CURRENT TOILET TRAINING METHODS & PRACTICES

By Danica Mamlet

To fully understand the particular difficulties care givers and teachers can have in toilet training autistic children, it is important to review the current and prevailing philosophies in toilet training typically developing children.

A review of current journal articles revealed that most practitioners advocate a child-oriented approach to toilet training. This emphasizes child readiness and employing a system of positive reinforcement (Stadtler, Gorski * Brazelton, 1999). Brazelton, et al wrote that achieving bladder and bowel control could contribute to a child's self-esteem. "This model of toilet training comprises three variant forces in child development: physiological maturation (e.g., ability to sit, walk, dress and undress); external feedback (e.g., self esteem and motivation, desire to imitate and identify with mentors, self-determination and independence) (Brazelton, et al., p. 2)."

Brazelton et al. stress the delicacy of a child's self-esteem during initial successes in toilet training and emphasize the need for strong parental support during initial and successive toilet training phases. Parents are told to have the child use a potty chair, place stool from the diaper into the potty chair, watch parents go so as to imitate them, let the child sit on the potty fully clothed, and to time when urination and bowel movements are most probable.

Parents are encouraged to explain to the child what is expected when they are taken to the potty and to praise and reward any successful eliminations while being careful not to criticize accidents, and to have the child say "bye-bye" to items being flushed so as to diminish anxieties.

The literature shows that even typically developing children often have difficulty mastering toilet training (Hagopian, Fisher, Paszza & Wiezbicki 1993, Blum, Taubman & Osborne 1997, Buchholz 1999, Issenman, Filmer & Gorski 1999). A common problem among typically developing children is regression, resulting in Encopresis (soiling) and Enuresis. Authorities highlight targeting self-esteem issues in treatment of these problems. In contrast, autistic children's difficulties in toilet training tend to be less related to self-esteem issues than to problems intrinsic to their disorder.

Problems of autism in toilet training

The specific characteristics that impede autistic children's independent use of the toilet are outlined below. Autistic difficulties in understanding social relationships limit the success of a social reward system such as recommended by T. Berry Brazelton, et al. (Stadtler, Gorski, & Brazelton, 1999). This method encourages the typically developing 2-3 year old child to have a sense of pride or accomplishment for success in toilet training. As discussed earlier, autistic children often do not feel pleasure from making their parents and teachers happy. Thus a program based on social motivation would not have great probability for success. Difficulties in comprehending language and logic may inhibit the ability to understand what is expected in regards to the toilet procedure. Autistic children often do not understand an explanation of why they need to eliminate in the toilet and not their diaper.

Furthermore, autistic children's attachment to routines and resistance to change may make the transition from diapers to the toilet difficult. They may be attached to the sensation of wearing diapers, having used them daily for 2-4 years. They may not like the stimulating environment of the bathroom with its bright lights, echoes, and sounds of running and flushing water and they may be averse to the change in temperature they feel when they take off their clothes (American Psychiatric Association, 1994; Boswell & Gray, 1995.)

Autistic children's toilet training can be further impeded by their idiosyncratic relationships with their bodies. They may not know how to read bodily cues, and therefore are not aware of the urge to use the toilet. In addition they may not mind the sensation of being soiled. The reasons for this are unclear but some experts have speculated that this may be related to central nervous system abnormalities in children with autism. (Hagopian, Fisher, Paszza, &Wiezbicki, 1993). All of these factors contribute to the need for adaptation of classic toilet training methods to suit the special needs of autistic children.

Successful toilet training techniques for autistic children

What follows is a brief review of various toilet training techniques that address the unique needs of autistic children. The focus of this review is to shed light on how the specific characteristics of autism can be addressed. In order to address the communication deficits associated with autism, visual versus verbal cues may result in higher favorable response rates (Dettmer, Simpson, Myles, & Ganz, 2000). Thus a system employing picture icons with each step task analyzed is recommended as a tool to teach toileting independence. Practicing a consistent, task analyzed routine capitalizes on Autistic children's predilection for repetition. This method must include a concrete, visual "what happens when I'm finished" piece of information because task completion is a powerful motivator for most children with autism (Boswell & Gray, 1995).

To address difficulties with the recognition of the urge to eliminate, timers may help the Autistic child learn to recognize when they are ready to eliminate. Also, a transition object (e.g., a preferred toy or book) may be used initially to shape smooth transitioning behavior. The use of the transitional object can also aid in teaching the child to initiate on its own. If the child has become accustomed to taking a certain book or doll to the bathroom when prompted by an adult, they may indicate the need to go by picking up this item on their own. A photograph of the toilet can also be used as an effective way to communicate the need to eliminate. This can be especially helpful for children with deficits in their use of verbal language.

