Potty Training for Children with Autism and Learning Disabilities

Is it difficult for those with autism to learn how to use the toilet? Most of the time, yes. These lovable children usually have problems with bowel and bladder control, but they can be potty trained. They just need to go through a learning process. It can be tiring because it may take months, but the effort is worth it.

“The acquisition of independent toileting skills is often delayed in children with developmental and intellectual disability and may not emerge without training that is more intensive than is required by typically developing children. For example, in a sample of 33 parents of children with ASD, up to 82 % reported difficulties in toilet training their child. Toileting difficulties can result in reduced access to inclusive community settings, social stigma, and inadequate hygiene. Inadequate hygiene related to toileting may lead to physical ailments such as skin irritation and infection. Finally, child incontinence can increase parental stress. Clearly, independent toilet use is a crucial life skill that has profound implications for independence, social relationships, vocational opportunities, and overall quality of life.”1

 

“Designing and implementing effective toileting protocols for young children with autism spectrum disorders (ASD) is challenging for parents and even the most seasoned practitioners.  Using a simple A-B design with gradual component withdrawal, the results of an intensive toileting protocol implemented with a four-year-old male with ASD is presented. The toileting protocol used is a modification of previously examined protocols  : (a) a leveled sit schedule, (b) programmed consequences for successful eliminations, (c) fluid-loading, (d) communication training, and (e) positive practice for accidents. Parents were directly and heavily involved in intervention implementation. The participant was successfully taught how to eliminate in the toilet and accidents discontinued.”2

 

“Researches have used different approaches, including video priming and modeling, graduate guidance, reinforcement-based training, scheduled sits, and increased fluid intake.

Priming to toilet train a 3-year-old boy with ASD.  

Providing information to the participant before they are required to perform the activity to increase the likelihood the behavior will be completed successfully.  

Toilet training video, which resulted in an increase of initiations and successful voids in the toilet, as well as a decrease in accidents. Results showed increased continence for the participants who watched the video as compared to those who did not.

Another method used in toilet training individuals with ASD is graduated guidance, one of the most commonly used components in toilet training protocols.

Most commonly used protocol, Rapid Toilet Training (RTT) consists of graduated guidance, in which prompts are increased and faded as necessary during training.

Reinforcement-based training is another component that several studies utilize during toilet training. A 12-year-old-boy with developmental disabilities, providing him with reinforcement contingent upon a successful void in the toilet. Results showed an increase in successful voids in the toilet that generalized across environments.

Another common procedure used when toilet training individuals with ASD is scheduled sits. Two boys diagnosed with ASD were taken to the toilet on a schedule and reinforced when they successfully voided into the toilet. The protocol was implemented in the participant’s homes using a parent training method. Results indicated that one of the participants was competently toilet trained by the end of day 10 and the other the end of day 5.

Increasing fluid intake is another common procedure used in toilet training to increase the likelihood the individual will void. “Providing free access to liquids and promoting hydration prior to the scheduled sitting increases the likelihood of urinary voiding, as well as contingent reinforcement for elimination,”. Research suggests increasing fluids during toilet training, especially in conjunction with scheduled sits.

If the amount of time to toilet train a child with ASD could be reduced, then the amount of time that child could be learning other important skills could be increased.”3

 

Here are some main guidelines on how to gradually help autistic children use the toilet on their own.

