Toilet Training the Challenged Child

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Toilet
Training the
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Challenged Child
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Written
by Kyra Harris in consultation with Dr. John Howard
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Preface
The number of potty training books on the market are endless. Some potty pros suggest training
your child at 3 months while others advise waiting until three years of age. With plans that boast training
your baby on cue, having your child trained in a matter of days or fixing incontinence by throwing a potty
party, it‟s understandable why many parents encounter problems deciding who to trust and where to start.
What makes finding the right plan even more difficult is catering to the strengths and weaknesses of
children with autism and developmental delay. Forgo the idea of trying to fit your child into a specific potty
plan. Instead try to embrace the idea of designing a potty plan to specifically fit your child. We all know that
no two children are the same, which is especially true for children with cognitive and physical disabilities –
so then why is it that we try to fit them all into the same potty plan? The purpose of this pamphlet is not to
promote one single potty training method. Instead the pamphlet provides a survey of resources available
on the topic of potty training children with autism and developmental delay to help you design a plan which
is right for your unique child.
Be aware: when it comes to potty training, there are no definitive answers. There is no one plan
which can work for all children. Once checking out this pamphlet, take the next step by checking out the
suggested resources at the very end. The resources will help you gather more information regarding potty
plans and tips which may work for your child. Always remember to consult your child‟s support staff
(physicians, psychologists, occupational therapists, support workers) before starting the potty training
process. They will be able to offer you important advice regarding when to start, what to aim for and how to
get there.
Introduction
Changing diapers can be a pain. Every parent is forced to do it and every parent envisions the day
when their child will use the toilet on his or her own. However, for some parents this day comes sooner than
others. For the parents of children with disabilities, toilet training takes more time, more patience and more
dedication. An average child with Down syndrome doesn‟t gain daytime bowel control until age 16 years
and daytime bladder control until 17 (20). Before you even begin to decide if your child is ready, let go of
any preconceived potty notions. Toilet training children with disabilities may take longer, but it‟s well worth it
when you see your child becoming more independent. So start making it a habit to celebrate your child‟s
daily successes and keep the bigger picture in the background.
There are many factors which will contribute to your child‟s potty training success. The 2 most
important factors are: correctly determining if your child is ready to begin the potty process and designing a
potty plan which is specifically suited for your child. This pamphlet will provide you with plans and tips
offered by professionals and parents on the topic of toilet training the autistic or developmentally delayed
child including sections on readiness, planning, rewards, accidents and more. However, these are just the
basics. For more information regarding any of the opinions offered in this pamphlet, please check out the
resources themselves. And always remember to consult with your child‟s support team: physicians,
psychologists, occupational therapists etc.
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Before starting any potty training plan there are 5 key
things you must remember:
1) Expressing anger and reprimanding your child will only get
you farther away from success: Frustration is a natural reaction to potty
training accidents. It can be hard to keep your cool when having to clean up
messes while worrying that your child may never learn how to use the potty.
However, your child‟s success is contingent upon you dropping that frustration at
the bathroom door. Reprimanding your child for their accidents is guaranteed to
prolong your child‟s potty training process by making her reluctant and scared to
go. If you feel you can‟t remain neutral during the potty process that‟s okay;
consider having your partner or family member take the reins. Just remember all
of the messy and frustrating days will be well worth it once you see your child
begins taking the next steps towards independence.
2) Give it time: With mounting peer pressure (often pressure from school and care facilities) to train your
child ASAP, it can be hard not to place too many expectations on your child. Before you get too caught up
in the potty training hype, realize that every child is different. While some children may potty train in a few
hours, the other 99.999% don‟t – and that‟s okay! The time it takes your child to become toilet trained has
no correlation to your child‟s IQ or your skills as a parent. Remember that toilet training a child with
developmental delay or autism is a much more drawn out process. Whatever length of time it takes for your
child to toilet train is fine. Don‟t think in terms of days, weeks or years – think in terms of accomplishments.
Approach potty training with the intention of relishing your child‟s small potty accomplishments daily rather
than becoming frustrated by the fact that your child is not 100% potty trained quite yet.
3) Set achievable goals:
Your dream may be to see your child out of diapers and independently
pottying in the next 6 months, however, this may not be realistic. When laying out a potty training plan, it‟s
most important to set achievable goals. Parents all want to see their children reach their full potential.
However, placing unrealistic expectations on your child will only increase the likelihood of turning him into a
discouraged, reluctant trainer. If you‟re not sure how to set physically and developmentally appropriate
goals for your child, talk to your his support staff. Don‟t try to fit your child into a potty training program, try
to design a toilet training program that fits your child.
4) Don‟t start until both you and your child are ready:
Diapers are a huge hassle. It makes
perfect sense that you may be frustrated with continuing to change your child while their peers and siblings
begin to toilet themselves. As frustrating as it may be to keep your child in diapers, if you begin toilet
training before your child is ready, this process will only become more frustrating. Although your seven year
old child may be the only one in her class still in diapers this may be perfectly appropriate for her
developmental age. Chronological age is not an indicator of potty readiness. Your 7 year old may seem
physically ready but if her developmental age is equivalent to a 2 year old, realize it‟s just not time quite yet.
Don‟t forget to pick a time when you feel you are able to put in the time and
effort to begin the process. Be careful to avoid periods of high stress at home,
work and school.
5) Get everyone on board: Whether your child has a support team
of twenty or two, make sure to get everyone on board. It‟s preferable for one
parent to teach all the potty training lessons but life is not compartmentalized.
In the modern world of day jobs, day care, babysitters and big blended
families, in most instances potty teaching solo doesn‟t create the consistency
your child needs to be successful. The best way to get everyone on board is to
create a handout that summarizes your child‟s plan.
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Readiness
There are many different opinions regarding when your child should start potty training. When deciding
when to start potty training you want to consider his physical, emotional and cognitive readiness not his
chronological age. Below are a number of toilet training readiness signs provided by various professionals.
Your child doesn‟t need to demonstrate all of the readiness signs -- but if he‟s not meeting a lot of them, it‟s
probably best to follow your gut and give it more time.
1) Health
Before you go any further you must make sure that your child‟s bowels and bladder are in perfect health. If
you think there‟s a possibility your child has a urinary tract infection (burning, low back pain, blood in urine)
go no further until you consult your doctor. Also, be on the look out for constipation. If your child is straining,
holding back stool, defecating less than once every other day, passing small balls of stool or “pop can” size
stools she may be constipated – do not start training until consulting your doctor. Constipation can also
present with the constant oozing of clay-like dark stool. If your child has any type of virus or bacterial
infection don‟t start training yet – wait until your child is in good health.
2) Longer periods of dryness
Staying dry for longer periods of time during the day and throughout naps is a
sign of physical readiness. If your child can stay dry for between 1-2 hours, he‟s
developing the physical readiness necessary to start training.
3) Awareness of needing to void:
Does your child tell you when she is eliminating in her diaper or when she feels
the need to go? Does she stop playing to eliminate? These are both very good
signs. It means that your child has begun to understand the sensation associated with “needing to go”. If
your child lets you know that she is urinating or defecating in her diaper, do not reprimand her. Instead
praise her for recognizing the proper sensations associating with using the potty.
4) Awareness of being wet or dirty:
If your child communicates that he would like to be changed or attempts to change himself, this is a very
good sign. This lets you know that your child recognizes when‟s he‟s wet or dirty and doesn‟t like it. Feeling
uncomfortable in a wet or soiled diaper can be great motivation for some children! Make sure that you
change your child as soon as you notice he‟s eliminated. If you leave him in dirty diapers for too long he‟ll
soon get used to the feeling of being wet.
5) Potty-Elimination Connection:
In order for your child to successfully potty train, she‟ll need to make the connection between peeing and
pooping and using the potty. Your child may demonstrate his understanding of the potty-elimination
connection by going into the bathroom to void, wanting to be changed in the bathroom, taking feces from
his diaper and putting them into the toilet or showing a general understanding of the potty procedure. To
help him develop his bathroom-elimination connection, begin changing him only in the bathroom. Keep all
potty related supplies (diapers, clean underwear, wipes, etc.) in the bathroom as well. Don‟t worry if your
child doesn‟t yet understand why we use the potty, for some children this will come with practice.
