Toileting difficulties are very common for children with autism. There are a number of reasons for this.

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1 Toilet training This includes: u learning to sit on the potty or toilet; u using the potty or toilet with your help; u adjusting clothes before using the toilet; u flushing the toilet. Toileting difficulties are very common for children with autism. There are a number of reasons for this. u Wanting to please parents is often a critical factor in determining readiness for toilet training. Most children with autism are not motivated by the desire to be a big boy/ girl and please their parents. u Difficulties in understanding language, or imitating what others do, may result in a child not understanding what is being expected of him on the toilet. u Focusing on all the steps required in toileting and staying focused on the task is a big challenge. u The routine of wearing nappies is very strongly established. Children with autism often have difficulty in accepting changes in routine. u The child with autism may have difficulty establishing the relationship between bodily sensations and what to do. Therefore he may not know how to read the body cues that tell him he needs to use the toilet. He also may become overly focused on sensory factors involved in the process, for example, frequently flushing the toilet. u Some parents report that their children have unusual bowel habits such as frequent diarrhoea, or particularly smelly poo. This can be upsetting both for parents and children and should be checked out medically, for example, through your health visitor who can make a referral to a community paediatrician, if necessary. 59 Good beginnings

2 First thoughts before starting a toilet training programme u Toilet training is time-consuming and can be stressful. Choose a good time to start training when there aren t too many other things going on at home and when there is possibly some support available, for example, from other relatives and friends. u It is often easier to start toilet training in the summer when your child will be wearing fewer clothes, or could play outside without clothes. Accidents will be more easily spotted and changing is easier. Always ensure that he is wearing clothes that are easy to remove, for example, tracksuit bottoms. u Decide what you are going to do and make sure everybody who is helping is doing the same things. How often will your child be taken to the toilet? How will he be rewarded? How will accidents be dealt with? u Choose rewards that are of interest to your child, although social praise should also be coupled with the reward, so he can learn that to be praised is something pleasurable. u Deal with accidents calmly and with minimal fuss. Helping your child link nappies and the toilet. Good beginnings 60

3 Establishing a toileting programme Some children show they are uncomfortable when they are wet or dirty. Others start to develop some regularity in their toilet habits, for example, having a poo shortly after a meal. It may then be possible to place your child on the potty or toilet and catch the poo. Your child may show some sign that he is about to have a poo, such as going quiet and sitting behind the settee. These are all indications that your child is ready to begin a toileting programme. For many children with autism, these signs will not be present and more direct intervention will be necessary. u Assess your child s readiness for toilet training by taking him to the toilet for a quick check every thirty minutes. Record whether he is wet or dirty. The information you obtain over a period of one or two weeks will help to decide if he is ready for a toilet training programme. You are looking to see if your child can remain dry for one to two hours. Also if the checks take place in the toilet it will be possible to determine if he has any particular fear or interests related to the toilet. If there is still no sign of readiness, then he may not be ready to learn to use the toilet, although it may still be worth working on some of the toilet skills mentioned below. u Decide whether to use a potty or move straight to the toilet using a child s toilet seat. There may be some advantage in the latter approach as it only involves one change for your child. It may be necessary to remove other distracting objects such as bath toys to enable the focus to be on the toilet. Also placing items such as baby wipes, cottonwool, and changing mat in the toilet may further enhance the association between the toilet and its function. Good physical support for your child will also reduce anxiety, such as a firm footstool to reach the toilet. u Decide whether to use training pants or pants/knickers. Training pants can seem a good idea to parents but as they are very absorbent your child will get little sensation of being wet or dirty. Your child will also then have to make the change from trainers to ordinary pants. If you are serious about training your child then they are best avoided. There are many colourful pants/knickers available in the shops and you can choose some that you know your child will like. Thomas the Tank pants may be a favourite for some children. u Your child should be placed on the toilet/potty at frequent intervals, such as every thirty minutes. Choose times that you have found out he is likely to want to have a wee or poo. Additional drinks may speed the process up. Frequent rewards will be necessary for success. Accidents should be dealt with quietly. 61 Good beginnings

4 u From the outset a visually supported routine needs to be established. Quite a number of children learn to use the toilet but never have a means of asking to do so. Clearly this will cause difficulties when your child is away from home. An object can be used to be associated with the visit to the toilet, such as a toilet roll, a box of baby wipes, a doll shouse toilet. This object serves to show a child they are going to the toilet, this helps your child to know what is to happen and where. u A photograph or drawing of the toilet could also be used. If your child is using a visual timetable this object or photograph can be placed on the timetable to show him how visits to the toilet fit into his daily schedule. Eventually it is intended that he will use the object or picture to indicate the need to visit the toilet. Object and picture sequences could also be used to show the child the sequence of actions involved in using the toilet. One such routine could be; enter bathroom, remove clothes, sit on toilet, use toilet paper, pull up clothes, flush toilet. Sam was four-and-a-half years old and still wearing nappies. Although his mother had put him on his potty, he had not been able to have a wee or a poo in it. Instead Sam preferred to continue to have a poo in his nappy. His mother felt that Sam wasn t sure what he was expected to do with the potty, so she got a book from the library about sitting on the potty and drew some large pictures for Sam to look at. She also asked Sam s dad to demonstrate what was to happen. One day when they were in the bathroom, Sam s mum noticed he was about to have a poo. She quickly sat him on the potty and he was unable to stop the poo and did it in the potty. Sam s mum showed him she was pleased and made the link with the book. From then on, his mum sat him on the potty when he looked as if he was about to do a poo and Sam gradually learnt to use the potty. u Children with autism may not accurately recognise their body signals, which tell them their bladder is full or that they need to do a poo. You will need to give them frequent reminders to use the toilet. They may also become involved in activities with an obsessional element and be reluctant to be distracted to visit the toilet. u Although children with autism do find it difficult to copy others, if members of the family, who are the same sex as the child, show him how to use the toilet he will then have a clear picture of what he is being asked to do. Sometimes demonstration with dolls may prove useful. It can also help some children if you start by changing their nappies in the bathroom; this can help them make the link between nappies and the toilet. Good beginnings 62

