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autism and toilet training
Autism and Toilet Training
written by Danica Mamlet Summary Toilet training children with autism poses unique problems for parents and professionals. Lack of intervention by specially trained educators can extend their dependence on caregivers. Remaining untrained as they age can inhibit children's independence, limiting future habitation and employment options.
The Autistic Disorder
Toilet training is one of the earliest tasks of the developing child. It is a task for which specific teaching techniques exist which are widely accepted and commonly practiced. When a child is hindered in this task by a developmental disorder, it is necessary to alter the techniques to address his or her specific deficits. This proposal aims to address the challenges involved in the toilet training of autistic children and provide a viable solution. To accomplish this goal, a description of autistic disorder as it is currently defined in the fields of education and psychology will be outlined. A review of the current trends in accepted toilet training methods recommended for typically developing children will follow. These two topics will then be discussed in terms of how the particular traits of autism require special adaptations to these methods. Finally, I will propose a pilot program designed to train parents and caregivers of children with autism to effectively toilet train their children. Autism is a spectrum disorder, falling under the umbrella of pervasive developmental disorders (American Psychiatric Association, 1994), which is brought on by a dysfunction of the central nervous system. It is usually diagnosed in the first three years of life with noted symptoms occurring as early as 18 months. Traits common to autism include the following three symptoms: impairment of social readiness (Thiemann, Howard & Goldstein, 2001), verbal and nonverbal communication delays and disorders (Pickles, 1996; Sarakoff, Taylor, & Poulson 2001), and stereotypical, repetitive behavior patterns. The more symptoms a child displays, the more severely impaired the child is considered to be. The DSM-IV considers milder cases not meeting every criterion for autism to be pervasive developmental disorder-not otherwise specified. For a child to receive a diagnosis of autism, the three core impairments must be present. Impaired social interaction can be demonstrated by "the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction." Impaired social interaction can also be regarded as a "failure to develop peer relationships appropriate to developmental level" as well as " a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people" and a "lack of social or emotional reciprocity (American Psychiatric Association, 1994, p. 70)". Often autistic children are happiest when left alone, not seeking out connections with parents or peers. Autistic children may actively avoid interactions with others, straining away to avoid eye contact or being held. An autistic child does not get pleasure, as typically developing children do, from making their parents happy or proud. They may be taught to say, "I did it!" or "Look at me!" but rarely think to do this on their own. Impairments in communication are demonstrated in autistic children by "a delay in, or total lack of the development of spoken language...marked impairment in the ability to initiate or sustain conversation with others...stereotyped and repetitive use of language or idiosyncratic language...(and) lack of varied, spontaneous make-believe play as well as lack of social imitative play appropriate to developmental level."(American Psychiatric Association, 1994, p. 70) Often autistic children show abnormalities in the use of gestures and other non-verbal communication. With the help of intervention, autistic children may develop some language skills, while others never use verbal communication effectively. Often, their speech patterns do not contain the intonations that are commonly paired with language to convey mood or feeling when speaking, giving their speech a halting quality that can be described as robotic. Some people with autism use augmentative communication devices such as computers or "cheap talk" devices or picture symbols (Capps, Losh & Thurber, 2000). Autistic children display some form of self-stimulatory behavior which is a repetitive, stereotypical motor or verbal action. Some common examples are hand flapping, rocking, tracking objects with their eyes, spinning, and repetitively waving or twirling objects. Extreme attachment to routines is very common. For example, an autistic child might insist on taking the same route from the kitchen to the bathroom and making the same sounds and gestures each time around. This behavior is described as a "compulsive adherence" to routines and rituals (Capps, Losh & Thurber, 2000). When playing with toys, their actions may seem on the surface to be appropriate but when closer attention is paid, one may notice that they are lining up the same objects over and over or repeating the same action such as picking up a play phone and saying hello repeatedly with no variance in words or behavior. In addition to the symptoms listed in the DSM-IV, other sources noted that autistic children might demonstrate unusual responses to stimuli. Autistic children may be very sensitive to their environment, such as sounds, the amount of light, smells, etc. Conversely, they may be oblivious to changes in their environment. They can also have very strong reactions to seemingly innocuous objects, songs or visual stimuli (Dettmer, Simpson, Myles, & Ganz 2000). Autistic children can have extreme difficulty attending to non-preferred activities. They are often constantly moving and may be seen as hyperactive. They can be extremely sensitive to changes in their environment (Copps, Losh & Thurber, 2000). Some children may also engage in self-injurious or aggressive behaviors. They may bite or hit themselves or others as well as engage in head-banging. It is unclear whether this behavior occurs out of frustration, anger or because abnormalities of sensory experience may result in pleasurable stimulation from self-injury. Some autistic children may show an aptitude for certain skills while exhibiting extremely low functionality in other areas, although true autistic "savants" are rare (Hendriks 1998). When all of the characteristics unique to autism are looked at, it is understandable that toilet training would pose particular problems for autistic children.
