Toilet training in children with Autism

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Experts have long said that people with autism are among the most difficult to toilet train because many traditional potty training techniques simply don’t work for them. While I agree that it’s difficult to teach children with autism these skills, it’s not impossible.

You will need at least two solid weeks of time to be home a lot to work on this skill and be able to be committed to working almost solely on toilet training. Then look at the following three months and make sure that no big changes are planned. It should incorporate all the family members in all settings like home , school, therapy centre etc. I’ve seen many families have “false starts” with their toilet training because they didn’t commit enough time when they began. Once you start a program, you’ve got to keep going. If you’re finding it hard (and it is hard) it will only get harder in a year or two.

The following steps and strategies can be used for effective toilet training program:

1.     Set schedule by toilet chart

2.     Increasing fluid intake / extra drinks / hydration

3.     Scheduling toilet training time

4.     Positive reinforcement

5.     Training the skills needed for undressing, dressing, opening and closing tap, flushing, and washing hand.

6.     Bowel training

7.     Introduce a request

8.     Overcorrection for accidents

9.     Night time training
10. Dealing with accidents after training is complete.

           Toilet training steps in detail

1.      Set schedule by toilet chart

        A toilet chart is used to monitor and/or schedule the toileting program for a child who is yet to be toilet trained. Initially it is meant to evaluate the number of times the child successfully uses the toilet for a bowel and bladder movement and the number of accidents and on a later stage to have to use as a schedule chart for training. A toilet chart must include components such as day, time, number and amount of fluid intake, number of successful bowel and bladder movements in the toilet and number of accidents. If required it can also have a note on how many times the child indicated to use toilet if the child is partially trained. This evaluation using a toilet chart can be made over a period ranging from 2 to 5 days depending upon the variables in each child.

2.      Increasing fluid intake/ extra drink/ hydration

       When the child is under evaluation for toilet routines, it is important to keep the child hydrated by increasing fluid intake so as to provide maximum opportunities to use the toilet. After 2 to 5 days of monitoring, the child must be encouraged to drink water and other drinks at fixed quantity at fixed intervals to enhance a fixed routine in urination. Marking this on the child chart can be helpful to stick on to the schedule perfectly.

3.      Scheduling toilet training timings

        It’s easy to get a toileting routine of a child using a toilet chart that is recorded at the time of evaluation. With this the average duration of when a child passes urine or motion can be noted and a regular timing can be set for a training program. For example if a child passes urine at 7.00 AM followed by 8.15 AM, 10.00 AM & 11.10 AM, the average would be approximately 1.20 hours. The timing can be fixed depending upon the average. At initial stages it is advisable to have a short duration between two trips to toilet to have better success rates. If a 45 minute schedule is set, the child can be given two ounces of water every 30 minutes and can be taken to the toilet at every 45^th minute. If the child didn’t urinate, take him/her to the toilet again after few minutes. Keep a note on all successful trips.

4.      Positive reinforcement

        Once a schedule is fixed for training, wait and spend quality time on finding out and fixing the reinforcements. Any behavior is expected to increase if it is reinforced positively and it holds good for toilet training too. So, the next step is to list out all the materials or toys or anything else that would keep the child happy. Select one or two reinforces from the list that are highly motivating to the child and are not always available to the child. Then pair the reinforcers with the toilet and reinforce the child with that for every successful trip to the toilet. For example, if the child likes and has real fun in playing with sand, then take little sand to the toilet and keep it in just before taking the child to the toilet. Once he/she successfully passes urine or motion in the commode, immediately provide the sand for play for some time. This will increase the child’s motivation to have a control over bladder/bowel movement reach the toilet when there’s a need next time. It’s important not to provide the reinforcement when the child didn’t use the toilet and instead reassure that he/she will surely be reinforced for next successful trip.

5.      Training the skills needed for undressing, dressing, opening and closing tap, flushing and washing

           At the initial stages of the program, the child should be preferably dressed with short and loose/elastic easily removable underpants or trousers. This will help in reducing the stress of hard work involved in manipulating clothes inside the toilet which would otherwise make the child demotivated to get into the toilet for training. But a toilet training program is incomplete unless and until the child independently manipulates dress, tap and other things used inside the toilet. Hence, steps like opening and closing doors, switching on and off the lights, dressing and undressing, flushing the toilet, using tap, using soap, washing and wiping self are very important. Though these skills can also be taught other times, it’s essential to make the child perform all these steps inside the toilet during training. This can be started by giving manual guidance or physical prompt gradually fading to verbal commands and simultaneous practice at other times. Parents should also focus on removing the undergarments up to the ankle level at initial stages so that it doesn't require extra effort to teach later.

