Ask An Expert / Elimination Disorders

A kindergarten student with SM refuses to use the bathroom at school. Do you have any suggestions?

Let him practice with a parent outside school hours

Rachel Busman, PsyD
Rachel Busman, PsyD

Senior Director, Anxiety Disorders Center, Director, Selective Mutism Service

Child Mind Institute

Our team has been working with a kindergarten student with selective mutism since the fall and we have seen progress in his ability to speak. But a second challenge/anxiety has been his refusal to use the bathroom at school. He has stated explicitly to the school psychologist that he will never use the bathrooms here. We began a plan of rewarding him when he walked to the Nurse's office and went into that bathroom. He was willing to do this and had great success but continues to refuse to actually use the toilet.There have been some accidents during the school day and we are worried about his bladder health, as well as the embarrassment he feels when he has an accident. He further refuses to even change out of his wet clothing after having an accident and removing him from the classroom will lead to a tantrum. Do you have any suggestions of how we can help him use the bathroom at school?

Thanks so much for reaching out. It sounds like you’ve seen a lot of successes with this student, which is fabulous. I’m glad that when he said he would never use the bathroom you kept working with him. It sounds like choosing a private, separate bathroom is a really good place to start.

A lot of the kids we work with who have selective mutism also have some difficulties using the bathroom. Sometimes this is related to anxiety about actually using the bathroom and other times it is more social anxiety — for example kids are worrying “Will somebody else know I’m going?” or “Will somebody be able to hear me?”

I love the approach you’re using where he gets rewards for walking to the nurse’s office and even going into the bathroom. That is a good way to reinforce and shape the behavior you want to see. You can do the same thing with helping him practice changing his clothes at school. For example he can splash some water on his clothes and then practice changing into new ones and get a reward. The objective is to give him practice changing his clothes after getting wet at school, whatever the reason.

His parents should be involved in these strategies, too. If they can, either mom or dad should be coming to school outside of school hours, when there are fewer people around, to help him practice using the bathroom in the nurse’s office and changing his clothes. He’s already used to doing these things around his parents, and they can help him practice while he is at school. Practicing a lot is important.

Depending on the frequency of his accidents and the amount of distress that is associated with them, his family may also want to use pull-ups while he is learning to use the bathroom at school. Use of a pull-up is by no means the solution, but if the accidents are happening often and are upsetting, pull-ups can help in the interim.