Flowchart – Children with Additional Needs

Every child must be fully assessed using the appropriate Continence Assessment Form.

Some children with complex additional needs may never achieve continence. However, even children with significant learning, mobility or communication difficulties can achieve a good level of continence. Every child has the right to be helped to achieve their best possible level and to maintain their dignity.

Even if a child is unable to achieve full continence, a healthy bladder and healthy bowels should be promoted at all times. Constipation is very common in children with additional needs, and is often overlooked as their bowel problems are incorrectly attributed to their learning disability. Constipation may result in frequent, loose bowel actions (overflow soiling) which can cause sore skin. The full rectum and colon also occupy the space required for the bladder to expand, resulting in frequent small voids, and placing the child at risk of Urinary Tract Infection (UTI) as bladder emptying is impaired.

NO child should ever be provided with nappies, pull-ups or pads without a full continence assessment to identify any bladder or bowel problems and to consider their toilet training potential. The small minority of children unable to achieve continence may be eligible for a supply of pads or nappies. As stated in NHS England’s Excellence in continence care guidance: “It must be the exception, rather than the rule, that children and young people are provided with containment products.”

The flowchart below should be followed to ensure the child receives the correct assessment, treatment and management. Continence care for children with additional needs is provided by the team who look after the child, which may include health visitors, special school nurses, learning disabilities nurses, children’s community nurses and others. It is provided in conjunction with the Children’s Continence Service.

Back to the Children's General Continence Flowchart

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Delayed toilet training identified by School Health Nursing / Health Visiting / Children's Community Nursing / Learning Disability Team

Delayed toilet training identified by GP

GP to inform/refer to School Health Nursing / Health Visiting / Children's Community Nursing / Learning Disability Team

Family to complete Bladder/Bowel Assessment Chart

Healthcare professional to review Bladder/Bowel Assessment Chart with family

If constipation present follow Flowchart for Constipation


If daytime bladder symptoms present follow Flowchart for Daytime Bladders

No concerns

Child not ready for toilet training

Issues identified and addressed e.g.

• If unable to sit on available toilet, refer to OT for assessment

• If child will not sit on toilet for sufficient time, implement behaviour programme

• Consider sensory needs – see Sensory needs and toileting

• If child is smearing the reason for this needs to be investigated and approach to this behaviour considered. Refer to Smearing factsheet

Toilet Readiness Assessment to be repeated 3 monthly

Child achieving sufficient skills

• Able to sit on toilet/potty for sufficient time

• Bowels open regularly with soft stools

• Bladder can store urine for at least 1½ hours

Toilet training programme to be drawn up by healthcare professional and family. To be shared with nursery / school / everyone who looks after child and implementation date agreed

Child’s eligibility for provision of continence products assessed – see national guidelines for product provision

Complete Paediatric Assessment Tool for Issuing of Containment Products - see Appendices 3a & 3b in the national guidelines


Not Eligible

Identify suitable products from local contract list

• Consider washable/disposable products

• If disposable, assess suitability of ‘all-in-one’ (nappy style) products or a two-piece system (shaped pad in pants)

• Measure child’s hips and waist to select appropriate size products

• Consider volume of wetting to identify required absorption

Discuss reasons why with family. Work with family to get child ready for toilet training

Provide family with samples of identified product(s) to trial BEFORE placing order

Toilet Readiness Assessment to be repeated 3 monthly

When suitable product confirmed, complete local product requisition documentation

Refer back to 'Complete Toilet Readiness Assessment' in flowchart

Review suitability of products after 3 months

Children for whom toilet training is never going to be possible

Annual Review to assess:

• Bowels – any constipation?

• Bladder – any UTI?

• Fluid intake - Assess using Continence Assessment Form – Child who has not yet been toilet trained – or local equivalent

• Size / type / absorbency of product

Children for whom toilet training is anticipated

Ongoing 6 monthly review. Refer back to 'Complete Toilet Readiness Assessment' in flowchart