I am a parent of an adolescent with autism who is urine trained but continues to have bowel accidents. What treatment strategies can I use to begin bowel training with him?
Answered by Frank Cicero, PhD, BCBA-D
Director of Psychological Services Eden II Programs
Lingering issues with bowel training are common in individuals with autism, even if urination training has been successfully completed. As with urination training, the key to success in bowel training will involve behavioral assessment, data collection, and behavioral teaching techniques.
The first step in any bowel training program is to collect baseline data. Data should be collected every day for at least two weeks. You can make a simple data sheet to record the following:
- the date and exact time of all bowel movements (please also record meal times);
- where the bowel movements occurred;
- what the individual was wearing;
- the consistency of the stool.
Once data are collected, you will use the information to better understand why the individual continues to have bowel accidents. Unlike a urination training program that takes the form of traditional toilet training, a bowel training plan more often resembles a behavior plan in which the plan is tailored to the function of the bowel accidents. Typically, an individual continues to have bowel accidents for one of the following reasons:
- a medical cause;
- a skill deficit (lack of generalization from urine training);
- presence of rituals and routines surrounding bowel movements.
For an individual affected by a medical cause, there is usually something atypical with the frequency of bowel movements or the consistency of the stool (e.g., the bowel movement may appear grainy or not well formed). You will notice this in your baseline data. In such cases, a medical examination is indicated and you should speak with your pediatrician. He or she may refer your son to a specialist for further testing. Medical treatment suggestions should be followed and you should direct any and all questions to these doctors. If the individual remains untrained after medical issues are cleared, an additional training program will be needed.
If an individual is having accidents due to a skill deficit, you will notice that there is no evidence of him holding his stool and no patterns indicating a ritual or routine. In this case, you will begin a bowel training intervention consisting of positive reinforcement for success and punishment for accidents. Prompt the individual to go to the toilet on a ten-minute schedule starting at the time when they are most likely to have a bowel movement (look at your baseline data to determine an approximate time of day). Choose one highly preferred reward that they can earn if they successfully have a bowel movement on the toilet. It would be important to restrict access to that reward at other times. If, however, they have a bowel accident outside of the toilet, initiate a punishment procedure such as an overcorrection (having them clean their own clothing) or a response cost (taking away a privilege). Although punishment strategies are not always needed, you will find that with only one or two bowel movements per day, opportunities to teach the individual to discriminate between a correct and incorrect response are limited. Adding a punishment component to the training procedure will likely increase the individual’s ability to discriminate between the two responses.
When noncompliance is an issue, you will find that the individual seems to be actively holding stool when asked to have a bowel movement on the toilet. In such cases, it is also common that the individual demonstrates noncompliance in other areas besides bowel training. Although intensive plans employing the use of physical prompts such as suppositories and enemas are successful, I usually recommend starting with a plan similar to the one suggested for skill deficits (simple reinforcement for success and withholding reinforcement for accidents). With noncompliance, you want to make sure that the reward you are delivering is very powerful. One good technique for doing so is to remove all access to the reward for two weeks prior to starting training. This will increase its potency once you reintroduce it for appropriate bowel movements. Because the individual is actively holding stool, you should continue to collect data daily so that any evidence of constipation can be identified and corrected prior to becoming an issue.
Last, there are issues related to rituals and routines. Individuals on the autism spectrum often have an inclination towards establishing and maintaining routines. When having a bowel movement becomes wrapped up in a routine (i.e., the individual will only have a bowel movement after school, while wearing a pull up and standing behind the couch), that routine can be very hard to break. One strategy is to slowly shape a new routine by introducing steps closer and closer to having a bowel movement on the toilet while reinforcing success at each new step. Keep introducing gradual steps. If you move too quickly, the individual might become resistant to the new routine and constipation could result.
Considering the above mentioned routine (the child always has bowel movements while wearing a pull up and standing behind the couch), the treatment steps might progress as follows:
- prompt and reinforce a bowel movement in a pull up in front of the couch
- prompt and reinforce a bowel movement in a pull up in the hallway by the bathroom
- prompt and reinforce a bowel movement in a pull up standing in the bathroom
- prompt and reinforce a bowel movement in a pull up sitting on the toilet
- prompt and reinforce a bowel movement on the toilet with pull up at the knees
- prompt and reinforce a bowel movement on the toilet while holding the pull up
- prompt and reinforce a bowel movement on the toilet without any pull up
Keep in mind that the gradual steps you design must be tailored to the routine and needs of your child.
The steps listed above are only an example.
With any of the treatment strategies suggested here, remember that it is important to collect data on a daily basis and make treatment decisions based on what your data are telling you. With bowel training, I usually suggest implementing a plan for at least three weeks before deciding whether or not the plan is working.
As you go through the training, make modifications as necessary, keep implementation of the plan consistent across days and maintain a positive attitude.