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Toilet Training

by Dr Avril Brereton

Toilet training is usually a difficult task for any child and family to accomplish. It can be especially difficult if the child to be toilet trained has autism. There are a number of factors to consider prior to commencing toilet training.

 

1. Is the child well?

  • Are there any medical problems that might impact on the child’s ability to be successfully toilet trained at this time?

 Have a check up with the GP to make sure that there are no medical problems that may affect toilet training.

   -  Impaired neurological bladder and bowel control

-  Small bladder capacity

-  Constipation

 Also need to check that the child is drinking well, exercising and eating foods high in fibre.

 

2. Is the child ready to be toilet trained?

  • Are all family members prepared for the intensity toilet training the child with autism will require?

  • Are there any other major life changes that will be happening at this time?

  • The child should be able to demonstrate signs of recognising the need to be changed, e.g. by approaching an adult, or by fidgeting and appearing uncomfortable when in a wet or soiled nappy

  • Adequate bladder control: able to remain dry for at least an hour at a time

  • Can the child sit still for about 2 minutes?

 

3. Establishing a pattern

  • This step requires the child’s current toileting habits to be documented, to establish a pattern that will then form the basis of the initial toilet training schedule

  • As unobtrusively as possible, check his/her nappy every 30mins and document if wet/soiled.

  • If he/she attends preschool or child care, it will be important for this documentation to continue there also.

A simple bladder chart can be used to record current toileting habits. 

 

TIME

 

DRINKS

AMOUNT/TYPE

 

WET/DRY

 

COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

  • Check hourly

  • Continue for 3 days.     Use a similar chart for bowel motions

  

4. Getting prepared for toilet training

  • Prior to commencing toilet training, it is a good idea to pair the nappy changing routine with future toileting habits, by changing the child in the bathroom or toilet, and involving him/her in the disposal of the nappy, usually in the toilet/bathroom bin.

  • Identify some highly motivating rewards that will be used solely for toilet training to maintain their novelty and effectiveness

 

Some tips for choosing effective rewards.

 1. List possible rewards with the help of people who know the child best (Verbal praise, physical praise, preferred activities, food)

 2. Try them out

 3. Note the response

 4. Do some rewards seem more effective than others?

 5. The final list will comprise only those rewards that are known to work!

     (Use only effective rewards / reinforcers)

 6. Ensure the child knows what he/she is being rewarded for by talking about it or having a visual cue

 7. Plan how frequently the reward will be used (reinforcement schedule)

 8. Watch out for satiation… don’t overuse the reward

 9. Tail off tangible rewards as soon as possible

 10. Continue the verbal praise

 

Provide visual supports for the child when beginning toilet training. Check with his/her parents and other professionals to know whether objects, photos or line drawings would be most developmentally appropriate

The following visual supports will help:

- the toilet at home and at preschool/childcare

- the child sitting on the toilet

- a motivating reward

- a toilet that has been used for urine and a bowel motion

 

For higher functioning children a simple schedule may be used:

                                   

 

5. Sitting on the toilet

The goal at this stage is for the child to sit on the toilet without fear or anxiety. It is not so important that they use the toilet just yet. The key is to make the initial toileting experience a positive one. Good motivators/rewards at this stage may include favourite games, books, objects, or sometimes food.

  • Take a “first-then” card to the child with a “first-toilet, then-reward” image shown, and say “Let’s go to the toilet” whilst showing them the card.

                      

  • Lead him/her by the hand to the toilet, showing the picture of the toilet

  • Encourage him/her to pull pants down. It is a good idea to have pants that are easy to un/dress in at this stage, such as pants with elasticised waist.

  • Say “sit down” as you help him/her to sit on the toilet. Make sure he/she is comfortable and secure when sitting on the toilet

  • Once seated, provide labelled praise, such as “good sitting on the toilet” paired with the immediate reinforcement of the reward.

  

6. Using the toilet

  • The aim at this stage is for the child to use the toilet for urine and bowel motions.

  • Review the toileting routine documented in the initial phase

  • Increase the child’s liquid intake 15-20mins prior to their usual toileting time

  • Take the child to the toilet 5-10mins prior to their usual toileting time, to maximise the chances of “catching” a success

  • Every hour or so take him/her to the toilet, by following the same routine as above with accompanying visuals

  • Encourage him/her to bear down when typically scheduled for a bowel motion by playing games that involve blowing, coughing or whistling

  • Keep him/her engaged and relaxed when sitting on the toilet to maximise their chances of a successful attempt

  • If they have done nothing, say “no poo, no wee” and let them leave the room

  • If he/she has successfully used the toilet, reward and praise them

 NB: A child with autism may not recognise what others know or do not know about their bodily state, and may not communicate the need to use the toilet. Asking the child intermittently throughout the day will help with this problem.

  

Managing accidents

  • If the child is not fully toilet trained during the day, avoid going back to nappies and use training pants instead

  • If the child is wet or soiled, help them to change their pants without fuss and take underwear to the laundry

  • If underwear is soiled, encourage the child to tip the contents into the toilet, explaining that is where it belongs

  • If the child has soiled or wet the floor, encourage them to assist in the cleaning up process (not to punish but to help the child to understand that they are responsible for their toileting habits).

  • Avoid bathing the child immediately following an accident, use a wet cloth instead. For some children the bathing may be seen as a reward and may increase the frequency of “accidents”.

 NB:  Becoming angry or punishing the child may lead to retaining faeces or urine, which can cause constipation and lead to a long cycle of toileting problems

 

 
Some children can become distressed and anxious when toilet training begins. This may lead to them becoming constipated and “hanging on”. Some signs of constipation to look for include:

  • Saying that it hurts when doing a poo

  • Showing signs of holding on (crossing legs, running around, crying or refusing to sit on the toilet)

  • Complaining of tummy pain

  • Soiling their pants (overflow)

 

Helpful Hints

  • Give the child a drink 10-15 mins prior to toileting to increase the chances of a successful attempt to wee/poo on the toilet

  • Wet wipes to wipe after a bowel motion initially, as these are easier for a child to use effectively

  • Flush the toilet at the end of the toileting and dressing routine to minimise the impact of the unpleasant noise of the flush. This also allows the child to have successfully completed the toileting routine, and an adult can flush the toilet if initially required to gradually introduce this step into the toileting process

  • The introduction of underpants and “no more nappy” should be generalised across all environments. It can become confusing for the child if they are wearing underpants at home, but a nappy is placed on them when going out, for example. This is likely to increase the time required to toilet train the child, as it sends confusing messages about what the expectations are.

  • A Social Story™ explaining “no more nappies” and the new toileting routine and expectations, with accompanying visuals, may be helpful for some children

  • Make sure the toilet seat has an insert that fits the child’s smaller bottom, with handles on each side and a step for them to place their feet on, to minimise their anxiety and ensure they feel comfortable, safe and secure when first toilet training.  

 

  

Useful resources:

 http://www.betterhealth.vic.gov.au/

 http://raisingchildren.net.au/

Toilet Time- a resource manual. Disability SA website: http://www.familiesandcommunities.sa.gov.au/ 

One Step at a Time. Victorian Continence Resource Centre website: http://www.continencevictoria.org.au/mambo/content/view/35/45/ 

National Autistic Society website: http://www.nas.org.uk/ for information handout, Toilet Training

Brown, N. & Halsted, A. Aim High!

Are you ready? Toilet training animation. Intellectual Disability Services Council. S.A.

 

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