Toilet Training Strategies

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1 RESOURCE PACKET: Toilet Training Strategies FAMILY & COMMUNITY RESOURCE CENTER Special School District of St. Louis County Clayton Road St. Louis, MO / / / (fax) (TTY) September 2014

2 ut Potty Training Children with Special Needs From Vincent Iannelli, M.D.,Your Guide to Pediatrics. Potty Training Information While parents often complain of difficulty potty training their children, for most families, potty training is a fairly easy experience. Even when there are problems or children show signs of potty training resistance, usually they will eventually become potty trained. However, this is not always the case for children with developmental delays or disabilities, such as autism, Down syndrome, mental retardation, cerebral palsy, etc. Children with special needs can be more difficult to potty train. Most children show signs of physical readiness to begin using the toilet as toddlers, usually between 18 months and 3 years of age, but not all children have the intellectual and/or psychological readiness to be potty trained at this age. It is more important to keep your child's developmental level, and not his chronological age in mind when you are considering starting potty training. Signs of intellectual and psychological readiness includes being able to follow simple instructions and being cooperative, being uncomfortable with dirty diapers and wanting them to be changed, recognizing when he has a full bladder or needs to have a bowel movement, being able to tell you when he needs to urinate or have a bowel movement, asking to use the potty chair, or asking to wear regular underwear. Signs of physical readiness can include your being able to tell when your child is about to urinate or have a bowel movement by his facial expressions, posture or by what he says, staying dry for at least 2 hours at a time, and having regular bowel movements. It is also helpful if he can at least partially dress and undress himself. Children with physical disabilities may also have problems with potty training that often involve learning to get on the potty, and getting undressed. A special potty chair and other adaptations may need to be made for these children. Things to avoid when toilet training your child, and help prevent resistance, are beginning during a stressful time or period of change in the family (moving, new baby, etc.), pushing your child too fast, and punishing mistakes. Instead, you should treat accidents and mistakes lightly. Be sure to go at your child's pace and show strong encouragement and praise when he is successful. Since an important sign of readiness and a motivator to begin potty training involves being uncomfortable in a dirty diaper, if your child isn't bothered by a soiled or wet diaper, then you may need to change him into regular underware or training pants during daytime training. Other children can continue to wear a diaper or pullups if they are bothered, and you know when they are dirty. More Potty Training Information Once you are ready to begin training, you can choose a potty chair. You can have your child decorate it with stickers and sit on it with his clothes on to watch TV, etc. to help him get used to it. Whenever your child shows signs of needing to urinate or have a bowel movement, you should take him to the potty chair and explain to him what you want him to do. Make a consistent routine of having him go to the potty, pull down his clothes, sit on the potty, and after he is finished, pulling up his clothes and washing his hands. At first, you should only keep him seated for a few minutes at a time, don't insist and be prepared to delay training if he shows resistance. Until he is going in the potty, you can try to empty his dirty diapers into his potty chair to help

3 demonstrate what you want him to do. An important part of potty training children with special needs is using the potty frequently. This usually includes 'scheduled toileting' as outlined in the book 'Toilet Training Without Tears' by Dr. Charles E. Schaefer. This 'assures that your child has frequent opportunities to use the toilet.' Sitting on the potty should occur 'at least once or twice every hour' and after you first ask, 'Do you have to go potty?' Even if he says no, unless he is totally resistant, it is a good idea to take him to the potty anyway. If this routine is too demanding on your child, then you can take him to the potty less frequently. It can help to keep a chart or diary of when he regularly wets or soils himself so that you will know the best times to have him sit on the potty and maximize your chances that he has to go. He is also most likely to go after meals and snacks and that is a good time to take him to the potty. Frequent visits during the times that he is likely to use the potty and fewer visits to the potty at other times of the day is another good alternative. Other good techniques include modeling, where you allow your child to see family members or other children using the toilet, and using observational remarks. This involves narrating what is happening and asking questions while potty training, such as 'did you just sit on the potty?' or 'did you just poop in the potty?' Even after he begins to use the potty, it.is normal to have accidents and for him to regress or relapse at times and refuse to use the potty. Being fully potty trained, with your child recognizing when he has to go to the potty, physically goes to the bathroom and pulls down his pants, urinates or has a bowel movement in the potty, and dresses himself, can take time, sometimes up to three to six months. Having accidents or occasionally refusing to use the potty is normal and not considered resistance. Early on in the training, resistance should be treated by just discontinuing training for a few weeks or a month and then trying again. In addition to a lot of praise and encouragement when he uses or even just sits on the potty, material rewards can be a good motivator. This can include stickers that he can use to decorate his potty chair or a small toy, snack or treat. You can also consider using a reward chart and getting a special treat if he gets so many stickers on his chart. You can also give treats or rewards for staying dry. It can help to check to make sure he hasn't had an accident between visits to the potty. If he is dry, then getting very excited and offering praise, encouragement, and maybe even a reward, can help to reinforce his not having accidents. Another useful technique is 'positive practice for accidents.' Dr. Schaefer describes this as what you should do when your child has an accident and wets or soils himself. This technique involves firmly telling your child what he has done, taking him to the potty where he can clean and change himself (although you will likely need to help) and then having him practice using the potty. Dr. Schaefer recommends going through the usual steps of using the potty at least five times, starting when "the child walks to the toilet, lowers his pants, briefly sits on the toilet (3-5 seconds), stands up, raises his pants, washes his hands, and then returns to the place where the accident occurred." Again, although you are trying to teach him the consequences of having an accident, this should not take the form of punishment. While it may take some time and require a lot of patience, many children with special needs can be potty trained by the age of 3-5 years. If you continue to have problems or your child is very resistant, then consider getting professional help. Our Storv I Be a Guide I Advertising Info I Work at About I Site Map I Icons I Help User Agreement I Ethics Policy I Patent Info. I Privacy Policy I Kids' Privacy Policy 2006 About, Inc., A part of The New York Times Company. All rights reserved.

