Toilet Training

Most typically developing children are toilet trained by the time they are 3 ½ years old. The recommendation for starting toilet training is when children begin to show they are ready, when they are interested in wearing underwear, and/or when they want to be "grown-up."

Children with Autism Spectrum Disorder (ASD) may not demonstrate or express such readiness. Additionally, children with ASD may be rigid with their routines and in their environments, which can make toilet training quite difficult. Children with ASD may not be able to tell you that they have to use the bathroom and may not have the language to indicate they are ready to use the toilet. When you, as the parent, caretaker, or guardian feel ready, it is time to begin toilet training. Most children with ASD take a while to understand the connection between the sensation of having to urinate and actual urination. It's the same with having a bowel movement. Hang in there!

It is helpful to use principles of Applied Behavior Analysis (ABA) to help increase the success of teaching toileting skills. The ideas below incorporate many ABA strategies. Additionally, it is essential to coordinate and communicate with all of the people in your child's life, especially your child's teachers and other caretakers. Let them know about your plan and enlist their help and support. It is also recommended that you check with your pediatrician before you begin to be sure there are no medical reasons for your child's incontinence.

Before beginning a toileting schedule, consider the following:

• Is the child motivated to begin to learn to use the toilet?
• Does the child have regular routines for urinating and bowel movements? How frequently does the child have a wet diaper? Does he or she have regular bowel movements?
• Can the child learn to say, sign, or use a PECS card for bathroom/toilet?
• Has the child learned to sit on the toilet?

Make A Plan:

When will you begin?

• Consider your schedule. Toilet training will require an emotional commitment and a time commitment. It is probably best to consider devoting an entire week to the project. You will need to be completely attentive to your child and put all of your plans on hold. If your efforts are consistent, you will more likely be successful. If you are not able to be consistent, the plan will be confusing and it will take much, much longer to achieve success.
• Some parents find it easier to teach toileting during the summer months, when children wear less clothes. Other parents prefer a time of year when children are running around outside less frequently. Choose a time a year that makes sense for your family.

Where will you do this project?

• It's best to be at home, in the most comfortable place for you and your child. Plan on being at home with as few interruptions to the training schedule as possible.

Prepare the environment

• Have extra underwear and changes of clothing (including socks) readily available in the bathroom.
• There may be many accidents, so chose a place where the floor can be easily cleaned. Consider putting a plastic tarp over the carpet and on the furniture where the child may sit.
• Have a highly desirable toy in the training area (bathroom) so the child will want to be there. This toy should remain in the training area for the purpose of encouraging the child to stay in the space and participate in training. It should not be brought out of the training space while you are in training mode.
• Use a timer and reset it each time the child goes to the bathroom.
• Encourage liquid intake, and have lots of special drinks to encourage frequent urination.
• Make sure the child will feel secure and safe on the toilet. If you are using a toilet trainer (a ring that is inserted onto a regular toilet to make the seat smaller) have a stool available so the child's legs are not dangling, but firmly rest on the stool.
• Choose a token to reward the child for any effort towards success. This motivator should be used only for toilet training, for example, if M&Ms are used, only have M&Ms for the training and not available at any other time or place until toilet training is complete.

How will you prepare your child?

• Talk to your child about what you are going to do and visually show him or her the equipment involved:
  • Bring your child to see the toilet
  • Take your child shopping to pick out his or her own training pants/underwear, and repeatedly show them to your child until you are ready to begin the process
  • Show your child what he or she will be drinking, etc.
• Have visual aids posted to show what will happen and ask special education staff to help with these.
• Story books are good, but children with ASD may need to see themselves in a photo to help them understand that this is about them! Consider a Social Story™.
• Consider having your child watch a parent or sibling urinate.

Executing the plan!

• Assist your child to say "bye-bye" to the diapers and put on "special" underwear.
• Have lots of favorite drinks available and encourage drinking! This will increase the number of times the child will need to urinate.
• Smile and remember this is going to be worth it!
• Bring your child to the toilet every 15 minutes and reward him or her for any attempt. For example, for a child who has never sat on the toilet before, set the timer for 1 second and reward him for sitting on the toilet with his clothing on. For a child who has no experience sitting on the toilet, this may be a huge step, and he needs to be "rewarded" for any effort! A child who has had experience with sitting on the toilet with his clothes on should be rewarded after sitting with pants down and for a few seconds on the toilet. Another child may need to be rewarded for simply entering the bathroom. This first step needs to be individually determined.
• Sit times should only last up to 3-5 minutes. If the child hasn't gone during this time, he or she is not going to do so willingly.
• Make the time together fun. Sing songs, read stories, play quiet games, etc.
• The child should wear training pants (and perhaps rubber pants to keep the mess contained). Learning to use the toilet may take longer if the child wears pull-ups because he will not feel as uncomfortable as if he wears underwear or training pants.
• Establish a hand washing routine each time after sitting on the toilet.
• Be attentive and stay with the child so you can "catch him" when he pees or poops. Wash hands and reward appropriately!

Tips!

• Most importantly: Remember, the child has ultimate control of his or her elimination. If toilet learning becomes a battle of wills, STOP, take time off (weeks or even months), and start the process all over when both you and the child are in a more cooperative mood and ready to begin again.
• Consider having a partner help you with this intense training. Work together and develop a rhythm together, then you can take turns participating in the training. This can be exhausting work.
• Rewards need to be out of reach, but not out of sight.
• It may be confusing for boys to understand when to sit and when to stand. Some parents recommend having boys sit when learning to urinate, in order to become comfortable using the toilet. (It is critical for social reasons to teach your son at some point how to stand to pee.) Other parents whose children are more rigid and have difficulty with change prefer to teach their sons to stand to pee from the outset.
• Use your child's favorite mode of communication, consistently, each time he or she goes to the potty. This may be a word, a picture card, a sign, etc. This will help the child learn how to label this activity, which is important when your child needs to tell others that he or she needs to "go to the potty" or "go to the bathroom."
• Keep it all positive: "That was a good try! You almost made it to the toilet."
• Turn on the water to stimulate urination.
• Use appropriate language to label body parts and functions; penis, vagina, urine, etc.
• Remain in control. Do not react negatively to accidents and use a neutral tone. Don't provide a reward, unless the child has done something to earn it. Emphasize that your child will be able to try again later.
• When accidents occur, change the child and have the child assist with the clean-up as appropriate.

Additional Resources:

• Parent's Guide To Toilet Training In Asd, From Autism Speaks®
• Toilet Training For Children With ASD
• How To Toilet Train A Child With Asd Video