1. Toileting Training for
Easter Seals Midwest
12/7/15
Toileting Training for
Children with ASD
Megan Tregnago, M.Ed., MHA, BCBA, LBA
Toileting Workshop

2. Pre-Workshop Worksheet
Please complete the pre-workshop worksheet to begin thinking about your child and his/her toilet training experience

3. Identifying Reinforcers Getting Started Intensive Elimination Training
Easter Seals Midwest
12/7/15
Outline
Setting Goals
Data
Identifying Reinforcers
Getting Started
Intensive Elimination Training
Trouble-Shooting
Our intent of this workshop is that by the end of this program, you will be confident and successful in
addressing your child’s toileting problems. It will take continued focus and practice to see
long-term changes. We encourage you to remain committed to the program. With that
commitment, it can and will work for you and the individual for whom you provide care.
Toileting Workshop

4. Commitment Toilet Training is intensive no matter how you go about it!
Are you committed to…
Learning about proper toileting habits?
Giving your child a balanced, high-fiber diet?
Giving your child increased drinks?
Giving your child regular exercise?
Frequent pants checks?
Frequent toilet sits?
Reinforcement for toileting behavior?
Cleaning up after accidents?

5. Be Positive
“I’ll give it a try” vs. “That’ll never work.”
Progress not perfection!
Toilet training takes time and patience
If the experience turns negative for you or your child, step back and try again later

6. Applied Behavior Analysis (ABA)
Focuses on the application of the science of behavior.
Effective, evidence-based, therapeutic approach for helping individuals with ASDs and other developmental disabilities gain the communicative, social and behavioral skills they need.
Provides positive reinforcement to teach for appropriate, desirable behaviors

7. Challenges in Children with Autism
Communication delays
Decreased receptive language
Sensory sensitivities
Impaired social interaction
Routine
Others?

8. Benefits to Toilet Training
Less time and effort spent changing soiled diapers
Saves money
Decreased skin irritations (diaper rash)
More independence
More time to engage in other activities
More pride and dignity
Decreased stress

9. SETTING GOALS

10. Setting Goals
Setting goals will allow you to objectively track changes.
When setting goals:
Be realistic
Start small
Focus on improvement rather than perfection
Be positive

11. Toileting Skills Notifying caregiver Entering the bathroom
Easter Seals Midwest
12/7/15
Toileting Skills
Notifying caregiver
Entering the bathroom
Turning on/off light
Pulling clothes up/down
Sitting on toilet
Getting toilet paper
Wiping with toilet paper
Standing up
Throwing toilet paper in toilet
Pulling clothes up
Flushing toilet
Washing hands
In addition to elimination, caregivers may also set goals related to skills on this list
Toileting Workshop

12. 3 Behavioral Goals
In addition to “elimination in the toilet”, list 3 target behaviors/goals.
Target Behavior
Behavioral Goal 1. 2. 3.

13. DATA:
Collect
Record
Graph
Data

14. Importance of Data Take baseline (3-7 days) to know where to start
Compare changes to baseline to chart success and detect small changes
Allows you to objectively detect change
Shows whether training is helping or not
Tells you whether to continue what you’re doing or to make a change

15. Baseline: Wet/Dry Checks
Check diaper every half-hour
Record whether diaper is wet, dry, or soiled
Tell child “Good job staying dry” or “You’re wet/dirty.”
Use these checks to determine whether your child has a consistent elimination pattern.

16. Baseline Data
If no pattern is found, consider contacting physician or child may not be ready.
Examples: Child is wet for several 30-minute checks in a row, child has more than 2-3 bowel movements per day.

17. Data Sheet

18. Graph

19. IDENTIFYING REINFORCERS

20. Preference Assessments
Your child may not be able to tell you what he likes/does not like
Use preference assessments to identify what might serve as reinforcers
Important to rotate reinforcers to prevent boredom
Limit access to reinforcers used for toileting (keep them in the bathroom)

21. Types of Reinforcers Food or Drink Object, Toys Activities Breaks/Rest21
Food or Drink
Object, Toys
Activities
Breaks/Rest
Social Interaction (nods, smiles, tickles, praise)
Feedback/Praise
Tokens/Money to earn other reinforcers

22. GETTING STARTED:
ARE YOU READY?

23. Reflect on toileting history Assess readiness
Before You Start
Medical Exam
Consider side effects of any medications
Do not give too much fluid with seizure disorders
Reflect on toileting history
Fear, sensitivities, successes, habits
Assess readiness

24. Is My Child Ready?
Able to sit on toilet for 2-5 minutes
Does not resist the bathroom
Able to pull pants up and down
Has regular, well-formed bowel movements
Stays dry for 1-2 hours and during naps
Shows interest in toileting
Show indication that he/she is wet/dry
Has a way to initiate

25. Increase Awareness Change diapers in the bathroom
Read stories about the act of toileting
A Potty for Me!
Pirate Potty
Super Pooper
Watch videos about toileting
The Potty Book and DVD
I Go Pee and Poop on the Potty
Signing TImes: Potty Time
Introduce a toileting doll
Potty Monkey
Betsy Wetsy

26. Guidelines for Success
Set aside a weekend to devote to training – start on a Friday or Saturday morning
Train all day or until you and your child are too tired to continue
Devote all your attention to toileting
Eliminate distractions, minimize interruptions
Use consistent vocabulary
Create a positive environment

27. Check-In
Do you think you will be able to adhere to these guidelines?
Are there any obstacles you are facing?
How can you address those obstacles to be more successful?

