Ahhh.....The Joys of Potty Training!

If just hearing the words "potty training" makes you tense and nervous,  then you probably are currently struggling with the toilet training process, or you have a child who will begin the process soon. Teaching any child to move from freely voiding in a diaper or pull-up to using a toilet is a difficult process. Now toss into that situation a child who has Autism, and potty training can go from being challenging to being a severely frustrating and stressful experience for the entire household.

Children with Autism may have challenges in the areas of language/communication, sensory processing, social skills/social thinking, and behavior control that need to be taken into consideration when formulating a potty training program. Other issues such as motor planning, sensory needs (feeling a full bladder or a wet diaper), communication abilities, and preference for predictability and routine may make potty training more difficult. It is also common to see an increase in problem behaviors during potty training, or to see an emergence of new behaviors at this time.

It is hard to predict which kids will struggle with potty training and which will not. I have potty trained some clients in days. Other clients it took years before they were consistently successful. The amount of time needed to teach this skill to a point of independence will vary. Before you actually start potty training your child with Autism, you can’t know with certainty what the process will be like. So the best approach is to be prepared and informed before you ever begin.

First, it’s important to redefine the potty training process. You may have other children you have successfully potty trained, you may have potty trained nieces or nephews, or maybe you have friends who have told you exactly what to expect. Throw all of those expectations out the window. 
Realize that your child with Autism is unique, and the techniques that worked for your 3 year old nephew may not work for your 3 year old child with Autism. Here are a few things that I have learned over the years about potty training & Autism:

  • Children with Autism may take much longer to show interest in the potty or display signs of readiness than typical children
  • Children with Autism may have fear or anxiety about using a toilet which could be exhibited through severe behaviors
  • Children with Autism may need a visual schedule to remember the steps for using the bathroom
  • Children with Autism may need to be separately trained to stay dry through the night, even after they are potty trained
  • Children with Autism may need to be separately trained to defecate in a toilet, even after they are potty trained to urinate in a toilet
  • Children with Autism may need to be separately trained to request the bathroom
  • Children with Autism may refuse to use unknown toilets, such as public bathrooms
  • It is critical to rule out medical issues as a reason for difficulties with bowel training. If the child has intestinal issues, chronic diarrhea or constipation, or is compacted with fecal matter, they are not “choosing” to have messy bowel accidents. They are not in control of their bowels, and any punishment or consequences will simply confuse or anger the child. A sign of underlying medical issues is a child with loose, watery stools, a child who does not defecate often (defecates 1-3 times per week), a child with a hard, distended belly, or a child with allergies. If any of these issues are going on, seek medical treatment before continuing.

This post is not going to be a step-by-step guide to potty training a child with Autism.  Just like when teaching any other skill, the approach must be individualized to the child and to their needs.
What this post is intended to be is an overview of two of the main approaches to potty training your child with Autism.

Technique #1: ITT (Intensive Toilet Training), also called "In The Bathroom" Training

