Autism toilet training dilemma

Today’s response is by behavior analyst Daniel W. Mruzek and graduate student Angeles Nunez, a candidate for certification as a child-life specialist. Both work with children at the University of Rochester Medical Center, one of 14 sites in the Autism Speaks Autism Treatment Network (ATN).

I’m trying to toilet train our 6-year-old, who has autism. But every time I try to take her to the bathroom, she fusses and fights all the way. So far, I’ve just given up. Help!

Understanding autism bathroom issues

Thank you for asking! While toilet training can be anxiety provoking – or just no fun – for any child, it proves particularly challenging for many children on the autism spectrum. We’re glad to offer a number of strategies to help your daughter.

Ruling out medical conditions and identifying the “why” behind the behavior

If you haven’t already, we strongly recommend that you begin by talking with your daughter’s pediatrician about her resistance to toileting. It’s important to ensure there are no medical issues complicating her training.

• Along these lines, might your daughter’s reluctance involve painful constipation? It’s a common issue among children with autism. So if painful bowel movements may be part of the problem, please consult your daughter’s doctor and see the Autism Speaks resources below. They include a constipation tool kit for parents and several related advice posts.

Once medical issues such as chronic constipation have been ruled out, let’s look closer at why your daughter fusses and fights when you try to take her to the bathroom. Behavior analysts call this process a “functional behavior assessment” because we’re trying to understand the underlying function, or purpose, that the behavior serves.

• We begin by looking at the person’s learning history – the prior experiences that may have shaped the behavior.
• In your daughter’s case, we probably want to consider the elements of her toileting routine that she has found unpleasant. For some children on the autism spectrum, this can involve overwhelming or otherwise unpleasant sensory experiences. Common examples include the loud flush of the toilet, the feel of a cold, hard toilet seat or an unsteadiness on the toilet seat that leads to a fear of falling in or off the toilet.
• You know your daughter best. Have you observed any reactions that suggest she might have such sensory aversions to toileting?
• It’s also common for children with autism to get upset when interrupted from their routines and favorite activities. We’ve worked with children in special-education classrooms who loathe trips to the bathroom because of they fear missing snack or computer time. Again, you know your daughter best. Does this sound like a challenging area for her?
• It may be that repeated, unsuccessful trips to the bathroom simply feel like a frustrating waste of time to your daughter. This may be particularly true if she has yet to actually pee or poop in the toilet. How frustrating!

Finally, it’s helpful to explore how you and others might be inadvertently reinforcing your daughter’s oppositional behavior. If her challenging behavior has allowed her to avoid toileting – even some of the time – that can reward and strengthen the behavior. So can attempts to bargain, plead, cajole or just throw your hands up and say, “Okay, you win!” As parents and teachers, we’ve all been there. But in these situations, our reactions may escalate instead of diminish the challenging behavior.

In summary, we need to look at the aspects of toilet training that your daughter may dislike as well as how your response to her protests that may reinforce her challenging behavior.

Through our functional assessment, we develop a good hunch – or a hypothesis – to address the “why” behind a problem behavior. Now we can develop strategies and supports that encourage the functional, or helpful, behaviors that will help her master toileting.

We recommend a combination of two approaches:

1. The first, which we called “antecedent support,” involves strategies that make the experience more doable – even enjoyable – for your child.
2. The second approach is something we call “shaping.” As the term suggests, it involves encouraging behaviors that come closer and closer to the desired skill.

Easing the training experience

Antecedent supports might include one or more of the following:

• If she’s feeling insecure or unsteady on the toilet, place a footstool in front of the toilet and/or a soft training seat on top for comfort and stability.
• Maintain a calm, quiet bathroom environment. This is particularly important in confining or echo-prone bathrooms. Remember, it’s hard to pee or poo when you’re tense.
• Do you sense that your daughter fears missing activities while in the bathroom? Briefly reassure her that her fun activities will remain undisturbed until she returns. Many children who have autism respond best to visual rather than spoken cues. You can make a “PAUSED” or “SAVED” sign with a smiling face to show her that her video or game will be waiting.
• You can likewise use a visual support to indicate that she’ll get a favorite toy or activity immediately after she completes the trip to the bathroom. 
• In our experience, many children who have autism find a task more doable when they can sense the end in sight. Consider a visual schedule that uses pictures to show the steps in the toileting routine and the reward for task completion. (See below.) You’ll find sample visual schedules in the ATN/AIR-P toilet training guide and ATN visual supports guide described above.
• Consider setting a timer for five minutes once your child is sitting on the toilet. Let her know that she’ll be able to return to what she was doing when the time is up. We think that five minutes is a good limit for unproductive time on the toilet. Success isn’t likely after that, and we want to avoid inadvertently turning bathroom trips into a battle of wills.
• We recommend using simple, direct language throughout the training routine. For example, “time for bathroom” or “potty time” paired with a smile and simple gesture is preferable to an ongoing discussion or pleading.

Shaping behavior

As parents and teachers, we tend to have a specific behavior in mind as the goal for our child. A useful approach to getting there is by rewarding each small step as a child approaches this goal behavior.

In your daughter’s case, you might start by asking her to simply walk to the bathroom and touch the door or turn on the light switch. Provide soft-spoken, encouraging praise when she stays on task – even if the attempt is just partially successful. You might also reward her with a treat – be that a favorite activity, toy or small snack.

After practicing this for a few days, explain that the next step is that she walk inside the bathroom. Again, reward her success – or even a partial attempt.

Next, you might ask that she briefly sit on the closed toilet lid with her pants still up. More praise and rewarding.

In this way, you are helping her reach the goal of sitting on the actual toilet seat with her pants down – and then gradually increasing the time she sits there up to five minutes.

The principle is to start with what your daughter will tolerate and reinforce her attempts at each step of a successful toileting routine.

If your daughter sees a psychologist or behavioral therapist, he or she can be a great help with this approach, which is sometimes called “systematic desensitization.”

Don’t reinforce unwanted behavior

Just as you provided calm and encouraging praise for your daughter’s attempts, it’s important to avoid responding when she fusses or fights. Remember even a negative response such as scolding, teasing, discussing or pleading can inadvertently reward challenging behavior.

A better strategy is to calmly ignore the challenging behavior while keeping an eye on her. Be prepared that her challenging behavior may temporarily escalate until she realizes it no longer elicits a response.

Finally, be sure to use lots of positive and immediate reinforcement for incremental progress. Smiles, hugs, high-fives and small, tangible rewards will help encourage her participation in her toilet training routine.

We wish you, your daughter, and your entire family all the very best with the toilet training. Thanks again for your great question.

Related resources:

• Seven toilet training tips that help nonverbal kids with autism
• Help for child with autism who forgets to use toilet when distracted
• Toilet Training: A Parent’s Guide
• Autism Speaks ATN Visual Supports Tool Kit
• Autism Speaks ATN/AIR-P Guide for Managing Constipation in Children
• Autism, Probiotics and Dietary Fiber: Q&A with GI Specialist Tim Buie

Editor’s note: The above information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional and/or behavioral therapist.