Many children with autism are difficult to toilet train. Parents and teachers have tried many approaches to teaching the children to use the toilet independently. Not all children respond to the same teaching techniques. A method that is helpful in one child's situation may not be useful in another case. TEACCH consultants are often asked for suggestions for successful toilet training. This article is the compilation of several experienced teachers' and consultants' suggestions about this area of programming.
In thinking about setting up a program to help a child learn to toilet independently, the first TEACCH recommendation would be to try to look at the problem from the perspective of the student with autism. Another TEACCH recommendation would be to build in many elements of visual structure to help the child understand exactly what is expected. Look at each element of Structured Teaching to decide how visual supports can be added to build positive routines, clarify expectations, and reduce confrontational situations.
The child's perspective
Even in typically-developing children, toilet training is often a difficult skill to master. While the child may have good awareness and control of his body, there are other factors… social factors… that determine how easily toileting skills are learned. Small children do not feel an intrinsic desire to become toilet trained. Rather, they acquire this skill in order to please their parents and to gain the social status of " big boy" or "big girl". This social motivation is a critical factor in determining "readiness" for toilet training.
How might the characteristics of autism contribute to a child's difficulty in learning to independently use the toilet?
- The child's difficulty with understanding and enjoying reciprocal social relationships would certainly interfere with this process. While other 2- or 3-year-olds might be proud of their "big boy pants" and might be happy to please their parents, this type of motivation is rare in a child with autism.
- Given the characteristic difficulties in understanding language or imitating models, a child with autism may not understand what is being expected of him in the toilet.
- A child with autism typically has significant difficulty organizing and sequencing information and with attending to relevant information consistently. Therefore following all the steps required in toileting and staying focused on what the task is all about are big challenges.
- Further, the child's difficulty in accepting changes in his routines also makes toileting a difficult skill to master. From the child's point of view, where is the pressing need to change the familiar routine of wearing and changing a diaper? After 3, or 4, or 6 years of going in the diaper, this routine is very strongly established.
- A child with autism may also have difficulty integrating sensory information and establishing the relationship between body sensations and everyday functional activities. Therefore he may not know how to "read" the body cues that tell him he needs to use the toilet. He may also be overly involved in the sensory stimulation of the "product"— smearing feces is not uncommon in young children with autism. The child may also be overwhelmed by the sensory environment of the toilet, with loud flushing noises, echoes, rushing water, and a chair with a big hole in it right over this water! A further consideration is that the removal of clothing for toileting may trigger exaggerated responses to the change in temperature and the tactile feeling of clothes on versus clothes off.
Elements of structured teaching
Structured Teaching is the term given to a set of teaching/support tools designed by TEACCH for people with autism. These tools are responsive to the characteristics of autism using their strong learning modalities (visual and motor skills and enjoyment of routine) to build bridges over some of the gaps in learning caused by their characteristic deficits. Structured Teaching not only increases the learning of new skills but also serves to increase independence and self-esteem, reducing behavior problems that result from confusion, anxiety, and over-stimulation. Structured Teaching combines the use of individualized assessment, establishment of proactive and adaptive routines, and the systematic use of visual supports to support learning.
I. Beginning step: Assessment
When hoping to toilet train a child with autism, one of the first things we must do is define a realistic goal, realizing that independent toileting may be many, many steps down the road. Each of the steps toward independent toileting is a goal itself. It is necessary to observe and assess the child's understanding of the toileting process in order to choose the correct starting point.
We should begin with establishing a positive and meaningful routine around toileting and collecting data about the child's readiness for schedule training or for independent toileting.
A simple chart can be used to collect the data needed about the child's readiness. On a routine basis, the child is taken to the bathroom for a "quick check" every 30 minutes and data is recorded on each occasion. A sample of one format for collecting this basic information is shown below.
|Child's Name:||Date Begun:|
Pants column – In the column marked PANTS you will record every hour either:
D if he is dry, U if he has urinated in pants, BM if he had a bowel movement, U / BM if he had both
Of course, you don't have to wait an entire hour. Anytime you think he is wet, check him, write in the time on the chart, and record the results.
Over a period of 1 or 2 weeks, patterns of data begin to emerge.
Is the child dry for significant periods of time?
Is there some regularity in his wetting/soiling?
Does he show any indication that he is aware of being wet or soiled?
Does he pause while wetting or soiling?
A child for whom the answers to all of these questions is "no" is probably not ready for a goal of independent toileting, although a goal of establishing a positive bathroom routine may still be very appropriate.
During the charting phase, we should also be assessing other aspects of the process of toilet training. As the data is being collected,
Is the child beginning to pick up on the routine involved?
