Journal of ICSAR ISSN (print): 2548-8619; ISSN (online): 2548-8600 Volume 8 Number 1; DOI: http://dx.doi.org/10.17977/um005v8i1p65 65 Associated Factors that Supporting Toilet Training for Children with Intellectual Disabilities: A Systematic Review Siti Jaleha*, Ahcmad Hufad, Imas Diana Aprilia, Sunardi Universitas Pendidikan Indonesia, Bandung, Indonesia E-mail : *sitijaleha@upi.edu, achmadhufad@upi.edu, masdiana@upi.edu, nardilembang@upi.edu Abstract: The basic aspect that must be mastered by children with intellectual disabilities before mastering other self-development skills is doing toilet training independently. Learning for children with intellectual disabilities in carrying out toilet training activities requires a separate technique and needs to pay attention to the factors that support the success of the program. This study aims to describe the associated factors that support toilet training for children with intellectual disabilities. This study uses a qualitative approach with a type of literature review research that seeks to describe the related factors that support toilet training for children with intellectual disabilities. This literature review was conducted from August to December 2022 using PRISMA. The authors conducted searches in online databases with large repositories of academic studies and fully accessible by the authors. The results showed that: (1) the toilet training program was made based on the results of an assessment containing the abilities, needs, and potential of children with intellectual disabilities, (2) knowledge and intervention skills possessed by parents provide a great opportunity for successful toilet training for children , and (3) there is collaboration between parents and teachers regarding the implementation of toilet training. The success of toilet training for children with intellectual disabilities is influenced by many factors so that the toilet training process requires intensive assistance, especially for parents. Keywords: Toilet Training; Children With Intellectual Disabilities; Associated Factors; Systematic Review. INTRODUCTION Children with intellectual disabilities are children who experience intellectual disorders, whereas academic conditions are below the average of a normal child (Sartinah, Sri, & Pamuji, 2023). Children with special needs who are intellectually limited which affect on intelligence, mental, and motor skills are referred to as intellectually disabled children (Karya, 2022; Putri, et al., 2022; Effendi, et al., 2022). Children with intellectual disabilities have the urge to develop from a dependent position to an independent position (Astati, 2010). Children with intellectual disabilities who are independent will act confidently and will not always rely on the help of other people or adults in acting (Astati, 2010). Independence is defined as an attitude characterized by self-confidence and regardless of dependency. Children with intellectual disabilities who are independent will be able to carry out their own activities without relying much on others. Independence develops apart from being influenced by intrinsic factors (the growth and maturity of the individual itself) as well as by extrinsic factors (through the process of socialization in the environment where the individual is located). Intrinsic factors such as individual maturity, level of intelligence and extrinsic factors are things that come from outside the child such as the treatment of parents, teachers and society (Astati, 2010). In the process of growing independence, the abilities of children with intellectual disabilities are different from the abilities of children in general, given their limitations. To develop the independence of children with intellectual disabilities, it is necessary to have self-development activities that seek to help children with intellectual disabilities become independent. Organizing education for students with intellectual disabilities is basically to http://issn.pdii.lipi.go.id/issn.cgi?daftar&&&&&2548-8600 mailto:sitijaleha@upi.edu mailto:achmadhufad@upi.edu mailto:masdiana@upi.edu mailto:nardilembang@upi.edu 66 Journal of ICSAR; Volume 8, Number 1, January 2024, 65-75 make them independent (Ratnengsih, et al., 2021). In order to realize this independence, teachers need to make maximum efforts in carrying out a series of activities that support the independence of children with intellectual disabilities (Astati, et al., 2010). Children with moderate intellectual disabilities experience barriers in intelligence, so the target of developing their independence must of course be formulated according to their potential, so that it can be said that independence for children with intellectual disabilities is a match between their actual abilities and the potential they have. Achieving independence for children with intellectual disabilities cannot be interpreted the same as achieving independence for children in general. One of the things that concerns parents and teachers is the independence of children in using the toilet, so that toilet