The Toileting Process

What might the toilet training process actually look like? This lesson will give an example by following a young boy with ASD.

Geraldo is almost 4 years old and is receiving educational services through his school district as well as some private speech and occupational therapies. He has some language, but much of it is imitative. He is very responsive to the use of visual sequences and schedules.

Geraldo's teacher and parents are working together on toilet training. His teacher has come to his home to help the family begin toilet training. Geraldo's parents and teacher have documented his toileting patterns for 10 days as best they could. They have checked his pants at least every 30 minutes and noted patterns of wet/dry.

They have also tried to note any behavioral patterns when he does wet, such as his habit of getting very quiet and moving away from an activity when he is wetting or having a bowel movement. Geraldo has been participating in some of his self-care by removing his diaper when he wets and putting it in a diaper pail. His parents and teacher have begun to help him identify "wet pants" and "dry pants" without using a judgmental or negative voice. They also note that when he wets, it is quite a large amount, which indicates that he can hold his urine longer than some children, who may be going very small amounts very frequenlty.

Geraldo's parents and teachers compiled a list of highly reinforcing items, including squishy sensory balls, flashlights, and sour "gummy" candies. Geraldo has a supply of 12 new pair of underwear, and has been wearing elastic-band pants to more independently participate in pushing and pulling his pants down and up at toileting. (Note: "pull-ups" are not acceptable as underwear. They are as thick as diapers and do not allow the child to experience feeling wet or dry as underwear does) He was also recently checked out by his pediatrician, who ruled out any bladder or urinary problems.

Geraldo's parents attended a workshop given by his teacher that addressed specific issues with regard to toilet training individuals with ASD. They have read information by other experts in the field of autism and recognize the unique issues they may be facing in toilet training. They have also networked with other parents of children with autism who have toilet trained their children and received some helpful tips and support.

Geraldo's teacher has brought over a visual sequence of the toilet routine for Geraldo, which visually depicts pulling down pants, sitting on the toilet, and so on, and shows graphic visuals of urine and feces in the toilet. This concrete specific visual is often necessary for individuals with autism to understand that the end process is elimination in the toilet.

Geraldo's teacher begins the process by showing Geraldo a picture of his bathroom, along with the verbal request, “Go to the bathroom.” Geraldo and his teacher go to the bathroom, and Geraldo assists in removing his dry diaper (which is documented on the data sheet, as are time and the condition of the pants) and is encouraged to put on regular underwear. Initially, Geraldo is reluctant and becomes distressed with the idea of putting on underwear; he is used to wearing his diaper and begins to fuss and cry. His teacher patiently waits, shows him the visual for "underwear on," and blocks the door to the bathroom so he cannot run out. As Geraldo's cries lessen, his teacher gently assists him in beginning to put on his underwear. He continues to whimper, but assists in putting them on. He is verbally encouraged (“Big boy, Geraldo! You are wearing big boy pants!”) and his parents verbally reinforce him as well. Once his pants are on, he is free to leave the bathroom area. He runs to the kitchen where he is offered juice. Geraldo quickly drinks 8 ounces of juice (which is also recorded so that the amount of liquid intake can be documented). His teacher and parents do a few activities with him, then his teacher again presents the Go to bathroom picture. She guides him to the bathroom, and this time he will be required to sit on the toilet.

It is important to note that all toileting activities should occur in the bathroom that and a toilet should be used, not a potty chair. Even with young children, it is important that they learn that all toileting needs take place in the bathroom. This reinforces the association of all toileting behavior with the corresponding appropriate environment (the bathroom). Even though it may be tempting to change pants in the living room because it is more convenient, Geraldo's parents understand the importance of reinforcing all toileting behaviors in the bathroom.

Geraldo has had many opportunities to observe his parents, siblings, and peers in the community use the toilet. Still, he is initially resistant to sitting on the toilet. Because he is small, an insert that fits over the toilet seat is provided for him. In addition, a footstool that allows his feet to be supported has also been provided.

Geraldo again is encouraged to push his pants down independently (he will have many practice opportunities for this skill!). His teacher directs his hand to his underwear, “Dry pants, Geraldo!” She shows him the visual for sitting on the toilet and gently assists him in sitting on the toilet. Geraldo immediately resists and begins yelling and arching. His teacher again positions herself so that Geraldo cannot escape the area, but is not forcefully pushing him to sit. Instead, she says, “Geraldo! Let's count to 10! 1...2...3...” She begins to count, and as Geraldo's attention is directed to an activity he loves (counting), he relaxes, sits on the toilet and attends to his teacher's counting. As he relaxes, she slows her counting down, so that Geraldo has a longer opportunity to sit on the toilet. When she reaches 10, she says “All done! Pull up your pants.” Geraldo gets off the toilet and pull up his pants. He reaches to flush the toilet (which he loves), but his teacher, already anticipating this, blocks his hand and shows him the visual sequence, “First potty, then flush!” She shows him the next step in the sequence, which is washing his hands. Geraldo will have many opportunities to practice handwashing as well.

