Toilet training for autistic children involves learning many different skills. It is no wonder this phase of development is stressful for many parents and children. If you are a caregiver just getting started with toilet training, you might consider first watching our pre-recorded webinar: “Toileting Without Tears.” If you are a caregiver who has already tried the usual strategies without success, this blog post is for you! You are not alone, and you don’t need to give up trying.
Viewing the experience through the autism lens helps us apply the supports that make independence with toileting an achievable skill, as well as understand ways we can make the experience more positive for the child. Because toilet training involves learning many different skills, I recommend focusing instead on how to teach the various steps, one by one, that are involved in achieving the final, long-term goal.
Autistic people experience co-occurring medical conditions at a higher rate than the neurotypical population, some of which can impact success with toilet training. Most notably, constipation is very common among the pediatric population, especially among autistic children. If your child does not produce a daily bowel movement with a normal consistency (i.e., reference the Bristol Stool Chart), it is a good idea to talk with their pediatrician about their bowel habits and determine if any changes in food/drink intake or other medical treatment is recommended. Constipation can be exacerbated by toilet training if the child is used to going in a diaper or pull-up and is changed to underwear, causing them to hold in bowel movements. Additionally, severe constipation can lead to discoordination of bowel muscles, requiring longer sit times to successfully produce on the toilet and may be very painful. Other medical conditions, such as motor apraxia or seizure disorders, may impact the ability to detect and control biological functions as well as to plan accordingly. If a medical condition is suspected, seek guidance from a physician prior to committing to intensive toilet training. Seek professional support if your child is showing refusal or if any regression is seen when the child is changed to underwear in the daytime.
Another important factor to consider when toilet training for autistic children is if the child has any known or suspected history of trauma. If history is unknown or trauma is suspected, it is recommended to approach toilet training with extreme caution and in coordination with specialty providers.
“Your consistency over time is largely what helps the routine become familiar and comfortable.”
Once medical conditions have been ruled out or addressed, start by identifying what skill to focus on teaching first. While producing on the toilet might seem like the priority, for many children, getting comfortable with transitioning to the bathroom is an important prerequisite skill to practice first. If your child shows resistance to transitioning to the bathroom, consider your first teaching goal to be to establish a new routine in which the bathroom is a safe space that is visited frequently throughout the day and is associated with private, hygiene-related daily living activities such as cleaning up and changing clothes. Autistic people often have a strong preference for sameness, predictability, and/or routine completion that can make transitioning from one activity to another challenging and stressful. Considering this perspective helps keep us grounded in focusing on ways we can help children feel safe during this life change. Prior to toilet training, it is common for children to be used to having diapers or pull-ups changed in different rooms in their home. Although your child may initially show resistance and feel stressed when you introduce frequent trips to the bathroom throughout their day, you can help your child feel safe by creating predictable routines, and by modeling calm, confident behavior even when your child may be unsure. If your child shows resistance, you can help set expectations by showing visual supports prior to transitions (e.g., a picture of a toilet), giving a consistent instruction (e.g., “It’s time to go to the bathroom”) and singing or playing a familiar, contextually-relevant potty song every time it is time for a change.
Keep in mind that if this routine is new, your child may have a difficult time even with these supports. Your consistency over time is largely what helps the routine become familiar and comfortable. I recommend giving your child some time to begin the transition on their own, and progressing to additional supports if necessary, including “first-then” statements and visuals, gestural guidance, and gentle physical prompts if necessary. Your child will come to understand over time that getting cleaned up after wetting or soiling a diaper is a non-negotiable routine, and the caregivers who provide consistency and predictability during this can be trusted and are here to foster independence and teach safe boundaries.
Once your child is comfortable with nearly all diaper or pull-up changes occurring in the bathroom and will transition there with you easily, you can shift your focus to teaching them to produce in the toilet. Have your child sit on the toilet for up to a few minutes at a time during these bathroom trips for changes. You might find that reading a contextually-appropriate book or watching a toileting video/song makes the routine more preferred for the learner and helps them start to grasp what bodily functions should occur during toilet trips. Once your child is feeling comfortable with sitting on the toilet for a few minutes at a time several times per day, they are likely ready for more intensive toilet training, in which they are dressed in underwear throughout the daytime rather than a diaper or pull-up. Caregivers can set children up for success by taking children to the bathroom at designated intervals. In the initial phase of toilet training, these intervals should be frequent to prevent accidents and to help the child successfully make the connection. Following each bathroom trip, it is important to provide lots of clear, positive feedback; when the child actually uses the toilet, reinforcement should be even stronger (e.g., an item from a prize box or a special treat).
The most common question I get asked by caregivers about their child’s toilet training is how to teach them to start initiating use of the bathroom. They will say, “my child can be successful if I keep checking if they need to go and keep them on a toileting schedule, but how do I get them to go on their own?” To learn this skill, children need to become familiar with the internal sensations that signal an increasingly urgent need to produce, and with enough warning to account for the transition time to the bathroom! This, like most other skills, is something that is learned primarily through contact with natural outcomes. They will likely need to have some accidents to begin to recognize what their limit is. Of course, if we stop the caregiver schedule altogether, it will probably be a disaster for everyone involved. Autistic people often describe having differences in sensory experience, including interoceptive skills. In other words, recognizing a full bladder or need to use the bathroom may be more difficult for an autistic person than for a neurotypical person. To help set them up for success, I recommend using data to inform gradual increases in the caregiver directed, time-based toileting schedule. Simply put, if your child has been successful (i.e., producing in the potty without any accidents) on a one-hour toileting schedule every day for the last two weeks, it is time to bump the schedule up to 75 minutes! Continue gradually increasing the time between sits over a period of weeks based on progress, and eventually the opportunities for the child to initiate will outnumber the opportunities the caregivers had to take the lead. It is also great to try to teach routines that are based more on context rather than time-schedule, such as going every time before you leave the house and as soon as you get home.
If you still feel after reading this that a more individualized approach is needed for your child, getting services through the Autism Society of North Carolina’s Clinical Department could be a beneficial source of support. Visit our Skill-building and Support webpage for more information and an interest form.
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