  • Q: What is it?
  • A: The ITT method requires a dedicated time and place to do nothing else but potty training. It is helpful to have two or even three people available to work in shifts. Your child should be in regular underwear with no pants for easy access and so you can clearly see if they have had an accident. Give your child plenty of liquids, which will encourage urination and increase the opportunities to reward successful attempts. Place him on the potty from his first waking moment for 3-5 minutes, then use a data chart to gauge how frequently to put him back on the potty (5- 10 minutes before the next regular voiding time). If he is staying dry between sittings on the potty, expand the time gradually by a set increment of minutes. If there is an accident, lessen the time between potty sittings to the previous length. If the child voids in the toilet, heap on the praise and rewards. If the child doesn’t pee in the toilet, instruct him to stand up, and get dressed (with assistance if needed). Sitting on the potty needs to be a fun time, with games, puzzles or social interaction. Blow bubbles, bring a TV and DVD player into the bathroom, sing songs, give the child candy, etc. Make sure the child cannot access any of these items outside of the bathroom.
  • Q: How long does it take?
  • A: The amount of time will vary from child to child. Generally, the ITT method is done over 2-4 consecutive days, where the child spends the majority of their time on the toilet.
  • Q: Why should I pick this method?
  • A: The biggest benefit of this method is the intensity. It’s a very quick approach, where the child pretty much spends all of their time in the bathroom. If you can stick to it and dedicate the time to being this intensive then the child could possibly be potty trained in a few days.
  • Q: What would I need to get started?
  • A: To get started you would need a large supply of 24 Karat gold reinforcers, a way for the child to communicate a need to go potty (could be a PECS card, or sign language), underwear, data sheets, timers, a clipboard, strength, and patience!
  • Q: Any quick tips?
  • A: When the child is sleeping, or anytime the child will not be around a bathroom (such as if the child rides the bus home), then it is ok for them to wear a diaper or pull up. Place the child in the diaper or pull up and put the underwear on top of it, so that they still are wearing the big kid underwear. As the child becomes more able to use the potty, phase out the diapers or pull ups completely.  
More Tips:
Keep reinforcers available in the bathroom so you don’t have to hunt to find them “in the moment.”
 Use simple, concrete directives that tell the child what to do. Rather than “Don’t pee on the floor,” say “Pee in the potty.” Speak slowly, clearly, and specifically. Remember that persons with autism may have difficulty with auditory directions. Most will need more time to process your words and form a response.
 Teach boys to use the potty sitting down, until they are completely toilet trained. There are 2 reasons for this: the child may accidentally have a BM while standing and urinating, and if the child always stands to use the potty then sitting to have a BM may feel strange and awkward for them and as a result they may choose to just not do BM's in a toilet. 
 Dress the child in easy on/easy off clothes during the potty training program, avoid pants that snap, button, or buckle. Potty training is often easier in the summer, when children wear less clothing.

Technique #2: Trip Training, also called "Schedule Training"

  • Q: What is it?
  • A: Trip Training is putting the child on a toileting schedule based on how often they void, such as every 15 minutes. Throughout the day at specific time intervals, the child is taken to the toilet. You prompt the child that it is time for the toilet, such as by holding up a picture of the potty and saying “Its time to go potty”. Take the child to the bathroom, help them pull down their pants, and sit on the toilet. The child must sit on the toilet at least 5 minutes. Block any attempts made by the child to get up, and ignore any behaviors. Every 45 seconds or so prompt the child by saying “Go potty”. If the child voids in the toilet give HUGE praise and reinforcement. If you get to the toilet and you see the child has had an accident, they still go through the whole toileting process. If the child consistently is already wet or soiled when they get to the toilet, then the time intervals are too long. Praise and reward if the child is dry (dry pants check) before they sit on the toilet. Once the child gets off the toilet, prompt them to wash and dry their hands.
  • Q: How long does it take?
  • A: The amount of time will vary from child to child. Generally, the Trip Training method takes several weeks to several months to teach. There usually is a learning curve as you discover what time intervals are best to avoid accidents.
  • Q: Why should I pick this method?
  • A: This method isn’t as time and labor intensive as ITT, and it is also much easier to use if the child cannot be kept at home for a few days. Trip Training works better for parents or teachers who do not have access to a staff of behavior therapists who can help you implement the ITT technique.
  • Q: What would I need to get started?
  • A: To get started you would need a record of when your child typically voids, a clipboard, timer, a large supply of 24 Karat gold reinforcers, a way for the child to communicate a need to go potty (could be a PECS card, or sign language), underwear, data sheets, strength, and patience!
  • Q: Any quick tips?
  • A: If you cannot avoid taking the child to a public bathroom while they are being toilet trained then plan ahead. Carry a small tote bag with you filled with the child’s favorite juice, cookies, chips, toys, etc. Take this bag with you into public bathrooms and try to mimic the home environment as much as you can.
More Tips:
  It can be helpful to use a small step stool for the child to rest their feet on. Some children with Autism do not like their feet dangling in space, and having both feet planted on a frim surface can help with BM's.
 Try not to let the child undress completely before getting on the toilet, this can be a hard habit to break.
 The reinforcement for defecation may need to be 3x as powerful as the one for urination.
 Having a consistent bedtime and wake up time will also help with night time training. If the child goes to bed at varying hours, and wakes up at varying hours it can be very difficult to see patterns of behavior and predict when they are most likely to void.

The most important things you can do before you begin potty training your child with Autism is decide on the approach you want to use and stick to it.

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