July 05, 2012

Establishing Habits That Lead To Potty Training

The following is written by Bonnie Marquis, a Positive Behavior Support Trainer for the West Virginia Autism Training Center.




These are all emotions every parent feels when faced with the momentous milestone of potty training. For obvious reasons parents look forward to this development, perhaps more than any other. But, it is yet again another challenging area for folks on the spectrum.  Research has shown that individuals with autism often have significant struggles learning this skill.
This task will certainly take considerable planning and effort. Gains may be slower and setbacks are likely, but success is possible.  With any child, individual differences play a key role in the pacing and selection of strategies. But, a basic understanding of the child’s learning characteristics and the main principles of positive behavior support can be critical to achieving your goal. 
Note: Many of the same characteristics that lead children on the spectrum to be extraordinarily picky eaters can also lead them to be resistant to potty training. In particular, sensory issues and anxiety over new or different experiences can be particularly vexing. These issues then can lead to challenging behaviors as the child attempts to escape and avoid the bathroom if he sees this as the cause of his/her anxiety and fear (Click here to further explore those concepts in Part 1 of Picky Eating.)

Another commonality with picky eating is a feeling of powerlessness over this issue. You cannot make a child control these bodily functions even if you are quite positive she has the ability to do so.  But keep in mind that control of bowels and bladder is a somewhat complex function. Most of us realize a child must have ability to understand that waste belongs in the toilet, and then be able to connect the sensations he feels with the necessary steps to make that happen.  Effective and efficient control of elimination requires the maturation of the nerves between the brain and the sphincter/bladder muscles. Since ASD’s are neurological disorders resulting in pervasive developmental delays, it can be assumed this control may be (and probably will be) delayed as well.  
It is difficult to tell by simple observation how neurologically developed one’s child is in this area, so we have to play detective and take the best steps we can to move forward. As with all other areas of life for the person on the spectrum, schedules and routines can become the surest path to independence. Getting a child on a regular schedule, sometimes called habit training, can get hi very near the goal of independence and at the very least dramatically reduce the number of diaper/ pull-ups that get soiled.

But habit training requires rigid scheduling; not only trips to the bathroom, but also times and quantities of food and drink (for health and safety, avoid excessive restrictions or pushing more than 8 -10 glasses per day). For some, watching the clock just doesn’t fit their active lifestyle or family dynamics, so it may be better to strive for more naturalistic routines such as going upon waking, before or after meals, leaving or arriving home etc..  Communicating this effectively, as with a visual cue or part of a schedule, is also critical. Facilitate cooperation with the routine by following it with a preferred activity.

Ensuring adequate fiber is also important. Given the challenges so often faced with eating, using fiber supplements, from gummy bears (not the candy) to natural fiber powders added to a favorite shake or smoothie may be the kind of creativity required to ensure they are getting the amount of fiber needed for more regular bowel movements.  If constipation is an issue for your child, your challenges will be compounded by the irregularity of experience and the all too common pain and discomfort the child will associate with it.
The beauty of habit training is that is can be started regardless of the child’s level of neurological or cognitive readiness.  As long as they can sit upright and have the ability pull pants up and down (a step you may need to teach) you can begin. To this end, be mindful of the clothing so that the person is not hindered by tight fitting garments or difficult buttons.  If the person is also showing signs of awareness of the elimination sensations or discomfort with being soiled (something which can be aided by special diapers that turn cold when wet) then it is imperative to begin training so that the window of opportunity is not lost.  It is all too easy for folks on the spectrum to learn that “This is just the way it is and what I do” (or don’t do as the case may be). Communicating the need to learn this skill through books, social stories or videos can be a critical component of your plan. If your child is past this point, do not give up, just recognize that with all you will be teaching, there may be some ‘unlearning’ that needs to be done as well.

