By Gary J. Heffner
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 – even here on The Autism Home Page! Of course, this is not a problem confined to the world of autism. Toilet training methods for children without autism range from the T. Berry Brazelton “If the kid’s not ready until age five, so what” method (did you expect anything less from a man who receives a paycheck from Pampers?) to the sometimes common sense approach of John Rosemond who says modern day kids are spoiled and offers the “Naked and $75” method of toilet training to eager parents of 18 to 30 month old children (His idea is to let the kid run around naked and when they potty they will experience the discomfort and want to be on the potty. The $75 is for the carpet cleaning supplies!). Want to be on the potty?! Boy, he doesn’t know my grandkids! Somewhere in between lies the answer for toilet training, I believe. Oh, let me introduce myself, Gary Heffner, “Official Toilet Training Expert”.Before you begin, understand that a child with autism/PDD-NOS may have a few extra obstacles between him or her and dry pants. All the characteristics that identify the child as having autism/PDD-NOS may well interfere with “normal” toilet training.
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.
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 autism/PDD-NOS. 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.
Insistence on routine, sameness, repetitive actions/interests? Children with autism/PDD-NOS 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 difficult skill.
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.
The method that has worked well for my children and those children with autism/PDD-NOS and developmental disabilities that I have worked with is a modified version of Azrin & Foxx’s Toilet Training in Less Than a Day method. Here are some general guidelines:
1. Relax – 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/PDD-NOS.
2. Stop Relaxing – 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.
3. 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. See the Internet links below for the methods.
4. Check for readiness – There are many checklists for toilet training readiness (see below). For children with autism/PDD-NOS 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 most nights.
5. 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. (Oh yes, you are!).
6. Find several reinforcers (things your child would do anything for) – Reinforcers may be special food treats (M&M’s, Smarties, Cereal bits, raisins, etc.); special drinks (Yoo-Hoo, soda, Koolaid, juices); special toys (cars, dolls, balls, blocks, McDonald’s toys, action figures, etc.); 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!
7. No punishment – 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!
8. 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. Begin reinforcing 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. The links below will go into even greater detail (see the TEACCH link for a great procedure).
A special note: Many children with autism/PDD-NOS may have unusual reactions to various sensory stimuli (smells, tastes, textures, colors, temperature, sounds). 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/PDD-NOS 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.
Please send questions, comments, & suggestions to: Gary J. Heffner.
DISCLAIMER: This site is intended to provide basic information resources on Autistic Disorder. It is not intended to, nor does it, constitute medical or other advice. The author of the web site is not a medical doctor. Readers are warned not to take any action with regard to medical treatment or otherwise based on the information on this web site or links without first consulting a physician. This web site does not necessarily endorse any of the information obtained from any of the links on this page or links that other pages may lead you to. Neither does this web site promote or recommend any treatment, therapy, institution or health care plan. The information contained in this site is intended to be for your general education and information only and not for use in pursuing any treatment or course of action. Ultimately, the course of action in treating a given patient must be individualized after a thorough discussion with the patient’s physician(s) and family.