TOILET TRAINING AND AUTISM
Toilet training a child with autism has nearly
become an "industry". "New and improved" methods
are bought and sold on the Internet, at bookstores, parent meetings,
conferences, and just about everywhere else. Experts seem to crop
up everywhere. Of course, this is not a problem confined to the
world of autism.
Before you begin, understand that a child on the
autism spectrum may have a few extra obstacles between him or her and
dry pants. All the the characteristics that identify the child as
having autism, Asperger's syndrome may well interfere with "normal"
Social interaction deficits? How much more intimate
can you get with a child once you have toilet trained together?
Many children with autism will resist the idea just because it is
your idea, or because it involves closeness, or because it involves
imitation, etc. The things that are reinforcing to children without
autism ("big boy" or "big girl") may mean very
little or nothing to a child with autism.
Be aware of possible communication issues
Are there communication deficits? Does the child understand
language? Does he or she understand "potty", "diaper",
"dry pants", "toilet", "bathroom",
or any other words, signs, or pictures/symbols that get the idea
of toileting across? Children with autism may have difficulty understanding
and associating words with actions and most will at least need more
time to process what you say. Can the child express the urge or
need to use the toilet? Expressive language is almost always a problem
for children with an autistic disorder. It will be important to
be able to read their cues and/or teach a way to express the need
or urge to use the toilet.
Be aware of sensory problems
Many children with autism or Asperger's syndrome
may have unusual reactions to various sensory stimuli (smells, tastes,
textures, colors, temperature, sounds) due to sensory
problems. Watch for signs of unusual reactions when a child
is in or near the bathroom. Bathrooms have been known to have an
unusual smell or two attached to them - a child may react with fear
or tantrum to perfumes, noxious smells, or other smells.
Bathrooms tend to be either hotter or colder
than the rest of the house - make sure the temperature is similar
throughout the house. Bathrooms are usually tiled - some children
may dislike or fear a cold tile, a fluffy rug, or the colors in
a bathroom. The answer may be in wearing socks or slippers, etc.
Flushing the toilet may be fearful to a child, noisy pipes may startle
a child, etc. - watch for signs and warn about noises and explain
the reasons for the noises. The more you can predict changes for
your child with autism and the more you explain the reasons for
things, the better prepared the child will be for changes. Along
these lines, it probably is better to make the switch to training
pants for toilet training. Pull-ups are too similar to diapers and
probably absorb too much liquid, etc.
understand the stress of learning a new life skill
Insistence on routine, sameness, repetitive actions/interests?
Children with autism will probably find it distressing to include
toileting in their already full schedule. Repetitive behaviors,
self-stimulation, and insistence on following their own routine
will certainly interfere with your new idea (toilet training). Of
course, once toileting is established as part of the routine, this
insistence on routine may work to your benefit. Problems with organizing
and sequencing actions may also interfere with learning a new and
Also before you begin: make sure your child does
not have a medical problem which would interfere with toileting
behavior. Usually, this can be ruled out by the family physician
after routine physicals, etc. However, if you notice any unusual
signs of too much or too little urination or painful urination,
contact your physician for a referral to a specialist. If you notice
too much, or too little, or too loose, or too hard stools, contact
your physician for a referral to a specialist. Children with autism
have a higher than expected rate of bowel problems (constipation
or loose stools or both) and require extra care if this is the case.
During toilet training make sure your child drinks plenty of fluids
and eats a diet that includes roughage or fiber (fruits are great)
to assure that the bowel movements will not be hard. One hard, painful
bowel movement during toilet training may set the child back for
a long time! Consult your physician for all of this.
Aids to toilet training
Remember kids on the autism spectrum usually
learn better with both visual and verbal information. Try simple
illustrations using stick figures, and show the step-by-step actions.
Try using these illustrations in a social
story, a powerful technique for learning new skills. There are
commercial toilet training materials that may help, but won't be
adapted for the communication issues that arise with autism and
Asperger's. With a bit of ingenuity, you may be able to use dolls,
water and play dough to simulate the toileting process.
Toilet training is hard work but don't make it
worse than it already is by stressing out on it. There is a saying
among those who teach toilet training methods that goes like this:
"How many 20 year olds have you seen walking around in diapers?"
The saying is supposed to help us relax and not pressure kids into
compliance with toilet training because it "always" happens.
Well, as one who has worked with many adults with developmental
disabilities who still wear diapers, I would have to say: Forget
about that saying. But do relax. There is no urgency here. Don't
worry about what your family or others say. Take your time, make
sure the child is ready, and then begin with the idea of a marathon
not a sprint. Perhaps "our" toilet training book should
be titled: Toilet Training in Less Than a Year! That's probably
closer to the time frame for some, but not all, children with autism.