training is needed by both parents at home and teachers at school. To get maximum results in toilet training, especially regarding children's independence, there are at least several factors that need to be considered in influencing children's independence, namely the environment, parenting from parents and education (Santrock, 2003, p. 145-146). Caring for children with intellectual disabilities often requires considerable effort from parents (Yoneda & Miura, 2021). The results of a preliminary study conducted at SLB Negeri 3 Banjarmasin in Banjarmasin City on 35 children with intellectual disabilities, found that 21 children were not able to use the toilet, 19 children were unable to clean themselves after urinating and 24 children were unable to clean themselves after defecating. Most children have the habit of using disposable diapers both when doing activities at home and when traveling. As an effort to overcome the low independence of intellectual disabilities in toilet training, researchers are interested in examining factors related to the success of learning toilet training for intellectual disabilities. METHOD This study uses a qualitative approach with a type of literature review research that seeks to describe the related factors that support the success of toilet training for children with intellectual disabilities. Sources of data in this study were journals, books, research results starting in 2012. This literature study was conducted from August to December 2022 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta- Analyses) reporting guidelines. Based on these guidelines, there are several steps in this study: 1) define the eligibility criteria; 2) define information sources; 3) study selection; 4) data collection process; and 5) selection of data items. Figure 1. describes the steps of this research in conducting a systematic review. Jaleha et al, Associated Factors that Supporting Toilet Training… 67 Figure 1. PRISMA Flowchart RESULT AND DISCUSSION Results Learning for Children with Intellectual Disabilities Learning for children with intellectual disabilities must be contextual, meaning that the implementation of learning follows the context that will be taught and relates to the goals to be achieved. To carry out functional, relevant and contextual learning, teachers can develop several learning models (Browder, Hudson, & Wood, 2013 in Supena & Hasanah, 2020). There are several different approaches parents should take when implementing home-based learning for children with intellectual disabilities. Parents should work closely with the school to follow directions, make changes, and adapt to identify resources at home for daily home and learning activities (Srivastava, de Boer, & Pijl, 2017). Here, parents and students must learn and understand each other. Not only that, the conditions of each house also affect learning in children with intellectual disabilities. Therefore, it is hoped that parents and children can learn from each other. Schools must also help solve problems with activities at home (Srivastava, de Boer, & Pijl, 2015). One of the effective learning models applied to children with intellectual disabilities is the project-based individual model. This model can facilitate various differences in the characteristics of children with intellectual disabilities that accommodate their learning styles. This also has a positive effect on children with intellectual disabilities and emphasizes the learning of vocational skills according to the implementation stages that have been simplified by the teacher. The use of projects can generate interest in learning for children with intellectual disabilities so that it is easier to understand the learning material presented (Supena & Hasanah, 2020). 68 Journal of ICSAR; Volume 8, Number 1, January 2024, 65-75 The project-based learning model is child-centered and provides meaningful learning experiences for children. Children's learning experiences and concepts are built on the products produced in a project-based learning process. In a project-based model, children understand content and develop skills in children to play a role in society (Bron & Barrio, 2019; Eckardt, Craig, & Kraemer, 2018; Parker, 2020). For children with intellectual disabilities, the project is more directed at vocational skills in soft skills and hard skills. These vocational skills aim to equip children to have abilities that can be used to meet their daily needs after completing formal education. These skills are in self-development, sewing, cooking, simple arithmetic, and so on. Functional learning is defined as learning that is useful in life (Supena & Hasanah, 2020). Implementation of Toilet Training The achievement of bladder and bowel control is an important developmental milestone and toilet training is an overview of a number of different practices aimed at helping children become independent (Breinbjerg & Kamperis, 2021). Toilet training is an attempt to train children to be able to control urination and defecation (Khoiruzzadi and Fajriyah, 2019). Toilet