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6) Intrigued by Grown-ups and Grown-up things:
Does your child tell you she wants to be more “grown up”, seem fascinated by grownups or imitates older peers and adults? When you catch your child taking interest in
how grownups use the potty, praise him and tell him how grown up she‟ll be when
she can use the potty all by herself too
7) Enough Time:
Is there enough space in your child‟s daily routine to start the potty training process
and keep consistent? There‟s no sense in beginning the process if your child‟s daily
routine is just too busy to keep consistent. If you don‟t think you‟ll have enough time to begin potty training,
don‟t start just yet. Instead, wait until your child‟s routine gets less busy such as during the summer.
8) Developmental Age:
Try not to consider your child‟s chronological age when deciding if now is the right time to begin potty
training; instead look at his developmental age. If your child is functioning below a two year old level, he‟s
probably not yet ready to begin toilet training. Typically children toilet train between 2-3 years of age,
therefore, until your child‟s developmental age reaches this point starting the process will probably just end
up being messy, frustrating and unsuccessful.
9) Interest in Personal Hygiene:
Does your child take pride and interest in his personal hygiene and appearance? This could be seen as a
distaste for being dirty, an interest in learning how to wash her hands and face, picking out her own
clothing, or generally wanting to be being clean or becoming upset when she soils himself.
10) Physical Capability:
Does your child have the physical capabilities to complete necessary steps in the toileting routine? If your
child has a physical disability as well as a cognitive disability, it‟s best to consult his physical therapist (PT)
or occupational therapist (OT) before beginning training. The OT or PT will provide you with information
regarding your child‟s physical ability to independently get to the washroom, get on and off the toilet and sit
upright for 5 minutes. If your child cannot complete most of the potty steps yet, don‟t begin toilet training.
Wait until you‟ve worked with your child‟s physical therapist or physiotherapist to master the necessary
potty skills or once you‟ve adapted your child‟s environment to better meet his physical needs.
11) Interest in watching others:
If your child is showing an interest in watching other people use the toilet
this is a great sign! Allowing your child to watch you and your family
members use the toilet is one of the first steps of the toilet teaching
process. If you see your child attempt to watch, invite her to do so and
make sure to explain what‟s happening throughout the process. ( 3 )
12) Cause and Effect:
Does your child understand cause and effect? For example, is your child able to understand that if he
urinates in the potty he‟ll get a reward? Until your child can comprehend basic cause and effect if may be
difficult to begin potty training (3).
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13) Agreeability:
Most children go through a “difficult” period during which “no” is the only word to come out of her mouth
and drawn-out tantrums are constant. If your child is throwing prolonged tantrums, now is probably not the
best time to potty train. Wait it out. Most children will grow out of their “tantrum-throwing-disagreeing” phase
after which they‟ll be much more open to learning how to use the potty.
14) Interpret and follow simply instructions:
Being able to comprehend and follow simple potty training instructions is a very important skill to have
before beginning the toilet teaching process. Beyond simply having the ability to interpret instructions, your
child needs to be agreeable and willing to comply with these instructions.
15) Comprehension and Communication:
Can your child communicate with you? Does your child communicate verbally, with visual symbols or by
using an augmented communication device? For accessing potty readiness, determining whether your child
has good communication and comprehension skills is very important . Can you communicate with your
child? Does your child understand your verbal or visual cues? As long as you and your child can
communicate with each other, the method of communication in not important.
16) Outward signs of needing to void:
Does your child display outward signs that let you know he has to go to the
bathroom? These outward signals may be different facial expressions, different
body positions, squatting, dancing, holding his crotch, verbal indications, ceasing
to play while urinating or defecating, or holding back. When you see your child
showing outward signs of needing to void, don‟t ignore it. Tell him immediately,
“You have to use the bathroom right now so we‟re going to go to the potty”. By
recognizing that your child has to go to the bathroom and letting him know, you‟ll
help him to recognize what it feels like when he “needs to go”.
17) Regularity and Larger Volume Elimination:
If your child has begun defecating larger amounts fewer times a day (rather then a little bit all throughout
the day) and seems to be urinating larger volumes at a time, this shows that your child is developing the
necessary physical readiness to potty train. Also consider whether your child is regular. Ask yourself
whether your child is having 1-3 bowel movements a day. If the answer is no, consult your doctor to learn
how to increase your child‟s regularity.
Readiness Recap:
If your child doesn‟t have every number checked off the readiness recap list this doesn„t necessarily mean
she‟s not ready to potty train. Use your gut feeling and your common sense! If you feel like your child is
meeting the majority of the readiness recap check points, your child‟s probably ready! Once you feel your
child is ready to begin the potty training process, it‟s a great idea to double check with her support team to
make sure you‟re both on the same page!
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16 Signs Made Super Simple:
1) healthy
2) extended dryness
3) awareness
4) dislikes wetness
5) elimination-bathroom connection
6) intrigued by grown-ups
7) time
8) developmental age
9) interest in hygiene
10) follows modeling
11) cause and effect
12) agreeable
13) instructions
14) comprehend and communicate
15) outward signals
16) regularity
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How we Poop
Normally we have a “breakfast poop”, “lunch poop”,
and “supper poop” which gather in the descending
colon. The poops join together to form a “poop train”.
This “poop train” travels into the rectum, the part of the
colon just inside the bottom. Here the poop meets two
valves. The first valve is the “I got to go” valve which
lets our bodies know that we have to poop. This valve
opens, allowing the poop to meet the second valve –
the “Not now, I‟m in the kitchen” valve. It is a voluntary
valve that holds the poop until we are sitting on the
toilet. Then we let go of the “Not now” valve and the
poop is pushed into the toilet. All the valves then close
until another poop comes. The “Not now” valve is very
important since it gives us the choice of when and
where to have a bowel movement.
Constipation
Constipation is the build-up of poop in the lower bowel
near the anus. It starts with the child holding back a
“poop train”. The sensation to pass the “poop train”
goes away. Another, then another “poop train” comes.
This stretches the strong muscles surrounding the
rectum, thinning them out. It becomes very difficult to
push the poop out because the muscles are stretched
and weakened. The child must strain a great deal and
may sit on the toilet and not be able to go. The child
will frequently pass huge poops – adult size or bigger.
The other classical sign of constipation is “boxcars”.
Here stool on the top of the huge mass of stool pushes
out little bits of stool out the bottom – causing constant
oozing of stool. So both large infrequent stools and
frequent small pasty stools are both signs of
constipation. Abdominal pain, relatively uncommon, is
often a dull pain below the belly button or in the left
lower abdomen occurring before a bowel movement or
attempt.
Children can become constipated during the potty
training process. This may be because we ask them to hold back their stool until seated on the toilet. If you
notice your child showing symptoms of constipation, don‟t potty train until consulting your physician. If you
notice your child develops constipation during the potty process also consult your physician
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Pee, Poop and the Potty
Before you begin the potty process, you‟ll need to take some of the initial steps of teaching your child about
pee, poop, and the potty etc. Here are three main things you can do to help your child understand his bodily
functions and why he uses the toilet.
1) introduce potty talk or potty pictures:
For your child to follow your instructions during the potty training process she‟ll need to understand the
meaning behind the words you‟ll be using. Pick out specific words and visual cues you‟ll feel comfortable
using consistently throughout the process. Sit down with your child and explain what these words mean. If
your child uses visual cues, signs or symbols introduce these at the same time by matching up potty words
with potty symbols when presenting them to your child. Most importantly remember that whatever words,
symbols or pictures you use must remain consistent.
2) use modeling and imitation:
if your child is able to imitate behaviours use this to your benefit. If you feel comfortable, invite your child
into the bathroom with you when you have to pee or poop. Allow him to watch you or other family members
go to the bathroom(4). At the same time, use the potty words you‟ve already introduced to let him know
what‟s happening throughout the process. Later on in this pamphlet you‟ll learn about creating a visual
schedule for your child to follow when in the bathroom. When modeling, make sure that you follow the potty
sequence that you will outline on your child‟s visual schedule as not to confuse him.
3) Introduce books or movies all about using the potty:
This is a great way to get your child‟s attention and educate her about the potty basics before you start your
potty process(4). However, make sure to pick books that will be right for your child. If your child is autistic,
choosing a potty books written for a 3 or 4 year olds will probably not be most effective. Instead, speak to
your child‟s support team to see if they have any resources available. Toilet Training Individuals with Autism
and Related Disorders provides information regarding how to choose appropriate text to create a unique
potty book for your autistic child which uses visual schedule symbols as illustrations. When choosing books
and videos for children with developmental delay, just be sure to choose materials which are appropriate for
their developmental age instead of their chronological age.
