Autism and Toilet Training

“I wish my child would learn how to use the toilet!” This is the dream of every parent, not just those who have a child with autism or other disability. After all, it frees up the need for diapers or pull ups and opens the doors for more social and educational options available to your child. Toilet training a typically developing child is hard enough, but children with autism bring an additional set of obstacles that could make the toilet training process more complicated (and yes, more frustrating).

Is My Child Ready?

Your child will not experience success with toilet training if he or she is physically not ready. Keep in mind that there is no “magic” age for any child, as every child develops differently. Basically, your child has to have the ability to control the muscles that serve to close off the bladder, and those muscles need to be strong and mature enough. In typically developing children, this generally occurs between 18 and 24 months, but even then, there are variations from child to child. The child with autism might be slower in developing these necessary skills. There are also other skills that need to be in place before starting a toilet training program (this holds true for all children). Other variables indicating readiness for toileting include having the ability to sit, dress and undress, and recognizing the internal clues that indicate the need to urinate or have a bowel movement. The general order of mastery in toileting skills is as follows; bowel control during the night, bowel control during the day, bladder control during the day, and lastly, bladder control during the night. Keep in mind your child may continue to wet the bed during the night even after mastering daytime control.

Look for additional signs that your child is “ready” to start a toilet training program. These “signs” will vary from child to child, of course, but may include indicating discomfort when wet or soiled, “zoning out” and pausing in the middle of an activity, pulling at one’s diaper, or hiding behind a piece of furniture or other barrier in the environment. Other children may start to show interest in the toilet or potty chair. An important telltale sign is when your child starts to stay dry for longer and longer periods of time. To determine the frequency of your child’s urination pattern, it is helpful to check your child frequently and record when your child is dry and when your child is wet. If your child can stay dry between 2 and 3 hours, you can start the process.

Once you have taken data for about a week and understand your child’s elimination pattern, create a schedule that involves taking your child to the bathroom at an interval shorter than when your child typically eliminates. Once you experience success with that interval, gradually increase the time between bathroom visits.

Rule out Medical Issues

Prior to beginning a formal toileting program, it is important to ensure that your child does not have any medical conditions that could possibly interfere with toilet training. This should actually be done for all children, regardless of whether they have autism, another disability, or are typically developing. Medical conditions that could interfere with autism will generally be ruled out during your child’s routine physical exams. Children with autism frequently have gastrointestinal (GI) problems that could make it difficult to maintain a regular toileting schedule. Try to address these GI difficulties (bloating, gas, constipation, diarrhea, abdominal pain) prior to embarking on a toilet training program. Continue to check for too much or too little urination throughout the day, stools that are too loose or too hard, or apparent pain while urinating or having a bowel movement. If you see any of these signs, it would be beneficial to contact your child’s pediatrician for a referral to a specialist.

Tips for Toilet Training

1. Relax. Make sure you approach toilet training in a positive and relaxed manner. Your child will be able to tell if you’re stressed out with the process. Be prepared and know that accidents will occur before your child experiences success.

2. REINFORCE!!! Look at your child’s list of reinforcers. Create a hierarchy of the reinforcers and use the best of the best for toilet training, and ONLY for toilet training. Positive reinforcement is your secret weapon, use it frequently and consistently for all pro-toileting behaviors. Initially, it may be that your child is reinforced for just entering the bathroom, then once your child has mastered that step, move on to the next step and reinforce only that step. Continue to heavily reinforce the current step that your child is working on. Previously mastered steps can be occasionally reinforced to ensure that your child maintains those skills while learning new skills.

3. No Punishment. It’s important that your child NOT be punished when an accident occurs. When your child has an accident, simply say “You are wet/soiled” (whatever words you’ve chosen to use), in a neutral tone of voice. Attempt to bring your child to the bathroom and have him or her sit on the toilet. At this time, reinforce your child just for sitting on the toilet, even if they do not urinate or have a bowel movement.

4. Lots of Fluids. Make sure your child is drinking PLENTY of fluids during the toilet training process. This will increase the liklihood of elimiation in the toilet and thus the opportunity to reinforce!

