This is something of a personal issue for me since my 3.5 year old daughter has autism. She has twice shown an interest in toilet training and it was a disastrous affair since she simply lacked the interoception necessary to sense and control her bladder. At the time, she hadn’t been diagnosed and I simply accepted that she wasn’t ready.
I had researched toilet training by attending workshops, reading books, searching through blogs, and talking to other parents. I also wrote a series of articles myself which are aimed at neurotypical kids. These covered:
- When should we start toilet / potty training?
- How can I help prepare my child for toilet training?
- What methods can I use toilet training?
- Rewards for toilet training
These are methods which will work for most families; however, some children need an extra level of support. For me, and others I know, it is because our children have special needs such as autism (ASD). Miss 3 struggles with sensory issues in a range of ways, including an awareness (and interpretation) of internal body signals such as the need to go to the bathroom. She’s not alone in this; many kids struggle with the leap from nappies to toilet for eliminating waste. Modern nappies wick away moisture and allow our little ones to stay comfortable without feeling a need to pause their play. We then place them in underwear and expect an awareness of being wet (sensory input) to result in a desire to be dry (perception) and a change in behaviour (action). In reality, these are all separate steps controlled by different regions of the brain and requiring different foundational skills; putting all of these together in a fluid and reliable manner is a complex change.
Extra Strategies to help with toilet training
Start by writing down all the challenges you associate with toilet training. Sort these into challenges for you (as a parent) and challenges for your child. Think about how you can address these challenges.
Write down goals for yourself and your child. Your long-term objective might be toilet training but there might be a number of short term goals that you need to address first (and this is where it comes in really handy that you’ve already written down all the challenges you need to work through).
Your child needs to feel safe and comfortable in the bathroom. It’s often a very functional room that adults spend little time in but the journey your child is embarking on means spending a lot of time in there. For those with autism and/or sensory issues, identifying triggers can be critical.
I knew my daughter didn’t like the bathroom but I thought it was because of associating it with nappy changing and discomfort as a result of very sensitive skin. I patiently worked as a detective to try and observe her behaviour and work out what she couldn’t tell me with words. One morning, I sat down with all the towels on the floor and struggled to find the right questions to elicit a response. I could see the progress in sensory integration and vocabulary work we’d been doing for months but she finds it impossible to answer general questions. At last I narrowed down my questions to ‘Which colour makes your body feel most safe and comfortable and still?’, ‘Which colour makes your body feel most muddly, shaky, and unhappy?’
Through a mixture of words and gestures, we were able to establish that a warm palette of soft sandstone and mocha were acceptable (as were accents of pink, white, and gold) but the jewel-like mix of towels in brightly coloured greens, red, and blue were highly upsetting. Other triggers, included the bright light (with the noisy ceiling fan powered by the same switch), the strong smelling soap, and the toilet paper (which to her felt like sandpaper).
I needed to identify which of these I could change (like the soap and towels) and which ones I could only minimize (like using the light in the adjacent room unless we were having a shower).
Sitting on the toilet requires both proprioceptive and vestibular skills; your child needs to be able to sense their body’s position in space and be able to balance. Consider sending time practising activities like naming which body part you are touching while they have their eyes closed, running, jumping, climbing, and walking on a balance beam.
The sensory feel of the potty or toilet seat is important. Some kids are happy balancing on an adult toilet seat, others are terrified by the feeling of space beneath their bare bum and the fear they might fall in. There are lots of options available on the market, my favourite is a cheap one – buying a toilet seat with an integrated flip-up junior seat.
Help your child understand how they need to be positioned on the toilet (and this requires modelling by a parent or sibling). Show them how they need to sit or move for each part of the process. For a girl, I’ve needed to teach her that her bottom needs to sit near the back, her knees need to be together, and her pelvis needs to be tilted down. I have a large textured sticker on the toilet seat (rear-middle) which she can feel with her hand to help guide her bottom. I also bought a super cheap mirror which we decorated together in colours she chose and which I hung opposite the toilet so that she could see herself and how she was positioned. The mirror also has the advantage of keeping her entertained!
Be aware that using the toilet is a complicated process; you can help your child by breaking down the steps into manageable tasks. Consider making a social story for potty training and putting visual reminders on the bathroom wall.
“Our sensory integration occupational therapist handed me pages of pictures showing the individual steps for using the toilet. Frankly, I felt overwhelmed. It’s such an automatic task that it hadn’t occurred to me how many micro-steps there are!”
