qwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmrtyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwertyuiopasdfghjklzxcvbnmqwert

Toilet Training the

Challenged Child

Written by Kyra Harris in consultation with Dr. John Howard

1

Preface The number of potty training books on the market are endless. Some potty pros suggest training your child at 3 months while others advise waiting until three years of age. With plans that boast training your baby on cue, having your child trained in a matter of days or fixing incontinence by throwing a potty party, its understandable why many parents encounter problems deciding who to trust and where to start. What makes finding the right plan even more difficult is catering to the strengths and weaknesses of children with autism and developmental delay. Forgo the idea of trying to fit your child into a specific potty plan. Instead try to embrace the idea of designing a potty plan to specifically fit your child. We all know that no two children are the same, which is especially true for children with cognitive and physical disabilities so then why is it that we try to fit them all into the same potty plan? The purpose of this pamphlet is not to promote one single potty training method. Instead the pamphlet provides a survey of resources available on the topic of potty training children with autism and developmental delay to help you design a plan which is right for your unique child. Be aware: when it comes to potty training, there are no definitive answers. There is no one plan which can work for all children. Once checking out this pamphlet, take the next step by checking out the suggested resources at the very end. The resources will help you gather more information regarding potty plans and tips which may work for your child. Always remember to consult your childs support staff (physicians, psychologists, occupational therapists, support workers) before starting the potty training process. They will be able to offer you important advice regarding when to start, what to aim for and how to get there.

Introduction Changing diapers can be a pain. Every parent is forced to do it and every parent envisions the day when their child will use the toilet on his or her own. However, for some parents this day comes sooner than others. For the parents of children with disabilities, toilet training takes more time, more patience and more dedication. An average child with Down syndrome doesnt gain daytime bowel control until age 16 years and daytime bladder control until 17 (20). Before you even begin to decide if your child is ready, let go of any preconceived potty notions. Toilet training children with disabilities may take longer, but its well worth it when you see your child becoming more independent. So start making it a habit to celebrate your childs daily successes and keep the bigger picture in the background.

There are many factors which will contribute to your childs potty training success. The 2 most important factors are: correctly determining if your child is ready to begin the potty process and designing a potty plan which is specifically suited for your child. This pamphlet will provide you with plans and tips offered by professionals and parents on the topic of toilet training the autistic or developmentally delayed child including sections on readiness, planning, rewards, accidents and more. However, these are just the basics. For more information regarding any of the opinions offered in this pamphlet, please check out the resources themselves. And always remember to consult with your childs support team: physicians, psychologists, occupational therapists etc.

2

Before starting any potty training plan there are 5 key

things you must remember:

1) Expressing anger and reprimanding your child will only get you farther away from success: Frustration is a natural reaction to potty training accidents. It can be hard to keep your cool when having to clean up messes while worrying that your child may never learn how to use the potty. However, your childs success is contingent upon you dropping that frustration at the bathroom door. Reprimanding your child for their accidents is guaranteed to prolong your childs potty training process by making her reluctant and scared to go. If you feel you cant remain neutral during the potty process thats okay; consider having your partner or family member take the reins. Just remember all of the messy and frustrating days will be well worth it once you see your child begins taking the next steps towards independence.

2) Give it time: With mounting peer pressure (often pressure from school and care facilities) to train your child ASAP, it can be hard not to place too many expectations on your child. Before you get too caught up in the potty training hype, realize that every child is different. While some children may potty train in a few hours, the other 99.999% dont and thats okay! The time it takes your child to become toilet trained has no correlation to your childs IQ or your skills as a parent. Remember that toilet training a child with developmental delay or autism is a much more drawn out process. Whatever length of time it takes for your child to toilet train is fine. Dont think in terms of days, weeks or years think in terms of accomplishments. Approach potty training with the intention of relishing your childs small potty accomplishments daily rather than becoming frustrated by the fact that your child is not 100% potty trained quite yet.

3) Set achievable goals: Your dream may be to see your child out of diapers and independently pottying in the next 6 months, however, this may not be realistic. When laying out a potty training plan, its most important to set achievable goals. Parents all want to see their children reach their full potential. However, placing unrealistic expectations on your child will only increase the likelihood of turning him into a discouraged, reluctant trainer. If youre not sure how to set physically and developmentally appropriate goals for your child, talk to your his support staff. Dont try to fit your child into a potty training program, try to design a toilet training program that fits your child.