How are the child's dressing skills?
Does he show any particular fears or interests related to the bathroom (reaction to flushing, water, toilet paper roll, or other bathroom fixtures)?
What is his attention span?
At the end of this assessment period, we will have the data needed to establish an appropriate goal to be working toward.
A task analysis of the steps of toileting can give a picture of all the skills needed. Assessing the child's current skills on each step of a task analysis will help us to choose a realistic goal and remind us not to try to work on several new skills at once. Task analyses can be global or very specific. Each step of a task analysis can be further detailed to determine teaching steps. Examples of a global task analysis and a more detailed analysis of one step are illustrated below.
Task Analysis Further Task Analysis
- Enter the bathroom (Does not do fasteners)
- Pull clothes down
a. Allows Adult to pull
b. Pull from calves
c. Pull from knees
d. Pull from thighs
e. Pull from hips
f. Pull from waist
- Sit on toilet
- Get toilet tissue
- Wipe with tissue
- Stand up
- Throw tissue in toilet
- Pull clothes up
- Flush toilet
II. Physical Structure
One of the principles of Structured Teaching involves structuring the physical environment for success. Our goal is to create a meaningful context for an activity to take place. We accomplish this through the creation of clear boundaries and the reduction of distractions.
When beginning the toilet training of a child with autism, we want to help the child learn that this set of behaviors (elimination) is associated with a particular place (the toilet). Moving all diapering, cleaning, and toileting-related dressing to this setting helps the child realize the purpose of this room. Another way to say this is that we are trying to "isolate the concept" of where toileting-related behaviors take place. Some families assign a half-bath in their homes to toilet-training, since the full bathroom has many objects that are associated with other activities and may be very distracting or confusing (bathtubs and showers, bathing toys, toothbrushes, makeup, laundry hampers, scales, etc.)
A second goal for creating clear physical structure to assist in toilet training is to create an environment that is secure and not over-stimulating. The child will be calmer and more responsive with good physical support for his body. Think about adding foot support, side rails, opening reducers, or other physical supports. Think also about the plumbing noises and echoes of many bathrooms. Many children appreciate soft music playing or the addition of sound-absorbent materials.
III. Establish a Visually Supported Routine
After establishing an appropriate goal for the child, it is important that we teach using visual supports for each step toward this goal. We must create a visual system to let the child know the step or sequence of steps to completing the goal.
At the most basic level, a transition object may be used to let the child know that the toilet routine is beginning. An object that is associated with toileting may be given to the child to serve as the transition object that takes the child to the correct location. Or, this object may be placed in a zip-lock bag that is glued shut. Or, this object may be glued to a card. In any case, it serves to initiate the bathroom routine, helping the child know what is to occur and where. At a more abstract level, a photograph or drawing of the toilet or the printed word on a card may given to the child or placed on his schedule to accomplish this goal.
Once the transition to the toilet area has been made, it is important to continue to visually support each step of the toileting routine. We need to let the child know each step he is to accomplish, when the sequence will be finished, and what will happen when the sequence is finished. Again, using an object sequence, a picture sequence, or a written list are all ways to communicate this information to the child. It is important that the child sees the information, manipulates the system so that he recognizes it's connection to his behavior, and has a clear way to recognize when each step – and the entire process – is finished.
Examples of visual systems a variety of children follow:
|Pull down pants _________|
|Pull down underwear _________|
|Sit on toilet _________|
|Use toilet paper _________|
|Pull up underwear _________|
|Pull up pants _________|
|Flush toilet _________|
|Go play _________|
The inclusion of a concrete, visual "what happens when I'm finished" piece of information is an important part of this system. For some children this may be looked at as a motivator or even a reward. For many children with autism, it is equally or more important as a clear indication of closure. Task completion is a powerful motivator for most people with autism.
IV. Trouble-shooting specific problems
Once a visually supported transition and sequencing system has been established, we continue to use a problem-solving approach to troubleshooting details. Whenever the child has a problem with any step of the process, we think about (1) what his perspective might be and (2) how we can simplify and/or clarify through visual structure. Examples follow:
Resists sitting on the toilet
- allow to sit without removing clothes
- allow to sit with toilet covered (cardboard under the seat, gradually cutting larger hole, or towel under the seat, gradually removed)
- use potty seat on the floor rather than up high
- if strategies are helpful for sitting in other places, use in this setting also (timers, screens, picture cues, etc.)
- take turns sitting, or use doll for model
- sit together
- add physical support
- help him understand how long to sit (sing potty song, length of 1 song on tape player, set timer 1 minute, etc.)
