Toilet training and Autism

TOILET TRAINING AND AUTISM
-TRIVENI GOSWAMI VERNAL
Registered Special Educator (A64010)

Toilet Training is one of the most important Activities of Daily Living that all parents and caregivers, work towards. Neurotypical children, usually get toilet trained by 3- 4 years. It is an arduous process for all children, but the process becomes more complex for children on the Autism Spectrum, who may require a wide variety of visual supports to aid their learning process.

As with all other ADLs, Toilet Training also has to be broken down into small, doable components and a strict visual schedule has to be maintained and followed for atleast two months, till it becomes a habit for the child.

TASK ANALYSIS OF TOILET TRAINING:
1) Enter the Bathroom
2) Pull down pant /pull up dress
3) Pull down underwear
4) Sit on the Toilet seat
5) Do the job
6) Use a Spray or Mug of water to clean themselves
7) Flush the Toilet
8) Pull up underwear
9) Pull up pant /Pull down dress
10) Open the tap of the sink.
11) Take soap from dispenser /bar of soap
12) Wash hands: Scrub hands with water and soap
13) Close the tap
14) Dry their hands with a towel

Please note: Instead of the visual of the use of Toilet Paper & Wipe, you can insert a clipart of a Mug or a Toilet spray, instead, depending on what the child uses.

One cannot teach all these steps at once. Initially the focus can only be on taking the child to the toilet every half an hour, like clockwork. Make the child drink enough water and take the child to the toilet. One can increase the time frame between toilet visits, incrementally over time.

There are a few important points to be remembered while Toilet Training. If the child is still wearing diapers, then training them while they have moved to wearing pull ups/diaper pants, is a good option, as they mimic, wearing an underwear. This case often arises, when the child is sent to a school or a day care, that refuses to take in a child, unless the child is toilet trained. The option, then, is to send the child in diapers and hope that the support staff in the school, would take the child to the toilet at regular intervals, even if the child is unable to express his/her need.

In case the child stays at home, and there is a caregiver/parent with the child at all times, then the child can be off diapers and made to wear an underwear and their regular clothing. It is important to teach the child to wear an underwear, beneath their regular clothing from their early days, because as they grow older, it becomes far more difficult to teach the children the importance of wearing an undergarment.

EXAMPLE OF A VISUAL SCHEDULE
(One can make it as detailed, or with as little information, as feasible)

Every time the child goes to the Toilet and is able to use the Toilet for his toileting needs, his /her behaviour has to be Positively Reinforced (it may initially be a tangible reinforcer like a toy/food or something the child really likes and care has to be taken that the reinforcer is only limited for Toilet Training and not used elsewhere. But later on, one can switch to non-tangible reinforcers only, such as Praise, Hugs, Giving lots of Attention etc). The child can be taught to place a mark on the schedule, when the job is done in the toilet. That also provides a sense of achievement and ownership to the child.

FIRST, THEN, NEXT VISUAL

Printable Resource:
https://adayinourshoes.com/wp-content/uploads/2017/10/first_next_then_boards.pdf

With a First, Then & Next visual, a few steps can be taught at one go, to the child. For example, Feel Pee Pee/Potty, Sit on the Toilet & do the job, Get a Reward. Or one can also use it to teach the first few steps in the Task Analysis of Toilet Training. The possibilities are endless.

CHALLENGES THAT A CHILD MAY EXPERIENCE DURING TOILET TRAINING AND THEREAFTER:

So, while the process of Toilet Training is quite arduous in itself, sometimes there are associated challenges that might make the process even more complex. Some of them are as follows:

a) Vestibular Sensory Issues: The Vestibular sensory system deals with our sense of balance and movement. It controls the working of our muscles and also our reflexes. An Over-Responsive Vestibular system or Vestibular Hypersensitivity can make a child fearful of sitting on the toilet. An over-responsive vestibular system can make a child fearful or anxious with uneven and unstable surfaces and the child can develop gravitational anxiety, a fear of their feet leaving the ground. The Middletown Centre for Autism, has listed down a variety of sensory strategies to work on a child’s fear of sitting on the toilet seat (https://sensory-processing.middletownautism.com/sensory-strategies/strategies-according-to-sense/vestibular/over-responsive/).

b) Constipation: A number of children on the Autism Spectrum also have digestive issues, like Constipation. Besides feeding them a fibre rich diet, a low foot stool can also be used at the base of the toilet, for their feet to be placed on and to help exert pressure.

c) Interoception: Interoception refers to a sensory system that provides an individual, the information about one’s internal bodily processes such as Hunger, Thirst, Awareness of when the Bladder is full, and when they need to use the toilet etc. So, even when a child may be completely toilet trained, they might still have accidents as they may be so engrossed in an activity of their choice, that they miss out on the signals provided by the body. The following website, https://www.education.sa.gov.au/sites/default/files/interoception-301-activity-guide.pdf , has a list of activities that can help improve the sense of Interoception in an individual. Teaching the child to be more aware of his/her bodily sensations, like tightening of the muscles in the stomach, or increasing pressure /pain in the stomach or the need to run to the toilet, are some important strategies.

The article, “Four Strategies to Improve Toileting through Interoception” on the website Fun and Function, https://funandfunction.com/blog/four-strategies-to-improve-toileting-through-interoception, includes doable and easy strategies that can help the child understand his/her internal bodily processes, better.

MY JOURNEY OF TOILET TRAINING MY SON:
Due to several disruptions earlier, my son was completely toilet trained only when he turned 8. It took strict scheduling for atleast two months, till he became habituated to using the toilet independently, without the need of a reinforcer. Although it has been three years since he has become independent in his toileting skills, accidents do occur, although rarely. Last year, after a series of accidents, I began to explore and look up articles on Interoception and Toileting. The more I read about it, the more I realized how important it is to keep working on this sense, to improve upon the child’s bodily awareness.

Being able to independently use the toilet, is one of the most important life skills, a child can ever have. But one must not lose heart, if the process takes longer than usual. One must always remember, that a child on the Autism spectrum, is battling with his or her own battles, that may not be visible to others, and that may complicate the process of Toilet Training, further. As a caregiver or parent, our aim should be to be aware of various associated factors that may be impacting the child’s toilet training and work on those aspects, diligently, till a pattern can be established for the child.

Printable Resources on Toilet Training:
https://www.andnextcomesl.com/2018/06/free-potty-training-visual-schedules-for-kids.html
https://autismlittlelearners.com/free-toileting-sequence/
https://www.withinmetherapy.com/post/potty-training-tips-for-children-with-autism
https://raisingchildren.net.au/autism/health-wellbeing/toileting-hygiene/toilet-training-autism#:~:text=Visual%20supports%20and%20toilet%20training,-Visual%20cues%20and&text=Stick%20the%20schedule%20on%20a,way%2C%20training%20will%20be%20consistent.
https://www.autismspeaks.org/sites/default/files/2018-08/Toilet%20Training%20Guide.pdf
https://www.marcus.org/autism-resources/autism-tips-and-resources/tips-for-toilet-training
https://www.milestones.org/resources/tool-kits/toilet-training-tool-kit
https://beaminghealth.com/article/the-complete-guide-to-potty-train-your-autistic-child
https://autismlittlelearners.com/free-toileting-sequence/

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Author Triveni Goswami Vernal

Triveni Goswami Vernal is an Autism advocate, registered Special Educator (CRR A64010) and an Independent Researcher. Her areas of interest include Autism, Disability Rights, Gender, Art and Northeast studies. She is a mum to an 11 year old on the Autism Spectrum.

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Creative representation for this blog is done by our extremely talented CreativeSaathi associate Kabir Vernal