One of the issues facing many of our families today is how to approach toilet training for children with autism and other developmental disabilities. Continence, or being toilet trained, is a crucial skill for independence and quality of life. Being incontinent “places limits on socialization, and residential and vocational placements. Quality of life impairments can include inadequate hygiene, stigmatism, physical discomfort and irritation of the genitals, diminished self-confidence, and restrictions from typical daily activities” (e.g., Cicero & Pfadt, 2002; Hyams, McCoull, Smith, & Tyrer, 1992; Lott & Kroeger, 2004; McCartney, 1990). At Reaching Milestones many of our children have either been successfully toilet trained or are currently in the process of being so.
There are several potty training procedures that have been found to be effective. The first recommended method is referred to as graduated guidance. Graduated guidance is a prompt based method using “behavioral chaining.” Behavioral chaining involves reinforcing closer approximations of the behavior targeted (using the toilet). In this procedure you begin with the least involved prompt to start the chain. For example you may bring the child to the potty and stand there with an obvious pause, if they don’t begin the process of undressing to use the toilet then point to their pants (gesturing to pull them down), if need be you would then present a verbal prompt, and finally move on to increasing levels of physical prompting. In the event that graduated guidance is successful there are other more involved procedures available.
One empirically based procedure that we have been using is based on the protocol from Kimberly Kroeger and Rena Sorensen (2010). The purpose of the procedure is to teach self initiation through a sitting schedule. The sitting schedule is:
- 30 minutes sitting on the toilet, 5 minutes off (for successfully going)
- 25 minutes on, 10 minutes off
- 20 minutes on, 15 minutes off
- 15 minutes on, 20 minutes off
- 10 minutes on, 25 minutes off
- 5 minutes on, 30 minutes off
If the child successfully urinates/defecates on the toilet (even if there is more time on the toilet) their minutes off automatically begin, and if they go during their time off the time off restarts. Each time they have successfully gone 3 times in a row you move down to the next sitting schedule. Once they have reached the 20 minutes on, if they are not already self-initiating then a chair is introduced. You begin by placing a chair 2 feet away facing the toilet and once they have successfully gone 3 times in a row you move the chair 2 feet further away from the toilet. Once the chair is 20 feet away you start decreasing the time again. This teaches them the sensation of their bladder being full and needing to stand up from where they are to independently go to the restroom.
Potty training children with developmental disorders may seem overwhelming, but these two protocols have been shown through data based research to be effective methods of potty training in both neurotypical and autistic children. With consistency, patience, and a plan toilet training will be quick and effective, and your child will benefit from the independence and comfort of being able to self-initiate.