1 Toilet Training List of Articles Toilet Training By The National Autistic Society (UK) Facts for Families: Tips For Toilet Training Children With Disabilities By Kent.edu website Sample Toilet Training Tips By Applying Structured Teaching Principles to Toilet Training By TEACCH Autism Program Toilet Training--Early Childhood Training Series (CD) Produced by CARD (Center for Autism & Related Disabilities) Toilet Training Difficulties--Treatment Suggestions (Parent Skill Building Series) By Kim Ward, Psychologist Toilet Training--Everyday Solutions By Mindy Small and Lisa Kontente How Do I Toilet Train My Autistic Child? By Temple Grandin Toilet Training and Autism By Gary J. Heffner Toilet Training Autistic Individuals in 21 Days By Joanne Stevens Tips for Toilet Training Children With Disablities (source: unknown) Elimination Chart Toilet Training Resources (websites, products, books) Updated: 5/27/08
2 Toilet training (The National Autistic Society-- Introduction There are many factors you need to take into consideration when deciding the right time to start toilet training. Choose a time when you have few engagements and are feeling relatively stress free. Concentrate on one behaviour; it's very difficult to change two behaviours at once so tackle one issue at a time. Ideally, everyone working with your child will start toilet training at the same time and follow your agreed approach, so make sure your child's school/childminder etc are aware of when you are starting the routine, the steps to be followed and the equipment needed. Your child may behave differently than normal during this time especially when the change of routine first takes place so it's a good idea to let everyone know why there could be a change in behaviour. Remember that independent toileting is the ultimate aim and may take many months but there will be many small steps and successes along the way. Developing a toileting routine Children with an autistic spectrum disorder (ASD) often like routine. You can build upon this desire for predictability to develop a successful toilet training routine. Teach as a whole routine from communicating need to using the toilet to drying hands, rather than just sitting on the toilet. Keep the sequence of behaviours the same every time and use visual cues to support the routine. Often when an activity is anticipated, less resistance occurs. There are some examples of visual supports on the do 2 learn website The first sign that a child might be ready to start toilet training is when they start to become aware of needing to go to the toilet. This may be displayed by changes in behaviour patterns, appearing distracted or fidgeting when they are wet or have soiled or they may inform a parent/carer when they need changing. In terms of physical readiness, it is suggested that a good indicator would be whether a child is able to remain clean for one to two hours at a time. As well as physical factors associated with toilet training, there are social factors to consider. It is rare for a child with autism to have the social motivation to want to be like mummy/daddy/friend and use the toilet. Your child might not see the point in changing to use the toilet after using nappies for a number of years. Change can be very difficult for children with autism so therefore it is often easier not to use a potty as part of toilet training to avoid another change from potty to toilet. When changing your child's nappy, do this where the toilet is so they can start relating toileting activities to the bathroom. Observe your child over a few days or a week to see when they do a wee or a poo. It is quite usual for a fairly regular pattern to emerge, especially if mealtimes and drinks are provided at about the same time every day. Identifying the times can help to establish when to take your child to the toilet with an increased likelihood of them doing a wee or poo leading to positive reinforcement. Show your child a photo or drawing of the toilet and say 'your child's name, toilet', take them into the toilet, follow your visual sequence (see below) for undressing and sit your child on the toilet. Even if they do not open their bowel or bladder, continue to follow the visual sequence as if they had. Continue to take your child at set times based on your observations of when they are most likely to go. If they wet themselves at another time, take them to the toilet as quickly as possible and try to get them there so some of the wee goes into the toilet. Ignore the wetting and positively reinforce that the wee has gone into the toilet and continue the rest of the toileting routine. You will need to decide whether or not and how to praise your child for successfully following the toileting routine. Some children enjoy and respond to social praise ('good boy', or a tickle) others respond better to an object. Some children find praise difficult and keeping a calm, structured routine with a preferred activity after toileting may work better. It's important to remember that all children are different and they will not all respond to the same teaching techniques - what works for one child may not work for another. Having a visual sequence beside the toilet can help your child understand what is expected of them, for example: trousers down, pants down, sit on the toilet, wee/poo in the toilet, wipe (you may need to show how many squares of paper to take), pants up, trousers up, flush toilet, wash hands. Above the sink at eye level you would then have another picture routine for washing hands (see hand washing section). Make sure the pictures are very clear so there is no misunderstanding. For example, if you are teaching your son to stand and wee in the toilet, show an outline drawing of him standing and weeing in the toilet, if you are teaching sitting show a picture of him sitting and weeing in the toilet. Page 1 of 6