5. Resistance to Change. Many children with autism have difficulty with change. Try introducing the new bathroom routine very gradually. Expose your child to the bathroom in a nonthreatening way. Start with having your child enter the bathroom fully clothed and see if your child will sit on the toilet clothed. Once your child can easily do this, sit your child on the toilet in his or her diaper, then without the diaper, etc. Try not to use a separate potty chair, this may make it difficult to transition to the regular toilet later on. Get a potty seat that fits directly on the large toilet and use a step stool if necessary.

6. Routine. Develop a structured routine that is followed consistently each time your child uses the bathroom. It is important to follow the routine in the exact same manner each time. Repetition is key! This will increase your child’s success and independence in the process. Make sure the routine you develop involves steps that your child already has the ability to complete independently. Also consider switching your child from diapers to training pants (not pull-ups). Pull-ups are very similar to diapers and absorb too much liquid for the child who may not be able to fully understand he or she is wet.

7. Visual Aids. Children with autism are notorious as being strong visual learners. Keep this in mind when toilet training your child. Try to use visual cues rather than verbal cues. Develop a picture schedule illustrating each step of the process. This can be velcroed on the bathroom wall. Have an empty pouch velcroed at the end of the picture sequence for steps the child has completed. Point to the picture (without saying anything), and then assist your child in completing that step. Once the step is complete, teach your child to remove the picture and place it in the pouch at the end of the sequence. Continue with each subsequent step until the sequence is complete. Bathroom Visual Schedule Here’s an example of how you might create a visual schedule for a child with autism (Child-Autism-Parent-Café.Com.). If your child has responded well to the use of social stories in learning other skills, try using a social story illustrating the toileting routine. Here is an example of a simple social story a parent created for her daughter about going to the bathroom.potty

8. Sensory Issues. Autism is generally associated with a variety of sensory issues. Children may be over or hypersensitive to a variety of environmental stimuli. Keep in mind the way your child responds to visual stimuli, smells, sounds, etc. It may be necessary to make some changes in your bathroom environment to make it more comfortable for your child. Consider things like the lighting, the air fresheners or perfumes that might be present, and even the flushing of the toilet. Bathrooms are also typically colder or warmer than other areas of the home, so make accommodations to ensure that the climate is comfortable for your child.

9. Teaching Initiation. Once your child is successful going to the bathroom on the toileting schedule you have developed, it will be important to start teaching initiation. The best way to do this is to be standing in front of your child and have a second person standing behind your child at the scheduled time. If your child is verbal and can imitate words, have the second person (behind the child) say the word “bathroom” for your child to repeat. When your child says “bathroom”, you (in front of your child) should acknowledge this and say “Oh! You have to use the bathroom!”, and reinforce this prompted initiation. If your child is nonverbal, have pictures of bathroom velcroed around the house. Use the same procedure (second person behind). In this scenario, the second person will prompt your child to get the bathroom picture and place it in your hand.
Why the second person you may ask? It is very difficult to teach initiation when you prompt your child from the front. In essence, you can’t teach initiation of any skill this way, because the very nature of prompting from the front involves you ”going first” and your child “responding” to your prompt. It’s like me standing in front of you and saying “go ahead, start a conversation with me.” See? You can’t because I have already “gone first”.

Patience is a Virtue

The key to success is simple… PATIENCE! Remember that toilet training your child with autism is likely to start a bit later and take a bit longer as it would with a typically developing child. A habit takes at least three weeks to become a habit! Choose a method that seems to fit you and your child and stick with it for at least three weeks (consistently). Be consistent, stick with it, and don’t get discouraged! Your hard work and your child’s hard work will pay off in time, and you’ll be able to forever say “goodbye” to those diapers!

By letstalkautism

Debunking the Myths (part 5; friendship)

Friendship is one of the greatest joys in life. A large number of scientific studies have found that in addition to bringing happiness, friendship improves individuals’ health and increases life expectancy. Other studies looking at friendship have found that a lack of friendship leads to an increased risk of various illnesses such as viral infections, heart disease and cancer.

Having worked in the field of autism for almost 30 years, I have heard many family members voice concerns regarding their child’s difficulty in forming friendships. The myth we’ll debunk today involves the notion that individuals with autism can’t form meaningful friendships or do not desire to form meaningful friendships.

