Toilet training for children with autism

toilet training and autism
Toilet Training is a life skill, ranking #2 after sleeping

Just like getting our autistic kids to sleep, nothing we read in a book worked for toilet training our children with autism. Learning to toilet independently and consistently has been a long journey.

Learning how to toilet independently is an important life skill and many neuro-typical children may successfully toilet train from 18 months old. However, reaching toileting as an independent life skill is often delayed for autistic children. In fact, children with autism are more likely to have incontinence compared to typically developing children of the same age (Niemczyk J, Wagner C, von Gontard A., 2018).

Toileting as an activity relates to sensory stimulation and can be a loud (think hand dryers and the flush), smelly (goes without saying), visually unappealing and boring activity. This can make it challenging for children with autism for a number of reasons. 

It doesn’t help to compare though. When living with a child who can’t toilet independently, getting frustrated, annoyed or telling them “they should have figured out how to toilet already” doesn’t help. We’ve struggled with incontinence in one of our children for most of their primary school years, and they still require adult input and reminders. Here’s some of what we’ve learnt over the years.

Daytime dryness toilet training

Doing wees in the toilet was a really unmotivating task. Firstly, having to go to the toilet meant interrupting whatever fun activity was happening with boring toileting. Secondly, the feeling of warm wee in pants was often a sensory comfort. This meant it wasn’t motivating to go to the toilet for multiple reasons!

There were many suggestions in books for how to motivate children to do wees in the toilet:

  • Add food dye to the toilet bowl so wee changes the water colour and make it fun.
  • Add a floating target to the bowl like scraps of toilet paper to make it fun.
  • Have a reward chart with stickers and a prize if a whole line of stickers is collected.
  • Toilet train in summer and have no pants time in the house.

Unfortunately, none of these things motivated our child or worked for us. However, what did work were some of the strategies outlined by Cocchiola, Martino, Dwyer et al (2012) in their Toilet Training Children with Autism and Developmental Delays

  • Scheduled times for toilet visits throughout the day
  • Timing how long to sit on the toilet
  • Giving reinforcing rewards straight after going to the toilet

1. Name toilet times

We ended up giving wees and poos names, such as “morning wee” or “after lunch poo”. Then we’d ask “Have you done your morning wee yet?”. This reinforced the expectation that there should be a wee at this time. It also created a schedule for when to expect toileting throughout the day. Our child does not have a strong interoceptive awareness. They do not have a strong sense inside their body of when they need to go to the toilet. So, scheduling times was essential.

2. Make toileting engaging

It was difficult keeping our child on the toilet for a long enough time in order for toileting to be successful. We had to make the bathroom as engaging as possible. This meant having books, toys and sometimes even a device, in the bathroom to keep them sitting down for a couple of minutes. Sticker charts didn’t work as the reward was too delayed. However, if a toilet break was successful we used small treats like skittles or sugary cereal as a reward.

3. Teach toilet sequences

Our Occupational Therapist worked on social stories, including videos like Tom’s Toilet Triumph. These outlined the steps to take to successfully complete a toileting sequence. Also think about public toilets compared to toilets at home – this can change the social story steps. In clearly going through the steps, we identified that elastic pants are our child’s preference, as buttons and zips were too difficult to remove and put back on.

Overnight dryness & toilet training

While overnight dryness is often one of the last skills to be developed by kids, it was ironically the first toileting skill learnt by our autistic child. However, there were still a lot of wet sheets, accidents and washing. 

Brolly sheets or bed pad mattress protectors were useful in reducing the washing load. It’s intended that you only have to swap out the waterproof sheet and the rest of the sheets on the bed stay dry. They were packed every holiday we went on so the hotel/caravan park beds didn’t get ruined while transitioning to night time dryness. Even when our child was consistently dry at home, the change in routine of going on holidays often meant night time dryness disappeared when we went away, up until about age 8.