4 page 1 0:1: 4 AJ'nerkan.AC'a,d~my of Pediattks Healthy Children> Ages & Stages> Toddler> Toilet Training> Toilet Training Children with Special Needs Ages & Stages Toilet Training Children with Special Needs The issue of when and how to begin tqilet training can be particularly challenging for parents of children with special needs. Whiie no parent wants to push an already challenged child to perform in ways that are impossible, the sense of accomplishment experienced when he does succeed in this important aspect of self-care can make an enormous difference in his level of self-esteem. Perhaps more than other parents, those who have children with ph~)'sica!, intellectual, or developmental disabilities can appreciate the toilet-training process as a way to follow and celebrate a child's overall growth. Rather than focusing on their child's mistakes, which are inevitable in any case, they can use this opportunity to discover how he leams best and to demonstrate to him that he is_able to progress.. Toilet training works best when parents of children with special needs have access to the guidance, instruction, and encouragement of their pediatrician, other trained professionals, or support grqups. The first step you must take is to determine whether your child is ready to begin. Signs of readiness are the same for your child as for all children: Is your child aware of the difference between being wet and being dry? Can he stay dry for at least two hours at a time? Can he sense when he needs to urinate or have a bowel movement? Is he capable of reaching the toilet or potty in time (perhaps with your help)? Can he undress and dress himself or is he ready to!eam? '!s he motivated at some level to take this next step? If your child is in a resistant phase, is not ready to take on a new challenge, or does not yet feel the urge to behave "Uk kids" in this way, you might take some extra time to prepare him mentally before starting the training process. If you feel that your child is ready: ask your pediatrician for her opinion. She can examine your child to offer a physical assessment and perhaps offer spedal insight into the particular needs of your child. She can also provide further infor! that you may need before starting, and let you know what types of special equipment may be advisable. it is also important to prepare yourself emotionally before you and your child embark on this experiment. ChUdren with needs often begin toilet training later than other children, frequently completing the process at age five or even later. ( course, children with severe physical disabilities may always neeci help with clothing and accessing the bathroom). Le; to use the toilet can be physically painful to some, initially incomprenensib!e to others. Accidents will happen. of coursl you wi!! need to draw on an extra dose of patience and humor when they occur. Lining up help from your spouse, rejal friends before you begin training-to spell you periodically as well as to help boost your morale-is a wise move for 'Ie child's sake as welf as your own. 2/20/2013 tf

5 Page 2 of4 Physical Challenges A number of physical disabilities and illnesses can hinder a child's ability to become fully toilet-trained or easily adjust; bathroom use. If your child faces such a situation, you will need to think about how her disability affects each stage of training and how you can compensate for this disadvantage. Whether your child is unable to sense the need to urinate difficulty getting onto or staying on a standard potty or toilet, or must adjust or readjust to toilet use after having used a ostomy device, she will need extra support from you and her other caregivers as she learns to master this new skill. Visual Disabilities Children with visual disabilities and those with sight deficiencies experience a disadvantage at several stages of toilet training. First, they are unable to observe family members and peers using the toilet, so they cannot mimic their behav many details of toilet or potty use-where the potty is in the bathroom, how the body is oriented to it as one sits down, the urine and feces get into the potty, how one tears off and uses toilet paper-are simple to understand if a child can the process but difficult if she cannot. Without sight to help her, your child will need to rely more on language to under! how the process works. Therefore, you will probably want to wait a little longer to begin-until she is three or four year even later, since language delays can accompany blindness)-so that she can fully comprehend what you are telling t When you are ready to introduce your visually impaired child to the concept of toilet use, start bringing her with you wi" use the bathroom. Allow her to explore the bathroom and locate the toilet. (Be sure it's well ventilated and smells pleal she will want to return.) Place her hands on your shoulders so she can feel you sitting on the toilet, explain what you a and why, and guide her hands to the toilet paper dispenser. Also show her the flush handle and the sink for hand wasl Once you have placed a potty in the bathroom, lead her to it, let her accustom herself to its presence, and keep it in th place throughout the toilet-training process. Talk to her about toilet use at other times, too-pointing out that most of tt people she knows use the toilet and that toilet use is a sign of being a big kid who can take care of herself. Once she begins practicing potty use herself, you will need to keep the bathroom and the passage to it clear of obstac musical potty that is activated when urine hits the bowl might make the learning process more fun. Teach her to feel th edge of the seat before tossing in the toilet paper and, if the child is a boy urinating standing up at a toilet, to position I" so he doesn't urinate on the toilet. Finally, as she grows more comfortable with bathroom use, make a point of taking t the bathroom at each public place you visit. By helping her familiarize herself with the wide variety of bathroom layoutf toilet styles, you will help build her self-confidence when away from home and prevent accidents. And don't forget to re her progress with praise, hugs, or a small, favorite treat. Hearing Disabilities Children who are deaf or have difficulty hearing mayor may not find toilet training challenging, depending on their abil communicate. A child who is already fluent in sign language can rely on a combination of visual observation and expla from you to understand what's expected of her-much like any other child. C.hildren who do not yet have the ability to understand your signals and simple signs may not be ready for toilet training until they are somewhat older. The key to training in these cases is to keep the process simple. When introducing the concept, emphasize the visual: your child to observe you (and, even better, other children) using the bathroom, and show her picture books about it. ( one gesture or sign for the essential terms (pee, poop, potty. wet, dry, and need to go). Use these gestures each time the bathroom, and use them with her as well-signing "wet" (with a sad face) when you change her diaper or wet unde "dry" (with a happy expression) once she's been changed, and "need to go" after lunch when it's time to sit on the potl' long as you are consistent and stick with the half-dozen signals you need, your child will get the hang of potty use with longer explanations. When she does, be sure to reward her with plenty of hugs, stars on a potty chart, or even candy ( another small treat. Continence Problems Some conditions have no effect on a child's ability to understand the process of toilet training but make it difficult for a comply. Your child may grow increasingly frustrated in her efforts to stay dry and may even give up trying. The best so this dilemma is to put your child on a regular potty schedule. By placing her on the potty frequently (reminding her eve: or so to visit the bathroom), you remove the burden of having to acknowledge so many times each day that she must i an activity to tend to her physical needs. Going to the bathroom at the top of every hour can become a habit similar to brushing her teeth twice a day or receiving her insulin-freeing her up to focus on other activities between visits. Cerebral Palsy Children with cerebral palsy not only tend to be slow in developing bladder control, but may not have enough bladder awareness to begin toilet training at age two or three. If your child has cerebral palsy, she will need to be helped to del awareness that she needs to go (which may be signaled to you when you see her clutching her genitals or fidgeting 2/20/2013 S--