training is one form of sex education for early childhood, so that children are able to use the toilet properly (Hayati & Suparno, 2020). In order for children to improve their toilet training skills, it is necessary to continuously train children (Hayati & Suparno, 2020). The purpose of toilet training is to train children to be independent in toileting, introduce uncleanness from an early age, identify items in the toilet and teach bowel movements and bowel movements correctly (Khoiruzzadi & Fajriyah, 2019). Toilet training in general can be carried out for every child who has started to enter a phase of independence in children (Keen, 2007, p. 292; Wald, 2009, p. 295). Independence is a condition where a person can try and do something on his own awareness and effort, and he is not easily dependent on others (Siswanto, Kholidah, & Minarti, 2010, p. 195). In toddler-age children, they experience three phases, namely: the autonomic phase (children can take their own initiative and are able to do everything on their own, but rather show their own desire to reject something they don't want and try something they want), the anal phase (the child enters the toilet training period), and the preoperational phase (children begin to be able to make simple judgments about objects and events around them (Musfiroh & Wisudaningtyas, 2014, p. 159). Independence must be trained and developed in children as early as possible so as not to hinder further child development tasks (Yamin & Sanan, 2010, p. 94). By instilling independence will prevent children from being dependent on other people, and most importantly in growing children's courage is done by providing motivation for children to continue to learn new knowledge through supervision of both parents at home and teachers at school (Khoiruzzadi & Fajriyah, 2019 ). There are two forms of child independence, namely physical independence and psychological independence (Nurfalah, 2010, p. 13). Physically, children are able to take care of themselves, such as simple examples of going to the toilet, urinating, defecating, ablution, and bathing. Meanwhile, psychologically, that is, children dare to toilet train independently, and children do not hesitate to ask teachers at school for help during toilet training (Khoiruzzadi and Fajriyah, 2019). Based on the theory above, it can be concluded that toilet training is an attempt to train children to be able to control defecation or urination activities according to the place, identify items in the toilet and teach proper urination and defecation. Independence in toileting should be introduced to children as early as possible. Effective toilet training can be taught to children aged 24 months to 3 years, because children aged 24 months have the language skills to understand and communicate Jaleha et al, Associated Factors that Supporting Toilet Training… 69 (Khoiruzzadi & Fajriyah, 2019). In carrying out urination and defecation training in children requires preparation both physically, psychologically and intellectually through this preparation it is hoped that children will be able to control defecation and urination (Yektiningsih & Infanteri, 2016, p. 47). Implementation of teaching and learning activities begins with: Planning At the planning stage, the teacher projects what actions will be carried out in a lesson by organizing and establishing teaching components, so that the objectives of the content, methods and techniques, and evaluation become clear and systematic (Suryana, 2016, p. 218). Planning is carried out the day before the activity is carried out based on the theme, which has previously been designed starting from activities for one year, determining the theme, dividing the theme in each semester, selecting activities for sub-themes up to the students' daily program (Khoiruzzadi & Fajriyah, 2019). Starting from welcoming students, activities before entering class, marching together, core activities until the time to go home and evaluate (Khoiruzzadi & Fajriyah, 2019). Implementation Implementation of toilet training can be done through several methods, namely the method of storytelling, hands-on practice, and the method of habituation. The storytelling method used for toilet training activities aims to make children understand what the teacher means about toilet training learning that children will do, and children will be interested in the books used by teachers (Khoiruzzadi & Fajriyah, 2019). This is very effective for teachers to do, because children aged 2-3 years are more interested in interesting stories coupled with pictures (Silranti & Yaswinda, 2019, p. 39). So that children will be much more enthusiastic in participating in toilet training. In terms of cognitive development, children aged 2-3 years enter the operational stage (Berk, 2012, p. 30). And one of the characteristics of children at the age of 2-3 years is perceptually bound, that is, children judge something what they see or hear. Apart from that, centration, that is, the child focuses his attention on the characteristics that are most attractive