To accommodate autistic children's resistance to change, it is recommended that instructors introduce the bathroom routine gradually, first requiring the child to enter the bathroom clothed, then to sit clothed on the toilet, then in diapers, then unclothed. The use of potty chairs are not encouraged with autistic children as the adjustment to the toilet may take longer if they have become adjusted to the potty chair. If a child resists eliminating on the toilet, the use of a water prompt can facilitate a child's recognition of the sensation of having to eliminate (Hagopian, Fisher, Paszza, & Wiezbicki, 1993). As it is important to reduce as many outside distractions and obstacles as possible, the use of a small half bathroom is recommended.

Autistic disorder poses many challenges to instructors and caregivers. One can see that with creativity and ingenuity, autistic children can learn many of the skills that will aid them in living the most independent life possible. Failure to develop toilet training independence can substantially hinder the autistic child. The untrained child will continue to be dependent on caregivers for the most basic of living skills. If this problem is addressed early, children with autism can enjoy increased independence, freedom for caregivers, and greater options for schools and residences in the future.

Program Objectives

This program seeks to assist caregivers in the difficult task of toilet training children with autism. This will occur through the placement of trained early childhood educators into eligible homes of families with young autistic children. The objective of this placement is to guide caregivers in effective toilet training methods. Such methods are not widely available and require specific training. Skilled early childhood educators will work in cooperation with caregivers through modeling, direct instruction, and conferencing. By the end of the intervention period, caregivers will maintain skills that will assist their children in achieving independent use of the toilet.

A practical example: Toilet Training for Steven

Toilet training for Steven Jones, currently aged 4.3, began at age 3. Before toilet training could begin, behavior issues such as noncompliance, aggression, and tantrums were addressed. Once instructors had instructional control, they met with Steven's parents to discuss the toilet training program. With a new baby in the house, Steven's parents were anxious to have him trained and out of diapers. Instructors explained that toilet training took an extreme time commitment as well as diligence on the part of the family.

The instructors explained that they would agree to undertake toilet training Steven during their sessions if the family would promise to carry through the program when the instructors were not present. Steven's parents agreed and the instructors laid out the plan. The plan included conditioning Steven's communication skills so that he could request the bathroom spontaneously, teaching him to tolerate being in the bathroom and sitting on the toilet first clothed and unclothed, maintaining a toileting schedule and data on each trip to the toilet as well as data on accidents, keeping a log on bowel movements, and antecedent behaviors.

The first thing the instructors did was teach Steven the words "toilet" and "bathroom". They taught him to expressively and receptively identify both words using a variety of mediums. Steven was taught in massed trials with tangible rewards. Meaning that each item was repeatedly presented with a stimulus, ex. With Steven seated in front of the instructor (knee to knee), and the instructor holding up a picture, the instructor said, "What is this?" Steven replied "bathroom" correctly and was immediately rewarded with an edible and praise.

After Steven had learned the words "toilet" and "bathroom", instructors taught Steven to tolerate sitting in the bathroom. One of the traits of Steven???s autistic disorder was extreme rigidity. He did not like the bathroom, except for baths. Steven also was extremely averse to changing routines. He associated the bathroom with baths and nothing more. To condition Steven to tolerate sitting in the bathroom, instructors gave Steven bits of his favorite candy and verbal praise for standing inside the bathroom. They increased the time between rewards so that by the end of week one, Steven was able to stand in the bathroom for up to four minutes. By the end of week one, Steven's mother reported that she had coaxed him to sit, fully clothed on the toilet. Instructors helped shape the "sitting on the toilet" behavior by using the same time interval/reward system to extend the ammount of time he would sit, fully clothed on the toilet. Steven tolerated sitting unclothed after learning to sit clothed with little problem.

By week two, instructors began encouraging Steven to drink more fluids. They did this by feeding him small bits of salty food (chips and pretzels) and continually offering preferred fluids (Steven liked apple juice and water). This was done in order to increase the opportunities for Steven to have successful voids on the toilet. In other words, the more he drank, the more he would have to "go". The more he would have to "go", the more opportunities for success he had.

Instructors had asked parents to withhold Steven's favorite treat, oreo cookies, when they began the training. Oreo cookies were a very powerful incentive for Steven who loved them and been very motivated by them in past learning situations. While Steven was trained, he only received Oreos for successful voids on the toilet, and not at any other time. This was done to increase the value of the Oreos and give Steven more incentive to earn them.