4) Dont start until both you and your child are ready: Diapers are a huge hassle. It makes perfect sense that you may be frustrated with continuing to change your child while their peers and siblings begin to toilet themselves. As frustrating as it may be to keep your child in diapers, if you begin toilet training before your child is ready, this process will only become more frustrating. Although your seven year old child may be the only one in her class still in diapers this may be perfectly appropriate for her developmental age. Chronological age is not an indicator of potty readiness. Your 7 year old may seem physically ready but if her developmental age is equivalent to a 2 year old, realize its just not time quite yet. Dont forget to pick a time when you feel you are able to put in the time and effort to begin the process. Be careful to avoid periods of high stress at home, work and school.

5) Get everyone on board: Whether your child has a support team of twenty or two, make sure to get everyone on board. Its preferable for one parent to teach all the potty training lessons but life is not compartmentalized. In the modern world of day jobs, day care, babysitters and big blended families, in most instances potty teaching solo doesnt create the consistency your child needs to be successful. The best way to get everyone on board is to create a handout that summarizes your childs plan.

3

Readiness There are many different opinions regarding when your child should start potty training. When deciding when to start potty training you want to consider his physical, emotional and cognitive readiness not his chronological age. Below are a number of toilet training readiness signs provided by various professionals. Your child doesnt need to demonstrate all of the readiness signs -- but if hes not meeting a lot of them, its probably best to follow your gut and give it more time.

1) Health Before you go any further you must make sure that your childs bowels and bladder are in perfect health. If you think theres a possibility your child has a urinary tract infection (burning, low back pain, blood in urine) go no further until you consult your doctor. Also, be on the look out for constipation. If your child is straining, holding back stool, defecating less than once every other day, passing small balls of stool or pop can size stools she may be constipated do not start training until consulting your doctor. Constipation can also present with the constant oozing of clay-like dark stool. If your child has any type of virus or bacterial infection dont start training yet wait until your child is in good health.

2) Longer periods of dryness Staying dry for longer periods of time during the day and throughout naps is a sign of physical readiness. If your child can stay dry for between 1-2 hours, hes developing the physical readiness necessary to start training.

3) Awareness of needing to void: Does your child tell you when she is eliminating in her diaper or when she feels the need to go? Does she stop playing to eliminate? These are both very good signs. It means that your child has begun to understand the sensation associated with needing to go. If your child lets you know that she is urinating or defecating in her diaper, do not reprimand her. Instead praise her for recognizing the proper sensations associating with using the potty.

4) Awareness of being wet or dirty: If your child communicates that he would like to be changed or attempts to change himself, this is a very good sign. This lets you know that your child recognizes whens hes wet or dirty and doesnt like it. Feeling uncomfortable in a wet or soiled diaper can be great motivation for some children! Make sure that you change your child as soon as you notice hes eliminated. If you leave him in dirty diapers for too long hell soon get used to the feeling of being wet.

5) Potty-Elimination Connection: In order for your child to successfully potty train, shell need to make the connection between peeing and pooping and using the potty. Your child may demonstrate his understanding of the potty-elimination connection by going into the bathroom to void, wanting to be changed in the bathroom, taking feces from his diaper and putting them into the toilet or showing a general understanding of the potty procedure. To help him develop his bathroom-elimination connection, begin changing him only in the bathroom. Keep all potty related supplies (diapers, clean underwear, wipes, etc.) in the bathroom as well. Dont worry if your child doesnt yet understand why we use the potty, for some children this will come with practice.

4

6) Intrigued by Grown-ups and Grown-up things: Does your child tell you she wants to be more grown up, seem fascinated by grown-ups or imitates older peers and adults? When you catch your child taking interest in how grownups use the potty, praise him and tell him how grown up shell be when she can use the potty all by herself too

7) Enough Time: Is there enough space in your childs daily routine to start the potty training process and keep consistent? Theres no sense in beginning the process if your childs daily routine is just too busy to keep consistent. If you dont think youll have enough time to begin potty training, dont start just yet. Instead, wait until your childs routine gets less busy such as during the summer.