5 A sequence showing a routine for using the toilet u Some children will only use the toilet if they are on their own and they are sure they will not be interrupted. If you feel this applies to your child, take him to the toilet, leave him and give him some clue as to when you will return, such as setting a timer. You may wish to give him something to do while sitting on the toilet, such as looking at a book or playing with a simple hand held toy. Only do this if you feel it will help your child sit on the toilet and not distract him. Common toileting problems and how to tackle them Fear of the toilet Some suggestions for overcoming this difficulty. u Try to get your child to wee or poo in the nappy while they are on the toilet. u Try to get your child to sit on the toilet with the lid down while they are still wearing their nappy. u Gradually move on to sitting with the lid up and undressed. u There are a wide variety of different potties and child s toilet seats available. Consider which would make your child feel most secure. Five-year-old James was using the potty well but refused to sit on the toilet. His potty was red, hard and felt secure to sit on, whereas the toilet seat was white, padded and shiny. James mother talked this through with a clinical psychologist and decided to try removing the soft training seat. Much to his mother s surprise James sat on the toilet and used it. u Give advance warning of the toilet flushing, your child may be better standing a little way from the toilet. Allowing him to flush the toilet will give him more control over the process. 63 Good beginnings

6 u Visit a range of different toilets from the outset, so your child will gain confidence in different settings. Initially he may not use these toilets himself but will be able to see parents confidently doing so. Some children have a fear of being messy or dirty. Playing with things like playdough, finger-paints and pastry can help to reduce their fears. Children may be more successful and comfortable using baby wipes to clean themselves rather than toilet paper. The toilet monster. Smearing Smearing poo by young children is often associated with boredom and too much unstructured time alone. Sometimes smearing is associated with constipation. Discomfort may result in your child touching his bottom and eventually smearing. Possible actions include: u a medical examination to check for constipation; u trying to reduce unstructured time by providing a range of activities; u considering whether your child is enjoying the attention that results from smearing, such as adult attention or a warm bath. Redirect the attention to more positive behaviour. u providing clothes that limit access to the bottom, for example, clothes that fasten at the rear. Sleepsuits are available for children to wear at night that will stop them from having access to poo, or from hurting themselves by scratching or digging at their bottoms. Toilet rituals Some children try to insist on specific rituals being undertaken when they are going to the toilet. Try to avoid these developing. One possible ritual is a preoccupation with flushing the toilet. If this is the case, it may be necessary to physically cover the toilet handle to remove it from sight and to give him something else to hold and manipulate. Your child should be provided with a visual timetable to show when to flush. Note that we have not included night-time toilet training in this programme as a significant minority of children do start school wearing nappies at night. It can also be disruptive to sleep routines and unless the child is clearly ready (dry nappy in the morning) should probably not be undertaken until later. Independent bottom-wiping is also a skill that many children don t acquire until later. Good beginnings 64

7 Achievements in toilet training 1. Shows some awareness of being wet or dirty, such as cries when wet. 2. Has established some regularity in function, such as has a poo shortly after a meal. 3. Shows a regular pattern of signs indicating the need to have a poo or wee. 4. Sits on the toilet or potty for a few minutes when placed there by an adult. 5. Occasionally has a small wee on the potty/toilet when placed there by an adult. 6. Remains clean and dry for up to an hour in between trips to the toilet. 7. Accepts being taken to the toilet every hour or two hours. 8. Is able to empty bladder on the potty or toilet. 9. Is able to empty bowels on the potty or toilet. 10. If taken to the toilet regularly, will remain dry with some accidents. 11. If taken to the toilet, will remain clean most days. 12. Associates a word, gesture, object or picture with being taken to the toilet. 13. Removes lower items of clothes with prompting. 14. Occasionally uses the toilet spontaneously and independently. 15. Stands at the toilet to wee (boys only). 16. Indicates the need to visit the toilet at home, by using a picture or object. 17. When asked regularly if he needs to use the toilet, will indicate yes or no. 18. Regularly uses the toilet spontaneously and independently. 19. Flushes the toilet appropriately. 20. Replaces lower items of clothes independently. 21. Uses the toilet in familiar houses. 22. Uses toilets in public places. 23. Indicates the need to visit the toilet away from home, by using a picture or object. 65 Good beginnings

8 Although the beginning of the sequence of achievements in toilet training starts with your child showing some awareness of being wet or dirty, many children with autism do not show this awareness. Parents need to take the initiative and start training their child. Do remember the advice given at the beginning of the chapter about needing time and a relaxed atmosphere to achieve successful toilet training. There is no need to be in too much of a hurry to toilet train your child. You may be more successful if you establish a means of communicating with your child before you start. Good beginnings 66