Ahhh.....The Joys of Toileting!

If just reading "toilet 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 often a difficult process. Now toss into that situation an Autism diagnosis, and the process can definitely get extra challenging.

Autistic children may have challenges in the areas of communication, sensory processing, social skills/social thinking, and behavior control that need to be taken into consideration when formulating a toileting program. Other issues such as motor planning, sensory needs (feeling a full bladder or a wet diaper), and preference for predictability and routine may make things more difficult. 

It is hard to predict which kids will struggle with toilet  training and which will not. For some clients, this is a skill we can implement and teach in a few weeks. With other clients, it has taken much, much longer.  The amount of time needed to teach this skill to a point of independence will vary, so the best approach is to be prepared and informed before you ever begin.

First, it’s important to redefine the toilet training process. You may have other children you have successfully toilet trained, nieces or nephews where you helped out, or maybe you have friends who have told you exactly what to expect. Throw all of those expectations out the window. 
Realize that the process could be quite different for an Autistic child, and the techniques that worked previously may, or may not, work this time around. 

A few  tips:

  • There could be less interest in the toilet, less concern/awareness of being wet or soiled, and a lack of "readiness" signs that typically developing children usually exhibit 
  • There could be significant fears or phobias about the toilet, the bathroom, or the smells/sounds/sights involved in the process 
  • Use of visual supports could be highly beneficial to teach the toileting steps/routine 
  • It may be necessary to separately teach staying dry at night, or bowel training, even if the child can fully use a toilet to urinate (sometimes these skills must be targeted individually) 
  • Requesting a toilet/telling someone "I need to use the bathroom" may need to be separately taught
  • There may be an aversion to unfamiliar toilets (like at school, or in a public place). This is common, and also happens with typically developing children  
  • 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 fully in control of their bowels, and any punishment or consequences will not be helpful. Signs of underlying medical issues could include loose, watery stools, crying/distress during BM's, a child who does not defecate often (defecates 1-2 times per week), or a child with a hard, distended belly. This is why seeking a medical evaluation is so critical, because there could be multiple medical explanations for toileting difficulties.

This post is not going to be a step-by-step guide to toilet training Autistic children.  Just like when teaching any other skill, the approach must be individualized to the child and to their needs.

 What is important is to individualize any technique used to the specific child, to ensure that toileting is motivating and not aversive,  and to focus on reinforcement.

The most important things you can do before you begin potty training is decide on the approach you want to use and stick to it. And of course, reach out for help (through a therapy provider) as needed.

Toileting research:

  • Azrin N., Foxx R. Toilet training in less than a day. New York: Simon and Schuster; 1974.

  • Blum N. J., Taubman B., Nemeth N. Relationship between age at initiation of toilet training and duration of training: A prospective study. Pediatrics. 2003;111:810–814. 

  • Luiseli J. Teaching toileting skills in a public school setting to a child with pervasive developmental disorder. Journal of Behavior Therapy and Experimental Psychiatry. 1997;28:163–168.

  • McManus M., Derby K. M., Dewolf E., McLaughlin T. F. An evaluation of an ın-school and home based toilet training program for a child with fragile X syndrome. International Journal of Special Education. 2003;18:73–79.

  • Stadtler A., Gorsky P., Brazelton T. B. Toilet training methods: Clinical interventions and recommendations. Pediatrics. 1999;103:1359–1361. 

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