  • Since children with ASD (autism spectrum disorders) and learning disabilities tend to have bladder and/or bowel issues (like constipation), it is suggested that parents consult health specialists and pediatricians to help them in the training process.
  • Parents and/or caregivers need to be patient by teaching kids in a progressive manner. They should be trained according to their actual developmental growth and not necessarily according to age. This means that training should be congruent with the maturity reached individually by each child.
  • Before starting the training period, it is important to determine if the toddler is ready. There are signs that we can identify easily, like when they are able to urinate or defecate at regular times every day or when they inform you that their diaper is wet. When this happens, you can monitor the time and place, and register it on a chart. If the child hasn’t shown readiness, don’t rush it. Give him/her a couple of months and check again!
  • Progress must be verbally transmitted in a clear way to avoid the child misinterpreting your actions.  For example, body language is not usually understood by children with ASD and learning disabilities, so speaking clearly to them is vital.
  • A series of rewards can be implemented to positively reinforce the learning process. The first step is to get the infant to sit on the toilet to defecate (while still wearing a diaper). Even though they are not technically using the potty, they can begin to associate sitting on the toilet with relieving themselves.
  • The next step is to get the child to sit on the toilet at his/her own. It doesn’t matter if they do so while wearing a diaper. If they seek a toilet, it means a positive association has been established.
  • It is common for kids to experience fear upon sitting for the first time due to the anxiety of falling, but once the toddler is used to sitting on a toilet, fear and anxiety are no longer an issue. It is at this stage that parents should remove the diaper when they see the child heading for the toilet. By doing so, the child will hear the stool falling into the potty and understand what is happening. Remember to continuously provide positive reinforcement on how well they are doing.

“Children with autism are often impatient. They don’t want to sit down in one spot, especially on a toilet, for 5 minutes. That’s a long time for a child! If only there was a way to get your child to sit happily on the throne with a full belly. That’s where the old fashioned 5-minute hourglass comes in. Children with ASD are likely to “stim” (stimulate) or perseverate while closely watching the sands of the hourglass slowly slide through the bottleneck. Typical children may be encouraged to read books while sitting on the toilet, but that often isn’t enough for kids with autism. While sitting there for a bit your child may accidentally poop. And that’s when you party! Make a big deal about it so your child remembers this celebration and does it again and again and again. Before you know it your child is into the habit of going big boy style (or big girl style).”4

 

To ease the process, you should give instructions and repeat them in a clear and sequential way. Below are some examples:

1. “Pull down your pants and/or underwear”
2. “Sit on the toilet seat to urinate or defecate.”
3. “Wipe properly with toilet paper” (some help may be needed with this step).
4. “Pull up your pants and/or underwear”.
5. “Flush the toilet.” 
6. “Wash and dry your hands”.
  • “Schedule Training” helps children learn toileting skills without placing other demands on them. Adults set the schedule and help train the child’s body to follow the schedule.
  • Sit for 6. Set a goal for 6 toilets sits per day. At first, trips will be short (as little as 5 seconds per trip), with one long trip each day to work on bowel movements. Over time, toilet sits can be long (up to 10 minutes). Setting a timer can be a helpful way to let your child know when the toilet sit can end. Your child also is allowed to get up from the toilet immediately if s/he urinates or has a bowel movement. Boys are taught to sit on the toilet to urinate until they regularly have bowel movements on the toilet.
  • Don’t Ask. Tell. Do not wait for children to tell you they need to use the bathroom or to say “yes” when asked if they need to go. Tell them it is time for a toilet trip.
  • Schedule. Make toilet trips part of your everyday life. Plan toilet trips around your usual routine. Stick with the same times of the day or the same daily activities.
  • Communicate. Use the same simple words, signs or pictures during each trip. This helps a child learn toileting language.
  • Keep Trying. They say it takes 3 weeks to make a habit. Once you outline the routine and methods, keep working towards the same goal for 3 weeks.
  • Make a Visual Schedule. Pictures may help your child know what to expect during toilet trips).

Take pictures of items in your bathroom (toilet, toilet paper). Place the pictures in order on a piece of paper to show your child each step of the toilet trip.

If your child does not yet understand pictures, you may show your child actual objects (a roll of toilet paper) for each step.

  • Identify Rewards. Make a list of your child’s favorite things, like foods, toys, and videos. Think of which ones will be easiest to give your child as soon as he/she urinates or has a bowel movement in the toilet. A small food item (fruit snack, cracker, chocolate chip) often works well.