8) Developmental Age: Try not to consider your childs chronological age when deciding if now is the right time to begin potty training; instead look at his developmental age. If your child is functioning below a two year old level, hes probably not yet ready to begin toilet training. Typically children toilet train between 2-3 years of age, therefore, until your childs developmental age reaches this point starting the process will probably just end up being messy, frustrating and unsuccessful.

9) Interest in Personal Hygiene: Does your child take pride and interest in his personal hygiene and appearance? This could be seen as a distaste for being dirty, an interest in learning how to wash her hands and face, picking out her own clothing, or generally wanting to be being clean or becoming upset when she soils himself.

10) Physical Capability: Does your child have the physical capabilities to complete necessary steps in the toileting routine? If your child has a physical disability as well as a cognitive disability, its best to consult his physical therapist (PT) or occupational therapist (OT) before beginning training. The OT or PT will provide you with information regarding your childs physical ability to independently get to the washroom, get on and off the toilet and sit upright for 5 minutes. If your child cannot complete most of the potty steps yet, dont begin toilet training. Wait until youve worked with your childs physical therapist or physiotherapist to master the necessary potty skills or once youve adapted your childs environment to better meet his physical needs.

11) Interest in watching others: If your child is showing an interest in watching other people use the toilet this is a great sign! Allowing your child to watch you and your family members use the toilet is one of the first steps of the toilet teaching process. If you see your child attempt to watch, invite her to do so and make sure to explain whats happening throughout the process. ( 3 )

12) Cause and Effect: Does your child understand cause and effect? For example, is your child able to understand that if he urinates in the potty hell get a reward? Until your child can comprehend basic cause and effect if may be difficult to begin potty training (3).

5

13) Agreeability: Most children go through a difficult period during which no is the only word to come out of her mouth and drawn-out tantrums are constant. If your child is throwing prolonged tantrums, now is probably not the best time to potty train. Wait it out. Most children will grow out of their tantrum-throwing-disagreeing phase after which theyll be much more open to learning how to use the potty.

14) Interpret and follow simply instructions: Being able to comprehend and follow simple potty training instructions is a very important skill to have before beginning the toilet teaching process. Beyond simply having the ability to interpret instructions, your child needs to be agreeable and willing to comply with these instructions.

15) Comprehension and Communication: Can your child communicate with you? Does your child communicate verbally, with visual symbols or by using an augmented communication device? For accessing potty readiness, determining whether your child has good communication and comprehension skills is very important . Can you communicate with your child? Does your child understand your verbal or visual cues? As long as you and your child can communicate with each other, the method of communication in not important.

16) Outward signs of needing to void: Does your child display outward signs that let you know he has to go to the bathroom? These outward signals may be different facial expressions, different body positions, squatting, dancing, holding his crotch, verbal indications, ceasing to play while urinating or defecating, or holding back. When you see your child showing outward signs of needing to void, dont ignore it. Tell him immediately, You have to use the bathroom right now so were going to go to the potty. By recognizing that your child has to go to the bathroom and letting him know, youll help him to recognize what it feels like when he needs to go.

17) Regularity and Larger Volume Elimination: If your child has begun defecating larger amounts fewer times a day (rather then a little bit all throughout the day) and seems to be urinating larger volumes at a time, this shows that your child is developing the necessary physical readiness to potty train. Also consider whether your child is regular. Ask yourself whether your child is having 1-3 bowel movements a day. If the answer is no, consult your doctor to learn how to increase your childs regularity.

Readiness Recap:

If your child doesnt have every number checked off the readiness recap list this doesnt necessarily mean shes not ready to potty train. Use your gut feeling and your common sense! If you feel like your child is meeting the majority of the readiness recap check points, your childs probably ready! Once you feel your child is ready to begin the potty training process, its a great idea to double check with her support team to make sure youre both on the same page!