Current toilet training methods and practices
To fully understand the particular difficulties care givers and teachers can have in toilet training autistic children, it is important to review the current and prevailing philosophies in toilet training typically developing children. A review of current journal articles revealed that most practitioners advocate a child-oriented approach to toilet training. This emphasizes child readiness and employing a system of positive reinforcement (Stadtler, Gorski * Brazelton, 1999). Brazelton, et al wrote that achieving bladder and bowel control could contribute to a child's self-esteem. "This model of toilet training comprises three variant forces in child development: physiological maturation (e.g., ability to sit, walk, dress and undress); external feedback (e.g., self esteem and motivation, desire to imitate and identify with mentors, self-determination and independence) (Brazelton, et al., p. 2)." Brazelton et al. stress the delicacy of a child's self-esteem during initial successes in toilet training and emphasize the need for strong parental support during initial and successive toilet training phases. Parents are told to have the child use a potty chair, place stool from the diaper into the potty chair, watch parents go so as to imitate them, let the child sit on the potty fully clothed, and to time when urination and bowel movements are most probable. Parents are encouraged to explain to the child what is expected when they are taken to the potty and to praise and reward any successful eliminations while being careful not to criticize accidents, and to have the child say "bye-bye" to items being flushed so as to diminish anxieties. The literature shows that even typically developing children often have difficulty mastering toilet training (Hagopian, Fisher, Paszza & Wiezbicki 1993, Blum, Taubman & Osborne 1997, Buchholz 1999, Issenman, Filmer & Gorski 1999). A common problem among typically developing children is regression, resulting in Encopresis and Enuresis. Authorities highlight targeting self-esteem issues in treatment of these problems. In contrast, autistic children's difficulties in toilet training tend to be less related to self-esteem issues than to problems intrinsic to their disorder.
Problems of Autism in toilet training
The specific characteristics that impede autistic children's independent use of the toilet are outlined below. Autistic difficulties in understanding social relationships limit the success of a social reward system such as recommended by T. Berry Brazelton, et al. (Stadtler, Gorski, & Brazelton, 1999). This method encourages the typically developing 2-3 year old child to have a sense of pride or accomplishment for success in toilet training. As discussed earlier, autistic children often do not feel pleasure from making their parents and teachers happy. Thus a program based on social motivation would not have great probability for success. Difficulties in comprehending language and logic may inhibit the ability to understand what is expected in regards to the toilet procedure. Autistic children often do not understand an explanation of why they need to eliminate in the toilet and not their diaper. Furthermore, autistic children's attachment to routines and resistance to change may make the transition from diapers to the toilet difficult. They may be attached to the sensation of wearing diapers, having used them daily for 2-4 years. They may not like the stimulating environment of the bathroom with its bright lights, echoes, and sounds of running and flushing water and they may be averse to the change in temperature they feel when they take off their clothes (American Psychiatric Association, 1994; Boswell & Gray, 1995.) Autistic children's toilet training can be further impeded by their idiosyncratic relationships with their bodies. They may not know how to read bodily cues, and therefore are not aware of the urge to use the toilet. In addition they may not mind the sensation of being soiled. The reasons for this are unclear but some experts have speculated that this may be related to central nervous system abnormalities in children with Autism. (Hagopian, Fisher, Paszza, &Wiezbicki, 1993). All of these factors contribute to the need for adaptation of classic toilet training methods to suit the special needs of autistic children.