3 Dressing and undressing While toilet training, dress your child in clothes they can easily manage themselves: elasticised waist bands on trousers and skirts or dresses that are not too long. The clothing needs to be comfortable so beware of labels, tags or seams that may rub. Thomas the Tank Engine or Barbie underwear can be a great motivator for some children to begin toilet training. Your child may have to be taught how much they need to undress to use the toilet. Use clear pictures and language. 'Backward chaining' can be an effective way to teach new skills. This involves breaking a skill down into smaller steps, teaching the last stage of the sequence first. So if you were teaching your child to pull up his trousers you would pull them up to his hips and then he would pull them up to his waist. Next time you would pull then up to just under his hips and he would pull them over his hips and waist. This is a particularly good way of teaching new skills as it raises your child's self-esteem as they have taken the final step of the task themselves to complete the sequence. Hand washing Teach hand washing as part of the whole toileting routine. Follow the same steps each time: sleeves up, tap on, wet hands, squirt soap, rub hands together, rinse hands, turn off tap, shake hands, dry hands. At first you may need to stand behind your child and physically prompt them, slowly withdrawing. Beware of using verbal prompts as your child can become dependent on these without you realising. Have a laminated hand washing sequence at eye level above the sink to remind your child of the steps they need to take. The sequence can either be in photographs, pictures or the written word - whatever is most suitable and motivating for your child. You may need to create a way of removing or covering over each symbol as the step is completed to show that it is finished and to move on to the next step. You may wish to teach your child to use the cold tap only. Beware that if you teach them to use the hot tap independently at home when they go into other settings and wash their hands the water may be too hot and could burn them. Boys - sit or stand? When deciding whether to teach a boy to sit or stand to urinate ask yourself the following questions: Can they distinguish between when they want to wee or poo? Do they have the co-ordination, focus and control needed to aim? If they learn by imitation, is there someone they can watch? If the answer to any of the above if 'yes', then they are probably able to be taught to stand to urinate. To start teaching them to aim, it can be useful to put a piece of cereal (preferably one they don't eat as this could lead to confusion) down the toilet so they have something to aim for and concentrate on. Bowel control Bowel control is usually learnt after bladder control - although all individuals are different and learn at their own rate and pattern. Some children with autism can find bowel movements very frightening and not understand what is happening, perhaps thinking that their insides are coming out. It can help to get a book with pictures from the library to explain the digestion process. For others the feel of a full nappy can be comforting, the weight of the nappy can squeeze them or they may enjoy the sensory feeling. You could replace these feelings in other ways instead of withdrawing them completely with toilet training. Those that enjoy a feeling of a full nappy may like to be tightly wrapped in a heavy blanket, this can be timetabled in to their daily routine and they can be given a means of communication to request this activity. When teaching bowel control, sit your child on the toilet, keep the nappy on but with a hole cut in the bottom, slowly cut away the nappy each time until they are able to go without the nappy at all. To start with they will still have the feeling of a security around their waist which in turn will enable them to feel relaxed enough to poo on the toilet. Those that enjoy the sensory feeling can be provided with messy play activities such as gloop (cornflour and water mix), playdough or other messy play activities. Habit training Page 2 of 6
4 Some children are toilet trained through habit. Habit training is effective for children who may: lack awareness, not understand the significance or meaning related to physical sensations, be limited by decreased or absent physical sensations or have unsuccessfully tried toilet training before. Habit training involves training the body to go at set times. Take your child to the toilet at set times throughout the day, every day. As before, keep a chart to discover the best time to take your child. While sitting on the toilet it is very important your child feels relaxed enough to open their bladder/bowels. Having the tap running in the background can help enable your child to wee and blowing bubbles or blowing up a balloon can help your child to open their bowel. Sometimes having a toy to handle - not one which causes excitement - can be useful to both keep your child on the toilet and relax them. Keep certain toys/books for just when they are sitting on the toilet. If your child lacks awareness or sensation, they may have to be taught a strategy before getting off the toilet to avoid accidentally weeing on the floor. You can start teaching this process by slowly counting to ten out loud when they have finished weeing before allowing them to get up or giving them a sand timer to look at before they get up. To help your child to independently manage their own toileting routine when they are older, you can buy watches which you can set to vibrate at certain times throughout the day (see resource section). You can then teach your child when the watch vibrates they are to go to the toilet. The environment The bathroom needs to be a calm, relaxing, structured environment in order to encourage independence and success with the complete toileting routine. Structuring the bathroom and removing all distractions can help your child understand what is expected of them while in the toilet. Removing objects which are not associated with toileting such as toothbrushes, make-up and laundry will help aid your child's understanding and avoid distractions. Think about making the bathroom as comfortable as possible, adding foot supports, side rails, reduced lighting, switching off the fan and a smaller toilet seat can all help reduce anxieties (see resources section). Make sure everything in the bathroom is set up