How to toilet train our kids with autism

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Two years ago, when my friend, who is an allied educator told me that he has never had a kid with mild and even severe ASD who could not be toilet trained by Primary One (i.e., seven years old), I didn’t believe him. Two years on, I am so thankful that my child is finally diaper free and able to fully self-initiate pee and 90% of the time poop.

 

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As I look back on this two years journey, I realised what was important is the perseverance of the caregiver in toilet training the child and recognising that this is an instructional challenge and not a behavioral challenge. While I have read the book by Maria Wheeler and watched the video by Dr Mirenda, who is an expert in this area, I felt that it was the use of a combination of techniques that worked for my child. I will elaborate on the techniques and support strategies that I used below:

Characteristics of Autism that influence Toilet Training

According to Wheeler (2007, p.2-3), every child is unique and there are particular characteristics associated with autism that impact behaviour. These factors will have a significant impact on both the successes and challenges one will experience when toilet training the child. To create a successful toilet training experience, a few characteristics need to be addressed:

·         Communication needs
·         Literal communication
·         Sensory awareness
·         Sensitivity to stimulation
·         Preference for routine or ritual
·         Motor planning difficulties
·         Limited imitation
·         Sequential learning
·         Increased levels of anxiety
·         Difficulty adjusting behaviours to fit new situations

Resources that are helpful in toilet training our child with autism

For the parent or caregiver to read up and watch:

  1. This is a lengthy but comprehensive video, ‘Toilet training for Everyone – It’s never too late‘ by the Dr Mirenda, is an excellent video on the myths of toilet training, how to toilet train our kids, and how to teach self-initiation peeing and pooping to our kids with autism.
  2. The book, that I ordered from Future Horizon, ‘Toilet training for Individuals with Autism or other Developmental Issues‘ by Ms Maria Wheeler, is a comprehensive read-up on how to toilet train our child.

Support strategies to use with the child:

  1. PhotoGrid_1469238591553
  2. A visual schedule for  A simple & effective way to teach toilet hygiene. So far, this visual schedule on flushing and washing is working ‘cleaningly’ well for my child.
  3. This entry from Autism Speaks provides Seven toilet tips for nonverbal kids.
  4. PhotoGrid_1470103968790
    Four books (to help with pee, poop and sensory disorder) that we have read and are still reading during this training process which I have elaborated below.

Basic similarities and differences in information from the book and video

Getting Ready (Ms Wheeler)

Getting Ready (Dr Mirenda)

Their proposed program

·         Develop a toilet schedule – Use a visual schedule; identify appropriate times for toileting and include those times in the visual schedule. ·         Break the training into two segments: First, fully train the child in Day-time training – “Phase 1:Trip training” ; Phase 2: Self-initiation training before proceeding to ‘Night-time training – “Trip training” ; Self-initiation training’
·         Use the schedule for eating foods, drinking fluids and accessing toilet, enter the bathroom, sit/stand on/by the toilet, access toilet paper, get off the toilet, flush, wash and dry hands, check what is next on the schedule ·         Phase 1 (give yourself three months at least to master this phase) – just about peeing, not necessary about being able to pull pants up/down, wiping, flushing, hand washing, etc
·         Use a chart (included in the book) to record peeing in toilet and accidental peeing at every half hour interval. ·         Figure out how often to take the person to the toilet. For 5 to 7 days, check on individual every 30 minutes to see if he/she is wet or dry. Record W for wet and D for dry

For caregivers or trainers

·         Assess the child’s chronological vs. mental age, awareness level, and physiological factors ·         Understand the difficulty of urination
·         Freedom from medical conditions that contraindicate participation in a toilet training program ·         Medical issues – neurogenic bladder; frequent bladder infection; urinary tract disorder, etc
·         Approach using the toilet as an entire sequence of related behaviours for the learner to complete ·         Prepare yourself – important to see this as an instructional challenge, not a behaviour problem
·         Good for training to take place in school and at home – aids in building similar ‘habit’ training ·         Decide where training will take place and who will be involved – does not advocate for toilet training to be done simultaneously at home and at school
·         Control the fluid intake in an effort to influence urination but never deprive fluids to decrease the number of times a person urinates ·         Understand that you are un-teaching old habits at the same time you are teaching new ones as the child has been so used to peeing in the diaper. Accidents are good – it means they are trying
·         For males, decide whether to train in a standing or seated position ·         Advocates for the child to be trained in a seated position which makes it easier to train the child for poop training later on