Successful toilet training techniques for autistic children
What follows is a brief review of various toilet training techniques that address the unique needs of autistic children. The focus of this review is to shed light on how the specific characteristics of autism can be addressed. In order to address the communication deficits associated with Autism, visual versus verbal cues may result in higher favorable response rates (Dettmer, Simpson, Myles, & Ganz, 2000). Thus a system employing picture icons with each step task analyzed is recommended as a tool to teach toileting independence. Practicing a consistent, task analyzed routine capitalizes on Autistic children's predilection for repetition. This method must include a concrete, visual "what happens when I'm finished" piece of information because task completion is a powerful motivator for most children with Autism (Boswell & Gray, 1995). To address difficulties with the recognition of the urge to eliminate, timers may help the Autistic child learn to recognize when they are ready to eliminate. Also, a transition object (e.g., a preferred toy or book) may be used initially to shape smooth transitioning behavior. The use of the transitional object can also aid in teaching the child to initiate on its own. If the child has become accustomed to taking a certain book or doll to the bathroom when prompted by an adult, they may indicate the need to go by picking up this item on their own. A photograph of the toilet can also be used as an effective way to communicate the need to eliminate. This can be especially helpful for children with deficits in their use of verbal language. To accommodate autistic children's resistance to change, it is recommended that instructors introduce the bathroom routine gradually, first requiring the child to enter the bathroom clothed, then to sit clothed on the toilet, then in diapers, then unclothed. The use of potty chairs are not encouraged with autistic children as the adjustment to the toilet may take longer if they have become adjusted to the potty chair. If a child resists eliminating on the toilet, the use of a water prompt can facilitate a child's recognition of the sensation of having to eliminate (Hagopian, Fisher, Paszza, & Wiezbicki, 1993). As it is important to reduce as many outside distractions and obstacles as possible, the use of a small half bathroom is recommended. Autistic disorder poses many challenges to instructors and caregivers. One can see that with creativity and ingenuity, autistic children can learn many of the skills that will aid them in living the most independent life possible. Failure to develop toilet training independence can substantially hinder the autistic child. The untrained child will continue to be dependent on caregivers for the most basic of living skills. If this problem is addressed early, children with Autism can enjoy increased independence, freedom for caregivers, and greater options for schools and residences in the future.
Program Objectives
This program seeks to assist caregivers in the difficult task of toilet training children with autism. This will occur through the placement of trained early childhood educators into eligible homes of families with young autistic children. The objective of this placement is to guide caregivers in effective toilet training methods. Such methods are not widely available and require specific training. Skilled early childhood educators will work in cooperation with caregivers through modeling, direct instruction, and conferencing. By the end of the intervention period, caregivers will maintain skills that will assist their children in achieving independent use of the toilet.
written by Danica Mamlet Summary Toilet training children with autism poses unique problems for parents and professionals. Lack of intervention by specially trained educators can extend their dependence on caregivers. Remaining untrained as they age can inhibit children's independence, limiting future habitation and employment options.
The Autistic Disorder
Toilet training is one of the earliest tasks of the developing child. It is a task for which specific teaching techniques exist which are widely accepted and commonly practiced. When a child is hindered in this task by a developmental disorder, it is necessary to alter the techniques to address his or her specific deficits. This proposal aims to address the challenges involved in the toilet training of autistic children and provide a viable solution. To accomplish this goal, a description of autistic disorder as it is currently defined in the fields of education and psychology will be outlined. A review of the current trends in accepted toilet training methods recommended for typically developing children will follow. These two topics will then be discussed in terms of how the particular traits of autism require special adaptations to these methods. Finally, I will propose a pilot program designed to train parents and caregivers of children with autism to effectively toilet train their children. Autism is a spectrum disorder, falling under the umbrella of pervasive developmental disorders (American Psychiatric Association, 1994), which is brought on by a dysfunction of the central nervous system. It is usually diagnosed in the first three years of life with noted symptoms occurring as early as 18 months. Traits common to autism include the following three symptoms: impairment of social readiness (Thiemann, Howard & Goldstein, 2001), verbal and nonverbal communication delays and disorders (Pickles, 1996; Sarakoff, Taylor, & Poulson 2001), and stereotypical, repetitive behavior patterns. The more symptoms a child displays, the more severely impaired the child is considered to be. The DSM-IV considers milder cases not meeting every criterion for autism to be pervasive developmental disorder-not otherwise specified. For a child to receive a diagnosis of autism, the three core impairments must be present. Impaired social interaction can be demonstrated by "the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction." Impaired social interaction can also be regarded as a "failure to develop peer relationships appropriate to developmental level" as well as " a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people" and a "lack of social or emotional reciprocity (American Psychiatric Association, 1994, p. 70)". Often autistic children are happiest when left alone, not seeking out connections with parents or peers. Autistic children may actively avoid interactions with others, straining away to avoid eye contact or being held. An autistic child does not get pleasure, as typically developing children do, from making their parents happy or proud. They may be taught to say, "I did it!" or "Look at me!" but rarely think to do this on their own. Impairments in communication are demonstrated in autistic children by "a delay in, or total lack of the development of spoken language...marked impairment in the ability to initiate or sustain conversation with others...stereotyped and repetitive use of language or idiosyncratic language...