6

16 Signs Made Super Simple:

1) healthy

2) extended dryness 3) awareness 4) dislikes wetness

5) elimination-bathroom connection

6) intrigued by grown-ups

7) time

8) developmental age 9) interest in hygiene

10) follows modeling

11) cause and effect 12) agreeable

13) instructions

14) comprehend and communicate

15) outward signals

16) regularity

7

How we Poop Normally we have a breakfast poop, lunch poop, and supper poop which gather in the descending colon. The poops join together to form a poop train. This poop train travels into the rectum, the part of the colon just inside the bottom. Here the poop meets two valves. The first valve is the I got to go valve which lets our bodies know that we have to poop. This valve opens, allowing the poop to meet the second valve the Not now, Im in the kitchen valve. It is a voluntary valve that holds the poop until we are sitting on the toilet. Then we let go of the Not now valve and the poop is pushed into the toilet. All the valves then close until another poop comes. The Not now valve is very important since it gives us the choice of when and where to have a bowel movement.

Constipation

Constipation is the build-up of poop in the lower bowel near the anus. It starts with the child holding back a poop train. The sensation to pass the poop train goes away. Another, then another poop train comes. This stretches the strong muscles surrounding the rectum, thinning them out. It becomes very difficult to push the poop out because the muscles are stretched and weakened. The child must strain a great deal and may sit on the toilet and not be able to go. The child will frequently pass huge poops adult size or bigger. The other classical sign of constipation is boxcars. Here stool on the top of the huge mass of stool pushes out little bits of stool out the bottom causing constant oozing of stool. So both large infrequent stools and frequent small pasty stools are both signs of constipation. Abdominal pain, relatively uncommon, is often a dull pain below the belly button or in the left lower abdomen occurring before a bowel movement or attempt. Children can become constipated during the potty training process. This may be because we ask them to hold back their stool until seated on the toilet. If you notice your child showing symptoms of constipation, dont potty train until consulting your physician. If you notice your child develops constipation during the potty process also consult your physician

8

Pee, Poop and the Potty Before you begin the potty process, youll need to take some of the initial steps of teaching your child about pee, poop, and the potty etc. Here are three main things you can do to help your child understand his bodily functions and why he uses the toilet.

1) introduce potty talk or potty pictures: For your child to follow your instructions during the potty training process shell need to understand the meaning behind the words youll be using. Pick out specific words and visual cues youll feel comfortable using consistently throughout the process. Sit down with your child and explain what these words mean. If your child uses visual cues, signs or symbols introduce these at the same time by matching up potty words with potty symbols when presenting them to your child. Most importantly remember that whatever words, symbols or pictures you use must remain consistent.

2) use modeling and imitation: if your child is able to imitate behaviours use this to your benefit. If you feel comfortable, invite your child into the bathroom with you when you have to pee or poop. Allow him to watch you or other family members go to the bathroom(4). At the same time, use the potty words youve already introduced to let him know whats happening throughout the process. Later on in this pamphlet youll learn about creating a visual schedule for your child to follow when in the bathroom. When modeling, make sure that you follow the potty sequence that you will outline on your childs visual schedule as not to confuse him.

3) Introduce books or movies all about using the potty: This is a great way to get your childs attention and educate her about the potty basics before you start your potty process(4). However, make sure to pick books that will be right for your child. If your child is autistic, choosing a potty books written for a 3 or 4 year olds will probably not be most effective. Instead, speak to your childs support team to see if they have any resources available. Toilet Training Individuals with Autism and Related Disorders provides information regarding how to choose appropriate text to create a unique potty book for your autistic child which uses visual schedule symbols as illustrations. When choosing books and videos for children with developmental delay, just be sure to choose materials which are appropriate for their developmental age instead of their chronological age.

9

Creating a potty plan The next few sections of this pamphlet will cover how to set up a potty plan for your childs specific needs, lifestyle and potty patterns. There are several different potty training outlines which you can customize to meet your childs needs. The one you pick depends on: your lifestyle, the amount of effort you can afford to put into the program and your childs level of development and disability. The two main potty training programs that will be covered in the next sections are: Habit Training and Intensive training.

Habit Training Habit training works by setting up scheduled toilet trials based on your childs elimination patterns. Based on the opinion of Toilet Training Individuals with Autism and Related Disorders, habit training is most effective for the child who has a developmental age of three or younger, or has a developmental age of above three but hasnt responded to regular toilet training methods or seems to have no awareness of needing to go (21).

Habit training is not an overnight process and it does require a lot of dedication and consistency. If you feel that your lifestyle would not be able to support a consistent longer term potty program you may either want to consider intensive training or wait until more time opens for the potty program. The first step in getting ready for habit training is the monitoring stage.