“One game we play is ‘What’s under my bum?’ She stands with her eyes closed while I put a tiny plastic animal on a chair behind her. I guide her into sitting and she has to try and feel which side the toy is, roll her pelvis, and reach with her hand for it. She thinks it’s hugely funny; more than a game, we’re building skills she will need for the toilet – sitting, balancing, and movements associated with wiping.”
Help your child understand how using the toilet will fit into their daily routine; for instance, needing them to sit on the toilet as soon as they wake up in their morning. Communicate what your expectations are and consider making a poster about how the toilet fits into their daily routine. Some parents find it helpful to use a digital timer or a smart watch with vibrating alarms (like the FitBit) to help remind children to take regular toilet breaks. Teach kids phrases like ‘pause my play‘ for going to the toilet; this is less frightening (and less likely to cause a power struggle) then ‘stop’ as it means they can return to their task after sitting on the toilet.
Create an elimination diary so that you can get a feel for how often they are eliminating; this is incredibly useful for identifying patterns. You may also want to seek advice from a nurse if they are regularly holding urine for 6-8 hours or have no bowel motions for four consecutive days or more. Constipation can become a vicious cycle when combined with dehydration and anxiety; it hurts when they eliminate and so that makes repeating the experience seem like a bad idea! There are great articles on how to help strong willed children who may have anxiety around bowel motions; this one includes a template for an elimination diary. These child friendly resources from Continence Foundation of Australia explain how the bowel and bladder work and can be helpful to support discussions.
Think about your stance on motivations vs rewards. A motivation is something that encourages your child to do something (a behaviour or action), a reward is something that comes after an action is successfully completed. Often parents use rewards for toilet training, this may include everything from stickers to jellybeans. Instead, consider creating a special toilet treasure box as a motivation for sitting on the toilet and tying reward charts to keeping underwear dry (rather than eliminating waste). Be consistent with your child that the treasure box can only be played with while sitting on the toilet.
An ideal treasure box will have a lid and can be decorated with the child’s name and any potty party theme you are using. It’s a good idea to include several books (including at least one relating to using the potty / toilet). Give careful thought to your child’s interests and sensory needs. Try to include a few small toys they can choose at the shop; pictures they can look at; things they can manipulate with their hands; things that make sounds. Get inventive!
“We found a dog toy that looks like a rubber zebra and makes a hilarious laughing noise when it’s squeezed hard enough.”
“She has a few princess dolls that sit on their own potty while listening to the music from a wind up jewellery box.”
“We got one of those dinner trays with a bean bag base, painted the top black and added white lines. He zooms cars around the race track.”
Find underwear they feel comfortable in. It’s a big step moving from nappies to something which feels completely different; this is even more true for children with sensory issues, sensitive skin, or eczema. Some children find it helpful to have a breathable material, no elastic, and to be seam free. Lulu Funk is one such online retailer specializing in New Zealand made underwear for sensitive bottoms.
Accept that accidents will happen. They do and sometimes in the most ridiculously awful of places; remember that if you are calm and matter of fact about it that your child stands a better chance of internalizing this without getting weighed down by shame. It can also be helpful to focus on praising them for keeping their underwear dry (rather than focusing on eliminating in the toilet).
“One exercise we did was to bring out a favourite soft toy, two identical pairs of underwear, a bowl, and some room temperature juice. Elmo put on some dry underwear and a pretend Elmo did a ‘wee’ in the other underwear. We practiced touching ‘dry’ and ‘wet’; I talked about how sometimes it can be difficult to feel warm wee when the weather is really hot. I froze the wet underwear and later we practiced ‘wet’ and ‘dry’ again.”
It’s a good idea to teach your child where they should touch their underwear to check if they are wet or dry; boys are often wet higher at the front, whereas girls tend to be wet lower down.
Consistency, consistency, consistency. Having worked out your game plan, share it with everyone else involved in your child’s toileting. It helps to have teachers at daycare, kindy, or school following the same methods and routines as at home (as much as possible).
Decide what success looks like to you. It can be easy to assume that every family has an easy time toilet training but I promise you that there are plenty that struggle. As adults, we may have a reasonable expectation of using a toilet 100% of the time whereas lots of young kids simply get excited or distracted and forget. Think about your child’s developmental age, temperament, and the challenges you wrote down. Success may involve focusing on a single micro-task and then adding a second step once that has been reasonably mastered. Remember that the long term goal is not only to help your child master a skill that gives them another step towards independence, it’s also about helping them to feel positive about themselves and successful along the way.