Well, now it is time to work. Look at this as
a job and give it the priority you would to anything important in
your life. The skill of toileting is very important in your child's
life. It opens doors of independence and privilege that you will
only be aware of as your child ages and remains in diapers. Can
your child move up into the next room at pre-school? Not until he
or she is toilet trained, probably! Not being toilet trained limits
your child's options for child care, school programs, and, if it
goes on too long, may be one of the factors that leads to more-restrictive
placements at school or residential programs in the future.
Make sure you have set aside a lot of time to
devote to toilet training, especially in the beginning. Azrin and
Foxx recommend taking a day off from work to devote to a full day
of nothing but toilet training. For us, let's start with a week
off from work. Many parents opt to have the toilet training begin
at pre-school or school. That's okay but make sure you are aware
of the methods they are using and do the same at home.
Choose a method and stick with it
They say a habit takes three weeks to become a
habit. Give any method at least this long to see if it works.
Check for readiness
There are many checklists for toilet training
readiness. For children on the autism spectrum, I would recommend
looking for the following: awareness that he or she has wet or soiled
and/or a desire to remove the wet or soiled diaper (pulling at it,
taking it off, digging in it, vocalizing displeasure, getting a
clean diaper, taking you to the bathroom or changing area); ability
to imitate actions (at least some actions); responds favorably to
some form of positive reinforcement (a behavior increases after
you reward it with something the child likes); and stays dry/clean
Know your child's routine
Spend at least one week charting the times of
day your child eats, drinks, wets, soils, gets changed (with results),
and sleeps. Use a day planner, chart (some of the links below have
good charts) or simply write down each item and the time it occurs
in a log. For example:
6:00am - change diaper - dry
6:15am - drink 1 cup juice
6:30am - ate cereal, toast - drink 1 cup milk
6:40am - change diaper - wet & soiled.
At the end of the week look at the data (or log) and see if you
see can pick out some general patterns of toileting. For example:
He soils 30 minutes after every meal or he wets 10 minutes after
drinking his juice, etc. These times can then be built into your
toilet training procedures you are about to set up.
Find several reinforcers (things your child would do anything
Reinforcers may be special food treats, special
drinks; special toys, or other items that your child loves. Make
a rule with everyone that has contact with your child that these
special reinforcers will be used only for toilet training rewards.
The items will forever be know as: "Potty candy" or "Potty
toys." This may produce neurotic behavior in the future but
we'll worry about that later - just kidding!
Make a rule with everyone that has contact with
your child that that toilet accidents are not be be punished. Instead,
if a toilet accident occurs use it to associate the toilet with
wetting or soiling. Matter-of-factly, without anger or emotion say,
"You are wet (or soiled, or had a boo-boo, or had a BM). Big
boys (or girls) do that on the potty (or toilet)." If you can,
without a tantrum, lead the child to the toilet and sit him or her
on the toilet or potty chair once the diaper or training pants (my
preference) are off. Immediately reward your child for sitting on
the toilet or potty and say, "Good pottying!" or "Big
boy (or girl)! Sitting on the potty!" (or something similar
that is reinforcing for your child).
If your child dislikes the toilet or sitting
on the toilet, you will have to "shape" his or her behavior
so he or she associates the toilet with the reinforcement. Shaping
is a step-by-step process that reinforces a child for getting closer
and closer to the behavior goal. For example: Reward the child for
coming into the bathroom, then going near the toilet, then sitting
on the closed toilet, then sitting on the open toilet, then sitting
for five seconds, then for wetting on the toilet, and finally for
the "grand-daddy" of them all: having a bowel movement
on the toilet!
Use positive reinforcement for appropriate toileting behavior
Use the reinforcers you have identified and save
them for toileting. Make sure everyone who has contact with your
child is aware of your method and means of reinforcement. If you
were able to devote a week to toilet training your child, use a
schedule (based upon the information you gathered from charting
his or her toileting activity) to provide many opportunities for
your child to use the toilet or potty chair. Use positive
reinforcement for each attempt at toileting by giving the reinforcer
(food or drink treat, time with a favorite toy, etc.) after the
child does what is expected of him or her.
You may have to "shape" this behavior
by reinforcing the child in steps that lead to the complete behavior.
For example: at first the child is rewarded for going in the bathroom,
then for pulling down pants, then for sitting, then for urinating,
then for having a bowel movement, etc. Once a child has mastered
one step, move on to the next and do not reward the first step as
much. Always give verbal praise as you give the special treat or
toy (the verbal praise will begin to take on the reinforcing powers
of the treat and, eventually, you can give verbal praise only).
Continue with this method until the child has mastered the steps.
by Gary J. Heffner, creator of The Autism Home Page at MSN Groups.
Visit Gary's page for a wide range of links concerning
toilet training techniques
Click here for the full
range of Asperger's and autism fact sheets and personal stories
Visit http://groups.msn.com/TheAutismHomePage/environmental.msnw which is the autism home page of Gary Heffner, the author of this
article. This fact sheet remains under his copyright and is used
with his permission. You are encouraged to visit his site as it
is one of the few autism websites offering free comprehensive information.