Specific Issues

Every individual with autism is unique, the often share certain characteristics with regard to toileting that impact behavior.

• A major issue related to successful toilet training is that social motivation is viewed differently by many individuals with ASD. Thus, pleading “Do it to make Mommy happy!” may be met with little or no reaction. For example, many children do not care if they please someone by going on the toilet. Thus what is “socially acceptable” for typical individuals is often not easily identified by individuals with ASD. Further, many young children with ASD have difficulties in identifying what social cues to focus on, or identify the pertinent social factors in a situation. If there is difficulty in considering “what other people think” with regard to what is considered socially appropriate, approaching toilet training from a purely social aspect will likely fail.
  
• Many individuals with autism spectrum disorder, especially young children, also have difficulties with interpreting sensory information including understanding the relationship between body sensations and the accompanying body function. In the case of toilet training, the child may not understand the body cues that tell him he needs to go to the bathroom. His reading of tactile sensations may be impaired; having a wet diaper or wet underwear may not be negative to him.
  
• Related to sensory integration, smearing feces may a pleasurable activity for some individuals, without consideration of the negative impact on others around them. Similarly, the feeling of a cold toilet seat may be so negative to an individual that they immediately resist sitting on a toilet again. Many individuals with autism spectrum disorder demonstrate hyper- or hyposensitivity to sights and sounds. For some young children, the sound of a flushing toilet may be frightening, especially if it is an automatic flushing toilet and it surprises the child. For children who have difficulty interpreting their body in space, just sitting on a toilet that offers no support for their feet or hands, or on toilet seat that feels too big and somewhat unsafe can be very scary and increase negative responses to the toileting routine. The smells of soaps or disinfectants used in bathrooms may be unbearable for some individuals with autism.
  
• Medical issues must be considered prior to toilet training. Some children may have urinary infections or difficulties with constipation or loose stools because of diet, medications or their physiological makeup. In addition, research is documenting the incidence of gastrointestinal (GI) symptoms in individuals with ASD. Fore example, Dr. Tim Buie, a pediatric gastroenterologist from Harvard Massachusetts General Hospital, is studying the relationship between what is called the brain/gut connection. Some children may associate the pain of elimination with toileting and set up more resistance to toilet training. Individuals with seizures may not be able to control their toileting needs.
  
• Communication difficulties also impact toileting. Difficulties understanding verbal requests for the toileting sequence may add to the frustration. Children who do not understand what is expected during toileting routines will not be likely to request going to the bathroom. Their literal interpretation of “sit on the toilet” is just that: they sit on the toilet but do not understand the step of actually going to the bathroom while on the toilet!!
• For many individuals with autism, organizing information, processing that information and then sequencing it into meaningful actions can be difficult. A characteristic frequently observed in individuals with autism is the inability to focus on relevant details in an activity. With the long, complicated sequence of toileting skills, anxiety levels increase and the chance of success is slim.
  
• Imitation skills and motor planning difficulties are disordered in individuals with ASD. There are countless stories of families who have their child watch them or a sibling go to the bathroom, and then wait hopefully for the child to imitate them and go to the bathroom. However, most often the child does not imitate the desired behavior, in fact imitation of non-desired behaviors can occur. For example, some individuals may become over-focused on flushing a toilet or watching the water swirl round and round.
  
• Routines and habits can become fixed and rigid in a short amount of time in individuals with ASD. Wearing diapers is typical with any young child; for children with autism spectrum disorder, making the change from diapers to underwear can be traumatic, especially the longer the child wears them.

Faced with all these issues, what are families to do? Often, families are overwhelmed with getting their child to intervention programs, private therapy, and a multitude of appointments, as well as trying to focus on other children in the family. Toilet training a child with ASD can seem such a daunting task, that it is easy to put it off until a child is ready. Soon, a child is 5 years old, and is still in diapers, and no closer to "readiness" for toileting than when he was 3.

Our next lesson will look into more specifics of toileting readiness.