6.      Bowel training

         Training bowel control might appear to be little taxing due to its less frequency than a bladder movement and the variations in time as per the changes in the diet. But with proper maintenance of balanced diet and by following few tips, it will be even easier. Bowel training can be done along with bladder training but with a fixed schedule. Initially the child can be doubly reinforced if there is a bowel movement along with urine in the toilet. To make this practically possible, boy children should be made to sit and urinate until they are completely trained for a good bowel control. As a schedule, fixed timings for 2 to 3 times a day can be allotted for passing motion apart from those set for urine. Giving 2 to 3 ounces of lukewarm water just before the schedule would make the trip highly successful. For example, if the child is scheduled for urine at 7.30 Am and 8.30 Am and has breakfast at 8.00 AM, he/she can be given lukewarm water at 8.15 AM and can be made o try for a bowel movement immediately. Positive results should be reinforced and noted. 

7.      Introduce a request

        Once the schedule for bowel and bladder training is fixed and there are regular trips with no accidents, it is time to start teaching the child to request for toileting. Here parents should decide what words can be used for indicating bowel and bladder needs. Words that are once selected should be practiced and uniformly used by all those who are involved in potty training. For children who are minimally verbal or non verbal, signs or vocalizations of any preferred syllable can be used. There are few children who can’t use fingers to produce a sign due to lack of fine motor coordination. In that case, a gross sign like touching the underpants or showing flash cards/ symbols can be used. At the beginning, when the child is on schedule prompted by adult, the adult should use these words or signs and make the child repeat them, both when he/she is on the way to the toilet and just before sitting on the commode. Gradually, when focusing on introducing request, the child must be watched for signals of need to use the toilet at those timings on the schedule. Parent can wait for 5 to 10 minutes for a spontaneous request, reinforce if a request is made and take him/her immediately to the toilet. Whereas when the child didn’t want to use toilet, delay the time for few more minutes and then take to toilet as done in the earlier steps. There might be chances when the mother can sense the child’s need to use toilet but the child doesn't know how to express it. These are times which have high opportunities of learning a request. In such case, mother can minimally prompt a request and reinforce heavily to increase the behavior.

8.     Over correction of accidents

          Accidents that are happening during a training program should not be overlooked. If the child is on scheduled trips and is ready for requesting, then accidents should also be addressed. An over correction procedure involves having the child engage in repeated behavior as a penalty for having displayed an inappropriate action. In toilet training, this is used to correct accidents. An example is, when a child passes urine/motion anywhere outside the toilet, the child is asked to clean the place with a cloth and rinse it inside the toilet near the commode and repeat the procedure for 4 to 5 times. The number of repetition varies in each child depending on the ability to understand consequences. This would help to pair the place of accident and the toilet to make the child understand the concept of toileting in the toilet.  It would also help the child to opt for using the toilet in order to avoid the strain of repeated cleaning or over correction.

9.      Night time training

        A toilet schedule with longer duration than the day time scheduling is used for night time training. Reducing fluid intakes in late evenings, taking the child to toilet before going to bed, waking up the child at the scheduled timings regularly for toileting, rewarding dry morning heavily with reinforces and reassuring the child for any bed wetting beyond these precautions are tips for night time training. When day time training is done bed -wetting will automatically come down in most of the cases. It is important not to scold or punish the child for night wets as it happens without awareness. Gradually the time duration can be increased so that the child gets good control and wakes up from sleep by self to use the toilet.

10.   Dealing with accidents after the training is complete.

         It is mostly unlikely that a child will have accidents after proper training. In some cases, when there is a change in routine, new environment, stressful day, infections, change in climate, etc, the child might have accidents that can be resolved easily in a week or two.  There might be situations when the child purposely does accidents a behavioral manifestation to gain attention or to demand/avoid a material or activity. In such cases, not meeting up the demand of the child and using over-correction principles will help to reduce accidents. It is also important to shape the child towards appropriate or socially acceptable way to request for needs or attention. When the child is exposed to a new environment like shopping mall, a new school or a friend’s house, he/she should be shown where the toilet is located and prompted to ask when needed. It is important to reassure the child that it is not a shame to use the toilet outside the home environment. Parents and other adults can role model by asking others for a toilet in front of the child so that the child will overcome the shyness behind making a request.

NOTE:

               Sensory issues hindering toilet training should be addressed right from the beginning of the program so as to account for quicker and efficient training. When the child has tactile defensiveness (avoiding few textures, wetness, etc) he/she might not wish to sit on the commode, or even step into the toilet. In such cases, activities to desensitize and get adapted to toilet environment should be carried out simultaneously. Monitoring and changing the lighting, Smell of the toilet, texture of the door mat/ towel, keeping the toilet dry, pairing the toilet with reinforces, etc., might be required depending on each child’s sensitivity. As mentioned earlier, children with fine motor problems might have difficulty in pointing  or showing signs using fingers, manipulating dresses, tap, door, etc., Which should be trained simultaneously or even before starting the program in order to have the child become completely independent in toileting.