Monitoring Stage: Most potty pros suggest monitoring your childs elimination patterns consistently for two weeks (2,3,15). If you feel your childs patterns are irregular during monitoring due to stress or illness continue the monitoring period for an additional two weeks. Use the attached charts in order to monitor your childs urination and defecation. When you begin monitoring if you have already started potty trials, keep consistent; if you have not started potty trials, do not begin them until youve finished the monitoring stage (15).

Important steps: 1) check your child for dryness every half hour or hour 2) if already toilet training dont stop if not, dont start 3) at night dont wake up child to check 4) check in morning 5) if child has already started toilet training note if in the toilet or in pants

Is it just about pee and poop? Many children have elimination patterns that are time related. There are some children whose elimination patterns revolve around eating, sleeping and physical activity. Therefore, during the

monitoring stage highlight when your child eats, drinks, sleeps and participates in physical activity (5). If you notice that theres a correlation between eating or drinking and elimination, increase your childs intake before a scheduled toilet trial (2). If you find that your childs intake seems to be scattered throughout the day, try to be more consistent. The more consistent your childs intake is, the more consistent your childs elimination will be (21).

How often do I check? If you have the time to check your childs diaper every 30 minutes this is preferable, however, not everyone will have this freedom. Daily life can get in the way of monitoring that frequently. If you predict monitoring that often will be hard to keep consistent, check every hour instead. The

most important thing is that you keep consistent by checking for wetness throughout the whole day, every

10

day for two weeks. If your child has begun toilet trials already it can be helpful to indicate when your child eliminates in the toilet and in his pants(15). For night time wetness it is not necessary to wake your child up to check his wetness or dryness. The best bet is to check before your child goes to bed, when you go to bed and first thing in the morning.

What happens when real life interferes with monitoring Its not easy to devote your whole day, everyday for two weeks to monitoring your childs elimination patterns but it is important. With knowing your childs elimination patterns you wont have a good idea of when to put her on the toilet. Toileting at specific intervals with no

consideration for your childs patterns is an option but it may also decrease your childs chances of having accidental successes on the toilet. Most children dont immediately understand the connection between the potty and elimination. This needs to be developed by rewarding accidental successes which happen when you put your child on the toilet at the right time. By knowing your childs elimination patterns you have a better chance of getting her in the right place at the right time. This does not mean that you have to single-handedly be in charge of monitoring. If your lifestyle is busy and doesnt afford time for consistent dryness checks elicit help. If you have to ask the babysitter to devote a few more hours a week during the monitoring period to make sure you do a good job of keeping a consistent record its well worth it. If your child is in an integrated program at school, it may be harder to keep the records accurate during the day. Discuss this with your childs teacher, educational assistant and administration. Try emphasizing the importance of the monitoring stage in the potty training process and how much easier it will be for everyone once your child stops wearing diapers.

What if monitoring just doesnt fit with my lifestyle? As stated earlier, there are no definitive answers when it come to potty training. There are some pros who disagree with toilet training on a timed schedule and completing the monitoring stage. They feel its just too difficult and may make it harder to teach self-initiation. Look for plans

towards the end of this section which do not use the monitoring stage.

Analyzing Your Childs Elimination Records: Begin by totalling up the total number of times your child urinates and defecates in the day for each day of monitoring. Next for every time interval, total up the number of eliminations your child had within that time period for each week (eg. If youre using a 30 minute interval you would total up the number of pees and poops your child had for the whole week between 7:30-8:30, next 8:30-9:30, next 9:30-10:30, next 10:30-11:30...).

Yes. My child does have a fairly regular schedule. There

are specific times of day that my child typically goes.

Now its time to put together your childs potty schedule. From the potty charts pick out the 4 - 5 most likely times your child urinates in the day and the most likely 1-3 times your child defecates in the day. When scheduling toilet trials, you should make sure not to schedule the toilet trials less than 90 minutes apart (15). There are numerous opinions regarding how soon you should put him on the toilet before your childs predicted time of elimination; however, you know your child best. The suggested range is between 5-30 minutes, so choose what you think works best for your child. If your child typically has only one poop a day, once she poops discontinue the rest of bowel trials. Subsequent attempts would likely be unsuccessful if the child has had her stool for the day. If you are finding that her stooling or urination is at a different time, wait a week before changing the schedule. Its best not to change routines too often.