to encourage independence. Is everything in your bathroom at the right level for your child? Can they reach the soap and towel? Is the soap too highly scented for your child? Do you need to adapt the bathroom for safety reasons such as the temperature of the hot water? Some children are sensitive to the sound of the fan so it may be necessary to adjust the light setting so it doesn't automatically come on with the light. Your child should be able to sit comfortably on the toilet with hips and knees flexed at a 90 degree angle and have feet flat on a secure object. Night-time Once your child is mostly dry during the day you will then be able to start night-time toilet training. Have a set bedtime routine which does not change with weekends or holidays. Limit the amount your child eats and drinks before bed, having no fluid an hour before bedtime, but ensuring your child has enough fluid throughout the day. Take your child to the toilet before they go to bed. They then may need to be taken once during the night. You could fit this in with your routine by taking them before you go to bed. Then take them as soon as they wake. If they are unable to keep dry during the night, you may need to try different times in the night to take them - may be not when you go to bed but in the middle of the night. There are a number of different products available to protect bedding (see resource section). Schools and early years settings Admission to school should not be refused simply because a child has difficulties with continence and the extract from the Code of Practice for Schools in the Disability Discrimination Act 1995, as amended by the Special Educational Needs Disability Act 2001, should be referred to in this context. The example below has been taken from the Disability Discrimination Act 1995 Part 4 Code of Practice for Schools. Example 5.17A A mother seeks admission to a nursery school for her son who has Hirschprung's disease. The school explains that they could not admit him until he is toilet trained. That is their policy for all children. Page 3 of 6
5 Is this less favourable treatment for a reason related to the pupil's disability? The child has difficulty in establishing bowel control as a consequence of having Hirschprung's disease, so the reason given is related to the child's disability. Is it less favourable treatment than someone gets if the reason does not apply to him or her? The treatment he receives has to be compared with a child to whom that reason does not apply, that is, the comparison is with a child who is continent. A child who is continent is not asked to delay admission to the school. It is less favourable treatment than is given to a child who is continent. Is it justified? In this case the decision was not based on any assessment of the circumstances of the particular case but on a blanket policy and so there is unlikely to be a material and substantial reason. It is likely that this is unlawful discrimination. You can download a copy of the Disability Discrimination Act 1995 Part 4 Code of Practice for Schools from the Disability Rights Commission website at codes regulation/ codes_of_practice.aspx Good practice guidelines have been written for local authorities, schools, early years settings and health professionals to enable them to develop policies and procedures for their setting. A copy of Managing bowel and bladder problems in schools and early years settings can be downloaded from the PromoCon (promoting continence and product awareness) website at School support staff are not obliged to change children in school or provide intimate care, but if your child is unable to access education without this facility then the school should find somebody who is willing to perform these duties and ensure they are written into the employees contract. If your child is going through statutory assessment for a statement of special educational needs and has difficulties with toileting, request that his need for support in this area are included in the statement. If he already has a statement which does not specify his toileting needs, you can raise this at the next annual review. If you are experiencing difficulties with school, it may also be worth writing to the chair of governing body of the school. The governing body has a duty to ensure that every effort is made to ensure that the school make provision for special educational needs under s317of the Education Act Top tips Giving a drink ten to 15 minutes before toileting can help increase the chances of your child successfully doing a wee on the toilet but avoid giving too much as this creates an unnatural routine. You will need to decide if you are going to teach your child to shut the door as part of the whole toileting routine or only in certain situations. Avoid using childlike terms for toileting as your child may find it difficult to change language later in life. It is not appropriate for a 20 year-old to say he is going for a pee pee. When your child first learns to poo on the toilet it may be easier for them to wipe themselves with wet wipes rather than toilet paper. If your child has a fear of flushing the toilet, you may wish to remove this from the visual sequence and leave it until the end of the routine - after your child has dried their hands. They then may need to stand in the door way while you flush the toilet and gradually stand closer each time until they are able to flush for themselves. Playing calming music to drown out the noise of the flush or explaining with pictures what makes the noise when the toilet is flushed may also help. When your child is in a car ensure they have a protector to sit on to stop the car seat from being soiled by accidents. Avoid drinks before long car journeys. Page 4 of 6