First and foremost, autism is a communication disorder. The difficulties in communicating with others can indeed hinder the ability to form friendships, but not necessarily because the desire is not there. A wide variety of variables are at play when discussing autism and friendships. The difficulties in communication make it challenging for many individuals with autism to interact with peers in traditional ways. Friendships are typically built on shared interests between two people. Think about your good friends, the common bond is that you probably share your thoughts, feelings and experiences with one another. It’s a two way street so to speak, friends generally give one another equal time to share such thoughts and experiences. Reciprocal communication does not come easily for many individuals with autism, it typically needs to be taught in the context of a formal communication training lesson. Additionally, many individuals with autism have strong interests in certain areas, and often times these interests may be somewhat unusual. It’s possible that the peer group available to the individual with autism does not share similar interests. Helping the individual with autism expand his or her repertoire of interests will serve to increase the possibility of shared interests with their peer group.

It takes a great deal of effort for many individuals with autism to develop the social skills required to interact with other people. This is why it’s imperative that parents and educators start developing a child’s social skills from a very early age. Social difficulties for children with autism are quite diverse. Sometimes the social challenges are mild, and sometimes they are much more complicated. Whether mild or more severe, such social challenges almost always involve problems with social understanding. This is further compounded by communication deficits, attentional abilities, poor problem solving skills, intellectual disability and sensory processing disorder. Social skill development comes naturally to typically developing children, so many educators and parents take it for granted that these skills do not naturally develop in children with autism. Rather, such social skills have to be taught explicitly and children with autism need to be given the opportunity to practice these skills (over and over again) in a safe environment.

Spreading awareness is vital. Educating typically developing peers on autism and characteristics associated with autism is critical. Without such education, typical peers will not understand why the individual with autism acts a certain way, and unfortunately, this can easily lead to teasing and bullying. The child with autism may be viewed as a “loner” or “odd”, therefore unapproachable. As a result, classmates are less likely to try to build a relationship with the child with autism. Many schools have implemented programs that strive to create a culture in which the understanding of autism is increased. Such programs result in greater acceptance of the differences in individuals with autism as well as an increased ability to interact effectively with the individual diagnosed with autism.

Here’s a link to one such program. This work was the culmination of The Inclusionary Practices for Children with Autism Spectrum Disorders Study conducted by the University of Prince Edward Island and the Prince Edward Island Department of Education.

Educating Children about Autism in an Inclusive Classroom

As one parent of a child with autism so eloquently stated, “I don’t profess to know how it is for you or your children, every individual is very different. What I can tell you though, is that friendship is extremely important in my son’s life… so important that if he’s mad at you, you don’t get to be his friend, if his friend isn’t friendly, he’s lost all hope on friendships, if a friend isn’t there, he’s sad. Next time I hear a doctor tell me that people with Autism are emotionless, or unable to have real friendships, I’ll have some words for them… clearly those doctors either don’t deal with people that have Autism or they aren’t paying enough attention.”

Yes, all individuals with autism need friends and most individuals with autism want friends. It’s a matter of taking the time to equip children with autism with the tools they need to form such relationships.

By letstalkautism

Another Musical Savant…

I recently posted about individuals with autism who possess unique skills. This 6 year old child stole my heart (he’s now 7). His name is Ethan Walmark and he’s quite remarkable (and adorable)! Ethan can not read music, he listens to music and then plays his favorite songs by ear on the piano (his vocal pitch is spot on also).

Ethan Walmark playing Piano Man at home, then at an Autism Speaks Gala. You have to watch these videos!

Ethan Walmart at Home with one of his therapists in April 2012

Ethan Walmart at the Autism Speaks Chef’s Gala October 2012

By letstalkautism

My Autism Comic

The “comic strip” below was written by Jordan A. Thomas, a 28 year old woman diagnosed with autism. She created this piece when she was 27. I thought it was so moving and enlightening, I wanted to share it with my readers. Here’s what she has to say about this “comic strip” she named My Autistic Comic.

“I have Autism and I am 27 years of age. There are many things in this world that confuse me. There are many things I cannot do. A lot of the time I feel very alone. A lot of the time I want to say things and share things with people but I can’t.

