“I wish my child would learn how to use the toilet!” This is the dream of every parent, not just those who have a child with autism or other disability. After all, it frees up the need for diapers or pull ups and opens the doors for more social and educational options available to your child. Toilet training a typically developing child is hard enough, but children with autism bring an additional set of obstacles that could make the toilet training process more complicated (and yes, more frustrating).
Is My Child Ready?
Your child will not experience success with toilet training if he or she is physically not ready. Keep in mind that there is no “magic” age for any child, as every child develops differently. Basically, your child has to have the ability to control the muscles that serve to close off the bladder, and those muscles need to be strong and mature enough. In typically developing children, this generally occurs between 18 and 24 months, but even then, there are variations from child to child. The child with autism might be slower in developing these necessary skills. There are also other skills that need to be in place before starting a toilet training program (this holds true for all children). Other variables indicating readiness for toileting include having the ability to sit, dress and undress, and recognizing the internal clues that indicate the need to urinate or have a bowel movement. The general order of mastery in toileting skills is as follows; bowel control during the night, bowel control during the day, bladder control during the day, and lastly, bladder control during the night. Keep in mind your child may continue to wet the bed during the night even after mastering daytime control.
Look for additional signs that your child is “ready” to start a toilet training program. These “signs” will vary from child to child, of course, but may include indicating discomfort when wet or soiled, “zoning out” and pausing in the middle of an activity, pulling at one’s diaper, or hiding behind a piece of furniture or other barrier in the environment. Other children may start to show interest in the toilet or potty chair. An important telltale sign is when your child starts to stay dry for longer and longer periods of time. To determine the frequency of your child’s urination pattern, it is helpful to check your child frequently and record when your child is dry and when your child is wet. If your child can stay dry between 2 and 3 hours, you can start the process.
Once you have taken data for about a week and understand your child’s elimination pattern, create a schedule that involves taking your child to the bathroom at an interval shorter than when your child typically eliminates. Once you experience success with that interval, gradually increase the time between bathroom visits.
Rule out Medical Issues
Prior to beginning a formal toileting program, it is important to ensure that your child does not have any medical conditions that could possibly interfere with toilet training. This should actually be done for all children, regardless of whether they have autism, another disability, or are typically developing. Medical conditions that could interfere with autism will generally be ruled out during your child’s routine physical exams. Children with autism frequently have gastrointestinal (GI) problems that could make it difficult to maintain a regular toileting schedule. Try to address these GI difficulties (bloating, gas, constipation, diarrhea, abdominal pain) prior to embarking on a toilet training program. Continue to check for too much or too little urination throughout the day, stools that are too loose or too hard, or apparent pain while urinating or having a bowel movement. If you see any of these signs, it would be beneficial to contact your child’s pediatrician for a referral to a specialist.
Tips for Toilet Training
1. Relax. Make sure you approach toilet training in a positive and relaxed manner. Your child will be able to tell if you’re stressed out with the process. Be prepared and know that accidents will occur before your child experiences success.
2. REINFORCE!!! Look at your child’s list of reinforcers. Create a hierarchy of the reinforcers and use the best of the best for toilet training, and ONLY for toilet training. Positive reinforcement is your secret weapon, use it frequently and consistently for all pro-toileting behaviors. Initially, it may be that your child is reinforced for just entering the bathroom, then once your child has mastered that step, move on to the next step and reinforce only that step. Continue to heavily reinforce the current step that your child is working on. Previously mastered steps can be occasionally reinforced to ensure that your child maintains those skills while learning new skills.
3. No Punishment. It’s important that your child NOT be punished when an accident occurs. When your child has an accident, simply say “You are wet/soiled” (whatever words you’ve chosen to use), in a neutral tone of voice. Attempt to bring your child to the bathroom and have him or her sit on the toilet. At this time, reinforce your child just for sitting on the toilet, even if they do not urinate or have a bowel movement.
4. Lots of Fluids. Make sure your child is drinking PLENTY of fluids during the toilet training process. This will increase the liklihood of elimiation in the toilet and thus the opportunity to reinforce!
5. Resistance to Change. Many children with autism have difficulty with change. Try introducing the new bathroom routine very gradually. Expose your child to the bathroom in a nonthreatening way. Start with having your child enter the bathroom fully clothed and see if your child will sit on the toilet clothed. Once your child can easily do this, sit your child on the toilet in his or her diaper, then without the diaper, etc. Try not to use a separate potty chair, this may make it difficult to transition to the regular toilet later on. Get a potty seat that fits directly on the large toilet and use a step stool if necessary.
6. Routine. Develop a structured routine that is followed consistently each time your child uses the bathroom. It is important to follow the routine in the exact same manner each time. Repetition is key! This will increase your child’s success and independence in the process. Make sure the routine you develop involves steps that your child already has the ability to complete independently. Also consider switching your child from diapers to training pants (not pull-ups). Pull-ups are very similar to diapers and absorb too much liquid for the child who may not be able to fully understand he or she is wet.
7. Visual Aids. Children with autism are notorious as being strong visual learners. Keep this in mind when toilet training your child. Try to use visual cues rather than verbal cues. Develop a picture schedule illustrating each step of the process. This can be velcroed on the bathroom wall. Have an empty pouch velcroed at the end of the picture sequence for steps the child has completed. Point to the picture (without saying anything), and then assist your child in completing that step. Once the step is complete, teach your child to remove the picture and place it in the pouch at the end of the sequence. Continue with each subsequent step until the sequence is complete. If your child has responded well to the use of social stories in learning other skills, try using a social story illustrating the toileting routine.
8. Sensory Issues. Autism is generally associated with a variety of sensory issues. Children may be over or hypersensitive to a variety of environmental stimuli. Keep in mind the way your child responds to visual stimuli, smells, sounds, etc. It may be necessary to make some changes in your bathroom environment to make it more comfortable for your child. Consider things like the lighting, the air fresheners or perfumes that might be present, and even the flushing of the toilet. Bathrooms are also typically colder or warmer than other areas of the home, so make accommodations to ensure that the climate is comfortable for your child.
9. Teaching Initiation. Once your child is successful going to the bathroom on the toileting schedule you have developed, it will be important to start teaching initiation. The best way to do this is to be standing in front of your child and have a second person standing behind your child at the scheduled time. If your child is verbal and can imitate words, have the second person (behind the child) say the word “bathroom” for your child to repeat. When your child says “bathroom”, you (in front of your child) should acknowledge this and say “Oh! You have to use the bathroom!”, and reinforce this prompted initiation. If your child is nonverbal, have pictures of bathroom velcroed around the house. Use the same procedure (second person behind). In this scenario, the second person will prompt your child to get the bathroom picture and place it in your hand. Why the second person you may ask? It is very difficult to teach initiation when you prompt your child from the front. In essence, you can’t teach initiation of any skill this way, because the very nature of prompting from the front involves you ”going first” and your child “responding” to your prompt. It’s like me standing in front of you and saying “go ahead, start a conversation with me.” See? You can’t because I have already “gone first”.
Patience is a Virtue
The key to success is simple… PATIENCE! Remember that toilet training your child with autism is likely to start a bit later and take a bit longer as it would with a typically developing child. A habit takes at least three weeks to become a habit! Choose a method that seems to fit you and your child and stick with it for at least three weeks (consistently). Be consistent, stick with it, and don’t get discouraged! Your hard work and your child’s hard work will pay off in time, and you’ll be able to forever say “goodbye” to those diapers!