Toilet training can be an uphill battle for many families. Altogether Autism researcher Rebecca Armstrong takes a look and some of the strategies and resources available to support toilet training for children with autism.

Parents of children on the autism spectrum commonly report toilet training can take longer and be a more complex challenge for their child. Unfortunately, there is very little literature on toilet training an older child with autism and there are many other factors that can impact on toilet training itself, including gastro-intestinal concerns, anxiety, resistance to change and sensory issues. In the following article we hope to offer information and share useful resources that may help you support your child through toilet training.

First it is recommended to rule out any medical explanations for toileting concerns. One explanation could be encopresis which is when a child soils his pants beyond an age that would be expected. This is commonly caused by long lasting (chronic) constipation and overloaded bowels. Our professional expert stated if a child is soiling at night when they are asleep this would be a serious red flag.  Additionally, for some children, emotional and behavioural problems are the underlying reasons. This would most often require professional support to help address the issue. More information on encopresis can be found at KidsHealth.

Toilet phobia is an umbrella term used to define anxieties and fears associated with aspects of using the toilet. Learn more about toilet phobia at AnxietyUK.

If you believe toileting difficulties are emotional or behavioural it is recommended to contact your local Needs Assessors and Service Co-ordinators (NASC) and asking for a referral to Explore Specialist Behaviour Support. Additionally, your NASC may be able to point you in the direction of other funded supports. If you contact us at Altogether Autism we will be able to provide a list of relevant and available services in your area.

Functional Behaviour Assessment (FBA)

Behaviour of any sort (e.g. toileting, aggression) sometimes requires professionals, parents and/or teachers to embrace a detective kind of stance. Each child or adult engaging in challenging behaviour such as this will require an individual assessment to try to determine the cause and motivation for the behaviour. An FBA is required so you can put in place an appropriate intervention. Putting in place an intervention without the proper procedure is unlikely to be effective. For example, if behaviour is thought to be occurring to gain attention then it might be addressed by ignoring the target behaviour and providing attention on other more desired behaviour. Whereas, if that same behaviour was a result of sensory sensitivities, then it would be addressed very differently and the focus would be finding a way to minimise sensory input or alleviating sensory experiences.

Behaviour is communication

What are they trying to communicate with their behaviour? Is it that they are afraid of using the toilet? Does s/he find bowel movements frightening?  Does s/he have a germ aversion? Is the seat too cold (keeping in mind that people with autism have different sensory experiences than neurotypical people).  Is there a time when s/he is using the toilet appropriately? Is there a lack of control? As you can see there may be a number of reasons that could potentially explain the behaviour. It is important to try and find out what their behaviour is communicating. This will help you figure out the why it is happening. Behaviour generally serves four functions; to gain access to a preferred item or activity, to escape or avoid a situation, sensory avoidance or seeking or attention based. It would be recommended that you investigate the cause of the behaviour objectively so you can come up with a behavioural plan which will be effective.

There are several ways you can do this e.g. your child may be able to tell you verbally why they do this behaviour. Additionally, you could try observing the patterns around the behaviour such as what happens before and after? When and where does it occur? How often is it happening? How severe is it?  How long does it last for?  Who is present? Are there demands being placed on the individual at that time? Is it always happening when there is a particular activity going on? What times of the day is it? Other important information may include when the behaviour doesn’t occur? When do they use the toilet appropriately? What is different about those times?   Additionally, if the behaviour occurs when they are under stress or during a meltdown this will mean that the anxiety may need to be treated by reducing the stressful situations (using FBA to find out exactly what this is), teaching meditation/relaxation techniques, accessing coping strategies and/or medication if necessary.  Here is a link to a form that is useful for recording specific details.

Knowing the details around the triggers (or antecedents) can help predict when the behaviour is likely to occur and then interventions can be put into place to reduce the behaviour. As well as identifying patterns of behaviour and developing an intervention strategy, the behavioural plan should include strategies to deal with the situation if it occurs (risk management). This might involve teaching new strategies or tools to deal with overwhelming situations or reducing the impact of the behaviour. I have included a link to a document to identify patterns in elimination and daily intake. If you do call in professionals to help they will likely ask you to collect the FBA and elimination information. The more information you can give them the better they will be able to help.