to the child (Ibda, 2015, p. 32–33). In addition, children's behavior in toilet independence is also based on direct observation, so according to Bandura, imitation and modeling are carried out (Suryono & Haryanto, 2012, p. 88). So here the teacher's role is very urgent in explaining what children need to do when they want to urinate, defecate, perform ablution, bathe, and so on related to activities in the toilet. The teacher sets an example and provides stimulation to children, so that children imitate what the teacher does in the toilet (Khoiruzzadi and Fajriyah, 2019). In addition, teachers need to motivate children so that children remain enthusiastic about participating in toilet training (Khoiruzzadi & Fajriyah, 2019). The method is taught directly (practice), namely the teacher gives directions to children to use toilet training directly in the bathroom (Khoiruzzadi & Fajriyah, 2019). From giving practical assignments directly, the teacher will know the child's development in toileting (Khoiruzzadi & Fajriyah, 2019). In addition, direct assignments with practice will develop children's independence (Rochwidowati & Widyana, 2016, p. 63; Silranti & Yaswinda, 2019, p. 60). The use of the habituation method is also seen as the best alternative, so that children remember and want to repeat it the next day (Khoiruzzadi & Fajriyah, 2019). The use of the habituation method is a method that really helps the child to remember what the child has done that day, then it will be repeated the next day and so on until the child memorizes it by himself (Khoiruzzadi & Fajriyah, 2019). The habituation method is used so that children do not quickly forget and try to get used to learning in the toilet that is good and 70 Journal of ICSAR; Volume 8, Number 1, January 2024, 65-75 right (Iswantiningtyas & Raharjo, 2016, p. 62; Silranti & Yaswinda, 2019, p. 39). According to Pavlov, from habituation carried out by children, reinforcement is also needed in the form of repetitions (Soekamto & Winaputra, 1997, p. 37) from the toilet training. Efforts to make it easy to help children understand toilet training material by providing concrete media, such as picture story books or cartoon videos related to toilet training (Ratne, Purwaningsih, & Apriatmoko, (2019). As Piaget's opinion (Santrock, 2011) children aged 2-7 years are still in the pre-operational stage. Where at this pre- operational age children begin to learn with symbols, children begin to explain what they see with pictures and words. So a teacher needs media to help communicate material about toilet training to early childhood easily (Hayati & Suparno, 2020). Evaluation Assessment evaluation, namely giving assignments; assignments can be independent or group. In relation to learning toilet training, children are given the task of identifying items in the toilet and practicing directly about urinating and washing hands properly (Khoiruzzadi & Fajriyah, 2019). The indicators used to see the success of toilet training are physical readiness which includes the age of the child and the child's ability to walk, sit, squat and jump (Hayati & Suparno, 2020). Furthermore, self-restraint activities which include the child's ability to express his desire to urinate and defecate both verbally and non-verbally, and keep his pants dry from urinating and defecating (Hayati & Suparno, 2020). Next is self-mastery which includes the child's ability to go to the toilet on his own, the child's ability to open and put on his own clothes, the child's ability to urinate and defecate in its place (toilet), the child's ability to clean himself and flush his bladder and bowel movements, and the child's ability to clean their hands after urinating and defecating (Hayati and Suparno, 2020). Discussion Factors Affecting Toilet Training There are several factors that influence the readiness of toilet training in children, namely physical, mental, psychological readiness and parents' readiness (Iskandar & Sari, 2017). There are some children who show signs of toilet training readiness at the age of 18-36 months, but there are also children who are ready earlier or later than that age. This is what will cause parents to be unsure when to start toilet training their children and demand that their children be able to do toilet training (Kessler, 2012). Basically the age factor in children plays an important role in the success of toilet training, if toilet training is carried out on children of the wrong age, the child will refuse to do toileting. The age for achieving optimal Toilet Training skills is 24-36 months (Islamiyah & Anhusadar, 2022). According to Gilbert (2012), the average age of children mastering toilet training is 35 months for girls and 39 months for boys, almost 90% of children can control their bladder during the day, namely at the age of 3 years, about 90% children usually stop wetting the bed at the age of 5-6 years, while others can only do it a few years later. According to Rahmi (2012) effective toilet training can be taught to children aged 18-36 months, but does not rule out the possibility of teaching it to children up to the age of 5 because at that age children have language skills to understand and communicate. Toddlers have a strong desire to imitate their parents. In Indonesia, cases of children who still wet the bed up to the age of 6 reach 12%. This is caused by the lack of awareness of parents and adults in teaching toilet training to children from an early age. Hidayat (2010) said that Jaleha et al, Associated Factors that Supporting Toilet Training… 71 toilet training independence that is not taught from an early age will make it more difficult for parents to teach their children when their children get older. Toddler aged children (1-3 years) experience three phases, namely, the phase of autonomy and doubt or shame in this stage of the development of children's abilities, namely learning to eat or dress themselves. The anal phase in this phase is the time for the child to be trained to defecate or Toilet Training (training to urinate in its place). The preoperational phase is where the child begins to imagine something but is not yet logical, here the role of the parents is to direct firmly in a logical and correct direction so that the child understands (Pulungan, et al., 2017). There are several signs that a child is able to control the urge to urinate and defecate which can be used as a reference, including physical, mental and psychological readiness. While the readiness of the parents themselves includes knowing the child's readiness to urinate and defecate, providing time and not experiencing familial conflict or stress. The American association of Paediatrics recommends starting training when a child shows certain signs of readiness, including physical, emotional, and behavioral accomplishments. (Breinbjerg & Kamperis, 2021). However, learning to use the toilet cannot be done until the child is able and willing, the child must learn to recognize these needs, learn to hold large or small water until he can do it himself in the toilet without the help of others (Khoiruzzadi & Fajriyah, 2019). Most toddlers are not ready, both physiologically, namely the ability to control urination and digestion (Rahayuningsih & Rizki, 2012, p. 274). Teachers need to carry out continuous habituation until children are truly able to be independent (Iswantiningtyas & Raharjo, 2016, p. 62; Silranti & Yaswinda, 2019, p. 39) in carrying out their activities in the toilet. In addition, the teacher's positive treatment of children is also a success in making children become independent (Anggraeni, 2017, p. 45). Teaching toilet training to children requires several stages, such as: getting the child used to using the toilet to defecate so that the child quickly adapts, routines are needed especially when the child seems to have the urge to defecate, the child is allowed to sit at certain times every day, especially 20 minutes after wake up and finish eating, it is intended that early childhood get used to the schedule for defecating (Pramono & Risnawati, 2018). The role of parents at home and the role of the teacher at school largely determines the independence of children in carrying out their activities in the toilet (Anggraeni, 2017, p. 45; Rahayu & Firdaus, 2015, p. 68; Salahudin, Pebrianti, & Maulana, 2018, p. 59 ). Parents and teachers should also become companions for children who are practicing, so that children feel excited about toilet training (Önen, et. al., 2012). According to Jayanti (2014) shows that there is a close relationship between the mother's role and the success of toilet training independence in early childhood, this is emphasized by Syahid (2013) showing that there is a significant relationship between the level of knowledge of mothers about toilet training and the implementation of toilet training in children toddler age. This research has been carried out by many previous researchers. The results of Murhadi's research explained that the success of toilet training conducted by mothers or child caregivers was influenced by several factors, namely parents' knowledge about toilet training 69%, parental education about toilet training 54%, and the use of diapers in children is still high 78.3 %. Where from the results of the study it was found that the percentage of respondents who had a negative attitude was more who did not do toilet training. This is because mothers who have a negative attitude towards toilet training are not motivated to do toilet training because mothers think using pampers is more effective and instantaneous so that mothers do not feel bothered (Murhadi, et al., 2019). 