6 Page 3 of4 anxiously) before she can begin toilet training. She will have to be able to delay urination until she is in position on the She will need to remove her clothing and then hold herself on the potty (with supports) long enough to achieve succes Again, these challenges mean that it is usually best to wait to toilet-train until she is older. Chances are that limited physical activity, undeveloped muscle tone, or medications tend to cause constipation for yo! with cerebral palsy, so pay special attention to her diet as you initiate the toilet-training process. Be sure that she is dr plenty of fluids and ingesting lots of fiber. As she begins to practice removing her clothes before getting onto the potty, easier by providing clothes with Velcro fasteners or loose elastic waistbands. (She may find it easier to remove her clo while lying down.) Since she will have trouble supporting her back, you will need to provide a special potty with back a supports. (Potties designed to fit in a corner work especially well, since the right-angle back support holds the child in I with shoulders forward, hips bent, and knees parted.) If your child has severe disabilities, you might begin by sitting in with the pot from a potty wedged between your knees. Place your child on the potty with her back against you and holt position until she urinates or has a bowel movement. Later, you may be able to graduate to a potty with adequate supi Spina Bifida and Spinal Cord Injury Spina bifida, spinal cord injury, or spinal tumors create toilet-training problems for young children similar to those of ce palsy, but since most children with this condition never develop an awareness of when they need to go, few can ever f a toilet. You can, however, teach your child to remove urine through a catheter on a regular basis, and to visit the bath for bowel movements on a regular schedule. (A high-fiber diet with plenty of liquids and meals served on a regular sch will make this process easier. Sometimes a stool softener or even a suppository or enema is required.) Since your chil find it difficult to remove her clothing, be sure to provide her with Velcro fastened clothes and allow her to lie down to u if necessary. Parents of children with physical disabilities such as cerebral palsy or spina bifida may become so distracted by the ne special equipment or physical support that they neglect the necessary cognitive and emotional input that all children nl succeed at toilet training. Don't forget, while installing that special potty in the bathroom, to talk to your child about batl use and why it's important, to let her observe you and others using the bathroom, and to praise and reward her when! succeeds even a little bit. Resist the temptation to let things go when she resists or protests a little, and remain firm ab schedule or routine you have created-unless the experience becomes negative and your child becomes very resistar Remember, her progress in this arena is especially significant if it increases her self-confidence and prepares her for r challenges. Give her all the information, attention, and support she needs to succeed. Behavioral Disorders Your experience toilet-training a toddler who is behaviorally, intellectually, or developmentally challenged will depend ~ deal on your particular child's temperament, behavior patterns, and coexisting conditions. In this arena more than any perhaps, the parents' knowledge of a child's strengths, weaknesses, tendencies, and interests will help her through thl process as much as any general guide. Toilet training can be particularly trying for parents of children who have intellectual or developmental disorders or whc behaviorally challenged-including those with autism, fetal alcohol syndrome (FAS), oppositional defiant disorder (00 in cases when it is diagnosed this early, attention deficit Ihyperactivity disorder (ADHD). Many children with these con, may not be strongly motivated, or sufficiently equipped, to respond to the social reinforcements that work so well with I children ("What a big boy!"), though small tangible rewards such as candy or a toy can be effective. Most find it extrem difficult to adjust to any change in routine. Some are particularly sensitive to touch and other sensory input and becom by the frequent pulling off and on of clothing, the physical closeness with an adult, and the unfamiliar surroundings of t bathroom. Simply getting across the concept of potty use can be complicated by the fact that some children with beha' disorders do not naturally imitate their parents' or peers' behavior, while others learn only through simple imitation or 0 concrete, nonverbal demonstrations. Such complications in the training process mean that early efforts can create a h, of frustration in your child and may lead to displays of temper, stubbornness, and refusal to cooperate. Still, nearly all children with these conditions can be toilet-trained-though in some cases the process may take up to 1 or even longer. Your first step, again, is to determine whether your child is ready to start training. There is no point in beginning until you see that he can stay dry for an hour or more at a time, has regular bowel movements, is aware tha about to urinate or defecate, and dislikes being wet or soiled. It is also important to have your child examined by his pediatrician, since he may be at a higher risk for constipation or loose stools, which may interfere with training. Once you have decided to begin, observe your child and consider carefully the specific traits, patterns of behavior, anc obstacles that may impact his learning process. If he seems to dislike entering the bathroom, determine what the caus discomfort is-the smell of disinfectant? the cold floor? the flushing toilet?-and change or neutralize it if possible (chc cleansers, put socks on his feet, move his potty away from the noisy toilet). If he does not overtly signal the need to ur defecate, does he pause just before voiding or otherwise behave in a way that will provide you with a cue? At what tim htlp:llwww.healthychildren.orglenglishlages-stagesltoddler/toilet-training/pages/toilet-tr... 2/20/2013 /.0

