Toilet Training an Older Child With Autism. Picture of feet and toilet and diaper

The Trials of Toilet Training An Older Child With Autism

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.

Look For Signs That Your Older Child Is Ready To Toilet Train

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.

Try A Variety of Approaches – Don’t Get Discouraged

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.

If Those Don’t Work, Try Something Else

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.

Find The Root Of The Issue If Possible By Trial And Error

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.

Remember This Will Be Stressful For Everyone…And Likely Messy

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.

Break Down The Process Into Stages And Don’t Give Up

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.

Helpful Reading

The Potty Journey

Toilet Training and the Autism Spectrum (ASD) – A Guide for Professionals

Toilet Training for Individuals with Autism and Related Disorders: A Comprehensive Guide for Parents and Teachers 2nd. Edition

 

 

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  1. Denise says:

    I have a 17 year old autistic non-verbal daughter. She has bowel movements in a pull-up only. I know she knows what to do, she is just very stubborn. Thank you for writing this article. It gives me hope!

    • Change is hard for everyone. You have to go cold turkey with the Pull Ups. My son was so clever and able to hold his bowel movements for days until I caved and put a Pull Up on him. Sometimes the feeling of the stool dropping away and into the toilet is such a new sensation, it causes stress. You could try putting Saran Wrap over the toilet bowl and letting your daughter still have the sensation of the bowel movement leaving her body and still making contact with her bum. I know it sounds unusual to try this, but sometimes these in-between steps are needed.

  2. Rae says:

    Please , please help!! My son is 16 , and REFUSES to sit on the commode to have a bowel movement. For weeks and weeks I will suggest go to the bathroom, and after a while he will start to get upset and become violent when asked. He rather go in his underwear, and most days I have to fight just to get him to let me change him. He pullls it out and puts it in the trash, sink, bowl or his mouth (gag).

    • This one is tough. He has to be shown that the bowel movement goes into the toilet. Can he do it in his underwear, then have to put the stool in the toilet and get rewarded for that step? We had to make this as a step for my son as well. We were able to fade this step after a week and get him sitting right on the toilet. Does you son have an unusual elimination position? Sometimes this is a problem as well.

  3. Sarah says:

    Hi Maureen,
    We are currently working with a parent to toilet train her child. We have a lot of questions as he sounds similar to your situation. Is there any way we could contact you by email?

  4. Sinia says:

    My grandson is 8 years old. He uses the bathroom with no problem. The only problem is when he sits on the toilet to poop and pee comes out he doesn’t understand how to keep the pee in the toilet and it goes all over the toilet and floor. Do you have any tips to help him with keeping the peep inside the toilet when he sits in the toilet to poop. Thank you .

  5. Julia says:

    Thank you so much for this information! We are desperately trying to toilet train our 6 year old son who has a rare genetic condition, is intellectually delayed and has Autism. He also has behavioural challenges that cause him to resist care. We are not totally sure if he has bowel control but are hoping to try this method. With his medical condition he suffers from severe constipation which he takes medication for. I am hopeful after reading this article that there may be hope to succeed. I am even considering a leave from work to try. Any suggestions if this method could be achieved in out of home scenarios? He attends school and daycare….Thank you for being so strong!

    • Julia, generalization of toileting can take some time. The important thing is to be consistent in all situations. For example, if you are using picture symbols for toileting, those same ones should be used everywhere. Use the same language around toileting. Because some toilets may be higher off the ground, you have to make sure the child can still sit stablized because feeling off balance can cause issues. With our son, he used the toilet successfully everywhere right away. I am not completely sure why as this is not often the case.

    • Grandma Ang says:

      I have read that letting a boy take of his pants and underwear and then getting them to sit facing the tank is helpful. It also has the added benefit of watching what is happening. 