6 Be aware that some children will hold onto their wee/poo until they have their nappy put on, for example if they know they always have a nappy on before going in the car they may wait until it is put back to release their bowel/bladder. There is a range of absorbent pants and swimwear for older children available (see resource section). While toilet training you will be spending more time than usual focusing on your child. If you have other children, you may need to put aside some extra time just for them. Once your child is toilet trained at home you will want to teach them to use toilets when out in the community. When visiting new places, show your child where the toilets are and use the same routine as you do at home. Use the same picture and toy or book they may have for toileting at home. Some children smear their poo. This is a very challenging behaviour to come to terms with. There are a number of reasons your child may do this. Firstly, take them to your GP to make sure there are no physical factors as to why this is happening (being in pain). They may not have understood the process of wiping and you may need to teach them 'hand over hand'. The toilet paper could be too harsh for their sensitive skin therefore using wet wipes may be easier for them. Some children enjoy the feel of smearing, provide other acceptable activities which give the same feeling such as finger painting, gloop (cornflour and water) or playdough. Some children may see clearing up after they have smeared as a reward particularly if they like water or receive lots of attention form their carer. Even if they are reprimanding them it can still be seen a reinforcement. Use minimal interaction and alternative clean up methods such as baby wipes or a tepid shower. If your child is learning to use the toilet in another setting as well as at home, eg school, send in any equipment you use at home, for example a toilet seat they may use to make the seat smaller. Also remember to send spare clothes, plastic bags to put any wet clothes in and wet wipes. It is important that you have clear lines of communication during this time so having a home/school book to share concerns and successes is vital. Resources ERIC (Education and Resources for Improving Childhood Continence) sells a range of bedding protection, swimwear, absorbent pants and vibrating watches. Web shop telephone number: Website: ERIC has a helpline providing advice and information to children, parents and health professionals on all aspects of toileting. Call (Monday - Friday, 10am - 4pm) or visit: Fledglings is a charity which helps parents and carers of a child with special needs of any kind to find simple, affordable solutions to practical problems. Tel: Website: PROMOCON (Promoting Continence and Product Awareness) has links to various organisations who sell toilet-related products including swimwear, absorbent pants and toilet seats for older children. Website: Tinkle Toonz has musical sensors in potties and ones which can be used in underwear, nappies and pull-ups, designed to alert the child or the parent that the child has 'gone' in his potty or pants. Website: Useful information sheets available from the NAS Helpline *Behaviour *Creating an autism-friendly environment *Obsessions, repetitive behaviours and routines Organising, sequencing and prioritising Sensory Social stories Using visual supports Page 5 of 6
7 Contact the NAS Autism Helpline on (Monday - Friday, 10am - 4pm) for a copy of the information sheets. Those marked with a star (*) are available to download at the bottom of this page in 'Related resources'. References/further reading A reference marked with * means that it is available from NAS publications (for contact details please see end of information sheet). TEACCH (Treatment and Education of Autistic and related Communication handicapped Children) *ERIC (Education and Resources for Improving Childhood Continence) (2002). We can do it! Helping children who have learning disabilities with bowel and bladder management: a guide for parents. (Code NAS 466) ISBN Wheeler, Mary. (1999). Toilet training for individuals with autism and related disorders. Future Horizons, Inc. By Mellissa Gordon If an item is marked as available from the NAS please contact: NAS Publications Central Books Ltd 99 Wallis Road London E9 5LN Tel: Fax: Website: If you require further information, please contact the Autism Helpline on Page 6 of 6
14 Sample Toilet Training Tips Here is a sample of some of the toilet training tips from the website. Parents and caregivers can log on to this site, and sign up for toilet training tips. How does habit training work? Habit training is used with special needs kids when it's difficult to determine clear toileting patterns. Basically, you are going to establish a toilet time for your child. You will establish a fairly rigid pattern of times you think it would be appropriate for the child to use the bathroom. From there you will put the child on the toilet. When he goes, he'll receive lots of positive reinforcement. Eventually, he'll want to complete the event to get the reinforcement. Habit training is based on the elimination schedule. Focus just on the urination at first, if you also get him to the toilet for bowel movements, great, but if not don't worry; you will work on the bowel movements next in the toilet process. In this method of training, you take the child to the bathroom frequently, usually every 30 minutes, regardless of activity. You let the child sit on the toilet for approximately three minutes. If the child goes, usually by coincidence, you give lots of praise. If the event doesn't take place, you calmly take the child off the toilet with little or no reaction. You are working first on teaching the child to sit on the toilet; hopefully with correct timing, he will eliminate at the time. You are helping your child through all of the events of the toileting process, but your focus is not on getting him to master the steps, as much as to develop an awareness of the toilet, the difference between wet and dry pants, and a desire to please you with success in the toilet. How can I overcome my child's fear of sitting on the toilet? Answer: Many autistic children develop a fear or discomfort of sitting on the toilet. This reaction can be worked through by helping the child become familiar with the toilet without requiring them to actually use it. - Practice sitting them on the toilet fully clothed. Let the child play, read, or color while sitting on the toilet fully clothed. They will become gradually more comfortable.