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Creating a potty plan
The next few sections of this pamphlet will cover how to set up a potty plan for your child‟s specific needs,
lifestyle and potty patterns. There are several different potty training outlines which you can customize to
meet your child‟s needs. The one you pick depends on: your lifestyle, the amount of effort you can afford to
put into the program and your child‟s level of development and disability. The two main potty training
programs that will be covered in the next sections are: Habit Training and Intensive training.
Habit Training
Habit training works by setting up scheduled toilet trials based on your child‟s elimination
patterns. Based on the opinion of Toilet Training Individuals with Autism and Related
Disorders, habit training is most effective for the child who has a developmental age of
three or younger, or has a developmental age of above three but hasn‟t responded to
regular toilet training methods or seems to have no awareness of “needing to go” (21).
Habit training is not an overnight process and it does require a lot of dedication and consistency. If you feel
that your lifestyle would not be able to support a consistent longer term potty program you may either want
to consider intensive training or wait until more time opens for the potty program. The first step in getting
ready for habit training is the monitoring stage.
Monitoring Stage:
Most potty pros suggest monitoring your child‟s elimination patterns consistently for two weeks (2,3,15). If
you feel your child‟s patterns are irregular during monitoring due to stress or illness continue the monitoring
period for an additional two weeks. Use the attached charts in order to monitor your child‟s urination and
defecation. When you begin monitoring if you have already started potty trials, keep consistent; if you have
not started potty trials, do not begin them until you‟ve finished the monitoring stage (15).
Important steps:
1) check your child for dryness every half hour or hour
2) if already toilet training don‟t stop – if not, don‟t start
3) at night don‟t wake up child to check
4) check in morning
5) if child has already started toilet training note if in the toilet or in pants
Is it just about pee and poop?
Many children have elimination patterns that are time related. There are some children whose
elimination patterns revolve around eating, sleeping and physical activity. Therefore, during the
monitoring stage highlight when your child eats, drinks, sleeps and participates in physical activity (5). If you
notice that there‟s a correlation between eating or drinking and elimination, increase your child‟s intake
before a scheduled toilet trial (2). If you find that your child‟s intake seems to be scattered throughout the
day, try to be more consistent. The more consistent your child‟s intake is, the more consistent your child‟s
elimination will be (21).
How often do I check?
If you have the time to check your child‟s diaper every 30 minutes this is preferable, however,
not everyone will have this freedom. Daily life can get in the way of monitoring that frequently. If
you predict monitoring that often will be hard to keep consistent, check every hour instead. The
most important thing is that you keep consistent by checking for wetness throughout the whole day, every
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day for two weeks. If your child has begun toilet trials already it can be helpful to indicate when your child
eliminates in the toilet and in his pants(15). For night time wetness it is not necessary to wake your child up
to check his wetness or dryness. The best bet is to check before your child goes to bed, when you go to
bed and first thing in the morning.
What happens when real life interferes with monitoring
It‟s not easy to devote your whole day, everyday for two weeks to monitoring your child‟s
elimination patterns but it is important. With knowing your child‟s elimination patterns you won‟t
have a good idea of when to put her on the toilet. Toileting at specific intervals with no
consideration for your child‟s patterns is an option but it may also decrease your child‟s
chances of having accidental successes on the toilet. Most children don‟t immediately
understand the connection between the potty and elimination. This needs to be
developed by rewarding accidental successes which happen when you put your child on
the toilet at the right time. By knowing your child‟s elimination patterns you have a better
chance of getting her in the right place at the right time. This does not mean that you
have to single-handedly be in charge of monitoring. If your lifestyle is busy and doesn‟t
afford time for consistent dryness checks elicit help. If you have to ask the babysitter to
devote a few more hours a week during the monitoring period to make sure you do a
good job of keeping a consistent record it‟s well worth it. If your child is in an integrated
program at school, it may be harder to keep the records accurate during the day. Discuss this with your
child‟s teacher, educational assistant and administration. Try emphasizing the importance of the monitoring
stage in the potty training process and how much easier it will be for everyone once your child stops
wearing diapers.
What if monitoring just doesn’t fit with my lifestyle?
As stated earlier, there are no definitive answers when it come to potty training. There are some
pros who disagree with toilet training on a timed schedule and completing the monitoring stage.
They feel it‟s just too difficult and may make it harder to teach self-initiation. Look for plans
towards the end of this section which do not use the monitoring stage.
Analyzing Your Child’s Elimination Records:
Begin by totalling up the total number of times your child urinates and defecates in the day for each day of
monitoring. Next for every time interval, total up the number of eliminations your child had within that time
period for each week (eg. If you‟re using a 30 minute interval you would total up the number of pees and
poops your child had for the whole week between 7:30-8:30, next 8:30-9:30, next 9:30-10:30, next 10:3011:30...).
Yes. My child does have a fairly regular schedule. There
are specific times of day that my child typically goes.
Now it‟s time to put together your child‟s potty schedule. From the potty charts pick out the 4 - 5 most likely
times your child urinates in the day and the most likely 1-3 times your child defecates in the day. When
scheduling toilet trials, you should make sure not to schedule the toilet trials less than 90 minutes apart
(15). There are numerous opinions regarding how soon you should put him on the toilet before your child‟s
predicted time of elimination; however, you know your child best. The suggested range is between 5-30
minutes, so choose what you think works best for your child. If your child typically has only one poop a day,
once she poops discontinue the rest of bowel trials. Subsequent attempts would likely be unsuccessful if
the child has had her stool for the day. If you are finding that her stooling or urination is at a different time,
wait a week before changing the schedule. It‟s best not to change routines too often.
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Recap:
1)
2)
3)
4)
pick 4-5 urination times and 1-3 defecation times
potty between 5-30 minutes before scheduled times
if your child typically has only one poop a day, once she poops discontinue the rest of bowel trials
wait one week before changing schedule
Frequently Asked Questions:
It takes quite a while for me to prompt my child to enter the bathroom, take off her pants and
sit on the toilet. How close to her predicted time of elimination should I begin prompting her?
If it takes you a long time to get your child seated and relaxed on the toilet, your best bet is to begin
prompting your child 30 minutes before her predicted time of elimination.
My child doesn’t seem to be having many successes on the toilet, and his patterns have
changed quite a bit since the monitoring stage. Should I reschedule his toilet trials to meet his
new elimination patterns?
If you‟ve been using the same plan for more than a week, feel free to change the toilet trial schedule to suit
your child‟s new elimination patterns. If you haven‟t been using the plan for a week yet, give it some more
time. If after a week your child still hasn‟t settled into the schedule feel free to change it to better fit his
patterns.
Every time I take my child to the bathroom, we’re in a rush to get her there on time and she
usually ends up either having an accident on the way. What should I do?
It seems as if you‟re probably waiting too long before bringing your child to the toilet. Instead try bringing
her a few minutes earlier and see if this makes a difference. If it doesn‟t seem to make any difference and
she‟s not having any successes on the toilet consider that your child may not be physically ready to start
toilet training. Consult your child‟s support staff and take a break from the process for a while as her body
continues to mature.
About a week ago I started bringing my child to the bathroom 15 minutes before his predicted
time of elimination. Almost every time he gets restless, gets off the potty and then urinates in
his diaper ten minutes later. What should I do?
It seems as if you‟re probably bringing your child to the bathroom too early. Next time try
waiting an extra 5-10 minutes and see if that makes a difference. If it doesn‟t your child
may not be relaxing enough while on the toilet to eliminate. Try some of the relaxation
suggestions seen later in this pamphlet, such as listening to music, playing with tactile toys
or reading a book together.
No. My child does NOT have a regular schedule. There are NO specific
times of day that my child typically goes.
If your child does not seem to follow any time related patterns, check if your child‟s elimination patterns are
linked to eating, sleeping or physical activity. For each day, calculate the time between activities and
elimination. If you notice a pattern and your child‟s elimination seems to be linked to specific activities do
one of the following:
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1) Setting up a time based schedule:
The following plan creates more consistency by taking your child to the toilet after the same activities and at
the same time every day.
a) Schedule related activities at the same time each day.
E.g. Julie urinated 20 minutes after drinking large quantities and 15 minutes after eating meals. Therefore
Mum and Dad decided to schedule meals at the same time each day.
b) Schedule potty trials based on how long it takes you to prompt your child to
go to the bathroom and how long after the activity she typically eliminates. This
is something you may have to play around with to get right, but aim to begin prompting your child between
5-30 minutes before she typically eliminates.
E.g. Julie‟s parents knew that it took her a good ten minutes to prompt her to go to the bathroom, get
undressed and sit on the potty. Therefore, Mum and Dad scheduled potty trials right after Julie‟s meals.
That way they‟d be able to get her there a few minutes early before she‟d hopefully have to poop and pee.
What Julie‟s parents found was that taking Julie to the toilet right after her meal seemed to be a little early.
Typically Julie got off the toilet and then eliminated in her diaper a few minutes later. So, Julie‟s parents
modified the plan. They asked Julie to help clear the table right after dinner and once all the plates were
cleared off the table, Julie and her Mum would go to the bathroom. What Julie‟s mother found was that
waiting a few extra minutes meant that she was able to get Julie to pee on the toilet 2-3 times per day.
Once Julie began regularly eliminating on the potty at these times, she began self-initiating after she
finished helping clear the table and at other times of day such as after snacks.
2) Setting up an activity based schedule:
If you know your child has to urinate or defecate 10 minutes after eating or drinking, take your child to the
potty as soon as he finishes eating or drinking. Instead of scheduling your activities around specific times to
bring your child to the potty, focus on how soon after activities your child typically eliminates. When you
bring your child to the potty will not be based on a clock but rather his activity patterns.
My Child’s Patterns aren’t activity based either!
If your child‟s elimination patterns don‟t seem to be linked to time or activities, you might
consider toileting your child every 2 hours. Other similar plans suggest toileting every hour
and a half. Pick which interval seems to work best for your lifestyle (6). If you find your child
typically goes for longer or shorter periods between accidents, adjust the time interval
between toilet trials(3). Schedule your child‟s first toilet trial of the day for 15 minutes before
the earliest time he urinated or defecated over the last two weeks of records (15). If you
want to increase the chance your child will have a successful scheduled trial try increasing
his liquid intake 7-30 minutes before the scheduled trial (4, 2). If your child is having multiple accidents
decrease the time between intervals to no less than 1 hour. However, if your child is toileting every two
hours, don‟t suddenly decrease to 1 hour between toilet trials; instead try decreasing by 20 minutes. Once
you‟ve got your child toileting at an interval that allows him to have less than one accident per day begin
expanding the time between toilet trials by 15-30 minutes a day (6).
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Putting the Plan into Action:
Should I teach my child all the potty routines as a whole right off the bat? Or, should I
teach my child the initial steps and then build up to completing the whole routine?
Some pros suggest teaching your child all the steps of the potty routine as a whole, while others
suggest adding steps to the potty routine one at a time as your child masters the basics. Because potty
training has no guaranteed results and all children are different, both ways are correct, but both may not be
correct for your child.
Does your child benefit from consistent routine, dislike change and/or respond well to
sequential learning?
If this sounds like your child, teach all the bathroom steps from the beginning (2, 7). Toilet Training
Individuals with Autism and Related Disorders promotes training autistic children by teaching the whole
routine at the same time including steps such as wiping and hand washing. If your child responds well to
routine, you‟ll probably be more successful introducing the potty training process as a set of steps
organized into a set routine instead of teaching one step at a time. If your child doesn‟t respond well to
change, continuously adding new steps may end up overwhelming him. If your child benefits from
sequential learning make the most of this by using a visual schedule (4). In the bathroom present a visual
schedule of the potty training routine broken down into small steps. Remember, once you introduce a
routine or sequence stick with it and make sure that your child‟s caregivers and family members stick with it
too.
Does your child learn better when tasks are broken down into smaller steps, responds
well to change and/or doesn’t get frustrated when new tasks are introduced?
If your child is fairly easy going but learns better when tasks are broken down and time is allotted to learn
one step before moving onto the next, then teaching toilet steps separately may be the best bet. Most
sources that promote this method suggest teaching your child first how to eliminate on the toilet and
secondly how to practice good hygiene and wipe herself (10, 15,8). This may also be a better plan if your
child seems overwhelmed by tasks with a lot of different steps. If your child has a fear of the toilet, refer to
the section on rewards to potty train your child using a reward process called “shaping”.
How do I deal with accidents?
Accidents happen. Having an accident helps your child to learn what it feels like to be wet and
how her body works. However, after the first few days, accidents can make you and your child
frustrated. The best way to deal with accidents is to act completely neutral (7,3). Many professionals say
that even negative attention can be reinforcing, so by acting anything but neutral you may actually be
rewarding the negative behaviour (15). When an accident happens, clean it up immediately - never let your
child stay in her wet clothing as this will only get her used to feeling wet. Always change your child in the
bathroom so that she can begin to form the connection between the potty and elimination.
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Positive Practice
While the majority of professionals agree caregivers should remain neutral after an accident,
there are a few differing opinions. Some professionals suggest using positive practice rather than
simply remaining neutral. When your child has an accident, tell him to feel his underwear and confirm they
are wet. Next let him know that “big boys wet on the potty”, take your child to the toilet and have him sit. As
soon as your child is sitting, praise him and offer him a reward (5). Even though your child already
eliminated in his diaper, this will help him to form the potty-elimination connection.
What happens if my child doesn’t go during a scheduled toilet trial?
For Habit training there are two choices regarding what to do when your child just doesn‟t go
during a toilet trial. Decide whether timed toileting or distributed practice will work best for your
lifestyle and your child based on the information below:
Timed Toileting:
The basis of timed toileting is to simply put your child on the toilet for five minutes at scheduled
times of the day. If after 5 minutes your child has not eliminated, remain neutral, prompt your
child to get off the toilet, redress and wait until the next scheduled time to go back on the potty (16). It is
very important that you do not reprimand your child or show any signs of disappointment. For some children
getting attention (even if negative) will act as reinforcement for negative behaviour. If your child eliminates a
few minutes after taking them off the toilet and they don‟t seem to have any problems sitting on the toilet or
longer, it‟s okay to extend the five minute sitting time.
Distributed Practice:
Distributed Practice is quite similar to timed toileting. The only difference occurs when your child
fails to eliminate while on the toilet. Take your child to the potty at the scheduled time. If your child
does not eliminate after 5 minutes remove your child from the toilet (5). After you‟ve taken your child off the
toilet in a neutral manner allow him to go back to playing. Ten minutes later take your child back to the toilet
for another 5 minute sit. If at this point the child does not urinate or defecate, take your child off the toilet in
a neutral manner and allow him to play again until his next schedule potty trial (5). If he‟s already
overwhelmed by the toilet training process the extra trials needed for distributed practice may just further
overwhelm him. However, for distributed practice it is okay to decrease the number of toilet trials to 2-3 (6).
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Alternative Plans:
The following two plans can be executed without going through the monitoring stage.
1) Activity linked toilet trials:
Indiana Resources Center suggests toilet training children with special needs by linking toilet trials to
everyday activities. These can be activities such as waking up, going to school, coming home from school
or eating. This will form a correlation between elimination and specific activities. Scheduled toilet trials
based on your child‟s elimination patterns instead of your lifestyle can mean having to toilet your child
during the busiest time of your day (21). This can rush the „toilet teaching‟ process and cut back on the
quality time needed for your child to learn how to use the toilet. If you
choose this method, pick out a few activities which can be followed up
which can be followed up by bathroom visits. The best type of
activities to correlate with potty trials are eating and drinking. Stooling
most likely occurs with exercise following a meal – often just arising
from getting up from the table after eating. Down Syndrome: From
Birth to Adults also suggests a similar method of taking your child to
the bathroom at times when you know your child will have a full
bladder such as, “ [in the] morning upon rising, after meals, midmorning, mid-afternoon and before bedtime” (107). Using a method of
activity linked toilet trials doesn‟t mean that you don‟t have to stick to a
schedule. You should be toileting your child after the same activities
everyday (8). In order to remember to do this, and help your child
understand, add these trials to your child‟s visual schedule. If you
want to increase your child‟s chances of having a successful toilet
trial, try increasing his liquid intake 7-15 minutes before his scheduled
potty time (21, 2, 4, 7). If your child begins displaying outward signs of
having to void, don‟t immediately rush your child to the bathroom.
Sudden rushing will cause them to tense up (8). Instead approach
your child and tell them they need to go to the bathroom, even if it‟s
not after a specific activity. By letting them know that they have to go to the bathroom, they will begin to
understand the feeling of having to go. Be aware that if your child doesn‟t seem to be having many
accidental successes on the toilet you may end up having to start again at the monitoring stage.
2) Generic Timed Toileting:
The following toilet training program is suggested for children with autism by Thames
Valley Children‟s Center. This program is not based on your child‟s elimination
patterns but rather on toileting your child every 90 minutes. Set a timer for 90 minutes
and every time the timer goes off prompt your child to sit on the toilet. If your child
seems to be having a lot of accidents and is not voiding at the 90 minute trials,
decrease the interval to one hour. If at the one hour mark your child is voiding
regularly, try to lengthen the time between trials to 90 minutes again. Avoid taking
your child to the bathroom more than once an hour. Toileting too often may not allow
your child to learn how to properly hold his urine. Once your child is having less than
one accident a day it‟s time to extend the time interval between each potty trial. Try by
lengthening the time between potty trials by 15-30 minutes at a time. Once your child
seems to be accident free move onto the independence stage (cite).
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Independence stage:
1)
2)
3)
4)
Put your child on a chair next to toilet without pants on
Praise your child frequently for good sittings
If the child gets off of the chair and moves onto the potty be ecstatic with praise and offer reward
If the child has an accident on the chair do not reprimand or prompt. Next time just start your child
off on the potty
5) After the child can move from the chair to the toilet without prompting start to move the chair further
and further from the toilet and start your child on the chair with his clothing on
6) Eventually your child should be able to self-initiate toilet training
Intensive Training
Intensive training is a shorter term training method as compared to habit training,
however, it requires a lot more daily work than habit training. Most intensive training
plans suggest setting aside a period of three to five days for the toilet training
program, however, there is no guarantee that this type of training will necessarily work
that quickly for children with disabilities.
Here are a few possible plans:
Plan # 1:
1) During the short term intensive potty plan it‟s a good idea to increase your child‟s intake of liquids. This
will increase the number of times your child urinates in the day, giving her more chances to have a potty
success! Increase your child‟s chance of going during a toilet trial by having her drink something shortly
beforehand.
2) Prompt your child to get to the bathroom for her potty trial. Once your child is seated and on the toilet,
wait 10 minutes to see if she will eliminate while on the potty. If your child does not eliminate take the child
off neutrally and let her go play. If your child does eliminate on the potty praise and reward her and then let
her go play.
3) After 15 minutes of play bring your child back to the toilet. Once your child has had a few successes on
the potty the time between trials can be extended gradually throughout the day.
4) In the event of an accident tell your child not to wet his pants and then prompt him to change himself with
help. If you‟re training an older child you can also prompt him to help to clean up any mess that was a result
of his accident.
5) Begin to do “dry pants checks” to see if your child is staying dry between potty trials. If your child is dry
praise and reward him for having dry pants.
6) Follow this plan for 4-8 hours a day until your child gets the hang of it.
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Plan # 2:
This plan, unlike the one above, is only used over a three day time period. In preparation, restrict your
child‟s favourite drinks a week before beginning your intensive potty program (this will encourage your child
to drink more when you offer her her favourite drinks during the potty program).
1) Begin by prompting your child to sit on the toilet.
2) Once your child is seated on the toilet offer her a drink.
3) Wait 5 minutes to see if your child will eliminate. If your child does eliminate praise and reward your
child. If your child doesn‟t eliminate, act neutral and allow him to go back to playing.
4) Time 10 minutes from the end of the last potty trial. When the ten minute timer goes off, take your
child to the bathroom for his next toilet trial.
5) Continue this process 30 minutes - 2 hours. Constant potty trial will help your child to make the
connection between elimination and the potty.
6) Once you feel your child understands this connection, stop the constant trials.
7) Begin bringing your child to the bathroom every 90 minutes. Do not prompt her to sit on the toilet.
8) Have your child sit on a chair next to the toilet without underwear.
9) Do not prompt her to get up off the chair and move to the potty.
10) If she urinates on the chair, remain neutral, clean it up and next time start her off on the potty
11) If she moves from the chair to the toilet offer a huge amount of praise and a reward.
12) Once your child is able to move from the chair to the toilet, move the chair farther away. Have your
child start seated with her underwear on.
13) Every time your child masters a new distance, extend the distance even farther and begin your child
in pants rather than underwear.
14) If your child is toileting fairly successfully, begin randomly checking his pants to see if he‟s dry. If he
is dry praise and reward him. If he isn‟t dry remain neutral and help him to get changed in the
bathroom.
How do I incorporate both intensive training and habit training into my child’s toilet
training plan?
Here‟s an alternative plan developed by M. Beattie based on the work of Azrin and Foxx. This
plan incorporates the scheduling pattern of habit training and the routine of intensive training plan.
1. Follow the habit training toileting instructions that explain how to monitor and set out scheduled potty
trials. If your child has no real pattern, toilet him every 2 hours and adjust the interval based on the length of
his periods of dryness.
2. When it‟s time for your child‟s potty trial, prompt him to the bathroom and put a chair next to the toilet.
3. Seat your child on the chair (without underwear) for one minute while
having your child drink as much liquid as possible.
4. Prompt your child to get off the chair, take down his pants and sit on the
toilet.
5. Have your child sit on the toilet for 3-5 minutes or until he eliminates.
6. When your child eliminates, praise him and offer him an immediate reward.
7. If your child does not urinate, stay neutral and let him go back to playing for
30 minutes. After 30 minutes put him back on the toilet. If the second time on
the toilet your child still doesn‟t go, remove him neutrally and wait to toilet
again until his scheduled potty trial.
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Rewards
Picking the proper reward method is one of the most important keys to successful potty training. There are
three main reward methods to choose from based on your child‟s level of development: immediate food or
small prize rewards, sticker charts or natural rewards. Rewards will not be effective if you offer them for
tasks that are too large or overwhelming. Instead make sure that you start off by offering rewards for simple
things like sitting on the potty or doing a good job relaxing. Whatever type of reward method you decide on,
always offer your love, support and verbal praise at the same time. When you phase out the tangible
reward be sure not to phase out your love and support.
Immediate Food or Small Prize Rewards:
This reward method works well for most children with a developmental age of 5 and under, but may also
work for some older children. Immediate food or small prize rewards are just that, small rewards given to
your child as soon as she completes a desired task. In order to make the reward method as effective as
possible do a reward preference test on your child by giving her a series of reward options to see what one
she chooses most often. Remember: when it comes to food, if you pick a reward that your child doesn‟t
love, the chances of it being an effective motivator are slim. Instead, choose rewards that your child really
likes but limit the portion size. You can also try to increase your child‟s motivation further by picking out a
special reward and offering it only for potty training. If you decide to keep a certain reward special to potty
training make sure that all of your child‟s caregivers follow the same plan. Once you come up with a reward
plan it is most important to break the larger task (going to the bathroom) into small steps to be rewarded
first (e.g. Sitting on the toilet for five seconds).
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Shaping
A reward method known as shaping can be used for children with a fear of the bathroom (5). Shaping is
used to overcome your child‟s fears by rewarding him for taking very small, baby steps that will build up to
the final goal. The example below demonstrates how shaping can be used with immediate rewards.
Example:
Todd was terrified of the toilet. Although Todd was non-verbal, his parents knew that he was afraid of the
bathroom by his reaction to it. As soon as Mum and Dad attempted to get Todd to enter the bathroom, he
freaked out. Mum and Dad had tried offering Todd a few Smarties for defecating or urinating on the toilet
but this didn‟t work. They couldn‟t even get him to sit on the toilet let alone relax enough to eliminate on it.
Mum and Dad heard about using a technique called shaping. Along with Todd‟s support staff they set out a
list of goals for Todd to accomplish toileting bit by bit:
1) walk towards the bathroom
2) touch the bathroom door
3) open the bathroom door
4) stand in the doorway of the bathroom
5) enter the bathroom
6) touch the toilet
7) sit on the toilet (fully clothed, lid down)
8) sit on the toilet (just diaper, lid down)
9) sit on the toilet (just diaper, lid up)
10) sit on the toilet (diaper unattached but draped over the toilet hole)
11) sit on the toilet for 3 seconds (no diaper)
12) sit on the toilet for 5 seconds
13) sit on the toilet for 30 seconds
The list continued to build up to the final goal which was for Todd to defecate or urinate on the toilet.
Todd‟s parents began by asking Todd to walk towards the bathroom. When Todd didn‟t follow the prompt,
Mum gently used hand over hand to guide Todd towards the bathroom. When this action was complete she
praised Todd and offered him a reward. The next time, when asked, Todd was able to do this all by himself.
After he was able to complete this action without guidance 3-4 times, Mum moved onto the next step. As
usual, Mum asked Todd to walk towards the bathroom door. Once he completed this action, Mum then told
Todd to touch the bathroom door. When he didn‟t follow their instruction, Dad used hand over hand, praised
him and offered him the reward. Todd only received the reward when he completed the first two steps in
order. After he was able to complete the first two steps in order, 3-4 times without guidance, Mum added
the next step. Using shaping to teach Todd to use the toilet was a very long process. However, Mum and
Dad felt it was well worth it once they got to step five and Todd actually entered the bathroom on his own.
They continued with this plan until Todd was able to complete all of the actions in the list without guidance.
By breaking the task of eliminating on the toilet into smaller steps with immediate rewards, Todd was less
overwhelmed and able to complete each step in good time.
Sticker Charts:
Sticker charts work well for children with good comprehension, an older developmental
age (5 or above) and a good understanding of cause and effect. This plan can also be
used for shaping, but only when working with developmentally older children. If your child
is the type of child who likes to work towards earning things, and understands long-term
concepts, this is probably the best plan for your child. Break the potty training process down into a set of
hierarchical steps and assign sticker sizes to the goals based on the level of difficult. Create a sticker chart.
Choose a large prize that your child may like (e.g. Going to a favourite restaurant, getting a special book
etc.) which will be the grand finale prize. For example, let your child know that if she has a clean month
she‟ll get to go to a favourable restaurant, or if he has two stickers on every day by the end of the week he
gets to pick a toy out of the “special toy bag”. Personalize the reward plan so that the stickers act as the
immediate motivator to complete an action, whereas the grand finale prize acts as a motivator to keep
having consistent progress.
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Example:
Elaine was displaying all of the signs signalling potty readiness. Elaine was well aware of when she needed
to defecate and would take the first few steps of self initiation by walking into the bathroom when she
needed to go. However once in the bathroom, Elaine would position herself on the floor and then defecate
in her diaper. It seemed as if Elaine really had no real motivation to sit on the potty. Pooping on the floor
was comfortable and being changed really didn„t bother Elaine. Mum and Dad tried offering Elaine
immediate food rewards for pooping on the toilet. However, this didn‟t seem to motivate Elaine to go.
Elaine had good communication skills, a high level of comprehension and was assessed as having a
developmental age of 5 years old so Mum and Dad decided that the best reward method would be to use a
sticker chart. They then spoke with Elaine‟s support team and put together the following list of hierarchical
goals:
1) sit on the potty with the lid closed and clothing on
2) sit on the potty with the lid up and clothing on
3) sit on the potty with the lid up and her diaper on
4) sit on the potty with the lid up and without a diaper
5) poop in the toilet
6) have a clean day
7) have a clean week
8) have a clean month
For each of Elaine‟s 8 goals, Mum and Dad assigned a specific sticker size -the harder the step, the larger
the sticker. Elaine‟s parents then let her know that when she got the biggest sticker of all she‟d receive a
special prize. The sticker chart helped Elaine gain immediate rewards for her positive actions while also
increasing her motivation. It worked by breaking down the desired action (going poop in the toilet) into
smaller steps that Elaine felt confident about and capable of doing. This gave Elaine the ability to have daily
successes which helped her to get excited about the potty training process.
Natural Rewards:
Natural rewards are great for a child who has a fascination with something bathroom related (e.g. flushing
the toilet, using soap dispenser, putting down the toilet seat)(4). For some autistic children, rewards that do
not have an obvious connection to the action may be overwhelming instead of reinforcing (21). If you find
your child seems stressed by exaggerated praise or rewards, try using natural reinforcers (21). For natural
rewards
such as flushing the toilet, it‟s fairly straight forward that if the child doesn‟t use the toilet he doesn‟t get to
flush(7) However, make sure to include this reward as a separate entity on the child‟s visual schedule. If
your child really likes to use the soap pump, allow him to wash his hands even if he„s not successful on the
toilet (for hygienic reasons). If he is successful on the toilet let him use an extra squirt of soap or lotion.
Natural Reward Ideas:
Water play in the sink, using the mirror, flushing the toilet, getting to use special soaps or lotions, turning on
and off the taps
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Phasing out
Once your child is able to complete the full potty process by herself without prompting, it is time to begin
phasing out your bathroom presence and the rewards.
Phasing out your presence:
Reference 15 suggests phasing out your presence by following these simple steps:
1) act distracted by something in the bathroom so you‟re not paying direct attention to the child
2) pay attention to things that are closer and closer to the bathroom door
3) after your child responds well to this, put your child on the toilet and stand in the doorway
4) if your child responds well to this try exiting the room next time and coming back to help your child wipe
and washing their hands
Phasing out immediate rewards:
The best way to phase out immediate rewards is to begin randomly removing them once your child seems
to be consistently using the toilet. Begin by offering rewards to your child only after he‟s completed the
whole potty process (including hand washing and hygiene). For the next 1-3 days (depending on how your
child reacts) only offer the reward every second or third time he completes the potty process. After your
child has adjusted to decreased rewards begin offering the reward at a random time once a day. At the
same time as decreasing rewards for completing the potty process, begin offering rewards for having dry
pants. Throughout the day randomly do a couple of “dry pants checks” by prompting your child to check if
they are dry. If they are, praise him and offer him a reward. If they are not dry, stay neutral and change
them in the bathroom. After your child seems to be using the toilet well and is dry most of the time, phase
out the “dry pants checks“ as well.
Personalizing the Plan
You know your child better than anyone. You know what she likes and what she doesn‟t like; what sets her
off and what helps her to calm down. With all of your expert knowledge regarding your child, personalize
her potty plan with the help of the following information:
Communication:
How does your child best communicate with you? How do you most effectively communicate with your
child? Communication works both ways. In the beginning, the most important thing is for you to be able to
communicate prompts in a way that your child will understand. Once your child begins to self-initiate you‟ll
have to be able to understand what he‟s trying to tell you. If your child is verbal make sure to explain body
words and potty words to him not only so that he can understand you, but so that he can one day use them
to self-initiate. Some children who are verbal also benefit from the use of picture exchange, symbols or
signs especially when communicating their needs to you. If you feel that visual cues may help your child
communicate with you, make these accessible. If your child is non-verbal, update his picture exchange
cards by making available cards that deal with the potty process. When introducing new symbols or
pictures, pair up the visual cue with the verbal words you„re explaining. If your child only uses visual cues,
make sure he has a travel size cue book to use when out in public or when he has to go to the bathroom
quickly.
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Communicating the process:
In order to communicate the potty training process with your child, use a visual schedule. Using the
toilet is a task that is made up of a lot of little baby steps that all need to come together in the right order. By
providing your child with a visual schedule you‟ll help her to understand the process and become more
independent. It‟s best to customize three visual schedules:
1) Master Visual Schedule: this is the schedule that outlines your child‟s activities for the
whole day. Add in the bathroom symbol based on the toilet trial schedule you‟ve set up for your child. Also
add in a reward visual to the schedule directly after the bathroom symbol.
2) Toilet Schedule: Place a special schedule in the bathroom that covers all the steps of using
the toilet (e.g. Take down pants, sit on toilet…)
3) Hygiene Schedule:
include a special hygiene schedule in the bathroom that will help your
child master the steps of washing his hands. For actions in the bathroom that your child likes to repeat (e.g.
Flushing or soap pumping) use a “1 only” picture exchange card (which can be either handed to the child or
taped on the object e.g. Toilet handle). Make sure that the schedules are posted where your child can see
them. If your child does a step wrong in the process (e.g. Begins to wash his hands before pulling up his
pants) do not simply restart the wrong action (e.g. Do not begin pulling up pants). Instead, go back to the
last correct step the child completed (e.g. Wipe again before having the child pull up his pants).
For children that comprehend and communicate best using verbal or written word, feel free to make a
schedule for them as well -- this will simply remind them of the proper order of the steps. Besides a verbal
schedule to prompt your child to use the toilet, you can use a visual cue or object exchange to indicate what
you‟d like them to do.
Let’s get Literal:
If you‟re toilet training an autistic child, it‟s very important to keep your
communication as literal as possible (21). Autistic children will often take
the most literal meaning of the word. For example, if you use the term
“going to the bathroom” to prompt your child to urinate or defecate your
child may think you‟re asking them to walk into the bathroom and not
actually eliminate. Make sure your child comprehends the intended
meaning of your prompts by pairing up your verbal cues with visual cues.
Assessing your child’s abilities:
Go through the following steps. For each step address whether or not your child is physically
capable of completing the step. If not, make the necessary environmental adjustments or talk to your child‟s
physical therapist. For each step also consider whether your child may have behavioural problems
completing the step. Before you even begin the potty process, troubleshoot to avoid your child‟s tactile
sensitivities or behavioural problems. Think of how you could use your child‟s abilities to get around any
problems (14). This may mean being completely realistic and reassessing whether or not your child will be
able to complete all of the potty training steps (14). Based on this assessment you may need to modify the
goals you had originally had in mind (14). Troubleshooting examples have been added in brackets to
certain steps in the checklist below.
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 Can indicate the need to go to the bathroom (e.g. Visual cue put into picture exchange
book which indicates need to go to the bathroom)
 Can walk to the bathroom
 Can pull down pants and underwear
 Can get onto toilet (e.g. step stool needed to get onto toilet)
 Can sit on toilet (e.g. Bag of tactile toys offered to keep child on toilet)
 Can relax enough to eliminate (e.g. Calming music played, lights lowered)
 Can wipe himself (e.g. Physically difficult task so mum or dad aids child in wiping)
 Can pull up his pants
 Can flush the toilet (e.g. Visual cue taped to handle to indicate one flush only)
 Can stand at the sink (e.g. Step stool needed)
 Can wash his hands (e.g. Sensory sensitivities - soft soap used instead of bar or soap,
wet wipes or hand sanitizer used instead of water (from citation)
Comment [MSOffice1]: Put in s=citation
Environment:
If your child doesn‟t feel comfortable in her environment, chances are no matter what potty program you
use it‟s not going to be successful (14). Modify your child‟s environment based on her sensitivities and
likelihood of distraction. The following section offers suggestions to how to change your child‟s environment
to combat their sensitivities and likelihood of distractions.
Avoiding Tactile Defensiveness:
Responds poorly to taking off diaper: If your child responds poorly to having his
diaper removed or sitting on the toilet bare bottomed, consider the room temperature. After having a
diaper on almost every moment of the day, having it taken off can be a big sensory shock. Try
increasing the temperature in the bathroom or buying a padded toilet seat that doesn‟t get so cold (20).
If changing the temperature of the room doesn‟t work, you may need to slowly transition your child out
of having their diaper on. First have him get comfortable with sitting on the toilet fully clothed, then have
him sit on the toilet with his diaper on, then have him sit on the toilet with his diaper off but spread
across the hole in the toilet and finally take off his diaper completely (7).
Child responds poorly to flushing the toilet:
Many children are initially
afraid of the toilet. In order to combat your child‟s toilet fear, try to figure why it bothers her so much. If
she is visually sensitive of flushing the toilet, teach her to put down the toilet seat first. If she doesn‟t like
the sound of the toilet flushing, Toilet Training children with…. suggests tape recording the flush noise
and let your child listen to it at various volume levels. The same book also suggests prompting your
child to open the door before flushing in order to give her an immediate escape route allowing them to
feel less trapped. If your child‟s flushing fear is getting in the way, teach your child to potty train now and
work on flushing later.
Child seems to feel unstable on the toilet:
for some children, especially
children with autism, making a few minor changes to your child‟s environment may help him to feel more
stable while on the toilet. Feel free to add grab bars around the toilet for him to hold onto, and buy a
step stool so that he‟ll have somewhere to place his feet (20). Placing a plastic table in front of your
child may also help him to feel more stable by giving him somewhere to rest his arms. If your child
benefits from tactile stimulation you can place toys on the table or books. However, never restrain him
to the toilet.
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Comment [J2]: is this outside of the toilet area
Child won’t sit still long enough to go: Put together a bag of toys or books that
can keep your child distracted while she‟s on the toilet. For children with autism this bag may include
objects that will provide your child with tactile distraction. If your find that your child seems stressed
while on the toilet, use various calming techniques. If your child relaxes when music is played get a CD
player to keep in the bathroom and try turning down the lights a little bit. In order for your child to urinate
or defecate, they must relax. Think of your child‟s strengths by making a list of all of the things that
typically help her to calm down. If your child seems impatient sitting on the toilet, or constantly asks how
much longer she needs to sit, get a visual timer and put it next to the toilet. This way your child is
constantly aware of the time, and can concentrate more on eliminating, and less on asking you how
much longer she must sit.
Sensitivity to Smells:
There are a lot of smelly products in the bathroom and most
soaps have very strong odours. If you know that your child has a sensitivity to strong smells, check out
hypoallergenic bathroom products that are usually perfume-free. Make the bathroom a scent free zone.
Ask other family members to put on perfume or use deodorant in their bedrooms so that perfumes are
not unique to the bathroom
Sensitivity to the feeling of soap or toilet
paper: Typically the two main feelings that cause problems in the
bathroom are the feeling of the soap and the feeling of the toilet paper. If
your child doesn‟t like the feeling of soft soap try using a bar or vice-versa. If
your child is still having problems try hand sanitizer or wet toilettes. If your
child doesn‟t like the feeling of toilet paper, try wetting the paper with warm
water or using wet toilettes that have been run under warm water (be aware
that wet toilettes are often very cold).
Child responds poorly to wearing underwear: For some children the weight of
the diaper becomes comforting. If your child seems upset by having to wear underwear instead of a diaper,
or panics when you take off the diaper, you may have to wean your child out of it. In order to do this you
want to gradually take away the weight and pressure the diaper creates. There are four ways to do this:
1) Cut away method:
1) place the diaper overtop of the child‟s underwear
2) cut a small hole in the crotch of the underwear
3) every day expand the hole
4) the last part of the diaper remaining should be the waist band because this provides the most
deep pressure
2) Loosen method:
Keep your child in diapers but put the child‟s underwear on underneath the diaper. Everyday make the
diaper a little bit looser by not attaching it as tightly. Eventually hardly do up the waist band at all so that the
diaper falls off on it‟s own. Typically by this point the child no longer feels bothered by not wearing a diaper.
3) Mixed Method:
Begin setting aside time in your child‟s day that he can spend without his diaper on. At first this may be for
only a few minutes. Gradually increase the time your child spends daily in underwear without a diaper on
overtop and use positive reinforcement.
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3) Slit Method:
Cut a slit in the bottom of the child‟s diaper big enough that the child‟s feces can fall through into the toilet.
Have the child use the toilet with her diaper on. Gradually make the hole bigger and bigger. Once the hole
is fairly large, have your child put on his underwear underneath the diaper. Cut away the diaper until just the
waistband is left and then get rid of it all together.
Bathroom Distractions:
For some children being easily distracted can prolong the potty process. Overcome a child‟s tendency to
become distracted easily, by removing all known distractions from the potty training process right from the
get go. This may mean having to hide or remove objects from the bathroom that may distract your child
(such as bath toys, toilet paper, soap). If possible, make potty trials a one-on-one experience. Some
children may be distracted by having too many people in the room or having the door kept open. Especially
for older children, privacy can become important. If your child seems nervous or embarrassed while in the
bathroom, do all that you can to give him the privacy he needs to become comfortable. Never leave your
child unattended on the toilet if they have special needs that may endanger him, or if he has a history of
fecal smearing.
Example:
Emmy was easily distracted. The moment Mum walked her into the bathroom she was immediately excited.
She loved to look in the mirror, turn on and off the taps and flush the toilet. While Mum taught Emmy not to
turn on and off the taps and flush the toilet by using visual cues, she could not get Emmy to stop looking in
the mirror. Even when she was on the toilet, she had no success because she would try to angle herself to
catch a glimpse in the mirror. Besides just her interest in the mirror, every time one of Emmy‟s two brothers
would walk into the bathroom to ask Mum a question or tell Mum something “important” Emmy wanted to
join the conversation and became distracted again. While Mum was lucky and had no problem getting
Emmy on the toilet, she just could not get her to concentrate and relax enough to go. The next day, Mum
covered up the mirror with a big sign that said reward. Instead of reprimanding Emmy for wanting to look in
the mirror while on the toilet, she used her natural interest in looking in the mirror as a reward. If Emmy
eliminated on the toilet, Mum would take down the paper sign while Emmy was washing her hands. Mum
continued to cut out distractions by explaining to Emmy‟s brothers that bathroom time was private for Emmy
and Mum. In order to make sure that her boys didn‟t feel left-out, after every toilet trial with Emmy, Mum let
Emmy play solo while she spent ten minutes reading to her boys.
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Relaxation:
Relaxation is key to potty training. Once your child is sitting on the toilet, your child needs to relax enough to
let her sphincters open and eliminate.
Here are some tips to try to get your child to relax once on the potty:
Play some calming music
Read your child his favorite book
If your child is easily excited by chatting, keep conversation to a minimum
To help your child go you can press gently on her lower abdomen
Try turning on the water (as long as he‟s not distracted by it)
Some children have a habit of getting too excited and jumping off the toilet either mid pee or
right after. This can lead to dribbles and accidents on your bathroom floor. After your child
feels she‟s finished urinating either count to ten with them calmly and slowly before they get
off the potty or sing a special song together. This will help you to make sure that she‟s
completely emptied her bladder and she‟s ready to get off the toilet
Place a table over your child‟s lap while on the toilet and place some tactile toys that tend to
calm him down.
Dressing for Success:
During toilet training, your child has to hold back and wait to eliminate until seated on the toilet. For the first
time ever, your child has had to actually have to stop himself from urinating or defecating immediately. At
first, it can be hard for many children to hold back long enough to make it to the bathroom in time. It
becomes important during toilet training to dress your child in clothing that can be taken off easily (2) even if
this means you may have to sacrifice his style for a while.
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Diapers vs. Pull-ups vs. Big Kid Underwear:
There are many different opinions regarding whether diapers, pull-ups or underwear are best to use during
toilet training. Even the experts don‟t all agree. Potty training has no definitive answers, so instead you have
to choose what‟s right for your child. Whatever option you choose, remember to always change your child in
the bathroom. This will help him develop the connection between elimination and the potty.
1) Diapers:
-
Makes potty training less messy
Often necessary if your child goes to school or daycare
Best for the family that‟s busy and doesn‟t have time to clean up constant messes
If you choose to keep your child in diapers:
Diapers are great for keeping messes to a minimum, but they don‟t allow your child to get that necessary
feeling of being wet. Feeling wet helps your child understand that she‟s in control of elimination. Feeling wet
can also motivate a child who prefers to be clean and dry to stay clean and dry. So if you‟re choosing to
keep your child in diapers, set aside some time everyday to allow her to great a feeling of being wet. If
you‟re training a younger child, waterproof a section of your child‟s diaper and allow her to go bare
bottomed for a short period of time everyday. If you‟re training an older child the place a “disposable nonabsorbent liner” in his diaper and prompt him every hour to check if he‟s dry or wet.
2) Pull-ups:
-
Depending on the type they may allow your child to get a chance to feel a little bit wet, however
most (similar to diapers) pull the moisture away fairly quickly.
Easier to get on and off when rushing to the toilet
Pull-ups may give your child a feeling of being a big kid, however, most soon learn that pull-ups are
very similar to diapers and that they can use them the same way.
3) Underwear:
- provides the child with a feeling of wetness which is necessary for learning how to stay dry
- accidents help your child to understand the difference between wet and dry, so accidents in the
beginning can actually be a very positive thing in the training of your child
- if your child doesn‟t seem bothered by wetting or soiling her diaper, this is a good indicator that you
should switch your child over to underwear.
If you choose to change to underwear:
Some children may have a problem switching from diapers to underwear (especially children with autism
who find that diapers provide them with a comforting heavy feeling and deep pressure touch). During the
transition period you can put diapers overtop of your child‟s underwear if he seems resistant to letting go of
his diaper (21). This way your child can get that feeling of heaviness while learning what it feels like to be
wet. Because night time urine continence is acquired later than daytime urine continence, keeping your
child in diapers at night is a good idea until you‟re ready to start night time training (15). Once your child is
using underwear it is very important to change them as soon as you notice they‟re wet (21). Your child may
come to tolerate or prefer being in dirty or wet diapers if he‟s not changed frequently enough.
Suggested Reading:
For more tips on personalizing your child‟s potty plan check out the book Toilet Training Individuals with
Autism and Related Disorders by Maria Wheeler. It offers some great ideas for troubleshooting with real life
case study examples!
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Dealing with Real Life:
All of the effort in the universe can‟t keep real life from interfering with your child‟s potty training. There are
sports and extracurricular activities, school, work, siblings and a whole whack of other responsibilities on
your plate as a parent. That‟s why, when designing a potty training plan the most important thing to take
into consideration is how your real life will affect the plan. The key to potty training success is
CONSISTENCY, so don‟t create a really great plan if you can only follow it on the nights when your child
doesn‟t have soccer or music class. Instead, create a plan that fits your child‟s needs and is do-able
whether your child is at school, at mum‟s house or dad‟s house, or on nights when they have extracurricular
activities. It can be even harder to maintain consistency when your child is in daycare, goes to school or
alternates between homes. In the sections below there are some tips to help you maintain consistency
throughout various situations.
The School or Daycare Partnership:
If your child is in school or daycare, it‟s important that you form a friendly partnership with the school. It can
be hard to find a happy medium in the midst of school administration power struggles, however, it‟s not
impossible. If you adopt a team mentality instead of an “us against them” attitude from the get go you‟re
guaranteed to have more success! Here are some tips:
1) Compromise to make a plan that may not be perfect but will
definitely be consistent:
In conjunction with your child‟s support staff, design the potty plan that will work best for you. Write
up all of the details of the potty plan. Instead of simply handing this over to the school and
demanding they follow it, request a meeting with your child‟s teachers, support staff and
administration to discuss whether or not the plan can work at school too. Work with the school to
make the changes necessary for the plan to be followed while at school. Distribute the plan to all
your child‟s caregivers.
2) Provide the school with all the tools they’ll need:
-
Create a shared binder which will follow your child from home to school. Here‟s what to include in
your child‟s potty binder:
a sheet for tracking potty progress along with their potty training schedule
a breakdown of the order of the potty training steps if you‟re teaching your child the whole process
using a specific routine
a recap of how you give rewards and respond to accidents
your child‟s visual schedule and visual cue (if you use this to prompt your child)
any necessary aids to help your child communicate her need to go the bathroom with her teacher
a page for your child‟s teacher or support staff to note any unusual events which may have
disrupted your child‟s potty progress for the day (ex. An assembly, bullying, a change in diet etc.)
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How to deal with divorce:
In North America divorce is a common occurrence. Divorce may make it more difficult to potty train your
child but it is not impossible. The keys to achieving potty training success in the midst of divorce are:

BE CONSISTENT: Come together

OPEN COMMUNICATION:

MAKE YOUR CHILD FEEL SAFE:
with your ex-partner to have a civil meeting to design a
potty plan which can be executed at both Mum‟s and Dad‟s house. At this time you‟ll also want to decide
on a reward program, how to deal with accidents and what your child‟s visual schedule will look like.
Open communication between divorced parents can
sometimes get a little messy. If you‟ve recently ended your relationship and things are still stressful, all
the messy phone calls and meetings will just stress your child out further. Instead create a shared
communication binder that outlines the plan, allows each parent to track potty progress and events
which may have disrupted the potty plan (e.g. Eating something new, illness etc.). Share this pamphlet
with your ex.
Too many divorced parents fight through their
children. This causes the child to become more stressed and more stress leads to potty training
reluctance. While you and your ex may disagree on many things, you both probably agree that you want
the best for your child. Therefore, make a peace pact and stick to it.
Sudden Regression:
Many parents complain that their child‟s progress suddenly comes to a halt, or that their potty training
progress begins to go downhill. If this happens to you and your child don‟t be alarmed. Instead of stressing
out about it, try to get to the root of your child‟s sudden potty regression by looking for any changes which
may have occurred recently. If your child is able tell you what the problem is that‟s great! However, even if
your child is communicative, he may not be conscious of the issue, so don‟t push it. Toilet Training Your
Special Child, a book put out by Thames Valley Children‟s Centre, suggests investigating the following
possible regression causes:
Is there a physical cause?
Is your child having painful or hard stools? Have your child‟s bowel or bladder habits changed? Is there
blood in your child‟s urine or do they complain of painful urination? If your child is presenting with any
unusual physical symptoms, consult your physician.
Has there been a recent increase of or new stress in your
child’s life?
Has your family become blended? Did you have a new baby? Have you recently moved? Are you going
through a divorce? Added stress can cause your child‟s potty training progress to go downhill.
If you figure out what‟s bothering your child and can make a change to help alleviate the problem that‟s
great! Whether or not you figure out what‟s bothering your child, don‟t push the toilet training issue. If you
feel your child would benefit from a toilet training break that„s okay! Make sure that if you choose to take a
break not to put your child back into diapers if your child is currently using pull-ups or underwear as this
may become confusing.
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Valuable Resources
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