  6. Farah says:

    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.

    im holding my self from crying as im reading this at work
    my son is only 4..i emptied his poop from the pants in the toilet hoping to teach him where poop goes..he did just that..pooped in his pants and then went to scope it by his hand to throw it in the toilet. i was so disgusted and it showed in my face. i didn’t see it this way..i didn’t see it as a step forward.. why didn’t i? thank you so much for giving me a new perspective

    • Farah, don’t be too hard on yourself. Toileting is a very complex issue and no child progresses in the same way. What you want to celebrate is now your son knows where the poop goes and this is a huge step! It won’t be long now before he learns that it is even easier just to sit on the toilet and not have to handle the poop himself. You’re on your way to successful toilet training. This is really something to celebrate!

  7. Samantha says:

    Hi. I have a 6yo son with autism. I have tried every toilet training method I could think of. He will only poop at home and he asks for a pull up. He goes and hides like a baby does and poops on all fours. I stopped the pull ups cold turkey but he would just go in his underwear. It doesn’t bother him. He could care less if he’s changed immediately or not. After 2mos I just went back to pull ups because I got tired of cleaning out his underwear. I also have a 13yo daughter who is severely disabled (non-mobile & non-verbal) and of course I have to change her diapers. I feel like I’m changing poop diapers all day. Sometimes between the two of them I change 6-10stinky diapers. I try to explain that poop goes in the potty but he sees me changing my daughter so I’m wondering if that is part of the problem. He asks me everyday why she can’t walk and things like that. He just doesn’t understand. And he doesn’t get why he should have to use the potty and she doesn’t. I try to explain that children his age should go in the potty and he just says no. I just don’t know what to do.

    • Samantha, I would try going cold turkey again with the Pull-Ups if you can and when your son poops in his underwear, you take him to the toilet to empty out the poop from the underwear. He may need to start learning that poop goes in the toilet and he has to be part of the process emptying it.

      The fact that he eliminates while on all fours tells me he may have some pain or difficulty passing a stool. Are his bowel movements hard or soft? Does he have any pain passing a stool. When on all fours, does he rock back and forth?

  8. Sylvia Barron says:

    I have a 42 -year old son with severe autism. He has been toilet trained since childhood, but I skipped a step in trying to avoid feces eating or smearing, so for almost 37 years I or another adult has been wiping him. ?This has led to him coming soiled from day program when his coach ignores my request that he needs that assistance. I’m racing the clock in planning for his future with me gone, I’m 63 and have tried for months to show him how to wrap the toilet tissue in his hand to wipe and have failed over and over. He washes his hands, but continues to wipe his butt cheeks without going into the crack. Any help will be much appreciated.

    • Sylvia, your son may need to lean forward with his legs a bit spread in order to get in between the butt cheeks. You may also want to try using wet wipes as they give more sensory feedback so your son may get better input with a wet wipe. Sometimes just a change in position helps. It may be too much for him to spread his cheeks on his own, handle the toilet paper, then wipe. If this doesn’t work, write back to me and I’ll do some more brainstorming.

  9. Amanda Ruth says:

    I am a 23 year old single mother of a 7 year old little boy, he’s currently in the process of being diagnosed through the IU13 unit here in Pennsylvania. I was at wits end with him having to use a diaper to relieve himself. My family blames me and says its because I’m a crappy mom, but this article right here, just proved them wrong. My sons uncle on his fathers side has autism– Asperbergers’ to be precise. I cannot thank the author enough, both for stating that this is a normal problem for autistic children, but also that it can be broken. THANK YOU SO MUCH !

    • Amanda, my son was not toilet trained until he was almost 10 and my daughter was 6. I was blamed by everyone for this – my mother especially. There is new research emerging that another part of this problem is interoception. This is the eighth sensory system that tells you how you feel internally (thirst, pain, need to go to the bathroom etc.). In people with autism, interoception is impaired. This can be taught in some individuals to recognize these internal signals, but not every person will be successful with aspects such as emotions.

      The first place to start with this process can just be teaching your son that relieving himself happens in the bathroom. Always take him in there when you are changing his diaper and get him involved in the diaper changing process. There is a really good book to read as well called The Potty Journey which I highly recommend. A nurse wrote it. I believe that every child can be toilet trained unless there is a true physical/medical reason that this can’t happen.

  10. Maria says:

    My 21 year old with autism and behavioral issues is non-verbal . I am trying to get him off pull ups at home first but it’s been difficult. Any suggestions?