So today I decided to do a small comic book about some of the things I feel now and some of the things I felt as a child. I wrote it all myself. I drew all the pictures myself. The world will not change for me. I will never fit in and I will never be normal but if just one or two people can understand a bit more about Autism and then teach another one or two people then the world will get easier to live in.

So what I ask of you is to have a read of this then pass it on to someone else. Then that person passes it on and so does the next and the next till this comic is falling to bits from being read so much. Its not a chain letter nothing bad will happen to you if you do not pass this on but something good might come to those of us with Autism if you do.

Autism will always be strange and odd but if we can make it a little less strange then there is hope out there for us all.”

My Autism Comic

By letstalkautism

Debunking the Myths (part 4; intelligence)

Do all individuals with autism have intellectual disabilities? Do all individuals with autism have “savant” abilities like Rain Man? These are two questions I get asked all the time. So, what’s the answer? Well, here are the facts as we know them today.

Let’s address the first question, “Do all individuals with autism have intellectual disabilities?”

Autism is generally associated with intellectual disability, which means that an individual has an Intelligence Quotient (IQ) below 70. While it is true that approximately 70% to 75% of individuals with autism do have intellectual disabilities, autism also occurs in individuals with average, above average and even superior intelligence.

Individuals diagnosed with autism have difficulties in three central areas; social development, communication, and interests/behavior (restricted and repetitive). The manifestation of symptoms is affected by a couple of variables, namely intellectual functioning and age. For example, individuals with autism who possess a higher Intelligence Quotient are likely to show more interest in social interaction, are more likely to be verbal communicators and have the tendency to become preoccupied with special interests or facts rather than becoming preoccupied with objects.

Important to note is that autism and intellectual disability (sometimes termed mental retardation) are two distinct neurological conditions. Yes, there are some similar characteristics, but there are also some significant differences. It is often difficult to obtain a reliable diagnosis when a child has severe autism or mental retardation because of the similarities, namely developmental delay, learning difficulties, communication deficits, delayed adaptive (self-care) skills and delayed social development.

The differences appear when we look at the areas of delayed development in individuals who have autism without intellectual disability. Autism affects brain development specifically in the areas of social skills, communication, and interests and behaviors (restricted and repetitive).

Intellectual disability without autism, however, looks quite different. Intellectual disability produces significant delays in both intellectual functioning and adaptive behaviors. As a result, individuals with intellectual disability experience significant delays not only in social skills, communication skills, and restricted and repetitive interests and behaviors, but also in most if not all other areas of development.

The biggest difference is in the pattern of skill development between the two diagnoses. While individuals with intellectual disability show relatively even (albeit delayed) skill development, individuals with autism typically show uneven skill development, with delays in certain areas of development and distinct strengths or skills in other areas. These skills are also known as “splinter skills”.

This brings us to the next question, “Do all individuals with autism have “savant” abilities like Rain Man?”

I mentioned “splinter skills” above. Such strengths are often seen in the areas of visual processing (such as completing complex puzzles) and auditory memory (the ability to hum a tune in perfect pitch after hearing it). Individuals with these types of skills are often called autistic savants. An autistic savant is an individual who has an unusual gift or ability, one that is clearly above their overall level of functioning and above the norm for the population in general. Autism is a spectrum disorder, meaning there is a significant difference in cognitive abilities, developmental levels, and severity of symptoms across individuals diagnosed. The same can be said regarding savant skills, an individual with autism can have splinter skills (such as memorizing specific dates), talented skills (skilled artist or ability to calculate complex math equation in one’s head), or prodigious skills (playing an entire concerto after listening to it only once).

Texas Boy with Autism, A Musical Genius Here’s a link to a brief video showing a boy with autism who would be considered a “talented” musical savant.

Jacob, A Mathematical Savant Another link to a young boy with autism who would be considered a prodigy.

It is estimated that about 10% of individuals diagnosed with autism have splinter and talented savant skills. It is further estimated that there are only 100 prodigious savants in the world, although I would hazard a guess that there are many more who have not yet been “discovered”.