72 Journal of ICSAR; Volume 8, Number 1, January 2024, 65-75 Parents' knowledge of teaching toilet training to their children will have a major impact on children's independence (Bukhari, et a., 2017, p. 86; Istianah, Indanah, & Farida, 2014, p. 28). Likewise with teachers in training children's independence through toilet training. Therefore, parents and teachers can work together to help children develop their personality and independence (Dhamayanti & Yuniarti, 2006, p. 19). In obtaining good and correct knowledge about toilet training, parents and teachers need to seek this information either through reading books or guide modules about toilet training (Iryanti & Kamsatun, 2016, p. 34) and from other people such as counseling programs from experts such as midwives (Musfiroh & Wisudaningtyas, 2014, p. 157). Delay in the success of toilet training in children causes delays in defecation control. The impact of delayed bowel control is increasing the prevalence of impaired elimination function, urinary tract infections, enuresis (wetting the bed), constipation, refusing to toilet, encorepsis (impaired bowel control) and impaired self-esteem (Meilisa, 2022). The active role of parents in the development of their children is needed, especially when they are still young (Suherman, 2010). The success or failure of toilet training depends on the readiness that exists in the child and the role of the parents. Efforts that can be used in developing children's independence are the active role of parents in creating the home environment as the first social environment experienced by children, where children are gradually able to escape from dependence and absolute protection from their parents (Gunarsa, 2010). The success of toilet training is inseparable from the role of parents in implementing toilet training on a daily basis. It is important for parents to provide reinforcement when their child shows progress in toilet training, that is, a child who is successful will be motivated to do the same thing the next day so that he will unconsciously turn it into a more sedentary behavior (Radina, 2020). The success of children in toilet training is also influenced by the role of parents in communicating with children. Parental communication that is too weak or too strong will affect children's actions in toilet training. Several studies have shown that children who are just starting to learn to use the toilet over the age of 3 tend to wet the bed more often until school age (Howe & Walker, 1992). Using diapers for too long in children can also have a negative impact on children's readiness for toilet training. With the habit of using diapers, a child will get comfort from that habit, thus making it difficult for children to leave dependence on using diapers (Islamiyah & Anhusadar, 2022). The use of diapers is related to the success of toilet training but does not have a significant relationship with the incidence of enuresis. Parents should consider the use of diapers and other predisposing factors in reducing the incidence of enuresis in children at their developmental age (Subardiah & Lestari, 2019). CONCLUSION The success of toilet training in children with intellectual disabilities is influenced by several factors. The supporting factors for the implementation of toilet training learning are (1) the existence of cooperation between the parents of students and the school or a mutual agreement with the learning. Parents will compensate their children for learning toilet training at home according to what is taught at school; (2) the age of readiness of the child influences his ability to accept the applied toilet training learning; (3) communication between parents and children. Parental communication that is too weak or too strong will affect the child's actions in toilet training; (4) providing reinforcement to increase children's motivation; and (5) habituation that is continuously carried out, habituation that is continuously carried out aims to make it easy for children to do toilet training, and so that children can easily remember. The inhibiting factors in learning toilet training are (1) Jaleha et al, Associated Factors that Supporting Toilet Training… 73 the age of the child who is not yet mature enough to do toilet training. readiness of immature children to do toilet training at school; (2) parents who are still dependent on using diapers/pads for their children; and (3) parents' incompatibility with schools that have provided toilet training lessons (parents who depend on using diapers/pads for children. People around children also greatly influence the success of toilet training for children, because the biggest support system is the person who is around the child to support and provide support to children and parents in carrying out toilet training. Therefore, cooperation from all parties to support the success of toilet training. Toilet training abilities in children with intellectual disabilities can develop well if given the opportunity through training that is carried out continuously and carried out from an early age. REFERENCES Anggraeni, A. (2017). kompetensi Kepribadian Guru Membentuk Kemandirian Anak Usia Dini. AWLADY : Jurnal Pendidikan Anak, 3(2), 28–47. Astati, M. (2010). Pendidikan anak tunagrahita [Education of children with disabilities]. Bandung: CV. Catur Karya Mandiri. Berk, L. E. (2012). Development Through The Lifespan. Yogyakarta: Pustaka Pelajar. Breinbjerg, A., Rittig, S., & Kamperis, K. (2021). 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