child with a stoma would be minimal and may just involve emptying the stoma appliance. It is important, however, that school staff are training to change the appliance if a problem develops.
Individual health care plans
When children have continence problem which affect them at school, it is useful for everyone involved to work together to resolve the issues. To establish an effective continence care plan, the following areas need to be discussed in a meeting with parents and the school.
Nature and extent of the problem
When parents and school staff meet, it is appropriate to invite a healthcare professional along, such as the school nurse or a paediatric continence advisor (if involved). If no other healthcare professional is involved, the school nurse should be asked to assess the child’s continence issues and ensure that any appropriate referrals are made. Other healthcare professionals who may be involved include occupational therapists (to assess the child and ensure that the toileting seating and environment is suitable) and physiotherapists (to help with moving and handling, toileting positioning and equipment).
The support required
It is important to establish the level of support required to manage the child’s continence. This can involve a number of factors:
- Independence: what is required of support staff to ensure that the child can be as independent as possible? A young child is likely to need help to change, if soiled. It needs to be clear who is to support the child at all times. For example, is there a midday or teaching assistant to support a child’s toileting after lunch, as this is likely to be a time when the child needs to be toileted
- Toileting times: does the child need to be prompted at regular intervals or does the child initiate toileting? Some children will know when they need to go and would be devastated to be asked to go to the toilet; others will wet if they are not prompted
- Communication: how does the child let you know they need the toilet? Bear in mind that some children are extremely embarrassed by even having to ask to go to the toilet. If a discreet system can be put in place, this will aid the child greatly
- Toilet facilities: the environment, the facilities and the distance to an appropriate toilet need to be taken into account. It may be necessary for a child to use a toilet that affords more privacy. Involving the child in these discussions is useful, as often the child will have valid reasons for not wanting to use a certain toilet, such as no lock or other children peering under the door
- Manual handling and lifting: does the child need to be hoisted when toileted or having their nappy changed? Is the equipment available? Is this manageable by one person? Is any training needed?
- Consistency of approach: for any toileting programme to be effective, family/carers have a responsibility to ensure that toileting routines are continued at home. If the parents/carers are unable to manage this, school staff need to liaise with the school nurse to see if there are any particular issues at home that are making it difficult for the family to engage with the toileting programme. If concerns are not addressed, schools can consider calling a “team around the child” (TAC) meeting to discuss issues and possible solutions.
Management of unplanned events
Planning for “unplanned” events means that should the child have a wetting or soiling accident, it is dealt with swiftly and in a sympathetic manner. Parents need to provide spare clothes, wipes and plastic bags, which should be kept in school in an easily accessible, discrete location. There needs to be a private area, such as a disabled toilet, where the child is able to get cleaned and changed with the support of a member of school staff, if necessary.
Advice on specific interventions
If a child has a specific continence issue which needs to be addressed, such as a catheter or a stoma, staff need to be trained to fully understand the procedure. Where intimate care needs are involved, a health care professional should be involved in instructing staff, in conjunction with parents. Depending on the local provision, this may be the urology or stoma nurse from the hospital, or a continence nurse based in the community.
It is always necessary for individualised child-specific training to be undertaken to enable school staff to carry out specific toileting procedures, even if school personnel have provided similar care to other children in the past.
June Rogers MBE is Team Director of PromoCon, which provides a national service, working under the umbrella of the charity Disabled Living, for children and adults with bladder/bowel problems, their carers and professionals:
Photos courtesy of KW Therapy Solutions Ltd: