Marina Sarris

Date Published: September 18, 2023

Other children have graduated to using the toilet, but your youngster with autism is still struggling with this skill. Why is this so hard, and how can you make this easier?

You and your child are not alone. On average, children on the autism spectrum learn to use the toilet later than both typically developing children and children with other developmental conditions.

Among 4- to 5-year-olds, 49 percent of autistic children were not toilet trained, compared with 24 percent of children with developmental delay. By comparison, only 8 percent of typically developing children in that age range were not toilet trained, according to a 2022 study.¹

Toilet training can be challenging because the traits of autism can interfere with learning this skill, experts say.

Those traits include:

• a resistance to changes in routine, called an “insistence on sameness”
• over- or under- reacting to one’s senses (issues with sensory processing) and
• communication delays

“We know these children thrive on routine, and this is a huge routine change,” says Elizabeth Cross, Ph.D., clinical psychologist at Kennedy Krieger Institute’s Center for Autism and Related Disorders, a clinical site for the SPARK autism study. “They’ve been using diapers their whole life, and now we’re asking them do something completely different. We also see that sensory preferences and sensory processing differences can impact toilet training.”

Feeling the need to urinate can be affected by the way children process information from their senses. And from a sensory standpoint, “bathrooms can be scary places,” explains Cross, an assistant professor at Johns Hopkins University School of Medicine in Maryland. “Bathrooms may feel cold, lights may be too bright, toilet paper may feel rough, and the noises ─ of flushing toilets or hand dryers ─ are loud and strange.”

Another potential problem is medical. Children on the spectrum are more likely to have bouts of constipation or diarrhea, although this is not an autism trait. Those gastrointestinal problems are linked to delays in toilet training.¹

Cross and SPARK parents have offered the following advice.

Check for certain skills and conditions before you start toilet training

“There’s no set age or developmental level for starting toilet training,” Cross says. “Rather, we want to look for baseline skills to be in place.” Those include being able to stay dry for one to two hours and being able to follow simple directions (“sit down”) some of the time.

Children should not be having constipation or diarrhea when you start. If they are, talk with their doctor.

And one more thing: “Parents and caregivers need to be ready to dedicate the time to toilet training before they get started,” Cross says. Set aside three to five days to focus on it.

Work on dressing and hand-washing skills before you begin

Children should learn to pull their pants up and down. They should wear clothing with an elastic waist – no buttons, zippers, or snaps that could slow them down in the bathroom. They also can practice washing their hands in the sink.

Assemble the equipment and rewards you will use

Some families prefer a small potty chair for youngsters. But Cross recommends an insert for the regular toilet seat, and a stool for the child’s feet. That way, the child can get used to the toilet sooner.

Make a picture chart that shows the steps to using the bathroom, she says. If possible, use the communication symbols or pictures that the child sees in school or an early intervention program. See examples of toileting picture cards, visual aids for boys, or visual aids for girls.

Select a favorite toy, snack, or activity that the child will receive as a reward, and only make the reward available for toilet training, Cross says.

Gradually require more from your child before giving a reward

First teach your son or daughter to sit on the toilet and be relaxed, but don’t expect them to urinate, Cross says. Have them sit 10 seconds, praise them for doing so, and immediately give a reward for cooperating. Bring the child to the toilet every 30 to 60 minutes, and gradually increase the amount of time they sit until it reaches 3 minutes.

Eventually, as they conquer those steps, they will only get a reward when they urinate or have a bowel movement in the toilet. “This will start to make that connection that this is what we do when we’re sitting in the bathroom,” Cross says. You should still praise them for sitting regardless.

Once children are relieving themselves in the toilet 80 percent or more of the time, you can take them to the bathroom less often. You may increase the time between visits by 15 to 30 minutes, and you can begin teaching wiping.

Put away the diapers or pull-ups

“I tell parents to switch the child to underwear because, if they’re in a pull-up or diaper, that gives them permission to use the pull-up or diaper,” she says. Many children dislike the feeling of wet underwear, even for a few seconds. That desire to be dry can motivate them to use the toilet, she says.

Manage sensory experiences as much as possible

Some families will adjust the lighting or air flow in their bathroom if bright lights, smells, or cold air is interfering with toilet training. If your child is sensitive to noise, allow them to wear their noise-cancelling headphones when flushing, Cross says.

Public bathrooms can be trickier because the noise is mostly outside your control. One SPARK participant, Candice Lurvey, says that she and her teenage daughter, Kaylee, look for a one-seat restroom, called a family bathroom, in public buildings. When they have to use a multi-stall restroom, Lurvey will let other people know that the loud electric hand dryers bother her daughter.

“Sometimes I say out loud to her, so others hear, ‘Let’s be quick in washing our hands so we don’t hear the loud hand dryer.’ A few people have been great about it, using paper towels or waiting for us to leave the bathroom before using the hand dryer. Other times, it’s too much and we leave with wet hands. If the bathroom only has an air dryer, we’ll use toilet paper to dry our hands,” Lurvey says.

Let your child’s school and day care staff know that you have started toilet training

You can ask if similar procedures can be used at home and school, to reinforce learning.

Children receiving early intervention and preschool special education services may have toilet training built into their day.

Karen Zarsadiaz-Ige, parent of a son in the SPARK autism study, said that her son’s preschool staff helped toilet train him when he was 3. Liam’s class included typically developing children who were using the toilet, and that helped him learn, she says.

Candice Lurvey says that toilet training was on her daughter’s special education plan when she began elementary school. Staff would take Kaylee every hour to use the bathroom. Kaylee had limited spoken language, so her family programmed her iPad device to say the words, “I have to use the potty.”

Stay positive during the inevitable accident

Accidents happen. Parents or caregivers should stay calm, help the child change his wet or soiled clothes as quickly as possible, and avoid scolding. “We want to make toilet training a positive experience for the child,” Cross says.

If your child with autism is still struggling

Sometimes parents try all of the steps recommended by their child’s doctor, therapists, or special educators, but their children are still struggling. Cross has this advice: take a break.

“Take a breath. This is hard. If you’ve given it a good try, and it isn’t working, take a step back and take a break from toilet training. You’re not going to do your child harm by that. Take that time to talk to your child’s provider,” Cross says. If the child is taking medication, ask his doctor if a side effect of the medicine, or another medical problem, might be affecting toilet training.

Consult a behavioral therapist or an occupational therapist who has experience working with children on the spectrum to develop an individualized plan for toilet training, she says. Your early intervention program or school special education department may have therapists you can consult.

Do not fret if your child takes longer to learn this skill than others do. “The vast majority of autistic children can be potty trained,” Cross says.

For more information, watch a SPARK webinar on “Developing Personal Care Independence Skills” with Cora Taylor, Ph.D., clinical psychologist at Geisinger’s Autism & Developmental Medicine Institute in Pennsylvania.

Interested in joining SPARK? Here’s what you should know.

Photo: iStock

Resources

• Download the Parent’s Guide to Toilet Training Children with Autism by Autism Speaks’ Autism Treatment Network.
• Read “The Potty Journey: Guide to Toilet Training Children with Special Needs, Including Autism and Related Disorders” by Judith A. Coucouvanis (2008) Shawnee Mission, KS: Autism Asperger Publishing Company.

References

1. Wiggins L.D. et al. J. Dev. Behav. Pediatr. 43, 216-223 (2022) PubMed