Other potential strategies include:

• Visual supports – Any visual display that supports children engaging in the desired behaviour or skills independent of prompts. Examples of visual supports include pictures, written words, objects within the environment, arrangement of the environment or visual boundaries, schedules, maps, labels, organization systems, and timelines (Wong, 2015).  Remember to pair visual and verbal. Use visuals consistently and across environments. Once the skills is mastered do not remove the visuals.
• First then Visual schedules are a very useful tool. These require a behaviour to be performed (an undesirable activity such as going to the toilet) followed by something desirable (a pleasurable activity for the individual).This would mean each time your child uses the toilet correctly or eliminates their bowels they  could get access to something that is desirable to him – this will help to encourage new patterns in behaviour.
• Visual Timers and cards – sometimes children may get to a point where discussing these matters has become aversive. It may be useful to have a system in places that uses an alarm or timer for times when they need to go (this may be found when you collect the elimination data). Additionally, rather than saying words related to toileting you may have a card that represents it. You could potentially get to a point where you give them the card – they go to the bathroom – and then they get access to something desired.  This relates to changing the language that has become a trigger for them and making sure instruction is focussed on what they should do not what they shouldn’t do.
• Social stories and children’s books – Social stories describe social situations in some detail by highlighting relevant cues and offering examples of appropriate responding. Social narratives are individualised according to the needs of the person and typically are quite short, perhaps including pictures or visual aids (Wong, 2015).  The social story could help your child to not feel any shame around what is happening for them.
• Sensory/environmental accommodations – Read about toileting and sensory processing this article provides a number of issues relating to autism and sensory processing specifically in the context of toileting. It also provides a number of useful modifications and strategies to help with toileting.
• Interoception – Often people with autism have difficulties with interoception which is the ability to feel sensations in our bodies and read what our internal functions and cues are telling us. Sometimes this needs to be more explicitly taught with people with autism. Learn more about interoception, or download this useful resource to teach interoception skills.
• Praise and reward charts – for the desired behaviour. Rewarding small successes as they learn this new habit is a simple and often effective strategy. What is rewarding for the individual will vary. The key is to find out what they would find reinforcing,
• Meditation and relaxation –This has shown to be an evidence-based practice in working with children with autism. This is especially useful if it is anxiety based. Headspace is a evidence based app that can be used to help children achieve more calm and may be helpful to develop awareness of their body.
• Milestones Autism Resources – Take a look at the Toilet Training Tool Kit from Milestones Autism Resources.
• Use special interests to engage them in the process. Autism Awareness Centre Inc. has written a blog titled The Trials of Toilet Training an Older Child with Autism. This also has a number of comments from others who are having shared experiences. This may assist with getting other ideas.
• Graded Exposure –Think of a step ladder and aim to master small steps at a time. Celebrate successes.
• Make a plan – Making a plan around your child’s toileting. This will be useful especially when it is occurring across environments. The plan should include the goal and the actions required to meet the goal. This will ensure everyone is consistent and therefore more likely to create behaviour change. This will help give certainty to the child. It will detail the goal, the action and the rewards.

Toilet training autistic children comes with many additional challenges. I hope that this article provides some ideas that may work for you and your family. Sometimes the key is to take it right back to the basics regardless of the child’s age. Please feel free to contact us if you have any questions or need any resources to help you on your journey.

References

Maskey, M., Warnell, F., Parr, J.R, Le Couteur, A. & McConachie, H. (2013). Emotional and behavioural problems in children with autism spectrum disorder. Journal of Autism Developmental Disorders, 43 (4) 851-859

Wong, C, et al. 2015. Evidence based practices for children, youth and young adults with autism spectrum disorders: a comprehensive review. Journal of Autism Developmental Disorders, 45, 1951-1966.