Once Steven sat on the toilet unclothed and fluids were being pushed, instructors implemented a toileting schedule. The first week Steven was taken to the toilet every 15 minutes. The routine occurred as follows: The timer went off, the instructor physically prompted Steven to give them a picture of the toilet and echoically prompted him to say, "I want toilet." Steven was then guided to the bathroom, praised for dry pants if he was dry, changed if wet, and sat on the toilet. If he voided, he was immediately given an Oreo and allowed to return to the work area. If he did not void, he sat for two minutes, then returned to work. Once he had achieved two days of one or fewer accidents, the 15 minute intervals was increased to 25 minute intervals. Once he was able to remain dry on that schedule (it took two more weeks), the schedule was relaxed to 35 and then 45 minute intervals. Steven remained dry on this schedule for two more weeks and when instructors attempted to eliminate the schedule and teach spontaneity, Steven had a setback. He began wetting himself. This was treated with over correction for accidents: When Steven had an accident, he had to change all his clothes and clean his chair or the area where he was when he had the accident. These activities were aversive to Steven and served as further incentive to void in the toilet. At this time, it was decided that Oreos were not motivating enough to teach spontaneity. After performing a reinforcement assessment, Steven's reward for voiding in the toilet was changed to five minutes of watching a preferred video. Both the over correction and extremely motivating reward allowed for achievement of the goal of Steven initiating use of the toilet independently.

Once bladder training was successful, bowel training began. During bladder training, Steven's family kept a log of times when Steven moved his bowels. They found that the times Steven generally moved his bowels was between 4 and 6pm daily. They also isolated certain antecedent behaviors to this activity. Before Steven "went", he usually hid in a corner, crouched down and got a far away look in his eyes.

To train Steven to move his bowels on the toilet, instructors had to wean Steven off going in his diaper - which was very familiar and comfortable for Steven. They did this by working and playing with Steven in the bathroom during target times (4-6pm). During initial phases, Steven wore a diaper. When he displayed antecedent behaviors, they had him sit on the toilet, with his diaper on (the diaper was removed for urine voids), and rewarded him for voiding in his diaper while sitting on the toilet. They then cut increasingly bigger holes in his diaper over the next few weeks, so that eventually, he was having bowel movements on the toilet, with only the waist of the diaper around his waist. They then were able to completely eliminate the diaper.

After 12 total weeks of toilet training, Steven was able to independently request to use the toilet for both bladder and bowel use, with accidents occurring only in isolated incedents.

References

Blum, N., Taubman, B., & Osborne, M. (1997). Behavioral characteristics of children with stool toileting refusal. Pediatrics, 99, 50-54.

Capps, L., Losh, M.,& Thurber, C. (2000). "The frog ate the bug and made his mouth sad": Narrative competence in children with Autism. Journal of Abnormal Child Psychology, 28, 193-202.

Dettmer, S., Simpson, R., Myles, B.S., & Ganz, J. (2000). The use of visual supports to facilitate transitions of students with Autism. Focus on Autism and Other Developmental Disabilities, 15, 163-170.

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.) American Psychiatric Association.

Hagopian, L.P., Fisher, W., Paszza, C., & Wiezbicki, J. (1993, Winter). A Water-prompting Procedure for the Treatment of Urinary Incontinence. Journal of Applied Behavior Analysis, 26 , 473-478.

Hendriks, R. (1998,Autumn). Egg Timers, Human Values, and the Care of autistic Youths. Science, Technology and Human Values, 23, 399-404.

Issenman, R., Filmer, R., &Gorski, P. (1999, June ). A Review of Bowel and Bladder Control Development in Children: How Gastrointestinal and Urologic Conditions Relate to Problems in Toilet Training. Pediatrics, 103, 1346-1351.

Pickles, Lord A. (1996, November). Language Level and Nonverbal social-communicative behaviors in Autistic and Language Delayed Children. Journal of the American Academy of Child and Adolescent Psychiatry, 35 , 1542-1553.

Sarakoff, R. A., Taylor, B. A., & Poulson, C. L. (2001, Spring). Teaching children with autism to engage in conversational exchanges: Script fading with embedded textual stimuli. Journal of Applied Behavior Analysis, 34, 81-84.

Stadtler, A., Gorski, P., & Brazelton, T.B. (1999). Toilet training methods, Clinical Interventions and Recommendations. Pediatrics, 103, 1359-1365.

Azrin, N.& Foxx, R. (1976). Toilet Training in Less than a Day. Simon and Schuster Trade.

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Reproduced with permission of Tom McIntyre from his site at www.BehaviorAdvisor.com on behalf of the author, Danica Mamlet.