So, intellectual disability, savant or both? That’s part of the puzzle that is autism, all the combinations seem to fit, and that’s what makes individuals with autism so unique.

By letstalkautism

Autism and Behavior Change

Let’s face it, coping with a child who has a disability can be very difficult; especially when they display challenging behaviors. It becomes even more difficult if your child is non-verbal, minimally verbal, or experiences other communication challenges. Challenging behavior can involve anything from physical aggression and property destruction to pica (putting inedible items in the mouth) and self stimulatory or repetitive behaviors and anything in between. If the behavior has a negative impact on your child or your family, I think we would all classify it as a challenging or interfering behavior. It’s important to keep in mind that while our children with communication deficits exhibit challenging behaviors, these behaviors do have a function, and there could be a number of reasons why they occur. Information processing difficulties, unstructured time, oversensitivity (hyper) or undersensitivity (hypo) of some environmental or internal event, changes in routines, and feeling unwell, tired or hungry are just a few examples of why challenging behaviors may occur.

When thinking about challenging behaviors, it’s helpful to think about human behavior in general. Behavior can be biologically driven (we put on a sweater when we’re cold) or reflexively driven (we close our eyes if a light is too bright). So, behaviors generally occur because they serve an important function or produce a specific outcome. When challenging behaviors occur, we have to keep in mind that it’s a form of communication. The critical part of addressing such behaviors lies in trying to understand the purpose or function of the behavior. Our behavior is shaped by our environment, specifically what happens directly prior to (antecedent conditions) the behavior and directly after (consequent conditions) the behavior.

As a result of these behaviors being “learned” behaviors, we often see dramatic improvements in behavior by changing the situations and environment surrounding the behavior, or as stated above, the events that come before and after the problem behavior occurs. Gathering this information will assist us in starting to understand why the challenging behavior is occurring. This is part of what is called a functional behavior assessment, and there are many ways to go about collecting such information. This is always the first step in determining how to teach replacement skills that are functional for the child experiencing challenges.

For more detailed information on functional behavior assessments, the National Professional Development Center on Autism Spectrum Disorders offers the following links:

Steps of a Functional Assessment

Functional Assessment Checklist

Challenging behaviors in children (and adults) with autism typically serve one of the following functions; To obtain a tangible desired object or outcome; To escape a difficult or unpleasant task or situation; To gain the attention of others (either positive or negative attention); To try to regulate or calm oneself through self-stimulatory behaviors; And in an attempt to respond to pain or illness. Once the functional behavioral assessment has been completed, the information gained will point us in the right direction regarding the development of a behavior intervention plan (BIP). The BIP is a concrete plan of action regarding what exactly will be implemented to manage the challenging behavior.

Such a plan will typically consist of the following components: A description/definition of the challenging behavior being targeted, information regarding the function of the target behavior from the functional behavior assessment, a list of interventions previously tried (and how well they worked or did not work in modifying the behavior), a description of the “new” behavior that will be taught to the student that serves the same purpose (replacement behavior), proactive strategies that will be put into place to prevent the target behavior from occurring, other specific interventions that will currently be utilized (including people responsible for implementation), what will take place if the target behavior occurs (reactive strategies), how data will be collected to track behavior change, and information on how often the plan will be reviewed to determine effectiveness.

For more detailed information on behavior intervention plans, check out this link to a great PowerPoint presentation on BIPs created by Sonja R. de Boer, Ph.D., BCBA and shared by Autism Speaks:

Behavior Intervention Plans

I’d like to conclude this post by sharing a quote by Temple Grandin, Ph.D., an adult with autism, “Special educators [and parents] need to look at what a child can do instead of what he/she cannot do. There needs to be more emphasis on building up and expanding the skills a child is good at. Too often people get locked into a label such as dyslexia, ADHD, or autism, and they cannot see beyond the label. Kids that get a label often have uneven skills. They may be talented in one area and have a real deficiency in another. It is important to work on areas where a child is weak, but an emphasis on deficits should not get to the point where building the area of strength gets neglected.”

My next post will focus on the use of positive reinforcement and positive behavior supports to decrease challenging behaviors and increase functional communicative behaviors!

By letstalkautism