News and Knowledge

Dr. Cicero is the director of psychological services for the Eden II Programs, an applied behavior analysis program in New York State serving children and adults on the autistic spectrum. He is a licensed psychologist and a certified behavior analyst. He teaches applied behavior analysis at Caldwell College, N.J., and sits on the board of the New York State Association for Behavior Analysis (NYSABA). He frequently conducts workshops, consultations, and research presentations nationally and has been published in the areas of toilet training and developmental disabilities.

Toilet training is a pivotal skill for a person with autism because mastering the skill can significantly increase a person’s independence in his or her home and community. It is also one of those skills that parents of children on the autism spectrum struggle with.

The good news for parents is that it becomes easier once you realize that you teach the skill just like any other skill — through behavioral intervention techniques.

Prerequisite Skills

But before you can get started, there are prerequisite skills a child needs. Do not go strictly by chronological age and do not “wait for the child to be ready.” Your child is ready to begin toilet training once the following prerequisites are met. First, the child needs to be able to sit on a toilet for about three minutes. Second, her bladder should be able to hold urine for at least one hour. Third, serious problem behaviors should be at a relatively low level. Last, toilet training will be easier if the child has already mastered some basic self-help skills such as pulling up her own underwear.

Urination Training

Initial urination training consists of four major components. Each component has its own purpose and is a necessary part of the treatment package.

1. You will be bringing the child to the toilet on a set schedule. Schedules teach the basic routine and behaviors associated with being toilet trained. I usually begin with a 30-minute schedule. Schedules more intense than 30 minutes will not allow for periodic accidents, which are also a necessary part of the training.
2. There must be positive reinforcement for success on the toilet. Reserve one highly potent reinforcer, just for the toilet training intervention. Each time the child appropriately urinates on the toilet, on his schedule, give him access to the reinforcer. This strategy increases the child’s motivation to have his urinations on the toilet.
3. Introduce a request. Use whatever form of communication is easiest for your child. Forms of communication can include a verbal word, a picture exchange, a manual sign, etc. Prior to bringing your child to the toilet each half hour, prompt her to make the request and then respond with a naturalistic phrase such as “You have to go to the bathroom? Okay, let’s go.” This request component will allow for future independence.
4. Without an accident correction component, your toilet training plan will not be effective. Whereas the schedule component teaches the routine of toilet training, correcting accidents teaches the child when he should be requesting to use the bathroom. You have two choices. Some plans suggest punishment-based procedures. Other plans use a prompting procedure in which the therapist uses a quick verbal statement to slightly startle the child thereby temporarily interrupting the urine stream. The child is then quickly prompted to the toilet where he is encouraged to finish urinating. Any urination in the toilet is then followed by a reinforcer. Typically, this is the procedure that I use for accident correction because it turns the accident into an effective teaching trial.

From the first day that the treatment package is implemented, data are collected on the frequency of appropriate responses, frequency of accidents, and percentage of urination on the 30-minute schedule. Treatment decisions and modifications should be made based on a daily review of the data. Keep in mind that toilet training is an intensive procedure that usually requires the dedication of a trainer for a number of hours each day. It is also helpful to conduct the training directly in the bathroom with the child wearing limited clothing.

Bowel Training

Often, bowel training is completed along with urination training. Sometimes, however, the child becomes urine trained, but continues to have bowel movements in a pull-up or other inappropriate locations. In this case, you first need to conduct an assessment of why the child is not bowel trained and then develop a plan of action accordingly.

There may be several reasons why a child is not bowel trained, the main reasons being medical issues, noncompliance, skill deficits, adherence to a ritual or routine, fear of eliminating in the toilet, and using bowel “accidents” to serve some other function (i.e. to escape demands, to gain attention from others, etc.). Whether or not you need a toilet-training plan, behavior plan, or medical intervention will depend on the reason why the child is not yet trained, so an assessment period of at least two to four weeks must precede any training plan. During this time, data and information are collected and analyzed to determine the function of the problem. Obviously, if the cause is determined to be medical, seek the recommendations of an appropriate physician.

If the cause is determined to be a skill deficit, initiate a training package consisting of prompted toilet sits (limited to the most likely times of day when your child needs to have a bowel movement), positive reinforcement for success, visual cues to teach the child what she should be doing on the toilet and once again either prompting to the toilet or punishment for accidents.

With a ritualistic behavior or fear of eliminating, try a gradual desensitization plan where you introduce appropriate toileting in small steps, offering reinforcers for success along the way. For noncompliance, the first step is often increasing the potency of the reinforcer being offered for success and initiating a punishment-based component for accidents. If that does not work, you can try a procedure whereby suppositories and enemas are used as prompts. For this procedure, always seek the advice and guidance of a medical professional.

If the bowel “accidents” are serving some other function, you do not need a toilet training intervention, but rather a more traditional behavior plan such as that which would target escape-maintained, attention-maintained, or access-maintained behaviors. Seek the advice and guidance of a behavior analyst in these circumstances.

Whichever plan you choose for bowel training, you must watch closely for any signs of constipation. Long-term constipation will not only result in a medical issue that will need to be corrected, but will undermine your treatment plan because the eventual bowel movement is likely to be painful, thereby punishing any compliance with going on the toilet. It is suggested that if the child does not have a bowel movement for three days past his or her typical schedule that the bowel training plan be temporarily placed on hold until bowel movements become regular. Then, it is time to start again, making modifications to prevent future episodes of constipation.

Keep in mind that with good behavioral intervention techniques, a commitment on the part of the trainers, good data collection and analysis, consistency, and some advice from professionals if needed, toilet training can be mastered relatively easily and rapidly.