Toilet Training Notes

Phases to toilet training

• Habit Training (also known as 'trip training')
  There are orders in which you teach; e.g. urine first, BM second; train for day first, then night
• Initiation Training - done second.

Assessment considerations

• Timing: what are the natural voiding patterns?
• What cues are given?
• Are there initiations?
• Frequency of urinations and BMs
• Current strategy used by the child to indicate need to void/accidents.

General Notes:

• the sensation to have to urinate is usually easier to detect that the one to defecate
• girls learn faster than boys
• habit training is the first job - get kids out of diapers asap - they're expensive!
• do not start this job until you're ready because there's no turning back - can be destructive to start and then stop - sends mixed messages - very confusing to the child - he'll learn that he'll eventually be 'rescued' with a diaper
• this process is based on reinforcement - make it GOOD and very SPECIAL!
• School's typical 'group' visits to the bathroom are NOT a good thing (e.g. there's a child that doesn't have to go very often, but is still taken to the washroom; why is she there, she wonders - the sensation of having to go should be paired with going to the washroom
• toilet training is nothing without a comprehensive assessment
• important to identify natural voicing patterns: is child a "sprinkler" or a "flooder"?
• also, learn to identify BM patterns; pay attention and learn the cues (e.g. "the look", going into a corner, etc. Pay attention to these cues, their lead-ins and their lead-outs
• study the child's natural schedule
• it's very important to study the child's natural schedule: do this by taking a baseline
• DO NOT use diapers - even when taking the baseline: diapers make it very easy to miss small amounts of urine because they are so absorbent. Basically, diapers stop the information system.
• Pull-ups are especially bad! They are like underpants, think the kids, BUT, they are designed to be absorbent - how confusing! They really send a message that it's OK to go in your underpants!
• never use a potty (unless exceptional physical disabilities make it absolutely necessary) - only a toilet. With a potty, there's no closure, no flush, has to be emptied - later it becomes difficult to generalize
• kids should not be tense when they're on the toilet; when you're tense, you don't go. Make it relaxing. Books and toys are OK. Make sure he feels secure.If he is too small, use an insert seat so he doesn't feel like he is going to fall in. Use a back support if necessary. Also, put a stool under his feet so the uncertainty of legs dangling is not present.
• it's better to start with as many toilets as possible to promote generalization from the start, however, work within your means. Maybe that will be a little difficult at the very beginning. Do what you can do.
• behavioral definition of "toilet trained" = no accidents, day or night, for 30 consecutive days.

General Procedures for Toilet Training

• Rule out any organic causes with pediatrician. e.g. seizure disorders - clear up these problems first Also, aggressive self-injurious behavior - those too must be dealt with first since the bathroom is such a potentially dangerous place - lots of hard surfaces paired with a situation that could create a lot of stress and/or anger
• Create a ritual. Finally - a ritual that's acceptable! Autistic kids love rituals - use it to work for you! We all have rituals (e.g. shaving left side of face before right), many of which we're not even aware to the point of it becoming almost neurological. That's OK in this situation. Toilet training should be very ritualistic and have a definite beginning and end.
• Take a baseline on the natural voiding patterns.
  * EARLY ACCIDENTS ARE NOT A BAD THING - THEY ARE A TEACHING TOOL
• Provide frequent opportunities to use the toilet. Whatever works for child.
• Reinforce for using the toilet and for voiding. Big time.
• Reinforce for dry pants. THIS IS JUST AS IMPORTANT! How to do it (because many kids don't understand what 'wet' and 'dry' both mean): Use hand-over-hand and put child's hand on crotch area, and excitedly say "dry... great job, excellent, I'm so proud of you, etc. etc. while also providing reinforcing object/video, etc.) - similarly, for accidents, put child's hand on crotch, and say in a very firm (but not scolding) voice "You are wet. You should pee in the toilet."
• 2-minute toilet sits every 60 minutes. Or more frequently - depends on child.
• Pants check every 30/15 minutes, or use a urine alarm
• Gauge reinforcement - the biggest praise is dry pants and eliminating on the toilet. Smaller praise to things like pulling up pants, etc.
• Increase fluid intake during the day, but discontinue 2 hours before bedtime Juice is especially good to promote urination.
  • nighttime training quite often evolves on its own, after daytime training is worked on
  • if night time training does not happen on its own, may have to use the alarm; sometimes the children do not rouse from the alarm - in this case, there may be a sleeping disorder to be investigated.
• Wiping - Teach wiping now! More difficult to teach later. Make it part of the whole ritual. Teach a ritual e.g. three 'swipes', and stick to it. Also, you may need a ritual dealing with how much tissue is taken. Maybe use a Kleenex box, it's easier - or, have the toilet paper pre-cut?
• Picture of the toilet - When the alarm goes off, you can use a picture of the toilet which the child should pick up and hand to a therapist/parent/caregiver (will initially have to be taught hand-over hand). If verbal, he should say "toilet" or whatever the word will be.

For accidents

• clean up and have the child expend effort This should not be a fun experience - you shouldn't be working harder than the child to clean up. Let the child finish going to the toilet, the clean up doing absolutely everything hand-over-hand. Create a correct, fast performance. This is a negative reinforcer.
• Positive practice Once clean, approach the situation educatively. Go back to where the accident happened and re-enact the event of going to the bathroom. Do it five times or for 20 minutes - whichever comes first.
• If a child starts going as an accident, rush him to the toilet to finish going on the toilet if he doesn't go himself. Even though he may finish in the toilet, he didn't start there, so this is treated as an accident - therefore NO reinforcer
• Flushing the toilet during positive practice and accidents: during positive practice when the toilet is empty, no flushing allowed for children who are reinforced by a flush, which is the case among many children). If there is something in the toilet that needs to be flushed, he should flush but close the lid and take him away quickly so he can't observe.
• Handwashing during positive practice and accidents: similar approach as flushing if it's very reinforcing for the child. Of course, if the child's hands need to be washed, they should be washed. No fun splashing allowed though - especially after an accident.
• Bathing during positive practice and accidents: similar approach. If the child needs a bath, he needs a bath BUT, make sure it's not a long, fun bath. The water shouldn't be cold, but it shouldn't be nice and hot either. Not too aversive but not fun.

• Recognizing the need to go.
• Waiting to eliminate.
• Locating the bathroom and entering.
• Pulling down pants.
• Sitting on the toilet.
• Voiding on the toilet.
• Wiping.
• Pulling pants up.
• Flushing.
• Washing hands.
• Drying hands.
• Returning to previous setting.