In addition to giving a reward for “going” in the toilet, you also can give your child time to do a favorite activity (watch a video, play with a toy) after the toilet trip is over.5

 

“The common issue of designing and implementing effective protocols for toilet training children with ASD can be a daunting task for parents, teachers, and service providers.  The available literature on toilet training components allows practitioners to make informed programming decisions when designing and implementing training protocols. Although pediatricians do not have clear  guidance to offer families of young children with ASD how to determine whether a child is ready to toilet train or how to best approach training, triangulating accessible research may provide practitioners  with information and inspiration for efficacious protocols.”6

 

“To increase the acceptability of toileting procedures for families, researchers have also recommended eliminating special equipment requirements, such as the urine alarm. Eliminating special equipment from toileting protocols may decrease burdens on the family by eliminating the financial costs of purchasing an alarm as well as providing a simplified toileting program. Urine alarms are often included in toileting programs to alert the trainer that an accident is occurring so that any consequences can be implemented. In addition, the alarm sound may also startle the participant and temporarily stop the flow of urine which allows for subsequent, successful completion of the void in the toilet. It may also help children to discriminate when an accident is occurring by increasing its saliency. However, previous evaluations have successfully toilet trained children without the use of a urine alarm which highlights that urine alarms are not necessary to achieve toileting success”.7

 

“Parent education programs have been shown to be effective in teaching children a variety of skills, from the use of an intensive toilet training protocol to speaking. One reason for this is that many practitioners are unable to meet with children frequently enough to provide an adequate amount of time for training and maintaining a skill, whether due to working with multiple clients during a time period or because services are limited to the number of available practitioners. If a client is on a waiting list to receive services in a treatment setting, the crucial early intervention stage may pass before the client is seen. Other times a family is unable to provide the time and resources necessary to facilitate a practitioner’s frequent visits. Given that a parent will spend hours each day with the child in his natural environment, the potential to frequently practice skills and maintain them is typically greater than that which a practitioner can provide”8

 

Potty training can be achieved, the learning curve simply requires a bit more persistence. Parents and/or caregivers need to wait patiently until the child is ready. Don´t worry if potty training the infant seems to take a long time, your efforts will be well worth it when you notice you have a happy child!

 

Reference:

(1) Journal of Developmental and Physical Disabilities· August 2015. Package to Toilet Train Two Children with Autism

https://www.researchgate.net/publication/

(2) DADD Online Journal. Effects of an In-Home Intensive Toileting Protocol for a Young Child with Autism

https://www.researchgate.net/publication/329222943_Carrero_Haas_Hussain_2018_Effects_of_an_In-Home_Intensive_Toileting_Protocol

(3) Toilet Training Protocol for Children with Autism. 2015

https://etd.ohiolink.edu/!etd.send_file?accession=osu1448013801&disposition=inline

(4) Physiotherapist, Life Coach and Mental Health writer Brittany Tacket. Potty Training a Child with Autism using ABA

Potty Training a Child with Autism using ABA

(5) A Parent’s Guide to Toileting for Children with Autism. Autism Treatment Network Toilet Training Guide. Seven toilet training tips that help nonverbal kids with autism

https://www.autismspeaks.org/sites/default/files/2018-08/

(6) Journal of the Division on Autism and Developmental Disabilities

Council for Exceptional Children. Effects of an In-Home Intensive Toileting Protocol for a Young Child with Autism

https://www.researchgate.net/publication/329222943_Carrero_Haas_Hussain_2018_Effects_of_an_In-Home_Intensive_oileting_Protocol

(7) International Electronic Journal of Elementary Education (IEJEE). December 2016. A Parent-Oriented Approach to Rapid Toilet Training. University of North Texas, USA

https://www.iejee.com/index.php/IEJEE/article/view/170

(8) Southern Illinois University Carbondale. Open SIUC. A Suggested Methodology for the Application of Parent Training in Teaching Verbal Behavior to Children with Autism. 2012

https://opensiuc.lib.siu.edu/cgi/viewcontent.cgi?article=1308&amp=&context=gs_rp&amp

 

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