- as he gradually begins to tolerate sitting, provide with entertainment
Afraid of flushing
- don't flush until there is something to flush
- start flush with child away from toilet, perhaps standing at the door (might mark the spot with a carpetsquare and gradually get closer to the toilet)
- give advance warning of flush, setting up flushing cue system, such as "ready, set, go"
- allow him to flush
Overly interested in flushing
- physically cover toilet handle to remove from sight
- give something else to hold and manipulate
- use visual sequence to show when to flush (after replacing clothing, for example)
- when time to flush, give child a sticker that matches to a sticker on toilet handle
Playing in water
- give him a toy with a water feature as distraction, such as a tornado tube, glitter tube, etc.
- use a padded lap desk while seated
- cover the seat until ready to use
- put a visual cue of where to stand
Playing with toilet paper
- remove it if a big problem, use Kleenex instead
- roll out amount ahead of time
- give visual cue for how much, such as putting a clothespin on where to tear, or making a tape line on the wall for where to stop
Resists being cleaned
- try different materials (wet wipes, cloth, sponge)
- consider temperature of above material
- take turns with doll
- supply a "target" in the water, such as a Cheerio
- larger target as toilet insert (contact papered or laminated cardboard with target drawn on it), gradually moved down
- add food coloring in the water to draw attention
Retaining when diaper is removed
- cut out bottom of diapers gradually, while allowing child to wear altered diaper to sit on the toilet
- use doll to provide visual model
- increase fluids and fiber in diet
- may need to enlist doctor if serious bowel withholding, may give stool softener
These ideas are not intended to be an inclusive list of steps to take to teach a child to use the toilet. They are, however, illustrative of the problem-solving approach needed and the effort to provide visual cues to increase understanding, cooperation, and motivation.
V. Communication System
Another important step in teaching independent toileting is to plan for a way for the child to initiate the toilet sequence. At first trips to the bathroom may be initiated by an adult directing the child to a transition object or schedule. However, eventually the child will need a way to independently communicate his need to go. Even though he may begin to spontaneously go into a familiar and available bathroom, he needs to learn a concrete way to communicate this need so that he will be able to request when a toilet is not immediately available.
As always, the first step in designing a goal is assessment. Is the child currently signaling in any way that he needs to go to the bathroom, or is he totally reliant on an adult initiating the sequence? If there are behavioral signals that you as an adult observer can "read", these signals can show you the "teachable moments" when you can help the child learn to use a systematic communication tool. Is he able to use objects, pictures, or words to communicate in other settings?
Many children first learn to use expressively the same tool that the adult has used to teach him about going to the toilet. For example, if Mom has been giving him an empty "baby-wipe" box to mean it is time to transition into the bathroom to be changed, the child might begin to use this same box to let Mom know he needs to be changed. Or, if a photograph of the toilet has been used on the child's schedule to tell him when it is time to sit on the toilet, the same photograph will make a meaningful expressive communication tool.
A child who is sometimes able to verbally say "bathroom" may not always able to pull this word up at the appropriate time. When he is tired, in a new place, with a new person, with too many people, catching a cold, upset for any reason -- his higher-level verbal skills may fail him. A child who shows this inconsistency will also be helped by a visual support that (1) helps cue the word he is looking for and (2) serves as a back-up system when he cannot use verbal language.
Chapel Hill TEACCH Center
Books to Read to Children About Potty Training
Going to the Potty
by Fred Rogers, Jim Judkis (Photographer), Jim Judkins (Photographer)
Your New Potty
by Joanna Cole and Margaret Miller (Illustrator)
The Toddler's Potty Book
by Alida Allison, Henri Parmentier (Illustrator)
by Bettina Paterson (Illustrator)
No More Diapers (Personalized Edition)
by Tina Dorman
Once Upon a Potty (Boy)
by Alona Frankel
Once Upon a Potty (Girl)
by Alona Frankel
Bye Bye Diapers (Muppet Babies Big Steps)
by Ellen Weiss, Tom Cooke (Illustrator), W. Weiss
by Barbo Lindgren, Eva Eriksson (Illustrator), Barbro Lindgrin
What Do You Do With Potty? : An Important Pop-Up Book
by Marianne Borgardt, Maxie Chambliss (Illustrator)
Have to Go (Sesame Street Toddler Books)
by Anna Ross, Norman Gorbaty (Illustrator)
On Your Potty
by Virginia Miller
by Taro Gomi, Amanda Mayer Stinchecum (Translator)
Toilet Training in Less Than a Day
by Nathan H. Azrin, Richard M. Foxx
Susan Boswell and Debbie Gray