7 Page 4 of4 how long after eating or drinking, does he usually urinate or defecate? What foods, toys, or other objects is he most passionate about? (These can be used 'as tangible potty-training rewards, which may prove more effective than praise does he learn best-with firm but gentle physical demonstrations (being placed on the potty at regular times), a formal containing a series of simple and predictable steps (verbally explained and reexplained, illustrated with pictures, or list chart), or offhand comments and conversations that inform without inviting resistance? Once you have made the necessary adjustments in your child's environment and your teaching style, it is time to start toward his first success. Some parents like to begin the training process with actual potty use-putting their child on th at a likely time and rewarding him when he uses it. Others-particularly those with a child who resists entering the bathroom-may want to focus on preliminary steps first. They may start by rewarding the child for entering the bathroc for approaching the potty or toilet, then for sitting on it, and finally for using it. To make this process easier, and to avoi physical closeness that your child may resist, consider letting him wear only his underwear at first, or even nothing bel waist. Handling clothing can be taught at the very end of the process, once the bathroom routine has been accepted a his day. Your child is likely to be resistant to adopting this new habit. It's important to insist, however-firmly but matter-of-factl~ he try. When accidents occur, point out that you disapprove, but don't punish or criticize your child for making a mistak is verbally challenged, be sure to stick to simple instructions such as "Wet! No!" As he gradually gets better at using th potty-motivated for the most part, perhaps, by the prospect of a tangible treat-your child's love of routine will begin t in your favor. He will expect to visit the bathroom at predictable times and may even become upset if this doesn't hapl= Until then, you will need to remind yourself how difficult this major step forward is for him. You should also think about to find support for yourself as you search for the patience you will need to succeed. Both you and your child are embal a difficult developmental task. Intellectual Disabilities and Developmental Disorders Most children with a developmental delay, an intellectual disability, or a pervasive developmental disorder (for example autism) can be toilet-trained, though the time it takes to achieve success ranges from a few months to a year or more. process becomes easier as your child achieves at least a minimal level of verbal ability, is able to manage his clothes (perhaps with some help from you), and shows awareness of the need to go. As you introduce your child to the concel potty use, be sure to keep your explanations very simple. Start by checking the state of his diaper or pants every hour and offering a one-word, nonjudgmental comment when he is wet ("Wet!"). Shake your head and then, after you chan~ smile and say "Dry!" If his verbal skills are very limited, you might substitute a special gesture or sign for the words we, potty, need to go, and so on. Begin bringing him to the bathroom with you when you need to use it. Smile and say "01) you've finished and pulled your pants up. If at all possible, have your child observe other children using the bathroom, may make the connection between himself and another child more easily than between himself and you. After you've 1 and are dressed, show him how happy you are and tell him "Dry!" If he has a favorite doll or stuffed animal, use it to pi "potty," demonstrating again how the potty is used. When he is ready to begin using the potty, begin setting him on it at regular times-quite frequently at first (as frequen you checked him for wetness earlier) and then gradually settling down to the times when he usually voids. Try to keep the potty for five or ten minutes at a time-keeping him company, reading to him, playing tapes of children's music, an otherwise ensuring that he stays in place long enough to succeed. Once he does urinate into the potty, give him a big. and say "Pee!" (or whatever word you have chosen for this event). Help him wipe off and then praise him with a happy and give him a treat. Food treats are often very effective and can be phased out once he has been trained. Eventually enough repetition, he will understand the connection. Children with an intellectual disability or developmental delay are best toilet-trained one step at a time. Don't expect yc to learn to signal or announce his need to go, pull down his pants, use the potty, wipe his bottom, and wash his hands once, the way his peers might. Toilet training will work best if you focus on the actual act of elimination first and addre! other skills later. It is more important to keep him motivated than to achieve instant success. Last Updated 5/1/2012 Source Adapted from Guide to Toilet Training (Copyright 2003 American Academy of Pediatric The infonnation contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may variations in treatment that your pediatrician may recommend based on individual facts and circumstances. topic landing page 2/20/2013 1

