I often hear parents come up to me with exacerbation saying “He does not even indicate” “when I put him on the toilet seat, he runs away as if the seat is going to eat him up” “He does not enter a wet toilet and starts crying after hearing sound of flush”. “I wish he just tells!” Do these lines sound familiar? If yes, then this article will help you to deal with these issues. Remember, potty training or voiding is a skill and like all the skills, getting independence in toileting is dependent on 1) Physical, physiological, cognitive and Sensory processing level of the child 2) Behaviour, environment and opportunities to practice play a big role in learning this skill. Sounds complex? But it is not. It just needs, like teaching any other skill, some investment.
PART 1: Sensory systems and potty training Large percentages of children (almost 98% according to an American study) have sensory processing difficulties. Parents of children with autism are familiar with the term sensory integration.
Over and above our 5 senses
There are 3 other senses
c) Vestibular sense.
A newly born baby is not toilet trained and indicates by crying after he has passed motion or urine. The first step in acquiring independence is the child needs to recognize the sensation. For example like one associates ‘that hollow feeling’ in the stomach means hunger the same way one knows that the heavy discomfort in the lower part of the stomach means need to urinate or defecate depending on the sensation which the Interoceptors from bowel and bladder send to the brain.
There are 3 readiness tests for toilet training.
- Bowel control
- Readiness to cooperate.
- Physical readiness.
Unless and until the child has passed these tests, he or she is not ready for toilet training. It is important that the parents recognize at what level their child is at, before they start to work on toilet training. Acquiring mastery over any skill, including potty training involve registering and responding to multiple sensory systems. Only if the child can ‘sense’ the sensation to defecate or urinate, he will be able to seek help or place to perform the act followed by all the steps like entering the toilet, undressing, sitting on the potty, understanding the sensation that the job is done, cleaning, dressing etc. An average age by which a typically developing child gets toilet trained is 2 years and 6 month. The child with autism needs to be chronologically and developmentally at that age.
Parents need to observe some of these points like:
1) Is the child able to recognize the sensation associated with an urge for potty?
2) Can the child indicate his need by a gesture or expression?
3) And control at least for a few minutes till he is undressed and taken to the toilet (if he needs help).
In most children with autism the third test mentioned above, i.e. the physical readiness may not be a concern, unless the child fears change in body position and therefore is reluctant to squat. Fear of movement, could be due to hyper responsiveness to vestibular sense and some of the strategies mentioned below could be tried. In most children with autism, the toileting challenge may start because the child takes a long time to understand the sensation associated with the ‘need to pass urine or stools’. Consequently, training the child to stay dry, needs to be done for at least 4 hours a day. Giving lots of liquids to recognize full bladder sensation works as a good strategy.
Children with autism often suffer from constipation and infrequent bowel movements. This along with ‘not so healthy dietary preference’ aggravates the problem.
What can you do?
As parents you continue working on improving child’s food habits? Introducing healthy food in small portions is the key to success but changing child’s food habits means the entire household need to change their food habits which is tough but not impossible! The biggest challenge is how to teach the child to associate that ‘discomfort with the need to go for potty?’ this can’t taught externally because this is an internal sense which has to be experienced but we can help the child register the sensation by making him sit on the toilet seat every day at fixed time, preferably after meals when the child is full and therefore likely to pass stools. Keeping a track of child’s routine or any indication (facial or gestural) which could be a cue can work as a hint to decide when to put the child on the seat.
Further discussion on this topic would continue in “Potty training a child with autism Part 2”. Check this space for the next article on “Potty training as Behaviour”. Parents, we would like to hear from you, so leave a comment below. Let us know from your experience any techniques you have employed in potty training your child.
- Building bridges through sensory integration by Ellen Yack, Shirley Sutton, Paula Aquilla
- A Work in Progress: Behavior Management Strategies & A Curriculum for Intensive Behavioral Treatment of Autism by Ron Leaf, John McEachin, Jaisom D. Harsh.
- Potty training for children with autism or intellectual disabilities. Developmental Information and Practical Procedures by Sue Bettison