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
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
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
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.
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,
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
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.