8 l ol.iet trammg tor chl!dren WIth autism spectrum disorder I Raising Children Network Page I or5 raising chudren ne'lvljork tl1$ auslr.liian parenting.wbsite Home! Sp~clal Needs I Childre.n w,th Autism i Hec!th ~.:. Daily Oire jl'oilibting Suitable for Toilet training for children with autism spectrum disorder Going to and using the toilet Is an exc:lting and sometimes ci1auenging step for any child. You can use some special strategies to make toilet training easier for you and your child with autism spectrum disorder (ASD). Toilet training stratecj.l1:.5 Oyercomlng toijet training chalienaes setbacks and difficulties Before you start toilet training, it might be helpful to speak with your child's pediatrician or GP. They will be able to rule out any medical problems that might get in the way of toilet training and advise if your child Is likely to be ready to start. Generally, children with autism spectrum disorder (AS D) will show the same signs of readiness for toilet training as typically developing children do. But these signs might appear when your child is older, ant.! the training might take longer. Some signs that your child Is ready Include: being able to tell you (or Indicate by a sign or gesture) that he has wet or soiled his nappy or clothes being able to follow a simple Instruction, such as 'sit on the toilet', and being able to pull her pants up and down did you knowtij Toilet training can take longer with children with ASD. This is because they are often very attached to their routines and don't like change. This might make it more challenging to go from nappies to the toilet. having regular formed bowel movements having adequate bladder control (able to stay dry for at least one hour at a time during the daytime). The steps for preparing your child and getting started with toilet training are also much the same for al! children. Children with ASD might neet.! a bit of extra teaching and some strategies adjusted to suit their needs. An Important first step Is to realise that toilet training Is largely about 'cooperation, communication and working together with your child. Visit our forum to share YOllr stories, advice and support with other parents of a child with ASD. Join the forum It mlg.ht also help to think of toilet training as Ii series of smaller goals, rather than one big goal. For example, start with simply familiarising your child with the toilet, what It's for, and how to use It. Then you could progress to starting the toilet training. Our general article on!qll.~ can help you get started. Then you can use the extra strategies below to help your child with ASD go from napples to the potty or toilet. Toilet training strategies Going to the toilet Is a complex task, made up of many small steps. It can help to break tasks like toilet training down to their most basic parts and teach those smaller parts to the child, step by step. Below we outline three strategies to help with toilet training your child with ASD: encouragement and rewards, visual aids end supports, lind Social Stories"". Encouragement and rewards Rewards and positive reinforcement can help with toilet training. As your child learns each step of. using the toilet, he can be rewarded, which encourages him to learn. Rewards and encouragement can Include: _ toilet_ training.htmllcontext... 2/20/20 13 ~

9 '!'ollet tralmng tor children with autism spectrum disorder I Raising Children Network Page 2 of5 descriptive ~ (,Charlie, well done for sitting on the toilet') nonverbal praise, using gestures (clapping) or signs (thumbs up) a favourite activity (playtime with trains) a star on a sticker chart a favourite healthy food. Try a variety of rewards, and use the ones your child responds best to. Before you start, plan exactly what your child will be rewarded for, and ensure your child dearly understands what behaviour Is being rewarded. Try not to overuse a reward. Some rewards that motivate typically developing children - such as stickers or stamps - might not Interest a child with ASD. Work out what rewards your child likes by presenting a variety of rewards - for example, hugs, high-fives, claps, foods, toys or activities - for a few seconds and watch your child's response. Once your child has made progress on a particular step, stop using food, activities and toys as rewards. Continue to use verbal and nonverbal praise. We used a reward system - Sesame Street stickers for wee and a lucky dip bag for poc. He cottoned on straight away for his bladder, but It took longer with his bowels. We just kept asking If he needed to poo and waved the lucky dip bag in front of him, making It very clear he would get something If he went. One day something just clicked for him and we haven't had an accident since. V'sual aids and supports $iton tcue: Children with ASD are often visual learners. So you can support your child's learning by providing visual cues and prompts. Visual schedules can help to reinforce the routine of using the toilet, and provide reminders for taking regular toilet breaks. Try creating a visual schedule to show your child the tolletlng routine. You can use the Picture Exchange Communication System (PECS) or other U~(?to~ltlt lmp"t to wlfl~ visual aids. The schedule can be stuck on a wall close to the toilet or potty. Go over the schedule with your child 2-3 times a day. Everyone who does tolleting with your child will need to know and follow the routine. This way, training will be consistent. Wat<hhanlk On the left is a simple example of a visual aid for tolletlng. Download and print an A4 version gf this ylsual aid for tolleting (PDF doc size: ll1kb). Social Stories ~ries"'" are used to help children with ASD develop appropriate behaviours and responses. They might help children with ASD cope with challenging or confusing Situations, like toilet training. Social Stories'": use simple story lines with clear pictures are written from your child's perspective describe the situation (such as going to a birthday party, starting school or using the toilet) give details about what happens In the situation suggest how your child might respond In the situation explain why your child should respond In a particular way. Trained ~ occupational therapists and early Intervention or school teachrrs will be able to help you create a SOCial Story"" for your child's toilet training. If your child will be going to the toilet at a friend's home or somewhere else other than home, practise a new story for this situation with your child ahead of time. When the event actually happens, your child can use the story to help guide behaviour. When writing a Social Story M, use words and pictures that are appropriate for your child's developmental level. Suggest possible responses and behaviours, rather than making the story an exact 'script' to follow. _spectrum_disorder _ toilet_ training.htmllcontext... 2/20/2013 (1