28. Data and Graphing
Keep going!

29. Water or preferred drinks Reinforcers Underwear Snacks
Easter Seals Midwest
12/7/15
Materials Needed
Water or preferred drinks
Reinforcers
Underwear
Snacks
Gloves, paper towels, wipes
Foot stool and chair
Data sheet
Timer
Pen
Toileting Workshop

30. Environmental Supports
Easter Seals Midwest
12/7/15
Environmental Supports 30
Potty seat
Potty seat with ladder to help child push
Stool to help child reach sink
Whiz kids tablets – put in toilet to help with “aim”
Faucet extender to help child wash hands
Malem enuresis alarm (urine alarm)
Toileting Workshop

31. No More Diapers! 31
Some research shows that putting a child in a diaper makes it more likely that they will eliminate in the diaper
The only exception is for naps, long car rides, or bedtime. Even then, be wary!
By doing this, you are reducing confusion and increasing the child’s chances for success by teaching them diapers and pull ups are only for these times

32. In the Bathroom
Place all materials in the bathroom
Keep your child in or near the bathroom throughout the training
Your child should wear clothes that are easy to take off (e.g., elastic waistband shorts)
Have several changes of clothing available
Make it fun!

33. Increase Liquids
Check with doctor first about providing increase liquid.
If the individual refuses to drink more water, try a different drink.
Provide saltine crackers or other snacks.
Use a variety of snacks, but do not provide the highly preferred edibles from the preference assessment. Those are reserved for successful voiding in the toilet.

34. Toilet Training Procedure
Time
Fluid Intake
Toilet Sitting
1-hour before training
Full cup
None
30 minutes before training
½ cup
Training starts
5-10 minutes
½ hour after training starts

35. Sits and Dry Pants Checks
Provide a half-cup of water and sit on the toilet every 30 minutes
Tell child “It’s time to potty” or prompt him to produce request
Check your child every 5 minutes afterwards
If your child kept dry during the 5 minutes, provide a brief praise and brief reinforcement
Set the timer to help you remember

36. Example

37. Success!
If your child begins to eliminate in the toilet, give him immediate attention with praise and provide a reinforcer from the Preference Assessment.
Be overly animated and enthusiastic (congratulate, smile, clap, etc.)
Continue with dry pants checks every 5 minutes
Sit again after 30 minutes

38. Accidents If your child urinated or defecated in his pants:
Say "No wet/soiled pants" in a neutral voice.
Have your child place the dirty clothes in the hamper/washer. Limit attention during this time.
Have the child assist with clean up (to extent safe and possible) and put on clean clothes. Limit attention during this time.
Prompt child to sit for 5 minutes or until he eliminates (whichever comes first).
Do not provide snacks for the next 30 minutes following an accident.

39. WHAT ABOUT…

40. Bowel Training BMs rarely occur without urination
Increase exercise, fiber, and liquids, decrease dairy
Consult physician if constipation or diarrhea exists
Record data to get routine
Set child on toilet 30 minutes after meals, repeat every 30 minutes until success
Provide a step-stool or Squatty Potty

41. Problem Behavior
TELL, SHOW, DO
Training should be a POSITIVE experience
We do not want to associate toileting with negative experiences
If child becomes extremely upset and resistant, back up and try again

42. Guided Compliance No Praise If Not TELL me (Verbal instruction)
Wait 5-10 Seconds
Praise and Reinforce Abundantly if Compliant
If Not
SHOW me (model)
Praise and/or reinforce briefly if compliant
Help me DO it (physical guidance)
No Praise

43. Lunch
Eat lunch in or near the bathroom
If child starts to void during the meal, immediately escort him to the toilet.
After the meal, resume training by placing your child on toilet for 5-10 minutes (if dry, begin 5-min pant checks).

44. Urine Alarms
A wetness detecting monitor can significantly cut down on the effort and time required for training.
Attach the monitor to the individual.
When the monitor beeps or vibrates to indicate wetness, simply follow the protocol for accidents
Wet stop ($50, or is an example of a commonly available wetness sensor.
Check with insurance company or funder for reimbursement

45. Functional Communication Training
Teaches child a way to communicate the to use the bathroom
Choose form of communication
Procedure:
Prompt child to communicate (Tell-Show-Do)
Once the request occurs, reinforce
Immediately take child to bathroom
Have child sit for 1 minute or less
Reinforce any success
Repeat about 10 times in10-15 minutes

46. Reinforce longer durations of sitting
Refusal to Sit
SHAPE: May need to start with reinforcing just being in bathroom/next to toilet/touching toilet
Reinforce longer durations of sitting
1 second, 5 seconds, 10 seconds….
Try a variety of toilet training seats
Place a piece of cardboard under the seat and gradually increase size of hole cut in cardboard

47. Refusal to Flush
Prepare individual – Ready, set, flush!
De-sensitize (watch videos)
Play background music or wear headphones
Put lid down to hide water

48. Accidents after Continence
Rule out any physical conditions
“You wet your pants. You need to use the toilet.”
Have child help with clean-up
Reinforce any success
Do NOT go back to diapers

49. References
Toilet Training for Individuals with Autism and Related Disorders by Maria Wheeler
Toilet Training Caregiver Manual, NYS Office for People with Developmental Disabilities
Toilet Training in Less than a Day by Azrin & Foxx
Intensive Outpatient Behavioral Treatment of Primary Urinary Incontinence of Children with Autism by LeBlanc et al.

50. Megan Tregnago, M.Ed., MHA, BCBA, LBA Easter Seals Midwest |Autism Services 918 Bernadette Dr. Columbia, MO (office)