What should we know about toilet training in children with autism spectrum disorders (ASDs)?

Children with ASDs often have delayed development or may be obsessed with their own routines or anxious about learning a new skill. They may not understand imitation or the words parents use in toilet training.

When are children with ASDs ready for toilet training?

Children may be ready for toilet training when they

• Tell a parent or caregiver they need a dry diaper (or bring one to them).

• Go off by themselves to have a bowel movement.

• Take an interest in others’ going to the bathroom.

• Stay dry overnight and for longer periods.

Being ready may also be linked to other medical and developmental factors. For example, your child may need to be treated for constipation. If your child has constipation, having a bowel movement may be painful, so the child may not want to go to the bathroom and could start to withhold stool (which may make constipation worse). If your child has a developmental delay or his level of understanding is less than that of a 1- to 1½-year-old, he may not be able to tell you when he needs to go to the bathroom, but you may be able to set up a routine to clock or time-train him.

How should we start toilet training?

Children with developmental delays may not be fully ready for toilet training, but clock or time training is a good start. For a few days, keep track of when your child has bowel movements and wet diapers. When you are ready to start clock training, you may want to have the child drink more fluids so she will need to urinate more often. Schedule times for your child to sit on the toilet. To avoid accidents, be sure to schedule times more often than your child usually wets. For example, if your child has wet diapers every 3 hours, schedule a time to sit on the toilet every 2½ hours.

To teach your child to sit on the potty, you may need to support her with music, a story, attention, or a favorite toy. Slowly increase the time your child sits on the potty (up to 2 minutes).

Your child does not need to urinate (you may call it peeing or something else) or have a bowel movement each time she sits. Your child needs to be able to relax on the toilet to go, so teach sitting as the first step. If your child is sitting on a full-sized toilet, she should be comfortable with her feet on a stool so all her muscles can relax. Consider using an adapter seat with side supports if your child seems unsteady.

If your child does not have the language to understand your teaching, use hand signals or pictures to let your child know it's time for sitting on the toilet. It may be helpful to show your child pictures of each step of the process to help her learn the new routine: sitting on the toilet, using toilet paper, flushing, and hand washing. Make an activity board with each picture attached in sequence. As each step is completed, you might remove the picture from the board or place it in the “completed” section. If your child is not verbal, teach your child a sign or provide a picture she can hand to you to indicate that she needs to use the toilet to help transition her from a time- trained schedule (see Resources).

When your child urinates or has a bowel movement in the toilet, reward her right away with something that is not given at any other time during the day. Rewards can be an inexpensive grabbag prize; a favorite toy, treat, or song; plus praise and hugs. If your child has a bowel movement between scheduled trips to the potty, she should help put the stool in the toilet and flush it away. Never punish your child for accidents. It may take weeks to months for training to catch on.

After clock training is successful, work on teaching your child to tell you when she needs to use the bathroom and in time to be completely independent.

What are some potential roadblocks to toilet training?

• Your child may not like the sound of flushing the toilet. If that's the case, flush the toilet later. Be aware that automatic flush toilets may cause refusal in sound-sensitive children.

• Your child may be very active and may not be able to sit on the toilet for any period. If so, try having your child sit for shorter periods, save favorite quiet toys or books for the potty, or play calming music to help your child relax while he is sitting on the toilet.

• Your child may be able to urinate on the potty but won't make a bowel movement. He may have hardened stool or be constipated. Ask your child's pediatrician for ways to help avoid constipation. It also helps “move the process along” if your child has some exercise before eating. Try sitting your child routinely in a comfortable position on the toilet for up to 5 minutes after meals. Pay attention to when your child normally has a bowel movement to increase chances of success.

• Your child may be reluctant to have a bowel movement in the bathroom and may choose another place to defecate. You can help your child by providing a small bath mat to stand or sit on when having a bowel movement. Move the mat closer to the bathroom over time. Have your child practice sitting on the toilet at other times to avoid resistance. Even if your child voids in another place, do all cleanup in the bathroom.

• When your child is alone (usually at night or nap time), he may smear his stool. If this happens, have your child help clean up (even if it must be done hand-over-hand). Remember to wash hands well if you or your child has any contact with stool. Try not to react in a dramatic way that might reinforce (encourage) the smearing behavior. Children who get sensory input from touching stool may benefit from clothing that limits their ability to remove clothes (such as zippered one-piece pajamas placed on backwards) in addition to providing them safe toys for stimulation at high-risk times when this behavior is most likely to happen.

• Your child may learn that wetting or soiling gets a strong reaction from adults. Try to respond to accidents without emotion and refer to your picture schedule to guide your child to the appropriate steps. Do all cleanup in the bathroom. Have your child help flush the toilet and wash hands. Praise and reward appropriate behavior.

Resources

American Academy of Pediatrics HealthyChildren.org: www.HealthyChildren.org

Schaefer CE, DiGeronimo TF. Toilet Training Without Tears. Rev ed. New York, NY: Signet; 1997

Wheeler M. Toilet Training for Individuals with Autism or Other Developmental Issues. 2nd ed. Arlington, TX: Future Horizons; 2007