10 TOIlet trammg tor children with autism spectrum disorder I Raising Children Network Page 3 of5 Overcoming toilet training challenges Toilet training a child with ASD can be more challenging than training a typically developing child. This Is because children with ASD are often very attached to their routines and don't like change. This might make it more challenging to go from nappies to the toilet. Try these tips to help your child make progress with toilet training: Consider skipping the 'potty' stage if your child with ASD has difficulty with change. Some parents go straight to putting their child on the toilet, sometimes with a toilet training seat. This limits the number of changes children experience in the toilet training process. Try washable reuseable training underpants or underpants with a protective liner (which are less absorbent than nappies or pull-up training pants). If your child has trouble knowing when it's time to use the toilet, these might help your child become more aware of the feeling of wetness. Use specific language. For example, say, 'Eddie, sit on the toilet so you can have a wee'. This is clearer than asking your child to 'sit on the toilet', and will help your child understand what to do. Choose one word to refer to going to the toilet. Get everyone In the family to use It. For example, always say 'toilet' or '100' or whatever your family Is comfortable with. The different words we use to describe the toilet - potty, 100, bathroom - can be confusing for children with ASD. Teach your child a way of letting you know she. needs to go to the toilet. This could include nonverbal Signing or the use of the Picture Exchange Communication System (PECS). Sensory overload If your child with ASD is sensitive to or upset by the sensory aspects of going to the toilet, try ways of controlling your child's sensory experience of toileting. For example: Get your child familiar with sitting on the toilet seat by practising for a few minutes every day. Make her comfortable - for example, If the floor Is cold, put socks on your child's feet. Try to match the temperature In the room to the rest of the house. Use a foot stool if your child needs foot support while sitting on toilet. Use a training seat if your child Is frightened of the big hole over the water. Tell your child there will be a noisy flushing sound, and explain the reason for the noise. For our son, it all revolved around change. We started by teaching him to wee in the garden, then into a bucket in the garden, then into a bucket inside, then into a bucket next to the toilet, then finally into the toilet. This took nearly a year! I tried to make the toilet a happy place for him to visit by putting Bob the Builder stickers all over the door and letting him have little matchbox cars. Toilet training setbacks and difficulties Sometimes toilet training children with ASD Is associated with other behavioural problems, such as fear of the toilet, going In places other than the toilet, stuffing up the toilet with paper and other materials, continually flushing the toilet, smearing poo on the wall and other places, constipation, and refusing to poo. If you find you're having any of these problems or If there hasn't been any improvement after a few months, here are a few ideas to consider: Keep a record of the times your child wets or soils for a week or so. If a pattern develops, target these times by taking your child to the bathroom just before your child would normally wee or poo in his pants. Speak to your paediatrician or GP for advice. There could be a medical reason for your child's lack of response to toilet training (such as c~.rls.tip~ti.<)i"i. or a urinary tract infection). Speak with the other people who are working with your child, such as a psychologist, occupational therapist, or your child's early Intervention service. They might be able to offer more intensive support. Constipation Constipation Is a common problem In kids. Constipation can be due to underlying health issues, but Is usually caused by not enough water or other fluids or not enough dietary ~I:!.r.~. Sometimes It happens when the child avoids doing poos. It's worth noting that normal bowel habits vary a lot among children. Some children do a poo 2-3 times a day, but others go only every 2-3 days. If you think your child Is constipated, see your paediatrician or _spectrum_disorder _ toilet_ training.html/context... 2/20/2013 J 0

11 Toilet training for children with autism spectrum disorder I Raising Children Network Page 4 ofs general practitioner. Your health professional will be able to rule out any underlying medical concerns, and assist you with strategies to manage your child's constipation. If toilet training becomes a battle with no signs of progress, take a break for now. Consider starting the training again In about three months. Don't feel that you've failed - It might just be that your child Isn't ready. Video: Toilet training.. <... Download vlded 16mb For children with ASD, toilet training might start later, take longer and need some special strategies. But children with ASD will probably show the same signs of readiness as typically developing children. This short video features parents of typically developing children sharing tips on toilet training, especially on knowing when your child is ready. For example, your child might: show interest In the toilet want to watch you go to the toilet tell you he's done a wee or poo in the nappy. Web links Victorian Continence Resource Centre - Parent guide to toilet skills for children with special needs Do2Learn - Toiletlng print cards Visual Aids for Learning - The complete toilet training pack TEACCH - Applying Structured Teaching Principles to Toilet Training GLOSSARY constipation A condition characterised by hard and large poo, and pain or problems when doing a poo. Constipation can also cause stomach pain. Constipation Is often caused by a lack of fibre or by dehydration. You can help your child avoid constipation by ensuring your child eats a healthy diet with lots of fruit and vegetables. Your child should also drink lots of water, exercise regularly, and maintain regular toilet habits. fibre _spectrum_disorder _ toilet_ training.html/context... 2/20/2013 II

12 Toilet training for children with autism spectrum disorder I Raising Children Network Page 5 of5 The parts of vegetables, fruit and cereal that can't be digested. Fibre plays an essential role in keeping our digestive systems healthy. It also helps to lower glucose and cholesterol levels. Adequate fibre Intake can help to prevent bowel cancer, diabetes, heart disease and constipation. Last Updated Last Reviewed References _spectrum_disorder _ toilet_ training.htmllcontext... 2/20/2013, ~,.' J,~

13 Please visit the links found at resources on the underlined subjects. Complete Guide to Special Needs Toilet Training In many cases, toilet training children with disabilities is similar to training other children. It simply requires more patience and some extra support. Here you'll find plenty of articles. strategies and tips for toilet training children with a variety of special needs. Plus you'll find resources for trouble shooting many types of potty problems like smearing poop, fear of the toilet and potty training regression. It's the most comprehensive guide of toileting resources for special needs parents and teachers with students who are not potty trained. If you found a resource I should add, please let me know at by Dawn Villarreal, One Place for Special Needs ADHD toilet training - Articles on toilet training and bedwetting for children with ADHD Autism toilet training - Many resources and strategies on toilet training children on the autism spectrum Bedwetting - Handling 'bedwetting issues for children and teens Blind toilet training - Suggestions for working on toilet training with the child who has visual impairments. Cerebral palsy toilet training - Articles discussing toilet training, incontinence, bladder functioning and other concerns related to the child with cerebral palsy Constipation - Articles on symptoms of constipation, why it happens and what to do about it Continence issues - Articles covering a variety of continence issues for individuals with physical disabilities Deaf toilet training - Resources on potty training children who are deaf or hard of hearing Deaf Blindness toilet training - A few articles on toilet training practices for these multiple disabilities Down syndrome toilet training - Tips and strategies on toilet training the child with Down syndrome Elimination chart - Detailed elimination charts can help you set up a toileting schedule for children who need extra support in toilet training Encopresis - Encopresis, or fecal soiling, can become a serious condition if left untreated. Read these resources to learn more. Fear of using toilet/public restrooms - Strategies and articles on why some children are afraid of using public restrooms plus videos of self flushing toilets to help those with sound sensitivities Having an accident - Accidents happen for a variety of reasons. These articles address why they happen and strategies for addressing your child's potty training accidents Hypotonia toilet training - Resources on toilet training for children with low muscle tone Intellectual disabilities toilet training - Toilet training resources for children with intellectual disabilities Normal bowel movement - What is a normal bowel movement? Not defecating in toilet - Resources about children who continue to poop in diapers or in other areas of the home Personal care toileting - A few articles on providing incontinence care for individuals with special healthcare needs Physical disabilities toilet training - Special considerations for those with physical disabilities Potty training apps - Apps to assist the toilet training process ~:'./ 1.J