There was also a long time when we woke our child up after 10pm before we went to bed. He got sleepily dragged to the toilet for a night time wee then straight back to bed. This helped in lasting the long night hours to transition to night time dryness. 

Continued incontinence with school aged children with autism

Many books and articles, including the often cited rapid method of toilet training by Azrin and Foxx (1971),  claim to successfully toilet train in 4 days. However, you may find that toilet training is actually more of a marathon than a sprint. One study from 1992 found that children with autism take on average 2.1 years to achieve bowel control. Here are a few more ideas that might work for you.

Have lots of opportunities

While toilet training at home, providing lots of opportunities to practice is important. If a child only wees a couple times a day, that limits the chance to practice. 

Providing lots of drinks throughout the day will lead to lots of opportunities to practice wees in the toilet. If water isn’t a popular drink, try drinking it with a fancy straw, putting in ice cubes, or colouring it with food colouring. Older children may also like weak tea or cordials to flavour water.  

Become an interoception detective

Listen and watch carefully. The ‘toilet dance’, holding, crossing legs, getting fidgety, hiding around a corner, going quiet. These are all signs of needing or going to the toilet. If your child doesn’t have good interoception, point out their body’s signs to them.

Draw pictures and talk about what it looks like, feels like, sounds like when needing to go to the toilet. Talk with your child about what sensations they feel on the inside when they need to toilet. Pin these pictures up on the toilet wall to keep reminding them. 

We kept track of toilet times and accidents with our weekly planner. This helped us investigate the triggers for accidents (extended screen time) and patterns in toileting behaviours (food sensitivity and tiredness related accidents). 

Other useful visuals are the Bristol stool chart (aim for a 3-4) and a Urine Colour Chart (aim for a 1-3). These help educate your child on their body and how to look after it. 

Consider what toileting is like at school 

Some children prefer to hold in their wees and poos until they feel safe or comfortable. Even without any autism, a 2020 study reported that 35% of middle school students always avoid school toilets. 25% never urinated at school and 80% had never defecated at school. While this study looked at school toilet facilities and bullying, add in the complexity of sensory, interoception and autism and you can see how toileting outside the home can be challenging.

Often children will hold on at school. So plan for toilet time when you get home from school and don’t have an extended shopping trip straight after school. 

Build independence with a watch timer

A smart watch for kids is helpful in building toilet independence. Setting alarms at intervals when the toilet should be visited can prompt children to enact Timed Toileting. Using the timer function on the watch can encourage children to sit on the toilet for 2-5 minutes – long enough to relax and allow the body to eliminate.The alarms might be set for

  • ‘Morning wee’ on waking up
  • 20 mins after morning tea 
  • 10-30 mins after lunch for ‘lunch time poo’
  • After school/afternoon tea around 4pm

If there is a regular time that poos happen, this makes setting an alarm easy. If they are not regular, adding fibre to the diet can help. 

Seek medical help

If you’re having lots of accidents or there seems to be constipation, talk to your doctor or paediatrician. Your doctor can feel the belly for a build up or blockage in the lower intestines, and can test for UTIs or other infections. There may be physical or medical reasons behind continued incontinence. They might recommend laxatives to clear any encopresis or help with regular elimination in the case of holding on. Refer to expert medical advice before trying anything at home.

Stay calm and keep toileting

Don’t get angry or yell. If you’ve been toilet training for 10 years like us, it’s not their fault. Stay calm and try to keep positive emotions around toileting. Don’t make toilet time scary or fearful. Don’t give punishments for accidents or make toileting boring. This might back-fire and lead to toilet avoidance.

Another reason to stay calm is to help co-regulate your child. They need to be relaxed to successfully go to the toilet. If their muscles are all tight and holding in, then toileting won’t be very successful. 

References

Cocchiola, M.A., Martino, G.M., Dwyer, L.J. et al. Toilet Training Children With Autism and Developmental Delays: An Effective Program for School Settings. Behav Analysis Practice 5, 60–64 (2012). https://doi.org/10.1007/BF03391824

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