Promoting self-care is crucial to anybody as we want our body to always be healthy and immune to diseases. Promoting self-care may reduce the lifetime costs associated with having a child with ASD and contribute to the individual’s well being like bringing comfort and happiness to the child. As children with Autism Spectrum Disorder have a gap between intellectual functioning and adaptive functioning, they often display moderate disadvantage in self care skills due to their developmental delays. One of the most important aspects in maintaining self-care is toilet etiquette. Children with autism spectrum disorder often received toileting instructions during older age because parents usually prioritized more towards other pivotal skills like language, communication and motor skills than instructions on toileting. Thus,toilet training is necessary as autistic children will be able to adapt their self-independence towards taking care of themselves. There are several ways on how to efficiently teach children with ASD on proper toilet training.
Parents need to understand about elimination when it comes to teaching children how to implement toilet training. A proper elimination would help in curbing the spread of germs, viruses and bacteria. Elimination is a behavior of interest during toilet training. Typical elimination problems can be divided into 2: enuresis and encopresis. Enuresis is the act of repeated urination in areas outside of the toilet, like clothing and beds, usually occurred with children below the age of 5. Encopresis meanwhile is the act of release of feces into inappropriate places and usually happens with children above 4 years old. Before selecting the suitable common treatment for both of the problems, parents should look at a few key aspects like the children’s age. For example, children below five years old should be given psycho-education in ensuring parental expectations can correlate with the child’s development in understanding instructions on how to respond to inappropriate elimination. Parents also need to find out if the child’s elimination problem can be connected to another biological problem like an urinary infection due to the child refusing to use the toilet. Both of these factors affect the treatment choice.
One effective way for toilet training is graduated guidance. Graduated guidance utilizes several actions which require less intrusive yet effective prompts like undressing, flushing and washing hands in arranged sequence to enable autistic children to learn a more complex skill like brushing teeth and toileting. The prompts are arranged based on required assistance and may include verbal prompts which are speech instructions, gestural prompt, model prompt and physical prompt.Foxx and Azrin (1971) recommended the Rapid Toilet Training method consisting of frequently-scheduled toileting opportunities, increasing in fluid intake, using a urine alarm, implementing positive and negative reinforcements.
From the Rapid Toilet Training method, the first aspect that needs to be observed are reinforcement-based treatments, both positive and negative, in order for autistic children to motivate themselves to improve on their toilet etiquette. Positive reinforcement presents a preferred stimulus once the elimination is successful for the autistic children. For instance, receiving praise from parents for successful urination. With this reinforcement, the child will be motivated to repeat the successful elimination. Negative reinforcement uses response restriction in encouraging successful elimination. As an example, the autistic child is restricted to a very small area inside the toilet to limit competing actions. Both of the reinforcement methods need to be balanced and should be given only when necessary to ensure the child understands the toilet training purpose.
Furthermore, parents are also recommended to schedule their child’s toilet sits and elimination for a fixed amount of time intervals to ensure efficient toilet training and avoid any difficulties in feces and urine elimination. The intervals may be chosen arbitrarily depending on the child’s pattern of elimination or parents can choose to utilize elimination schedules, which include the frequency and timing of the child’s elimination. Parents may observe certain patterns that their child is experiencing like waking up in the middle of the night and requesting for parents’ help. For instance, we bring the child to the toilet initially for every 15 minutes and then, gradually increasing over time. One recommended solution for scheduling is a transition from diapers to cotton underwear to improve the child’s awareness on the potential risk of enuresis or encopresis.
The hydration method is also another method whereby parents are recommended to provide unlimited access to a child’s most preferred liquids during the child’s elimination training. However, excessive liquid intake can lead to electrolyte imbalance and can cause side effects like coma, seizure and cardiac arrest. Thus, this method is not recommended for children with urinary retention issues.
Another type of method is by overcorrection which requires an intensive disruptor to practice preventing the mistake from being repeated. Overcorrection can be divided into positive practice and restitution. Positive practice is a type of repeated practice with positive forms of responding, contingent upon observed instances of bad behavior. A good example is the children practicing walking to the toilet several times. Restitution is when the parents correct the consequences of their children’s inappropriate elimination by restoring the environment back to normal before the elimination happens like cleaning themselves after the incident.
A technological innovation that is also beneficial in teaching autistic children toilet training is the urine alarm. The alarm is an effective detector for parents to know if their child is urinating inappropriately, either during daytime or nighttime. The alarm contains a small clip-on sensor that can be used to detect any moisture. The sensor is put specifically on the children’s undergarments. The alarm is safe and comfortable for children since the alarm emits low volume signals and does not disturb the children too much.
Finally, parents are also recommended to give the children a ‘toilet pass’ to trace if their children are aware of going to the toilet. The ‘toilet pass’ can become a visual prompt like a paper ticket or a simple passport given to the children for the parents to stamp on every time for the children to recognize as a way to make them remember to use the pass every time they enter the toilet. Thus, making the autistic children train on how to keep on track with their toilet usage.
To summarize, toilet training is critical for parents to teach their autistic children on how they are able to use the toilet effectively. The Rapid Toilet Training (RTT) is an excellent method for parents as the method provides necessary guidance on how to train children to use the toilet properly.
Jarbrink, K., McCrone, P., Fombonne, E., et al. (2007). Cost-impact of young adults with high-functioning autistic spectrum disorder. Research in Developmental Disabilities; 28(1): 94–104.
Byra, K.L., Hope Group, White, S., Temple, M., Hopebridge, Cameron, M.J., Cedar Group. An Approach to Cleanliness Training to Support Bathroom Hygiene among Children with Autism Spectrum Disorder. Running Head: An Approach to Cleanliness Training to Support Hygiene, 1-16.
Sleep, Elimination, and Noncompliance in Children. Clinical and Organizational Applications of Applied Behavior Analysis; 11, 256-262.
Paredes, P.R. (2004). Enuresis. Case Based Pediatrics for Medical Students and Residents; pp 466-467. Department of Pediatrics, University of Hawaii John A.Burns School of Medicine. Retrieved from http://www.hawaii.edu/medicine/pediatrics/pedtext/pedtext5.pdf
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association.
Pachter, L.M., Dowrkin, P.H. (1997). Maternal expectations about normal child development in cultural groups. Archives of Pediatrics and Adolescent Medicine; 151, 1144-1150
Kroeger, K.A. & Sorensen-Burnworth, R. (2009). Toilet Training Individuals with Autism and Other Developmental Disabilities: A Critical Review. Research in Autism Spectrum Disorders; 3, 607-618
Azrin, N. H., Foxx, R. M. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied Behavior Analysis, 4, 89-99.
Boles, R.E., Vernberg, E.M., Roberts, M.C. (2008). Treating Non-Retentive Encopresis with Rewarded Scheduled Toilet Visits. Behav Anal Pract.; 1(2), 68-72
National Kidney and Urologic Diseases Information Clearinghouse. (2014) Retrieved from: http://kidney.niddk.nih.gov.
Miltenberger, R.G., Fuqua, R.W. (1981) Overcorrection: A Review and Critical Analysis.
Carey, R.G., Bucher, B. (1983). Positive practice overcorrection: the effects of duration of positive practice on acquisition and response reduction. J Appl Behav Anal.; 16(1): 101–109.