14 Potty training in public places - Handling potty training issues when out in the community Potty training motivation - Strategies for rewarding good potty behavior Potty training readiness - Look to these articles for help in knowing when your child is ready for toilet training Potty training regression - Why does it happen and what to do about it Public restroom safety - Keeping your child safe when using bathrooms in the community Resistance to bowel training - These resources cover a variety of issues including fecal soiling, holding stool too long and impacted feces or encopresis Resistance to toilet training - Children who are resistant to potty training in general as well as problems during the training process Sensory processing toilet training - Potty training strategies for children with sensory issues Smearing poop - Yes it's disgusting but not so uncommon. Strategies for ending this behavior Special needs toilet training (alll - All toilet training resources that pertain to special needs or various disabilities. Spina Bifida/Hydrocephalus toilet training - Special considerations for toilet training children with spina bifida Timed voiding -A method of bladder retraining used for individuals with urinary incontinence Toilet training (all) - This link comprises all of the toilet training articles on our site. Some are not special needs specific but contained good information. ) Toilet training action plan - These are very detailed toiilet training programs for parents Toilet training at school - Resources for parents and teachers on toilet training children with special needs in school Toilet training older children - These articles offer some support for toilet training the older child who has not mastered this skill Toilet training social stories - Social stories and sequence of steps for using the toilet. Toilet training videos - Videos for parents on potty training as well as videos for kids. Toilet training visual support - Potty training charts, self help picture cards and other visual support Urinal etiquette - Etiquette for guys when using the public restroom Using the public restroom - Articles, tips and strategies for using the public restroom and what to expect in a restroom Washing hands - Potty training is not complete without learning how to wash our hands Want to be included on this web page? Contact us at: li l \ 6i.~I ~tl +: - }- ~.. bout the writer Dawn Villarreal runs One Place for Special Needs, a national disability resource that lets you find local and online resources, events and even other families in your neighborhood plus thousands of online disability resources! Stay awhile and check out the site. She is also moderator of Autism Community Connection, a Yahoo group for families of children with autism spectrum disorder. Reprint permission granted by including: Reprinted with permission from One Place for Special Needs

15 ~'~ Toilet Training Tips -- Home FACTS FOR FAMILIES: TIPS FOR TOILET TRAINING CHILDREN WITH DISABILITIES Children with disabilities are often more difficult to toilet train than other children. Not all children will respond in the same manner to a particular technique. Therefore, if is often helpful to be aware of different strategies. Overall, it is important to be consistent, patient, and never punitive when there are toileting acciden ts. Remember I this is a lea:cning expe:r:ience for you.r child, so treat accident.s in a neutral way! Assessing Your Child's Readiness Before beginning' any training, assess your child's readiness by asking the following questions:.~ Does the child have awareness of, and control over, his/her own body?,* '* Is the child socially motivated to be trained? (Is s/he pleased by the thought of being a "big boy" or "big girl", or of wearing big kid's underwear? by '*- -Frequently children with autism are not motivated by these occurrences. Is your child able to speak and / or understand the language used in the process? - - Sometimes a child with a disability may {5

16 not involved. understand the explanations or process * Is your child able to sequence and organize information and attend to relevant stimuu or information? - Many children with autism have difficulty following steps, keeping their focus on the relevant information, or have difficulty with awareness of bodily sensations "* Is your child agreeable to changes in routine? - Some children may balk at changes due to toilet training, such as wearing underwear when they had been wearing diapers. They may also have difficulty switching their focus from the activity they were engaged in before the potty session. Is your child able to integrate sensory information, such as establishing a relationship between bodily sensations and the need for toileting functions? - Many children with disabilities, especially autism, are not aware of the cues that signal a need to visit the bathroom. Also, some children are overwhelmed by the sensory stimuli in a bathroom, from the sound of rushing water, to the sight of the huge hole in the toilet, to the tactile senses in taking their clothes off and on. If you were able to answer "YES" to the previous questions, your child may be ready for toilet training! If, however, you answered "NO" to many of the questions, your child may need more structure and visual cues to help him or her succeed at toilet training. Following the steps outlined below may help the child with autism and other disabilities reach the goal! Follow these important steps to help guide you in the toilet training process: 10

