Effective Interventions for Toilet Training Children with Developmental Disabilities

 By: Hallie Rosenthal, Sabrina Riera & Suzi Naguib, Psy. D. 

Are you experiencing difficulty in toilet training your child who is diagnosed with an Autism Spectrum Disorder (ASD)? If so, you share a common experience with many parents of children with ASD. Research shows that while typically developing children are usually toilet trained between ages 2–3, toilet training is often delayed and at times never achieved in children with ASD 4. Given these findings, it is not surprising that the state of Michigan, through Medicaid and the Family Support Subsidy (FSS) Program, provides financial assistance to families with a child with severe developmental disabilities to aid in the cost of special care expenses, including diapers when deemed appropriate. Incontinence in children with ASD can further exacerbate challenges with the child’s hygiene, self-confidence, and acceptance4. Various toilet training interventions have been developed specifically for children with developmental disabilities including ASD. The achievement of proper toileting allows children to participate in daily activities, specifically at school. 

Before toilet training can effectively begin, a child must show that they are ready. If your child is showing any of the following signs, it may indicate that they are ready for training2:

  • toilet training autismAsking to have their diaper changed
  • Formed bowel movements
  • Indicating that their diaper is wet
  • Physical ability to sit and hold their body upright 3
  • Staying dry throughout the night
  • Child has a mental age of 18-24 months
  • Remaining dry for 1-2 hours throughout the day

In addition to these signs, if your child is at least 4 years old and/or does not have any medical restrictions, they may also be ready for training 2.

Before you begin training, it is important to understand the desired outcomes and target behaviors for toilet training. There are two main goals of toileting: (1) recognizing the need to go to the bathroom and (2) mastering the behaviors associated with using the toilet 3. These behaviors include: waiting until on the toilet to urinate, undressing, sitting on the toilet, correctly using toilet paper, flushing, re-dressing, and washing hands 4. While this list of behaviors may seem daunting, success is within reach! Included below are descriptions of existing behavioral interventions that have been found to be effective in toilet training children with ASD:

Priming and Modeling
Priming is a teaching method that involves providing information that will help someone perform a task or activity. The idea is to present information before completion of the task in order to allow the person to become familiar with what is expected. This consequently increases the likelihood that they will complete the behavior appropriately 1. Given that children with ASD may require more time to learn a new task 1, video priming is suggested as a toilet training method because some children with ASD have keen visuo-spatial abilities 4. One study tested the use of an animated toilet training video before the onset of training, finding that it increased the speed at which a child acquired toileting skills 3. A video also minimizes the need for oral instruction, which is especially helpful for children who are non-verbal 4 .

Positive Reinforcement
Because toilet training is a difficult task for most children, it is important to recognize and praise your child for their achievements. Reinforcement-based training involves rewarding your child when they successfully learn and complete a toilet training behavior 3 .The first step in this intervention is choosing a reward to use as reinforcement. Make sure to choose a reward that your child will respond to and like. You should also keep in mind that all caregivers (i.e. parents, teachers, therapists, babysitters) should be involved in the reward system; however, all rewards do not have to be the same 2. When rewarding your child, be sure to do so in small amounts and limit access to the reward outside of successful toileting behaviors. This will help ensure that your child stays motivated and interested in earning the reward2. For example, if M&M candies are chosen as the reward, then your child should only have access to 2-3 M&Ms for engaging in successful behaviors. Also ensure that this special treat is reserved only for completion of toileting tasks.

Once a reward has been established, it is important to have specific target behaviors for your child to achieve. For example, your first goal may be for your child to effectively flush the toilet after each toileting attempt. Receiving the reward should be contingent upon completing these specific goals 2. If your child asks for the reward at other times during the day, remind him or her specifically what they need to do to receive the treat. Lastly, be sure to provide behavior-specific praise and a lot of attention, including hugs, high-fives, and cheering throughout the entire process 2.

Positive Practice, Overcorrection, and Restitution
Positive practice, also known as overcorrection, and restitution, are considered “aversive procedures” because they are used after an accident occurs with the goal of preventing such mishaps from occurring in the future. Although reinforcement procedures are generally preferred, these practices are shown to be successful and have fast rates of learning proper toileting behaviors 3. The first step of this intervention involves “environmental restitution”, which means that the child helps to clean up the site of an accident. After restitution, the child is made to sit on the toilet a number of times, walking from the site of the accident to the toilet. The main goal here is to teach the child the proper toileting behaviors that are desired in place of having accidents 3.

Schedule Sittings
Scheduled sittings is a practice that involves designing a schedule of specific times during which your child will sit on the toilet. You can create this schedule in one of two ways: (1) observe your child’s bathroom behaviors for a period of 1-2 weeks, paying attention to the times in which they urinate or defecate in their diaper or (2) identify regularly scheduled times, such as every 60 minutes. Regardless of how you create the schedule, the sitting procedure will be the same. At the designated times, place your child on or near the toilet for a set amount of time (e.g., 5-15 minutes). If the child successfully urinates in the toilet, make sure to provide the appropriate reward and then allow the child to leave the toilet area 3.

Hydration
This intervention involves increasing your child’s access to preferred fluids 3. It is typically used in conjunction with the scheduled sitting procedure. Increasing fluid intake will increase the likelihood that your child will urinate during the scheduled times and continue to engage in the positive behavior. It is important to keep in mind, however, that risks such as electrolyte imbalance are possible, so be sure to seek the advice of a doctor before initiating this practice 3.

The above-mentioned interventions have been shown to be effective in clinical studies of children with autism. It is important to note that these interventions are typically provided by or in conjunction with a behavioral psychologist. As such, we strongly recommend that parents consult with a professional prior to implementing some of the above interventions. Sunfield Center psychologists are available to help address toilet training challenges and other issues faced by families of children with autism. To schedule an appointment, please call us at (734)-222-9277.

References
1 Bainbridge, N., & Myles, B. (1999). The use of priming to introduce toilet training to a child with autism. Focus On Autism And Other Developmental Disabilities, 14(2), 106-109. doi:10.1177/108835769901400206
2 Coucouvanis, J. A., 2008. The potty journey: Guide to toilet training children with special needs, including autism and related disorders. Shawnee Mission, KS: Autism Asperger Publishing Company.
3 Kroeger, K. A., & Sorensen-Burnworth, R. (2009). Toilet training individuals with autism and other developmental disabilities: A critical review. Research In Autism Spectrum Disorders, 3(3), 607-618. doi:10.1016/j.rasd.2009.01.005
4 Keen, D., Brannigan, K. L., & Cuskelly, M. (2007). Toilet training for children with autism: The effects of video modeling category. Journal Of Developmental And Physical Disabilities, 19(4), 291-303. doi:10.1007/s10882-007-9044-x
5 Luiselli, J. K. (1997). Teaching toilet skills in a public school setting to a child with pervasive developmental disorder. Journal Of Behavior Therapy And Experimental Psychiatry, 28(2), 163-168. doi:10.1016/S0005-7916(97)00011-6