    • You have to go cold turkey with the pull ups if you want to get rid of them. My son could hold his bowel movements for a week at a time waiting for me to give in with the pull up. Teach him that toileting happens in the bathroom and help him make the association that’s where that activity occurs. If you have specific questions, feel free to ask me.

  11. Jennifer says:

    This is a great article. I’m going to try this with our 12 year old son.
    Just wondering if you taught the entire toileting process of wiping and washing hands after having a bowel movement from the very beginning or if you taught that later? Thanks for sharing!

    • Thank you for your kind words, Jennifer. To answer your question, you have to teach the entire toileting process as a complete routine. It is really difficult to try and add in separate steps later. My son took 6 weeks to learn the entire routine, but he has never made a mistake since and he’s soon to be 21. He has always washed his hands and often uses Wet Wipes after a bowel movement. He puts those wipes in the wastepaper basket.

  12. Stacey says:

    My 3 year old has autism but also tuberous sclerosis,Epolepsy ,developmental delay,she underwent brain surgery a year ago,everyone is making me feel pressured to potty train her,she can’t yet talk,walks very wobbly,and at the moment is getting into her nappy and eating playing with her poop,I tell her what it is and that it’s yuk not to eat it etc then wash her ,I’m feeling pretty useless just now and deflated to be honest and I just don’t know where to start,I hv two older children and a one year old

    • Do not give in to the pressure to toilet train. You never go by chronological age to start this process. You have to look where a child is developmentally. Look for signs of readiness -http://www.friendshipcircle.org/blog/2013/08/07/6-readiness-indicators-for-toilet-training-young-children-with-special-needs/ . If the signs aren’t there, don’t start. You can also look at the topic of interoception – https://autismawarenesscentre.com/what-is-interoception-and-how-does-it-impact-autism/.

      I have two children with autism – one was toilet trained at 6 and the other closer to 10 years of age. We had years of fecal smearing and some eating, but now that we have done the process, we have never looked back.

      When your daughter is getting into her nappy, take her to the toilet and have her empty the contents of the nappy into the toilet. This is often the first step in helping a child to understand where poop eventually goes.

      It sounds like your daughter is having gross motor issues since her surgery. Toileting involves gross motor movements so don’t put so much pressure on yourself. It is better to wait until your daughter is more stable than to push and put unnecessary stress on both yourself and your child.

  13. Tessa Bools says:

    We have spent years trying to toilet train our severely autistic 10 year old, who is still in pull ups, because he constantly wees and poos. He has absolutely no control over his bowel movements, and constantly wets himself inbetween toileting and changes of pull ups. We have to change him all the time. I would like to go cold turkey, and take the pull ups away. But I would probably have to change him  even more frequantly. Also I  don’t think school are ready for him to start wearing “normal pants,” just yet. Thanks for sharing your article. I might try some of the ideas.

    • Tessa, you may have to determine if there is an actual physical problem that is causing frequent bladder and bowel movements. I spent 3 solid years trying to train the bowel movement (ages 6 – 9). One place to start is to help the child realize there is an actual place for wee and poo and that is the bathroom. Keep him in the Pull-Ups but see if you can get him to associate going with being in the actual bathroom. Can you son be involved with the clean up? Often, when the child becomes involved, they are more motivated to get rid of the Pull-Ups. Please let me know if you try any ideas. This is not easy, believe me. I thought my marriage would end over the trials of it all.

  14. Sherie paris says:

    We are about to restart toilet training for our 16 year old. Having tried all the typical routes before, it’s been great seeing this and maybe we can use these tips to finally achieve some success. Thank you for sharing

    • Sherie, I am a huge believer that any person with ASD can be toilet trained unless there is an actual physiological reason it can’t be done. The key is to experiment and stick with it. Ours was a 6 week process. The previous 3 years of trying, I had always given up at the end of the third week. I really kicked myself when I saw we were probably half way to success on those 3 tries, but I just didn’t know it.

      The first step is helping the child realize that elimination happens in the bathroom. We also found we had to get rid of the diapers completely, otherwise Marc could hold on to a bowel movement for up to 7 days and he could wait for that diaper at any point.

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