17 1. Define a reasonable goal for your child.,. Your child may need many smaller steps before reaching the final goal. 2. Observe and assess your child's understanding of the toileting routine.,* Consider your child's disability and look at the task from your child's point of view. 3. Establish meaningful routines and collect "data" about your child's readiness for toilet training. Ask yourself the following questions: Does my child remain dry for long periods of time? According to the data, does he or she have a regular schedule for wetting or soiling? Is the child aware that he or she is wet or soiled? Are there signals or clues that the child is about to, or is engaged in, wetting or soiling? If you answered "no" for all of these statements, your child may not be ready for toilet training; however, you may be able to work on bathroom routines in the meantime. * You may need to teach the child how to dress and undress him/herself. "*- You may need to work on allowing the child to get used to the noises and sight of flushing.... You might consider working on consistent routines for your child, and expanding his or her attention span long enough to complete a bathroom sequence. '*- It may also be necessary to assess you child's ability to complete each step of the toileting sequence.,.. Then proceed to teach one step at a time, using a task analysis sequence, such as entering the bathroom, pulling pants down, pulling training pants down or diaper off, sitting on the toilet! getting toilet tissue, using toilet tissue, throwing tissue into toilet, standing up, pulling clothes up, flushing toilet, washing hands, drying hands, leaving bathroom, returning to the play area. Specific Toilet Training Tips and Methods: Many teachers and parents of autistic children have found it helpful to incorporate physical and visual structure to the process. Using a concrete or abstract transition object allows some children to make the transition easier, such as carrying an empty baby wipe box or a picture of a toilet on a card. Making the bathroom and toilet area secure by providing stepstools, rails, and opening reducers have helped many children. A visual sequence of the process using picture cues is often helpful for those with sequencing and attention problems, including what happens when the child finishes the process (to provide closure, as task completion is a powerful motivator for some children with autism). 17

18 I :: ~~::: ~: The "DRY ~ ~~NTS " ME~r:8oD: Another popular method is to teach children the difference between wet and dry sensations, and to deliver reinforcement contingent upon having dry pants..,.. For this method, it is important to not use diapers or Pull-Ups on the children, so they can actually begin to feel the difference between wet and dry. Instead, use cloth training pants with rubber pants over them. '. Complete a dry pants check every 1/2 hour to 1 hour, using a timer. Ask the child, "Are your pants wet or dry?" If they are dry, reward the child. If they are wet, give only a neutral expression. If the child answers incorrectly, guide the child's hands to his or her pants and say, "They are (complete the correct word) wet/dry".,. Use a sticker chart to reinforce the child for urinating and having bowel movements in the toilet..,. Make the learning experience one of fun and excitement, by offering books, a stool, music, and other comforting items. Adding Structure to the Child's Environment Many teachers and parents of autistic children have found it helpful to incorporate physical and visual structure to the process. Using a concrete or abstract transition object allows some children to make the transition easier, such as carrying an empty baby wipe box or a picture of a toilet on a card. Making the bathroom and toilet area secure by providing stepstools, rails, and opening reducers have helped many children. A visual sequence of the process using picture cues is often helpful for those with sequencing and attention problems, including what happens when the child finishes the process (to provide closure, as task completion is a powerful motivator for some children with autism).

19 MORE TOILET TRAINING TIPS: -Use a problem solving process when you are troubleshooting problem areas. -Remember to think about the process from the child's perspective. -Consider how you can manipulate the environment to simplify or clarify the process for your child. Children's Books on the Topic: Going to the Potty by Fred Rogers Everyone Poops by Taro Gomi Bye Bye Diapers (Muppet Babies Big Steps) by Ellen Weiss Sam's Potty by Barbo Lindgren Books for Parents and Caregivers: Azrin, N.H. 8: Foxx, R.M. (1974). Toilet training in less than a day. New York; Simon 8: Schuster. Lansky, V. Practical parenting: Toilet training.

20 Applymg ~tructurea 1 eacnmg l'nnclples to 1011et 1 tammg by Susan Boswell and Debbie... Page 1 of 8 TEACCH Autism Program Applying Structured Teaching Principles to Toilet Training by Susan Boswell and Debbie Gray Many children with autism are difficult to toilet train. Parents and teachers have tried many approaches to teaching the children to use the toilet independently. Not ali children respond to the same teaching techniques. A method that is he!pfui in one child's situation may not be useful in another case. TEACCH consultants are often asked for suggestions for successful toilet training. This article is the compilation of several experienced teachers' and consultants' suggestions about this area of programming. In thinking about setting up a program to help a child learn to toiiet independently, the first TEACCH recommendation would be to try to look at the problem from the perspective of the student with autism. Another TEACCH recommendation would be to build in many elements of visual structure to help the child understand exactly what is expected. Look at each element of Structured Teaching to decide how visual supports can be added to build positive routines, clarify expectations, and reduce confrontational situations. The child's perspective Even in typically-developing children, toilet training is often a difficult skill to master. While the child may have good awareness and control of his body, there are other factors... social factors... that determine how easily toileting skills are learned. Small children do not feel an intrinsic desire to become toilet trained. Rather, they acquire this skill in order to please their parents and to gain the social status of " big boy" or "big girl". This social motivation is a critical factor in determining "readiness" for toilet training. How might the characteristics of autism contribute to a child's difficulty in learning to independently use the toilet? 1. The child's difficulty with understanding and enjoying reciprocal social relationships would certainly interfere with this process. While other 2- or 3-year-olds might be proud of their "big boy pants" and might be happy to please their parents, this type of motivation is rare in a child with autism. 2. Given the characteristic difficuities in understanding language or Imitating models, a child with autism may not understand what is being expected of him in the toilet. 3. A child with autism typically has significant difficulty organizing and sequencing information and with attending to relevant information consistently. Therefore following all the steps required in toileting and staying focused on what the task is all about are big challenges. 4. Further, the child's difficulty in accepting changes in his routines also makes toileting a difficult ski!! to master. From the child's point of view, where is the pressing need to change the familiar routine of wearing and changing a diaper? After 3, or 4, or 6 years of going in the diaper, this routine is very strongly established. 5. A child with autism may also have difficulty integrating sensory information and establishing the relationship between body sensations and everyday functional activities. Therefore he may not know 2/20/ )

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