15 - Allow your child to sit on your lap on the toilet. As you hold the child, they will be secure knowing you are there to help them and will gradually relax. - Practice the procedure using a doll or favorite toy. If your child is able to observe the procedure with their favorite item, and realize nothing bad will happen, over time the unease will go away. What can I do to get my child to use a bathroom at a public place? Answer: Sometimes the fear of the unknown is the biggest hindrance for us all. Try to make trips to public restrooms as predictable as possible. - Provide a travel toilet kit stocked with toys, a visual cue, preferred wipes & hand cleaner. - Bring along a Walkman or MP3 player to mask some of the sound of others in the bathroom. - Accompany the child into the bathroom to direct them and eliminate unnecessary distractions. What do you do if your child refuses to flush the toilet? Answer: Flushing the toilet may seem like a mysterious process to some kids - where does the water go, how does it come back, why is it so noisy? Most kids respond well to predictability. Establishing a pattern to flushing will reduce some of the fear of the process. - Use a visual schedule to indicate when it's appropriate to flush. - Use a verbal cue - "Ready, set, flush, all done, its time to wash hands." - Allow them to wait at a "safe" distance while you do the flushing. Gradually encourage her/him to get closer to the toilet (think baby steps.) How do you use slightly less than a roll of toilet tissue per bathroom trip? Answer: Toilet paper can be a great plaything for most kids and many pets. Here's what you should do: - Take the roll off its holder. Only tear off the amount needed and stack it by the toilet. - Mark the roll with an "X" to indicate where to tear off.
16 - Make a counting game with the paper - "We always use X number of squares, let's count: one square, two square, etc. What can I do to get my child to use a bathroom at a public place? Answer: Sometimes the fear of the unknown is the biggest hindrance for us all. Try to make trips to public restrooms as predictable as possible. - Provide a travel toilet kit stocked with toys, a visual cue, preferred wipes & hand cleaner. - Bring along a Walkman or MP3 player to mask some of the sound of others in the bathroom. - Accompany the child into the bathroom to direct them and eliminate unnecessary distractions. What if the child doesn't want to give up diapers? Answer: Some kids are really attached to their diapers and don't want to switch to underwear under any circumstances. You can ease them out of diapers gradually. - Start by wearing underwear under the diaper. Let them get used to the idea of having underwear on, but still offer them the option of wearing the diaper over the underwear. - Gradually cut away small parts of the diaper. Keep making the holes in the diaper bigger, and bigger. Keep in mind that the last parts to cut away are around the legs or waist. - Allow them to switch to pull-ups. Pull-ups aren't as likely to be so absorbent as the diapers, some parents even let them feel when wet. Pull-ups also let them work on the skill of pulling up and down pants. What do you do if your child won't wash his/her hands? Answer: Some kids don't want to take the time to wash hands or just don't like the process. Try to overcome his/her discomfort by experimenting with getting hands in water or playing with soap. - Try shaving cream. Some kids love the feel of shaving cream and have fun playing with it in their hands. There are a variety of foam soaps that are similar in texture to shaving cream, once you have them interested in shaving cream you can switch to soap.
17 - Have a soap box/basket and let them choose. Load the box up with shaped soaps, samples, and hotel give-aways. Some kids might love the option of picking out their own soap and will be encouraged to wash. - Use an anti-bacterial hand cleaner. Just squirt on hands, rub and the kid is good to go. What do you do if your child refuses to urinate in the toilet? Answer: Sometimes children don't fully understand what they are being asked to do. Communication problems can make the discussion of urination challenging. The best thing to do may be to use the "show me" method. - Adding food coloring to the water helps illustrate what urinating in the toilets is all about. Just like magic, a little urine combined with the previously colored water will guarantee a color change. This can be very intriguing for the child trying to master the skill. - Having something to aim for is always fun as well - try biodegradable packing peanuts, special made animal shaped toilet floats, or cheerios cereal.