(and) lack of varied, spontaneous make-believe play as well as lack of social imitative play appropriate to developmental level."(American Psychiatric Association, 1994, p. 70) Often autistic children show abnormalities in the use of gestures and other non-verbal communication. With the help of intervention, autistic children may develop some language skills, while others never use verbal communication effectively. Often, their speech patterns do not contain the intonations that are commonly paired with language to convey mood or feeling when speaking, giving their speech a halting quality that can be described as robotic. Some people with autism use augmentative communication devices such as computers or "cheap talk" devices or picture symbols (Capps, Losh & Thurber, 2000). Autistic children display some form of self-stimulatory behavior which is a repetitive, stereotypical motor or verbal action. Some common examples are hand flapping, rocking, tracking objects with their eyes, spinning, and repetitively waving or twirling objects. Extreme attachment to routines is very common. For example, an autistic child might insist on taking the same route from the kitchen to the bathroom and making the same sounds and gestures each time around. This behavior is described as a "compulsive adherence" to routines and rituals (Capps, Losh & Thurber, 2000). When playing with toys, their actions may seem on the surface to be appropriate but when closer attention is paid, one may notice that they are lining up the same objects over and over or repeating the same action such as picking up a play phone and saying hello repeatedly with no variance in words or behavior. In addition to the symptoms listed in the DSM-IV, other sources noted that autistic children might demonstrate unusual responses to stimuli. Autistic children may be very sensitive to their environment, such as sounds, the amount of light, smells, etc. Conversely, they may be oblivious to changes in their environment. They can also have very strong reactions to seemingly innocuous objects, songs or visual stimuli (Dettmer, Simpson, Myles, & Ganz 2000). Autistic children can have extreme difficulty attending to non-preferred activities. They are often constantly moving and may be seen as hyperactive. They can be extremely sensitive to changes in their environment (Copps, Losh & Thurber, 2000). Some children may also engage in self-injurious or aggressive behaviors. They may bite or hit themselves or others as well as engage in head-banging. It is unclear whether this behavior occurs out of frustration, anger or because abnormalities of sensory experience may result in pleasurable stimulation from self-injury. Some autistic children may show an aptitude for certain skills while exhibiting extremely low functionality in other areas, although true autistic "savants" are rare (Hendriks 1998). When all of the characteristics unique to autism are looked at, it is understandable that toilet training would pose particular problems for autistic children.
Current toilet training methods and practices
To fully understand the particular difficulties care givers and teachers can have in toilet training autistic children, it is important to review the current and prevailing philosophies in toilet training typically developing children. A review of current journal articles revealed that most practitioners advocate a child-oriented approach to toilet training. This emphasizes child readiness and employing a system of positive reinforcement (Stadtler, Gorski * Brazelton, 1999). Brazelton, et al wrote that achieving bladder and bowel control could contribute to a child's self-esteem. "This model of toilet training comprises three variant forces in child development: physiological maturation (e.g., ability to sit, walk, dress and undress); external feedback (e.g., self esteem and motivation, desire to imitate and identify with mentors, self-determination and independence) (Brazelton, et al., p. 2)." Brazelton et al. stress the delicacy of a child's self-esteem during initial successes in toilet training and emphasize the need for strong parental support during initial and successive toilet training phases. Parents are told to have the child use a potty chair, place stool from the diaper into the potty chair, watch parents go so as to imitate them, let the child sit on the potty fully clothed, and to time when urination and bowel movements are most probable. Parents are encouraged to explain to the child what is expected when they are taken to the potty and to praise and reward any successful eliminations while being careful not to criticize accidents, and to have the child say "bye-bye" to items being flushed so as to diminish anxieties. The literature shows that even typically developing children often have difficulty mastering toilet training (Hagopian, Fisher, Paszza & Wiezbicki 1993, Blum, Taubman & Osborne 1997, Buchholz 1999, Issenman, Filmer & Gorski 1999). A common problem among typically developing children is regression, resulting in Encopresis and Enuresis. Authorities highlight targeting self-esteem issues in treatment of these problems. In contrast, autistic children's difficulties in toilet training tend to be less related to self-esteem issues than to problems intrinsic to their disorder.