 Immediate success may not result with habit training but your initial goal is to establish familiarity and routine. The results from a regular schedule of meals and fluid intake may take time to translate into regular elimination patters.  It is also true that for many, the erratic appetites and eating patterns that have persisted will be a significant obstacle, but again success should not be expected overnight and persistence with maintaining a routine will, over time, help both eating and potty training. It goes without saying that what goes in determines what comes out!
But there are many who have reached the point where the child fears the bathroom. Sometimes power struggles occur, and can leave folks feeling defeated. If this is where you find yourself, take a bit of time to ‘back off’ temporarily and only work on the food and fluid intake (on as close of a schedule as you can) for a few weeks, longer or shorter depending on the severity of the anxieties  or power struggles that have developed.
Once you have both relaxed a bit, it may take a bit of creativity to make the bathroom a safer, more inviting place – if your child enjoys bath time, maybe during your break you can begin to play some favorite music (not too raucous if it is before bed time). Once you are ready to return to the bathroom for elimination, maybe play a different favorite tune. You don’t want the child expecting his bath just because he hears his favorite song- but you want him to view the setting as relaxed and comfortable.
You might need to do this in stages, in ABA terms you may need to shape his behavior, gradually getting him comfortable in stages until he is IN the bathroom and ON the toilet. In addition to the music, offer a few books or whatever it takes to get him to relax, but not so engaging that he focuses too intensely on the item. These items can be also a useful bridge for assisting the child to use the bathroom in new and unfamiliar places.  For many, the seat itself can be a major obstacle. Too cold, hard or large can make the child fearful of just sitting on the toilet, so consider a soft seated insert. Offering a foot stool so feet do not dangle can help with stability, comfort and aids in sphincter control as well.
Remember also that when teaching the routine, it is necessary to teach all of the steps, in sequence, ending with hand washing -also a multi-step process that can be aided by the use of a step by step visual.
A word of caution with regards to flushing – some children love to flush and this can be a natural reinforcer for the finished task. Be sure all the other necessary steps have been completed before she is allowed to flush or inappropriate routines may easily become established.  Others however, find the noise and swirling water frightening. If this is the case, structure your routine so that hands are washed and the door is open before the flush takes place and an immediate escape can be made, but all the necessary steps have been followed. Remember that what you do for the child now will be learned, and unlearning it later will be a greater challenge than finding a solution or teaching an adaptive skill now.
Also – restrain yourself from rejoicing in your success until the child has fully finished emptying his bladder or bowels. Shouts of “Hurray!” can stop the child midstream and lead to accidents a short time later. Too much enthusiasm can also scare the child if it is too loud and startling, and leading to refusal or resistance in the future.
While no discussion of potty training would be complete without mention of sticker charts or some other reinforcement, it is important to note that rewards only provide motivation and are ineffective when the necessary skills and neurological development are not also in place. In addition, making sure the person understands the connection between completing the task and obtaining the desired item is critical and not always as obvious as we may think. Finally, they are only effective if the item is truly desirable. Sticker charts often fail because stickers are not that exciting for some of us and even if they are building to a really great reward, the payoff may be too distant and perceived as too unattainable to be effective.  This is not to say that a reinforcement system should not be used, but only to caution you to the reasons why they often seem to fail. If you are confident that motivation is your missing link, but your reward system just isn’t working, tweak it a bit. Something more immediate – such as access to a preferred game or activity) might be better than stickers that build to a big and exciting reward.
While we have only scratched the surface on a number of issues, the West Virginia Autism Training Center library has some excellent resources. One of the best on this topic is Maria Wheeler, M.ED. ‘s Toilet Training for Individuals with Autism and other Developmental Disabilities. Her book goes into greater detail than is possible here and WV ATC has multiple copies.  If you are struggling with this issue or see it looming on the horizon,  take some time to develop a plan and prepare yourself for a few setbacks – numerous factors can contribute to those and should not, in and of themselves,  be interpreted as a failure or be cause to abandon an otherwise well considered plan.  As with everything else related to teaching your child with Autism, patience and persistence mixed with some understanding and creative problem solving are your keys to solving this puzzle.