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There is almost no literature available on training the older child with autism. Traditional children’s books all use the potty chair to teach toilet training. Animated characters on videos do not explain the elimination process or show exactly what to do. There are also other factors that come into play for children with autism: sensory issues, gastrointestinal concerns, anxiety, resistance to change, and often no social motivation to please the parents. Not all children will work for praise or rewards. Some children stand up to have a bowel movement and a change in the elimination position can cause difficulty. It took us nine years to get my son Marc using the toilet on his own, and here is how we did it.
By the time we started really trying to get him out of diapers, Marc had used the toilet successfully for urination for three years already, and was familiar with using the toilet. He knew when he was going to have a bowel movement, because he would ask for a Pull-up and then ask to be changed when he was done. He never had accidents and could hold his bowel movements until he was home, demonstrating control. With all of these signs in place, he seemed ready to start the toileting process.
My husband and I had tried various methods over the past 3 years. We used picture symbols breaking down the process of toileting on a Velcro strip. We kept a bowel movement chart for 3 weeks so we could see what time of the day Marc tended to have his bowel movement, and then we sat him on the toilet for those times. We created a social story for toileting. When none of those methods worked, we used a behavioural contingency plan with photos of Marc sitting on the toilet, a photo of broken pieces of Oh Henry bar in the toilet, and a photo of his reward – ripple chips. If he didn’t poop in the toilet (shown with a red line through the photo), then there would be no chips. None of these methods worked.
The attempt in the summer of 2006 had to be different. Marc could read and was interested in the printed word. When Brenda Smith Myles spoke for Autism Awareness Centre, she talked about the use of Power Cards. Power Cards use the child’s special interest as a way to motivate them. The Power Card is a recipe sized card with the rules you want the child to follow as told to them by whom or what interests them. We decided to try this technique using Queen Elizabeth, someone Marc is very interested in.
Instead of putting all of the toileting steps on one card, we wrote out one step per card and avoided the use of all pronouns since Marc did not understand them. We kept the text as simple as possible. Everything was stated in the present tense using Marc’s name – “Marc sits on the toilet. Poo comes out.” His reward was a scrapbook to collect photos of the Royal Yacht Britannia. He was to get one photo of the yacht to paste in the scrapbook each time he made an attempt on the toilet. We soon discovered the Power Cards were anxiety provoking, and were back to square one.
I realized there was much more to transitioning from diapers to the toilet. We had to discover what the root cause of the anxiety was. This is difficult to do when a child has very limited language skills. Was it having to sit down on toilet rather than stand? Was this a fear of having something fall away from Marc’s body? Did he think he was losing a part of himself? Was he in physical pain sitting down trying to release a bowel movement? It was time to try another strategy.
I tried draping a towel across the toilet bowl so Marc would not have the feeling that something was falling away from him – didn’t work. We then changed the emphasis to just sitting on the toilet. We asked Marc to simply sit on the toilet and then rewarded him with chips if he did. During the toileting process, Marc was smearing his feces all over the house. He picked out just enough to relieve the bowel pressure.
During the first week of toilet training, Marc withheld his bowel movement for seven days. His anxiety levels were very high. Our first breakthrough was after the first seven days – Marc went on the bathroom floor. This was progress because even though he wasn’t on the toilet, he was in the right area so we rewarded him for that. Once he got the chips, he then withheld his bowel movements for only three days at a time. It took five weeks for Marc to stop smearing his feces, but we noticed it decreasing as Marc continued to have his bowel movements on the bathroom floor. Now it was time to up the ante.
We then said no chips unless the poop was in the toilet. He had watched Ron and I empty bowel movements out of his underwear into the toilet so this now became the step for him. He emptied his bowel movement from his underwear into the toilet with almost no mess which we rewarded him for. Marc was independently washing his hands with no prompting.
Marc had his first bowel movement while over at his Grandma’s house during the sixth week of toilet training. She was sitting him on the toilet with his favorite Thomas the Tank Engine book at regular intervals throughout the day for ten minute periods. He finally had the success we had been waiting for. The question was – would he repeat this at our house? Children with autism have a difficult time generalizing so maybe he would only use the toilet at Grandma’s. Success came two days later. Marc used the toilet without any prompts from us. He didn’t flush the toilet and came and got us. He said, “Poo in the toilet. I want chips.” It was a celebration.
I discovered the key to toilet training an older child is patience, persistence, and breaking down the process into achievable goals. I wanted to give up when the fecal smearing was happening throughout the day for the first month. I was discouraged when the Power Cards didn’t work. I combed the internet for some words of wisdom and found nothing. The key was going in stages and rewarding each stage, then raising the bar as those goals were achieved. Any habit can take weeks to break. Marc had been in diapers for nine years and I was kidding myself thinking toileting would not take several weeks, maybe even several months. It was also important to take the emphasis off of having a bowel movement into the toilet. Getting into the bathroom was the first thing that needed to happen. We had jumped too many steps, not realizing how hard this transition was going to be for Marc.
Even though toilet training Marc was a challenge, it was worth it. He gained a new level of independence and confidence. Marc was so proud of himself. As parents, we were relieved to have achieved this milestone, one that we are still celebrating nine years later.
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