TOILET TRAINING CHILDREN WITH AUTISM SPECTRUM DISORDERS

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1 TOILET TRAINING CHILDREN WITH AUTISM SPECTRUM DISORDERS Karishma Chengappa, Ph.D. Pediatric Developmental Disabilities Clinic

2 Objectives Challenges associated with toilet training a child with autism. Strategies that can be implemented when toilet training a child with autism.

3 Why is it important Milestone of independence Opportunities for socialization Opportunities for vocational placements Hygiene and less physical discomfort Expense and time.

4 Toilet Training Figures Typically developing Children with ASD Time to Train 5.3 months 24.6 months

5 Challenges associated with Autism Spectrum Disorders Features of autism Social Motivation Communication difficulties Sensitivities Motor difficulties Behavior Problems Restricted or repetitive behaviors Peeing in pull-up is a time honored tradition!! Problems with ANYTHING NEW Less likely to benefit from modeling and imitation

6 Pre-requisite Skills?? Interest in toileting Regular bowel movement schedule Follow simple instructions Demonstrate discomfort with dirty diapers, Ask to use the toilet! Request to wear underwear! Pull pants up and down Identifying wetness or soiling Puts things were they belong Some degree of independence with dressing associated with toilet training

7 Pre-requisite Skills Urine Stream indicates that they can hold urine for a brief period Ability to Sit on the Potty/Toilet for approx 3 minutes Boys?? Potty Versus Toilet.

8 Pre-requisite Skill: Sitting on the Potty/Toilet Start off in small increments (15-30 seconds) a. tell him/her that it is time to go to the bathroom b. Set the timer c. If the child tries to get up, just guide them back and remind them (show timer).

9 Pre-requisite Skill: Sitting on the Potty/Toilet Shape sitting time to 3 minutes Timer different from time-out timer Provide reward at end Continuous Reward (e.g. preferred video) Focus is on sitting, not eliminating But be ready to reward ANY elimination

10 Intensive Toilet Training Toilet training is a priority!! Preparing a window of time 3-4 days to start intensive program Ideally around school breaks

11 Intensive Toilet Training Full-time Underwear! Learning new sensory cue Exceptions: Night time Public Places Easy-to-remove clothing

12 Intensive Toilet Training: Communication Words Bathroom versus Potty Symbols, Sign, or PECs Prompt communication for bathroom as you go Time to sit Near the toilet

13 Visual Supports Task analysis of toileting sequence All the steps in pictures Completion of one step become a cue for the next

14 Picture Schedules

15 Questions??

16 Intensive Toilet Training : Reinforcement Based Training POSITIVE REINFORCEMENT Increases Motivation Rewards not bribes Rewards should be IMMEDIATE Offer reward before problem behaviors. Use the Good stuff!! Personalized Rewards Free access?? Pair with praise

17 Intensive Toilet Training : Reinforcement Based Training NEGATIVE REINFOCEMENT Strengthens response Confused with punishment Getting out of an unpleasant situation Getting off the toilet early is also a Reward

18 Intensive Toilet Training: Scheduled Sits Sitting on the toilet at regular, non-contingent time intervals Typically every 30 minutes child must sit on the toilet. Provide low-level engagement while your child is sitting Avoid making it too much fun!! Developing habit of using bathroom regularly Rewards for cooperation

19 Intensive Toilet Training: Scheduled Sits Initial focus is on sitting and gradually on voids Be consistent and persistent Minimize frustration Get a foot stool!! Pair trips to the bathroom with a communication symbol Re-set timer after accident

20 Planned sit chart with visuals Sit on the toilet for = Urine in the toilet = BM in the toilet =

21 Intensive Toilet Training HYDRATION Fluid Loading is a Plus! Increases the likelihood of voiding in the toilet Increases likelihood of rewards for voiding Increase likelihood of accidents.

22 Questions?

23 Data Collection

24 Data Collection Charting while actively training: Assesses progress Identifies new patterns Behaviors that indicate the need to eliminate Elimination-likely sits Guide for increasing duration between sits

25 Intensive Toilet Training - Punishment Accidents? Mildly aversive consequence Positive Practice Overcorrection Over-teaching correct behavior

26 Intensive Toilet Training - Punishment When there is an accident (even with Wet Stop): 1. Deliver a brief reprimand/reminder no wet pants 2. Physically guide child to the bathroom 3. Guide the child to pull pants down 4. Guide the child to sit on the toilet 5. Guide the to stand up, pull up pants, leave bathroom and return to the area in which the accident was discovered. 6. Give another reminder no wet pants (this will be repeated for a total of 3 times).

27 Intensive Toilet Training - Punishment Important not to substitute telling the child what to do Do NOT have child use communication for Bathroom during positive practice Different forms of punishment Rapid acquisition of toileting skills Paradox of punishment?

28 Intensive Toilet Training: Wet Stop Moisture sensor and alarm Allows for quick parent response Resistance to wearing the wet stop?? Accidents? If you aren t using a wet stop Dry Pants checks Light colored sweat pants

29 Questions?

30 Self-Initiation Discriminate natural cues for using the toilet Not dependent on prompt Indicates he/she needs to go to the potty More difficult to acquire Accept any form at first Have kids echo bathroom

31 Self-Initiation Duration in between Scheduled Sits is gradually increased Guideline : increase duration by 15 minutes for every two days there are approximately 70-75% successful voids Calculate percentage of successful voids : number of successful voids. total of number of successful voids + number of accidents Resistance from caregivers? We want some accidents

32 Planned Generalization Once the children demonstrate reliable continence To increase the likelihood of successful toilet training as well as positive skill transfer. First another toilet in the home setting Systematically generalize to other bathrooms in routine settings outside the home.

33 Independence Is aware of the need to toilet Only infrequent accidents Pre- and post-voiding skills. Fade prompts Infrequent rewards/praise in new environments Maintenance of toileting acquisition

34 THANK YOU!

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