Problems of Autism in toilet training
The specific characteristics that impede autistic children's independent use of the toilet are outlined below. Autistic difficulties in understanding social relationships limit the success of a social reward system such as recommended by T. Berry Brazelton, et al. (Stadtler, Gorski, & Brazelton, 1999). This method encourages the typically developing 2-3 year old child to have a sense of pride or accomplishment for success in toilet training. As discussed earlier, autistic children often do not feel pleasure from making their parents and teachers happy. Thus a program based on social motivation would not have great probability for success. Difficulties in comprehending language and logic may inhibit the ability to understand what is expected in regards to the toilet procedure. Autistic children often do not understand an explanation of why they need to eliminate in the toilet and not their diaper. Furthermore, autistic children's attachment to routines and resistance to change may make the transition from diapers to the toilet difficult. They may be attached to the sensation of wearing diapers, having used them daily for 2-4 years. They may not like the stimulating environment of the bathroom with its bright lights, echoes, and sounds of running and flushing water and they may be averse to the change in temperature they feel when they take off their clothes (American Psychiatric Association, 1994; Boswell & Gray, 1995.) Autistic children's toilet training can be further impeded by their idiosyncratic relationships with their bodies. They may not know how to read bodily cues, and therefore are not aware of the urge to use the toilet. In addition they may not mind the sensation of being soiled. The reasons for this are unclear but some experts have speculated that this may be related to central nervous system abnormalities in children with Autism. (Hagopian, Fisher, Paszza, &Wiezbicki, 1993). All of these factors contribute to the need for adaptation of classic toilet training methods to suit the special needs of autistic children.
Successful toilet training techniques for autistic children
What follows is a brief review of various toilet training techniques that address the unique needs of autistic children. The focus of this review is to shed light on how the specific characteristics of autism can be addressed. In order to address the communication deficits associated with Autism, visual versus verbal cues may result in higher favorable response rates (Dettmer, Simpson, Myles, & Ganz, 2000). Thus a system employing picture icons with each step task analyzed is recommended as a tool to teach toileting independence. Practicing a consistent, task analyzed routine capitalizes on Autistic children's predilection for repetition. This method must include a concrete, visual "what happens when I'm finished" piece of information because task completion is a powerful motivator for most children with Autism (Boswell & Gray, 1995). To address difficulties with the recognition of the urge to eliminate, timers may help the Autistic child learn to recognize when they are ready to eliminate. Also, a transition object (e.g., a preferred toy or book) may be used initially to shape smooth transitioning behavior. The use of the transitional object can also aid in teaching the child to initiate on its own. If the child has become accustomed to taking a certain book or doll to the bathroom when prompted by an adult, they may indicate the need to go by picking up this item on their own. A photograph of the toilet can also be used as an effective way to communicate the need to eliminate. This can be especially helpful for children with deficits in their use of verbal language. To accommodate autistic children's resistance to change, it is recommended that instructors introduce the bathroom routine gradually, first requiring the child to enter the bathroom clothed, then to sit clothed on the toilet, then in diapers, then unclothed. The use of potty chairs are not encouraged with autistic children as the adjustment to the toilet may take longer if they have become adjusted to the potty chair. If a child resists eliminating on the toilet, the use of a water prompt can facilitate a child's recognition of the sensation of having to eliminate (Hagopian, Fisher, Paszza, & Wiezbicki, 1993). As it is important to reduce as many outside distractions and obstacles as possible, the use of a small half bathroom is recommended. Autistic disorder poses many challenges to instructors and caregivers. One can see that with creativity and ingenuity, autistic children can learn many of the skills that will aid them in living the most independent life possible. Failure to develop toilet training independence can substantially hinder the autistic child. The untrained child will continue to be dependent on caregivers for the most basic of living skills. If this problem is addressed early, children with Autism can enjoy increased independence, freedom for caregivers, and greater options for schools and residences in the future.
Program Objectives
This program seeks to assist caregivers in the difficult task of toilet training children with autism. This will occur through the placement of trained early childhood educators into eligible homes of families with young autistic children. The objective of this placement is to guide caregivers in effective toilet training methods. Such methods are not widely available and require specific training. Skilled early childhood educators will work in cooperation with caregivers through modeling, direct instruction, and conferencing. By the end of the intervention period, caregivers will maintain skills that will assist their children in achieving independent use of the toilet.
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