Geraldo's teacher knew that sitting would be hard for him, so she utilized an activity that he enjoyed (counting). This helps divert his attention, as well as turning his behavior into something more positive (sitting on the toilet). His fussing was not reinforced by allowing him to leave the bathroom area; rather it was redirected, which let to more acceptable behavior and he was reinforced for the behavior that we want to see an increase in. The counting also helped Geraldo understand how long he would be sitting (“Let's count to 10!”). Other techniques that the child understands can be used, such as singing a song or using a visual or digital timer. Initially, the time should be short and just long enough so the child is still relaxed when time to get off the toilet.

Geraldo runs back to the kitchen/play area and enjoys some time jumping on his small trampoline. His mother has a snack on the table for him and he eats some chips (to make him thirstier) and drinks another 8 ounces of juice. His teacher notes that he has been dry for almost an hour and that, typically, his data has shown that he goes approximately every hour to hour and a half. This time his mother takes him to the bathroom and follows the steps she has observed his teacher use. Geraldo begins to fuss because, after all, this is a new pattern with his mother! His mother calmly ignores his fussing and redirects him to the visuals. Geraldo is still dry, and as he fusses as he sits on the toilet, his mother says, “Let's sing Baby Bumblebee!” Geraldo immediately stops fussing and joins in some of the actions with the song. When it is done, he gets off the toilet. He pulls his underwear up, washes his hands and runs to the play area. His teacher is watching him very closely now as he must be getting close to having to go. Sure enough, at one point, Geraldo gets very quiet, then begins to "dance." His teacher quickly directs him to the bathroom, but Geraldo has already wet his pants. He is not scolded, but rather, his teacher uses a matter-of-fact voice and says “Wet pants, Geraldo. Pee goes in the toilet.” She shows him the visual picture of urine in the toilet. Geraldo is then directed to change his own underwear, wipe himself, and put on dry underwear.

Michael Powers, who has a lot of knowledge and expertise in the area of toilet training individuals with autism, warns, “When toilet training, you should not be working harder than your child” (Powers, 2000). Your child needs to take responsibility for changing their wet pants, cleaning themselves, and putting on dry pants. Not only does it increase awareness of going to the bathroom, it also builds in natural opportunities for practicing self-care skills.

Returning to Geraldo, the process continues: liquids are given, he is taken to the toilet on a routine, and documentation is continued. Even though Geraldo has wet his pants, it is still a learning process, and he will become more aware of being wet. After awhile his father takes his turn with toileting Geraldo. Not only does this take the pressure off one parent being the only to toilet the child, it helps Geraldo learn to generalize and realize that other people expect him to use the toilet.

As the process continues, Geraldo's teacher has identified a more clear pattern of when he wets, and the behaviors he begins to exhibit prior to going. As a result, when it gets closer to the time that he might be expected to go, he is directed to the bathroom, then kept in the bathroom area even though he did not go. He is allowed off the toilet, but kept in the bathroom. As his teacher plays with him, she is carefully monitoring his actions. At one point, he begins to quiet. She quickly gets him to the toilet; he pulls his pants down and sits on the toilet. He begins to fuss, but he is encouraged to sit. Finally, Geraldo goes to the bathroom on the toilet! He is just as surprised as everyone else! He is verbally praised “Hooray! You went potty in the toilet”! and given his squishy texture ball (which was included on his visual schedule). Geraldo and his parents have experienced success after all their hard work! Geraldo's teacher stayed at his house for about three hours helping his parents through the beginning process; now they are more confident about continuing the process.

This is just the first step in toilet training; however the sequencing of urinating and having bowel movements in the toilet is as follows. Typically, children learn to urinate in the toilet during the day, have a bowel movement in the toilet during the day, and develop the ability to hold their urine through the night or wake up in the night and go. The final step in this process is to develop the ability to keep from having a bowel movement during the night.

Geraldo will continue to have "accidents,” but they will continue to be a teaching tool. His awareness of wet and dry will increase, and if his reinforcers are motivating enough, he will continue to go on the toilet. The teachers reminded his parents that the reinforcer is given only if he is dry and then goes on the toilet. If he wet his pants, then sat on the toilet and urinated, he would not get his reinforcer. It is important that the desired behavior is the behavior being reinforced. We want to see dry pants, and going to the bathroom in the toilet.

Geraldo's parents continue to document his toileting and observe patterns. They can increase the length of time before they take him to the toilet based on the patterns they see. They also begin to take him to toilets elsewhere, such as at his Grandma's house, at his favorite restaurant, and shopping centers. His mother found a fold-up toilet insert that works well when they travel so he learns to use the toilet in a variety of places. His parents and teacher continue to share information and data regarding his toileting.

Geraldo's parents also have a social story about using the toilet that he enjoys having read to him. He has pictures of a toilet in his communication book so he can begin to initiate using the toilet, rather than always waiting for someone to tell him when to go.

A behavioral definition of being toilet trained, as defined by Michael Powers, is 30 consecutive days, no accidents day or night (Power, 2000). Geraldo has a ways to go, but he has experienced the beginning successes of toilet training.

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