18 The University of North Carolina at Chapel Hill Division TEACCH Applying Structured Teaching Principles to Toilet Training 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 all children respond to the same teaching techniques. A method that is helpful 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 toilet 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 difficulties 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 skill 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 how to "read" the body cues that tell him he needs to use the toilet. He may also be overly involved in the sensory stimulation of the "product" smearing feces is not uncommon in young children with autism. The child may also be overwhelmed by the sensory environment of the toilet, with loud flushing noises, echoes, rushing water, and a chair with a big hole in it right over this water! A further consideration is that the removal of clothing for toileting may trigger exaggerated responses to the change in temperature and the tactile feeling of clothes on versus clothes off. Elements of structured teaching Structured Teaching is the term given to a set of teaching/support tools designed by Division TEACCH for people with autism. These tools are responsive to the characteristics of autism using their strong learning modalities (visual and motor skills and enjoyment of routine) to build bridges over some of the gaps in learning caused by their characteristic deficits. Structured Teaching not only increases the learning of new skills but also serves to increase independence and self-esteem, reducing behavior problems that result from confusion, anxiety, and over-stimulation. Structured Teaching combines the use of individualized assessment, establishment of proactive and adaptive routines, and the systematic use of visual supports to support learning. I. Beginning step: Assessment When hoping to toilet train a child with autism, one of the first things we must do is define a realistic goal, realizing that independent toileting may be many, many steps down the road. Each of the steps toward independent toileting is a goal itself. It is necessary to observe and assess the child's understanding of the toileting process in order to choose the correct starting point. We should begin with establishing a positive and meaningful routine around toileting and collecting data about the child's readiness for schedule training or for independent toileting. A simple chart can be used to collect the data needed about the child's readiness. On a routine basis, the child is taken to the bathroom for a "quick check" every 30 minutes and data is recorded on each occasion. A sample of one format for collecting this basic information is shown below. Elimination Record Page 1 of 6
19 Child's Name: Date Begun: Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Time Pants Toilet Pants Toilet Pants Toilet Pants Toilet Pants Toilet Pants Toilet Pants Toilet 7:00 8:00 9:00 10:00 11:00 Pants column In the column marked PANTS you will record every hour either: D if he is dry, U if he has urinated in pants, BM if he had a bowel movement, U / BM if he had both Of course, you don't have to wait an entire hour. Anytime you think he is wet, check him, write in the time on the chart, and record the results. Over a period of 1 or 2 weeks, patterns of data begin to emerge. Is the child dry for significant periods of time? Is there some regularity in his wetting/soiling? Does he show any indication that he is aware of being wet or soiled? Does he pause while wetting or soiling? A child for whom the answers to all of these questions is "no" is probably not ready for a goal of independent toileting, although a goal of establishing a positive bathroom routine may still be very appropriate. During the charting phase, we should also be assessing other aspects of the process of toilet training. As the data is being collected, Is the child beginning to pick up on the routine involved? How are the child's dressing skills? Does he show any particular fears or interests related to the bathroom (reaction to flushing, water, toilet paper roll, or other bathroom fixtures)? What is his attention span? At the end of this assessment period, we will have the data needed to establish an appropriate goal to be working toward. A task analysis of the steps of toileting can give a picture of all the skills needed. Assessing the child's current skills on each step of a task analysis will help us to choose a realistic goal and remind us not to try to work on several new skills at once. Task analyses can be global or very specific. Each step of a task analysis can be further detailed to determine teaching steps. Examples of a global task analysis and a more detailed analysis of one step are illustrated below. Task Analysis Further Task Analysis 1. Enter the bathroom (Does not do fasteners) 2. Pull clothes down a. Allows Adult to pull b. Pull from calves c. Pull from knees d. Pull from thighs e. Pull from hips f. Pull from waist 3. Sit on toilet 4. Get toilet tissue 5. Wipe with tissue 6. Stand up 7. Throw tissue in toilet 8. Pull clothes up 9. Flush toilet II. Physical Structure One of the principles of Structured Teaching involves structuring the physical environment for success. Our goal is to create a meaningful context for an activity to take place. We accomplish this through the creation of clear boundaries and the reduction of distractions. When beginning the toilet training of a child with autism, we want to help the child learn that this set of behaviors (elimination) is associated with a particular place (the toilet). Moving all diapering, cleaning, and toileting-related dressing to this setting helps the child realize the purpose of this room. Another way to say this is that we are trying to "isolate the concept" of where toileting- Page 2 of 6
