Toilet training is an area of child development that worries many parents. It is not helped when there is conflicting information given by other parents, relatives, healthcare professionals and others. If your child has additional needs, or differences in development then toilet training becomes even more challenging.

Why might children with autism struggle with toilet training?

Communication differences:

Children who are on the autistic spectrum often have difficulties with understanding words, with non-verbal communication (picking up cues from facial expressions and body language) and with expressing their needs (saying what they want, feel or need).

This means that they may struggle with:

• Understanding the words for toileting and so may not understand what is expected of them.
• They may not have or be able to say the words to let others know that they need to wee or poo.
• May interpret language literally and therefore be confused by some of the expressions we use to describe weeing (passing urine) or pooing (opening bowels). E.g. going to the toilet is literally about going to a place. It does not describe doing a wee or poo.

Using picture cue cards and social stories may help overcome these issues

Social interaction differences:

Children who are on the autistic spectrum may not understand expected behaviour and may have difficulties with relationships.

Because of this they may:

• Not be interested in being the same as, or doing the same things as others
• They may not learn by imitating other people, in the way that many children do
• They may not be concerned about being wet or soiled

Using rewards to motivate may help. Discuss appropriate rewards with your child’s healthcare professionals. These should be something small that your child is interested in and which can be provided as soon as they have done what is expected of them.

Imagination differences:

Children who are on the autistic spectrum may not use imaginary or social play, they may be rigid in their thinking and struggle to understand what comes next, which means that they struggle if their  familiar routines are changed.

This means that they:

• May assume that you know when they need help and not realise that they need to tell you.
• Changes in their routines are very confusing for them and may make them fearful or anxious.
• They may struggle to transfer knowledge: if they learn to do something in one. place they may not realise that they should do the same thing in other places e.g. if they learn to use the toilet at home, they may not realise they should do so at school as well.

Making changes slowly and gradually, with the support of picture cues or social stories may help them to feel safe and accept the changes better.

Sensory issues

Many children who are on the autistic spectrum have sensory problems. They may:

• be more sensitive than other children, or be less sensitive. They may have a mixture of increased sensitivity in some areas and reduced sensitivity in others
• have difficulty filtering sensory information that occurs at the same time. Most of us can ‘switch off’ to some information that we don’t need e.g. if there are lots of background noises when we are having a conversation, we can concentrate on the words being said to us and ignore the other noises. Children who are not able to filter information cannot ignore all the other noises, but also sights, sounds, smells etc. that are going on at the same time.

Try to think about how the toilet environment affects your child with their sensory need and try to make adjustments to help them. Your child’s occupational therapist may be able to make some suggestions.

How do these affect toilet training?

To be able to use the toilet appropriately and successfully we need to learn a series of skills, but learning these can be more difficult if children are on the autistic spectrum.  Causes of the difficulties will vary according to how the autism affects them. Success with toilet training involves working out what is causing issues for the child and making changes to reduce the effect of the issues.

What can help?

Starting work on the skills for toilet training early is often successful as there has been less time for rigid behaviours and thought processes to become established.

Try to ensure that your child is having fruit and vegetables every day and is drinking plenty of water based fluids, as far as their behaviours and habits allow. Fruit and vegetables help prevent constipation, which can delay toilet training. Good intake of water based fluids (about 1 ¼ litres a day for children aged 2-4 years and about 1 ¼ – 1 ½ litres per day for children aged 5-11 years) helps develop a healthy bladder as well as prevent constipation.

Where can I get more information and support for toilet training children with autism?

Bladder & Bowel UK have lots of information on toilet training children with additional needs including autism on their website at www.bbuk.org.uk/children-young-people/children- resources/ that is free to access and download.

For individual advice consult your child’s healthcare professional or contact the Bladder & Bowel UK confidential helpline at email: bbuk@disabledliving.co.uk or telephone 0161 214 4591.

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Toilet training a child with autism is often difficult. Autism is a spectrum condition that affects social communication, social interaction and imagination. There are often sensory issues as well. These impact on many areas of learning and life for the child and their family.

Communication difficulties may mean that the young person with autism struggles to understand what is being asked of them. The problems with social interaction may mean they are not concerned about being wet or soiled, they may not be motivated to please their parents or carers and may not be able to learn through imitation of others.

Problems with public toilets

Problems with imagination may lead to a lack of ability to know what is going on or what will come next, resulting in inflexibility, difficulty changing routines, fears and anxieties, as well as an inability to transfer a skill learned in one place to another. Therefore, the child may be able to use the toilet at home or at school, but does not understand that they can or should do this in different toilets.

These problems may on their own make public toilets a difficult place for children and young people with autism to be. However, if there are sensory differences, particularly hypersensitivities, which is an increased awareness of different sensory inputs, these may make public toilets a particularly difficult or frightening place to be. It needs to be remembered that sensory problems can make things that most of us do not even notice intrusive or even painful for some people with autism.

Children who are sensitive to sounds and who struggle with imagination find echoing spaces with unpredictable banging of toilet doors, flushes and loud hand driers very difficult to deal with. Those who struggle with visual sensitivities may find flickering strip lights and reflective surfaces a problem. Smell can also be an issue, with odours from different people and strong cleaning materials. For children who are hypersensitive to touch and internal body feedback systems (interoception), colder environments may be distressing.

What can be done to help?

Introducing different toilets early in the toilet training process is usually a good idea, but not always achievable. Trying to understand what is causing the difficulty for the individual allows opportunities to consider what can be adjusted to improve things. If the problem is with understanding then picture cue cards and social stories can help.

Changing the environment is not usually possible with public toilets. However, many children and young people with autism are able to manage better if they have access to a disabled toilet. There are numerous locked toilets across the UK which can only be accessed with a RADAR key. These keys are available from Disability Rights. The idea behind the scheme was that disabled toilets would remain clean and available for those that needed them, rather than to the general public.

The advantage of a disabled toilet for children and young people with autism is that they are separate from main public toilets. This reduces sudden and unexpected noise, particularly from hand driers. There will be fewer smells, a more consistent layout and therefore what is behind the door is more predictable. There is also more space for a parent or carer to go in with them.

Introducing change

Introducing change gradually is also helpful. It would be a good idea to take the child who struggles with public toilets to the door of the disabled toilet, unlock it, have a quick look, point out something that is the same as at home or school and then leave. If this is done on every trip out, then gradually the young person will be persuaded to step into the toilet with the door left open, then  to wash their hands and finally to sit on the toilet with the door closed. Use of picture cue cards and social stories may help.

As with all life skills for the child with autism, patience, consistency, a calm manner and unpicking the particular area of difficulty and finding a way to reduce the impact all help.

For more advice, information or support for toilet training a child with autism or to discuss any area of bladder or bowel problems or toileting issues for people of all ages and abilities visit our website, email us, or ring our helpline on 0161 214 4591.

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