My 3-year-old daughter was recently diagnosed with autism, and I have several concerns and worries. At the top of my list is toilet training and if she or I will ever be ready to tackle such a big challenge. I know it’s critical that we start toilet training, but I’m not sure how or where to even start.

Shannon M. Arthur, PhD, BCBA-D, LABA
Dragonfly Behavioral Solutions

Toilet training can be overwhelming, and many caregivers, like yourself, may be hesitant to take those first steps or may be unsure about what those first steps should be. Toilet training is a critical skill that can contribute to developmental, social, and health-related success. Yet, there are often barriers that many caregivers face that may prevent them from starting the toilet training process. Further, if they do attempt toilet training, barriers can lead to unsuccessful outcomes or discontinuation of the toilet training process altogether. The average age of toilet training for children without a diagnosis is around 27 months. For those on the autism spectrum, toilet training is reported to occur closer to the age of 4. This finding may be in part due to the perceived or actual barriers that accompany a diagnosis of Autism Spectrum Disorder (ASD). A diagnosis alone does not limit a child from becoming toilet trained at a younger age. However, there are symptoms that may coincide with ASD that could create barriers. Those on the autism spectrum may have difficulty communicating, engage in ritualistic routines, have difficulties in social environments, and may display challenging behaviors which may impact toilet training efforts. Additionally, these symptoms may directly oppose some suggested pre-requisite skills for toilet training.

Child Prerequisite Skills

Pre-requisite skills are often mentioned, suggested, or at least thought about when getting ready to begin toilet training. In some cases, a list of prerequisite skills may stop families from beginning the toilet training process as many of the commonly listed prerequisites may be deficits for their child. Families may wait until they see some of those prerequisites before starting (e.g., tells you when they need to use the potty, asks to have their diaper changed, enjoys copying others). One thing to note is that no universally agreed-upon necessary prerequisite skills for toilet training have been identified in research (Greer et al., 2016; Kroeger & Sorensen-Burnworth, 2009; Wyndaele & Vermandel, 2023).

There are a few prerequisite skills to consider that will lead to an easier toilet training process and provide an indication of readiness:

    • Sits up for a few minutes at a time
    • Walks independently
    • Follows instructions and understands language related to the process – “It’s time for the potty”, “Sit down”, “You’re wet”.
    • Possesses some dressing skills such as pulling underwear up and down.
    • Remains dry for extended periods of time

Some of the listed prerequisites, such as receptive language or dressing skills, can still be taught within the process of toilet training. This point also holds true for initiating use of the bathroom. If a child has limited expressive communication, you can teach the initiation to the bathroom throughout the toilet training process using a variety of modalities including sign language, picture communication, or use of an alternative augmentative communication (AAC) device using prompting and reinforcement. For example, if a child uses an AAC device, before a transition to the bathroom, a caregiver may want to point to the button requesting the bathroom and guide the child to press the same button. Once they press the button, caregivers can provide praise for using the request button and begin the transition to the bathroom. If a child uses vocal language, a parent may model how to request for the bathroom by saying, “I need the potty” and have the child repeat the phrase before transitioning to the bathroom.

Another commonly recommended prerequisite that can be learned during the toilet training process is that the child can hold their urine for a specified amount of time.  Most children are physically able to hold their urine between 24 and 30 months. However, in many cases, the motivation to stay dry for longer periods of time comes with the introduction of underwear. When a child has an accident in underwear, it is likely that they will begin to hold their urine for longer periods of time in order to avoid being wet and in turn be more likely to use the toilet. So, you can proceed with toilet training even when one or more prerequisite skills are missing.

Caregiver Barriers in Initiating Toilet Training

The previously mentioned barriers are evident from the child side of toilet training. But there are also barriers that present from the parent side of toilet training. Questions that should be asked prior to beginning the toilet training process as a caregiver is “Am I ready?” “Is this the right time to begin potty training?” “What support do I need to for this process?.” Parents always ask if their child is ready, but the question should ensure that the caregiver, the primary teacher of the skill, is ready given how this process may impact their daily life. Some barriers that affect a caregiver beginning toilet training include:

    • The parent believes the child is not ready or does not “care” about being potty trained.
    • Effective toileting plans may require adherence to intense schedules that require too much time or commitment.
    • Location of the toilet in the home may not be conducive to toilet training.
    • Some recommendations may cause inconvenience or disruption to an already established family schedule.
    • Cleanup required during toilet training may be perceived as too effortful.

These barriers can be addressed prior to beginning toilet training. As previously mentioned, many children are successfully toilet trained despite missing prerequisites indicating readiness. Additionally, identified barriers and apprehension can be taken into consideration when developing a toilet training plan for each child. For example, if a family is concerned about cleanup, one accommodation that could be made is to roll up any rugs or put a play mat down that makes it easier to clean, and have the child spend most of their time in that room during the first few days of potty training. If a family is concerned about the level of commitment to potty training, it is important to be aware that consistent commitment to the potty training process will result in greater success and that an individualized plan that will work best for that family can be developed. An open and honest conversation at the beginning of the toilet training process with a supportive clinician will help identify specific barriers and allow for advance planning to address those barriers compassionately and effectively.

Toilet Training Process

The toilet training process most often includes wearing underwear, transitioning to the bathroom on a set schedule, providing rewards, and sometimes having the child assist with cleanup or changing after an accident occurs. Research has supported that the shift to underwear is a crucial component in the success of toilet training (Greer et al., 2016; Simon & Thompson, 2006; Tarbox et al., 2004). Therefore, caregivers and recommending clinicians alike should consider this factor when starting a toilet training program. Remaining in diapers at the start of toilet training may inhibit the effectiveness and efficiency of toilet training.