20 related behaviors take place. Some families assign a half-bath in their homes to toilet-training, since the full bathroom has many objects that are associated with other activities and may be very distracting or confusing (bathtubs and showers, bathing toys, toothbrushes, makeup, laundry hampers, scales, etc.) A second goal for creating clear physical structure to assist in toilet training is to create an environment that is secure and not overstimulating. The child will be calmer and more responsive with good physical support for his body. Think about adding foot support, side rails, opening reducers, or other physical supports. Think also about the plumbing noises and echoes of many bathrooms. Many children appreciate soft music playing or the addition of sound-absorbent materials. III. Establish a Visually Supported Routine After establishing an appropriate goal for the child, it is important that we teach using visual supports for each step toward this goal. We must create a visual system to let the child know the step or sequence of steps to completing the goal. At the most basic level, a transition object may be used to let the child know that the toilet routine is beginning. An object that is associated with toileting may be given to the child to serve as the transition object that takes the child to the correct location. Or, this object may be placed in a zip-lock bag that is glued shut. Or, this object may be glued to a card. In any case, it serves to initiate the bathroom routine, helping the child know what is to occur and where. At a more abstract level, a photograph or drawing of the toilet or the printed word on a card may given to the child or placed on his schedule to accomplish this goal. Once the transition to the toilet area has been made, it is important to continue to visually support each step of the toileting routine. We need to let the child know each step he is to accomplish, when the sequence will be finished, and what will happen when the sequence is finished. Again, using an object sequence, a picture sequence, or a written list are all ways to communicate this information to the child. It is important that the child sees the information, manipulates the system so that he recognizes it's connection to his behavior, and has a clear way to recognize when each step and the entire process is finished. Examples of visual systems a variety of children follow: Finished Pocket Pull down pants Pull down underwear Sit on toilet Page 3 of 6
21 Use toilet paper Pull up underwear Pull up pants Flush toilet Go play The inclusion of a concrete, visual "what happens when I'm finished" piece of information is an important part of this system. For some children this may be looked at as a motivator or even a reward. For many children with autism, it is equally or more important as a clear indication of closure. Task completion is a powerful motivator for most people with autism. IV. Trouble-shooting specific problems Once a visually supported transition and sequencing system has been established, we continue to use a problem-solving approach to troubleshooting details. Whenever the child has a problem with any step of the process, we think about (1) what his perspective might be and (2) how we can simplify and/or clarify through visual structure. Examples follow: Resists sitting on the toilet allow to sit without removing clothes allow to sit with toilet covered (cardboard under the seat, gradually cutting larger hole, or towel under the seat, gradually removed) use potty seat on the floor rather than up high if strategies are helpful for sitting in other places, use in this setting also (timers, screens, picture cues, etc.) take turns sitting, or use doll for model sit together add physical support help him understand how long to sit (sing potty song, length of 1 song on tape player, set timer 1 minute, etc.) as he gradually begins to tolerate sitting, provide with entertainment Afraid of flushing don't flush until there is something to flush Page 4 of 6
22 start flush with child away from toilet, perhaps standing at the door (might mark the spot with a carpetsquare and gradually get closer to the toilet) give advance warning of flush, setting up flushing cue system, such as "ready, set, go" allow him to flush Overly interested in flushing physically cover toilet handle to remove from sight give something else to hold and manipulate use visual sequence to show when to flush (after replacing clothing, for example) when time to flush, give child a sticker that matches to a sticker on toilet handle Playing in water give him a toy with a water feature as distraction, such as a tornado tube, glitter tube, etc. use a padded lap desk while seated cover the seat until ready to use put a visual cue of where to stand Playing with toilet paper remove it if a big problem, use Kleenex instead roll out amount ahead of time give visual cue for how much, such as putting a clothespin on where to tear, or making a tape line on the wall for where to stop Resists being cleaned try different materials (wet wipes, cloth, sponge) consider temperature of above material take turns with doll Bad aim supply a "target" in the water, such as a Cheerio larger target as toilet insert (contact papered or laminated cardboard with target drawn on it), gradually moved down add food coloring in the water to draw attention Retaining when diaper is removed cut out bottom of diapers gradually, while allowing child to wear altered diaper to sit on the toilet use doll to provide visual model increase fluids and fiber in diet may need to enlist doctor if serious bowel withholding, may give stool softener These ideas are not intended to be an inclusive list of steps to take to teach a child to use the toilet. They are, however, illustrative of the problem-solving approach needed and the effort to provide visual cues to increase understanding, cooperation, and motivation. V. Communication System Another important step in teaching independent toileting is to plan for a way for the child to initiate the toilet sequence. At first trips to the bathroom may be initiated by an adult directing the child to a transition object or schedule. However, eventually the child will need a way to independently communicate his need to go. Even though he may begin to spontaneously go into a familiar and available bathroom, he needs to learn a concrete way to communicate this need so that he will be able to request when a toilet is not immediately available. Page 5 of 6
