One of the most common questions I receive from families with a child diagnosed with autism is: “How do I know when my child ready for toilet training?” My first step in guiding families through the process of toilet training is to start with an evidence-based readiness checklist.
Dr. Michael Luxem developed a toilet training readiness checklist adapted from Azrin & Foxx Toilet Training in Less than a Day (1974). He includes the following general areas of readiness:
1. Development & Compliance: Can your child independently follow simple one step directions (e.g., come here, sit down) or locate any of their own body parts (e.g., touch nose)? Toilet training involves the delivery of many directions from caregivers including to pull down pants, sit down, stand up, wash hands, and more; therefore, it is important that the child has some receptive language skills (understanding of spoken language) to be able to toilet train successfully. Does the child also have the gross and fine motor skills to be able to pull underwear and pants down and up or wash their hands? If you want your child to be completely independent using the bathroom, it will be important that they have the motor coordination to manipulate their clothing items and operate sink components like faucets and soap containers.
2. Bladder functioning: Does the child completely empty the bladder rather that going a little bit at a time? Is the child able to stay dry for longer periods of time? These questions attempt to determine if the child has some control over the muscles involved in urination which will be helpful during toilet training. If the child does not, coordination with the child’s pediatrician or medical provider may be needed to rule out other medical issues.
3. Bowel functioning: Does the child have regular bowel movements of normal size and consistency? Issues regarding bowel movements can significantly interfere with a child’s ability to be fully toilet trained and should be resolved prior to initiating intensive toilet training. If the child suffers from chronic constipation, pain associated with bowel movements could lead to pain when the child sits on the toilet during training and result in avoidance of the bathroom and the toilet training program.
4. Potential complications: Is the family under significant pressure to toilet train or does the child have any serious ongoing medical issues that might interfere with toilet training? It is important for families to understand that toilet training may occur very quickly for some families and may take significantly longer for others. Having a set deadline can lead to excessive pressure on the child to gain a skill, which could have negative effects on the process, so it’s helpful to start toilet training when the family is not managing any major issues at home and the child is exhibiting good health.
Once the checklist is complete, I review the results with the family and discuss next steps. If the child appears ready to move forward with toilet training, I like to review the following aspects of toilet training to ensure the family is also ready to proceed.
- Professional Support: It is vital that families have the support of a professional (psychologist, BCBA) when starting an intensive toilet training program. Every child moves through the process at their own pace and may present with unique complications. When you have the support of a clinician, that individual can be there to help you quickly problem solve or modify your toilet training plan to keep progress moving forward. That individual can also provide you with immense resources such as data sheets, reading materials, and other needed supplies before you begin toilet training. Starting and stopping the toilet training process can lead to increased difficulties in a child becoming fully continent so it’s helpful to be as ready as possible from the beginning.
- Time: Toilet training may take a day or possibly several weeks/months so ensure your family is ready to invest the time needed to fully toilet train the child. Having multiple caregivers involved can be important to ensure that no one person is responsible for all the trips to the bathroom or all accident clean-ups. Caregivers should plan to have some time each day to devote to toilet training; one or two days a week will typically not lead to successful outcomes.
- Accidents: I like to ensure that caregivers understand many accidents will happen in the beginning, and it’s important that the child is not punished in any way for those accidents. Accidents are a natural part of the toilet training process so the family will need to prepare for them. I often suggest trying to set up a space near the bathroom where the child can play that will allow for easy clean up (in a tiled area of the house rather than carpeted room).
- Communication: One of the most overlooked parts of toilet training is determining how the child will communicate the need to go to the bathroom. The end goal is for the child to be able to request to use the bathroom, not be on a rigid bathroom schedule that is always involves adult initiations to go. While some children may be able to ask verbally to go to the bathroom (e.g., “I need to go potty.”), other children may need an alternative communication system such as a picture card or manual sign to request the need to go. The mode of communication should be determined prior to initiating toilet training, and all individuals involved in the child’s care should know how to prompt the child to communicate the request. It is also important to choose a modality that the child can be successful with (e.g., choosing a manual sign for a child with very poor motor skills would not be recommended).
- Collaboration: If the child is receiving therapy services like applied behavior analysis, occupational therapy, physical therapy or is attending school, families should let their child’s providers know when they are planning to start the process of toilet training so that all members of the child’s team can be taking them for toilet sits and working on communicating the need to go at the same time in the same manner. If the child is only toilet training in one location, this could lead to difficulties in full toileting independence across locations throughout the day.
- Supplies: Below is a list of common toilet training supplies for families.
o 6-8 sets of gray or other light color underwear and pants (Avoid white or very dark colors which will be difficult to notice accidents as they are occurring).
o Crocs or similar close-toed shoes that are easy to clean when accidents happen
o Toilet training seat insert and/or steps up to the toilet if needed for the child to feel comfortable while sitting
o Small steps to access sink
o Books or other small toys the child can hold while sitting on the toilet
o Supply of preferred salty snacks to increase thirst
o Supply of your child’s various preferred drinks (avoid giving large amounts of juice and milk as this can lead to diarrhea or constipation)
o Kitchen timer to keep track of when to take your child to sit
o Pen and paper to keep track of successes and accidents as well as the timing of those events
o Cleaning supplies for accidents
o Urine alarm (could be needed to help teach a child to contract bladder muscles and is used for both daytime and night time accidents)
o A highly preferred item (edible or tangible) that can be delivered easily for toileting successes, which the family will only use for toilet training. For example, if the child loves gummy bears or stickers, one bear or sticker could be delivered for successes on the toilet and only provided at that time; the item is restricted in all other settings.
Toilet training can be a very intensive and difficult process, but it can be completely rewarding when your child is able to use the bathroom independently. Being fully prepared before starting the process helps families and their child immensely and improves the outcomes of the process as well. If you have additional questions regarding toilet training, contact Dr. Hoppe today to request a consultation session. NTX Psychological Services, PLLC is located in McKinney, Texas.
This article offers a wealth of valuable information in preparing for and succeeding in toilet training children with autism. I appreciated the detailed list of supplies and the attention to all the facets of toilet training that need to be considered before attempting to toilet train a child with autism.