Some barriers that affect caregiver consistency of toilet training include:

    • Recurrent accidents
    • Excessive urine retention or holding occurs
    • Lack of self-initiation
    • Challenging behaviors that occur during visits to the bathroom

These barriers may lead to inconsistency of training procedures or halting the toilet training process altogether. It is important to note that recurrent accidents and retention is common at the start of the toilet training process and these should be monitored closely. If your child has an underlying medical condition that may result in recurrent accidents or excessive withholding, then a medical professional should be consulted prior to beginning toilet training.

Challenging behaviors may occur at the start of toilet training. These instances may include refusal to transition or to sit on the potty, tantrums when directed to use the potty or challenging behavior in response to an accident, making it difficult to change or continue with the toileting plan. In these cases, it is important to first target the challenging behavior in the context of toilet training. For example, if your child exhibits challenging behavior related to transitioning, an additional reward component for walking to the bathroom may need to be added (and ideally this reward would be offered only in this context). So, if you tell your child, “It’s time to go the bathroom” and they walk to the bathroom appropriately, you may provide a sticker once you arrive at the bathroom. In this way, the transition becomes associated with a positive reward. If your child demonstrates minor behaviors such as crying or whining once in the bathroom, you may be able to alleviate that by keeping preferred items in the bathroom. One way to do this is to keep a basket of preferred books and small toys in the bathroom that 1) your child may engage with once in the bathroom and 2) you may be able to use to calm your child. These items may also contribute towards developing the bathroom as a positive space for your child. Of course, these modifications can and should be individualized to each child should they be required during the process.

It is also important to acknowledge that toilet training is likely to take longer after one failed attempt and increase the likelihood of these barriers to occur in the future. If these are barriers in your toilet training process, seek consultation and support for next steps before halting altogether.

Who can I contact for support?

    1. Pediatrician – Speak with your pediatrician to ensure that there are no medical barriers to successful toilet training (i.e., persistent constipation, muscle weakness limiting bowel or bladder control).
    2. Board Certified Behavior Analysts (BCBA) – Consult and work with a BCBA who can develop an individualized plan using behavioral strategies that are supported by research and can be tailored to your child’s needs.
    3. Special Education Teacher – if your child is in a special education program, their teacher may be able to provide recommendations and support you in consistently implementing an agreed upon toileting plan
    4. Physical Therapists (PT) – Some PTs specialize in toilet training can support your child with postural needs to increase appropriate sitting on the toilet and provide exercises to strengthen muscles for bladder and bowel control.
    5. There may be other professionals, including psychologists or child development experts in your area who specialize in toilet training who can support in the process.

The toilet training process might come easily with the first plan you implement, or it might involve a higher level of commitment, or it may disrupt the household’s typical schedule. Luckily, there is more than one way to tackle toilet training! Yes, some toilet training procedures may be more efficient, but only if they are implemented with consistency. If your lifestyle creates barriers for consistency with certain plans, there are ways to work around it. It may take longer to become toilet trained but it results in a higher level of adherence to the program and more positive experience for everyone involved.

Tips for Getting Started

Here are some ways to prepare that may decrease stress and increase consistency and feasibility of the toileting program:

    1. Choose a time to start, usually a 3–5-day window, when there are little to no other commitments (e.g., birthday parties, family visits).
    2. Have lots of spare clothes and underwear available for frequent changes.
    3. Have an appropriate potty seat ready based on your child’s size and comfort (please see accompanying graphic for more information)
      Autism Toilet Training
    4. Ensure that you can restrict the reward you have chosen to only toilet training success (e.g., the iPad is only used as a reward for urinating and not for leisure after school).
    5. Roll up the rugs or stick to a room that has easy to clean floors or put a play mat down for easy clean up. It is likely that once your child shows some success you will not need to restrict to one room or area.

Potty training early leads to increased self-confidence, increased personal hygiene, increased community participation, decreased discomfort, decreased stigmatization, and an overall better quality of life (Kroeger & Sorensen-Burnworth, 2009). But remember, consistency is key! So, make sure that you are implementing a plan that works for you and your family to ensure success.

References

Greer, B. D., Neidert, P. L., & Dozier, C. L. (2016). A component analysis of toilet‐trainingprocedures recommended for young children. Journal of Applied Behavior Analysis, 49(1), 69-84.

Kroeger, K. A., & Sorensen-Burnworth, R. (2009). Toilet training individuals with autism and other developmental disabilities: A critical review. Research in Autism Spectrum Disorders, 3(3), 607-618.

Simon, J. L., & Thompson, R. H. (2006). The effects of undergarment type on the urinary continence of toddlers. Journal of Applied Behavior Analysis, 39(3), 363–368. https://doi.org/10.1901/jaba.2006.124-05

Tarbox, R. S., Williams, W. L., & Friman, P. C. (2004). Extended diaper wearing: Effects on continence in and out of the diaper. Journal of Applied Behavior Analysis, 37(1), 97-100. https://doi.org/10.1901/jaba.2004.37-97

Wyndaele, J. J., & Vermandel, A. (2023). Toilet training. In Handbook of Clinical Child Psychology: Integrating Theory and Research into Practice (pp. 689-715). Springer International Publishing.

Reference for this article:

Arthur, S. (2024). Clinical Corner: How can caregivers address common toilet training barriers?  Science in Autism Treatment, 21(11).

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