23 As always, the first step in designing a goal is assessment. Is the child currently signaling in any way that he needs to go to the bathroom, or is he totally reliant on an adult initiating the sequence? If there are behavioral signals that you as an adult observer can "read", these signals can show you the "teachable moments" when you can help the child learn to use a systematic communication tool. Is he able to use objects, pictures, or words to communicate in other settings? Many children first learn to use expressively the same tool that the adult has used to teach him about going to the toilet. For example, if Mom has been giving him an empty "baby-wipe" box to mean it is time to transition into the bathroom to be changed, the child might begin to use this same box to let Mom know he needs to be changed. Or, if a photograph of the toilet has been used on the child's schedule to tell him when it is time to sit on the toilet, the same photograph will make a meaningful expressive communication tool. A child who is sometimes able to verbally say "bathroom" may not always able to pull this word up at the appropriate time. When he is tired, in a new place, with a new person, with too many people, catching a cold, upset for any reason -- his higher-level verbal skills may fail him. A child who shows this inconsistency will also be helped by a visual support that (1) helps cue the word he is looking for and (2) serves as a back-up system when he cannot use verbal language. Susan Boswell TEACCH Preschool Debbie Gray Chapel Hill TEACCH Center Books to Read to Children About Potty Training Going to the Potty by Fred Rogers, Jim Judkis (Photographer), Jim Judkins (Photographer) Your New Potty by Joanna Cole and Margaret Miller (Illustrator) The Toddler's Potty Book by Alida Allison, Henri Parmentier (Illustrator) Potty Time by Bettina Paterson (Illustrator) No More Diapers (Personalized Edition) by Tina Dorman Once Upon a Potty (Boy) by Alona Frankel Once Upon a Potty (Girl) by Alona Frankel Bye Bye Diapers (Muppet Babies Big Steps) by Ellen Weiss, Tom Cooke (Illustrator), W. Weiss Sam's Potty by Barbo Lindgren, Eva Eriksson (Illustrator), Barbro Lindgrin What Do You Do With Potty? : An Important Pop-Up Book by Marianne Borgardt, Maxie Chambliss (Illustrator) Have to Go (Sesame Street Toddler Books) by Anna Ross, Norman Gorbaty (Illustrator) On Your Potty by Virginia Miller Everyone Poops by Taro Gomi, Amanda Mayer Stinchecum (Translator) Toilet Training in Less Than a Day by Nathan H. Azrin, Richard M. Foxx Susan Boswell and Debbie Gray Division TEACCH Page 6 of 6
24 TOILET TRAINING DIFFICULTIES PARENT SKILL BUILDING SERIES by Kim Ward, Psychologist TREATMENT SUGGESTIONS Collect data regarding typical accident times (try to keep fluid intake consistent during the data collect period) to determine the most appropriate times to have the child sit on the toilet. Initially focus on sitting on the toilet. It is often helpful to provide the child with a special "toilet toy" when he/she is sitting on the toilet (i.e., remove from the child's possession when they stand up). Gradually increase the length of time that the child is expected to sit on the toilet. For most children 4 to 10 minutes is sufficient. Some children respond positively to a picture script which outlines the routine associated with going to the toilet. Some children develop toileting more quickly if they are provided with a visual model (e.g., sibling, peer, or parent). Kathleen Quill advocates the development of video scripts. Provide the child with a foot rest to increase feelings of security and to reduce straining Try to encourage to a child to eat high fiber foods and to drink plenty of water to ensure that stools are soft enough to avoid pain and straining. Salty foods such as crackers can increase fluid intake. Also, for children who resist drinking water, foods such as jello, soup, and milkshakes can provide a "sneaky" source of liquid. Whenever the child has a BM in their pants or diaper, ensure that the stool is placed into the toilet. This can help the child learn where "poo" should be placed. Ensure that the bathroom is perceived as a positive place. It should also be easily accessible to the child. On outings make sure that the child knows where the washroom is located. Teach the child at least one word, sign, picture symbol or gesture to indicate when they need to use the toilet. Prompt the child to use the word/sign/gesture whenever you take them to the toilet (i.e., so they will associate with the word/sign/gesture with the act of going to the toilet). Have the child take some responsibility for his/her accidents. For example, having the child take their soiled clothing to the laundry. To help the child develop more awareness of their accidents, prompt them to touch their wet pants, look at their wet pants, etc. Tight fitting clothing is often more uncomfortable when it is wet. Discomfort can be a big motivator for a child to use the toilet. Toilet training often represents a good time to work on self help skills such as pulling pants up and down, washing hands, etc. Consistency between home and school can often facilitate the toilet training process. One way to ensure consistency is to use the communication book to discuss the approaches that have been attempted and the effectiveness of each approach. Remain as neutral as possible during clean ups. Some children seem to find negative attention as reinforcing as positive attention. Avoid warm baths after accidents. Some children inadvertently learn that the way to request a bath is to have an accident. As such, it is often a better idea to provide a sponge bath. Some children engage in smearing to gain sensory feedback. Provide alternative sensory experience such as playing with dough, kneading dough, playing with shaving cream, etc. to satisfy their sensory craving.
Your guide to Toilet training your child Contents Toilet training your child 4 Getting started 5 Developing a routine 6 Hand washing 8 Habit training 9 The environment 10 Night time 11 Further information
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