For the child

·         Use a visual schedule to make toilet training part of the entire day’s schedule ·         For individuals with limited or no speech, provide a manual sign, photograph, or some type of symbol for “bathroom”
·         Avoid asking if the person needs to use the toilet, but simply prompt the child that it is time to use the bathroom. ·         At the appropriate time, say something like “it’s time to go to the bathroom” or use the visual prompt. Have the child say “bathroom/pee,etc” Do not talk in the bathroom. Use hand over hand instructions if needed, to assist the child to pull down the pants, etc
·         Basic cooperation with undressing related to toileting – pull-on pants or shorts with an elastic waistband ·         Get rid of diapers or pull-ups in the training setting. It’s okay to wear diapers or pull-ups alone during non-training times and at night.
·         Modeling – have the child watch someone else complete the behaviour correctly. ·         Motivation – identify several items, activities, etc that can be used to reinforce urination in the toilet. These should not be available at any other time (preferred “treat” foods, drinks, toys, leisure, activities) Let the child pick his or her own motivation of choice
·         Stories that teach – use stories that describe someone engaging in the desired behaviour. ·         When urination occurs in the toilet, provide the reinforcers as soon as the child is finished. Don’t get all excited while urination is taking place.
·         Pre-teaching – provide clear reminders to the learner immediately before the skill is to be used. ·         If wet in between times: ignore if possible – OR change him/her into dry clothes as rapidly and neutrally as possible. Don’t get into power struggle land.
·          Others: There are many case studies in this book which were extremely useful in letting the caregiver know what other kids go through and how the technique has worked for them. ·         Don’t talk, scold, explain, spend a long time on this, have the person clean up. Just clean up and have minimal attention and interaction with you.
·           Others: I particularly like the ‘Caution’ portion in her book that can be found in all the chapters. They were like alarm bells for me as I have done many of those caution-things which she suggest for us to not do. ·         Phase 2 (this phase if finished when the child self-initiates and stays dry 100% of the time for at least 2 weeks)– child will urinate when needed without someone taking or reminding him/her
· ·         Signs to show they can self-initiate on their own
· ·         Grab him or herself

·         Do the pee dance

·         Say pee

·         Use the symbol

·         Takes your hand and lead you to the bathroom

·         Stand by the classroom or bathroom door, and look distressed

· ·         If any of these occur…Don’t ask, just bring them there or say “Oh you need to do, let’s go”.
· ·         If no signals are seen, just extend the length of the toileting interval very gradually by 5-10-15 minutes
· ·         Continue with reinforcers. Will take longer and less secure than Phase 1.

Successful techniques and support strategies that I use to toilet train my child

  1. Recorded the how often my child goes to the toilet. For 5 to 7 days, check on individual every 30 minutes to see if he/she is wet or dry. Record W for wet and D for dry. Instead of a chart, I used a book to indicate the times.
  2. Engaged the after-school caregiver to do the same and record my child’s toilet schedule.
  3. Brings my child to the toilet 5 minutes earlier than required, saying, “Let’s go to the toilet”. At the after-school caregiver’s house, he is given IPad to motivate him or as a reinforcer. At home, I will provide him with pastilles and gummy as reinforcers after he is done with the toilet routine. I decided not to use IPad, which took a while for him to get used to as I wanted to reduce the ‘technology’ time he has.
  4. Read story books that teach pee, sensory disoder and poop.

Story books to teach to pee

  • I want my potty (Book Depository link) by Tony Ross is a good introductory book for the child. I love how I can exaggerate my voice while reading the book. However, as the child in the story is a princess, I wanted to find a book which shows a male instead.
  • So, I ended up buying ‘Potty‘ by Leslie Patricelli. This book is simple and not so wordy, unlike Tony’s book.

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Storybook for child with sensory disorder

  • My son has sensory issues, and for a long time, he fears the flushing of the toilet. I chanced upon this book, ‘There’s a monster in the toilet‘ (Amazon link) at a second-hand book store which solved my issue.
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    I use this book to show my child that there are others who fear the flushing of the toilet too.

     

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    Max, the boy in the story, did not like flushing the toilet either. He would push the button and run out of the bathroom. This is what my son does as well. Before, he did not even dare to flush the toilet. He would rush out once he is done without even washing his hands.

     

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    On this page, it would write that the dad put in toys and books on the shelves. On our end, I use the gummies and the pastilles as a form of reinforcers which my child will not get at other times.

Storybook to teach poo

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Ready to Go! Toilet time (Book depository link)
  • We’re using this book now as it is illustrated in the book that the child in the book can take off his underpants, can stand and pee, can wipe his own bottom, flush the button, wash his hands all by himself. It ends with a direct question, “Are you a BIG boy too?”
  • My son likes this last question a lot and he would always shout “Yes!” He still has accidents every now and then when he poops, as he would be distracted by something, and would hold his poop in. By the time he needs to go, often there would be a bit of poop in the underwear or he does not make it to the toilet in time. This is when he would have a melt down.
  • I am still using Dr Mirenda’s technique by giving him the gummy and pastilles he don’t get at other times to toilet train him on the poop part.

Reflection

Is this a simple process? No. However, like what both authors have delineated, it’s about perseverance from the caregiver/s who is/are training the child. After two years, I finally agree with my friend that it is possible to toilet train our child with autism. Yes, it takes time and cooperation from many involved. But, the ability to toilet train a child  brings a lot of comfort to the child and also to the family. It makes it easier to bring them out and have them go on school outings and other outings.

My best advice: When the going gets tough, do not give up. The end is in sight if you persevere.

Lots of love,

A

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