The subject of toilet training is usually brought to the attention of a physician as they start a conversation with parents regarding problematic behaviors.  The conversation will usually veer into a narrative of a young child who has problems at a day care center or elementary school because he/she is not toilet trained. In some cases, “accidents” may happen even after the child has been toilet trained for years. Not surprisingly, school personnel often find themselves ill prepared to cope with these accidents.  In this era of sexual vigilance some teachers may require that the changing of diapers to be included under an IEP before they take any action!

Toilet training is a common problem in autism.  There are books (see below) and helpful blogs written on the subject. The National Autistic Society has offered guidelines towards toilet training success. One of the better guides to toileting was written by Stacy Blasko from the Kennedy Krieger Institue.

For many autistic individuals a major threshold for toilet training is their inability to understand their own body sensations:

“Difficulties with interoception help to explain why I have a hard time identifying my exact symptoms when I am sick, why sometimes I seem to eat snack after snack without feeling full and why I get upset so quickly, because I don’t feel it until I’m already far into the storm of the discomfort and frustration. —Chloe, 23-year-old with autism (For those interested in more information about interception, please see our blog on the subject, “Interoception: The Eight Sensory System”).

Toilet training requires a certain level of development wherein a person recognizes the urge to void and desire to be cleaned after urination/defecation. Making all of this into a routine plays into the strengths of an autistic individual.  Prepare a schedule, a visual guide offers the best the best way to reinforce learning. You can get lots of instructional visual examples from the internet.

Have the bathroom always prepared (footstools, children’s commode). Be attentive to sensory issues, for some individuals  the presence of incandescent lights in the restroom, cold toilet seat, and the swooshing sound of flushing may be hurtful.

For some ASD chldren, toileting may offer an opportunity to enhance their areas of interest. A kid interested in astronomy may find toilet paper a useful way to measure relative distances between the planets (see below). With the internet, the possibilities for performing toilet paper science seem limitless.  All of these projects may indirectly enhance a child’s interest in toileting.

Be supportive and establish positive communication and reinforcement about toileting. Validate immediately after a successful attempt. Praise may come with stickers or some favorite food.

Be aware that dietary peculiarities in your child may promote constipation and toileting refusals. Lack of fiber in the diet and sedentary habits promote constipation. Some autistic children receive vitamin and mineral supplements in large amounts which themselves may change bowel habits.  In addition, some autistic individuals may suffer from medical conditions (e.g., inflammatory bowel disease) which need treatment more than toilet training. In some cases individuals with inflammatory bowel disease may receive “Can’t wait cards” for access to toilets in times of urgency.

References

Casanova MF. Benefits of a fiver diet for autistic individuals

Casanova MF. Autism: Antibiotics and the Microbiome

Fleming E, MacAlister L. Toilet training and the autism spectrum (ASD): a guide for professionals. Jessica Kingsley Publishers, 2015.