11

Recap: 1) pick 4-5 urination times and 1-3 defecation times 2) potty between 5-30 minutes before scheduled times 3) if your child typically has only one poop a day, once she poops discontinue the rest of bowel trials 4) wait one week before changing schedule

Frequently Asked Questions:

It takes quite a while for me to prompt my child to enter the bathroom, take off her pants and sit on the toilet. How close to her predicted time of elimination should I begin prompting her?

If it takes you a long time to get your child seated and relaxed on the toilet, your best bet is to begin prompting your child 30 minutes before her predicted time of elimination.

My child doesnt seem to be having many successes on the toilet, and his patterns have changed quite a bit since the monitoring stage. Should I reschedule his toilet trials to meet his

new elimination patterns? If youve been using the same plan for more than a week, feel free to change the toilet trial schedule to suit your childs new elimination patterns. If you havent been using the plan for a week yet, give it some more time. If after a week your child still hasnt settled into the schedule feel free to change it to better fit his patterns.

Every time I take my child to the bathroom, were in a rush to get her there on time and she usually ends up either having an accident on the way. What should I do?

It seems as if youre probably waiting too long before bringing your child to the toilet. Instead try bringing her a few minutes earlier and see if this makes a difference. If it doesnt seem to make any difference and shes not having any successes on the toilet consider that your child may not be physically ready to start toilet training. Consult your childs support staff and take a break from the process for a while as her body continues to mature.

About a week ago I started bringing my child to the bathroom 15 minutes before his predicted time of elimination. Almost every time he gets restless, gets off the potty and then urinates in his diaper ten minutes later. What should I do?

It seems as if youre probably bringing your child to the bathroom too early. Next time try waiting an extra 5-10 minutes and see if that makes a difference. If it doesnt your child may not be relaxing enough while on the toilet to eliminate. Try some of the relaxation suggestions seen later in this pamphlet, such as listening to music, playing with tactile toys or reading a book together.

No. My child does NOT have a regular schedule. There are NO specific

times of day that my child typically goes.

If your child does not seem to follow any time related patterns, check if your childs elimination patterns are linked to eating, sleeping or physical activity. For each day, calculate the time between activities and elimination. If you notice a pattern and your childs elimination seems to be linked to specific activities do one of the following:

12

1) Setting up a time based schedule: The following plan creates more consistency by taking your child to the toilet after the same activities and at the same time every day.

a) Schedule related activities at the same time each day. E.g. Julie urinated 20 minutes after drinking large quantities and 15 minutes after eating meals. Therefore Mum and Dad decided to schedule meals at the same time each day.

b) Schedule potty trials based on how long it takes you to prompt your child to go to the bathroom and how long after the activity she typically eliminates. This is something you may have to play around with to get right, but aim to begin prompting your child between 5-30 minutes before she typically eliminates. E.g. Julies parents knew that it took her a good ten minutes to prompt her to go to the bathroom, get undressed and sit on the potty. Therefore, Mum and Dad scheduled potty trials right after Julies meals. That way theyd be able to get her there a few minutes early before shed hopefully have to poop and pee. What Julies parents found was that taking Julie to the toilet right after her meal seemed to be a little early. Typically Julie got off the toilet and then eliminated in her diaper a few minutes later. So, Julies parents modified the plan. They asked Julie to help clear the table right after dinner and once all the plates were cleared off the table, Julie and her Mum would go to the bathroom. What Julies mother found was that waiting a few extra minutes meant that she was able to get Julie to pee on the toilet 2-3 times per day. Once Julie began regularly eliminating on the potty at these times, she began self-initiating after she finished helping clear the table and at other times of day such as after snacks.

2) Setting up an activity based schedule: If you know your child has to urinate or defecate 10 minutes after eating or drinking, take your child to the potty as soon as he finishes eating or drinking. Instead of scheduling your activities around specific times to bring your child to the potty, focus on how soon after activities your child typically eliminates. When you bring your child to the potty will not be based on a clock but rather his activity patterns.

My Childs Patterns arent activity based either! If your childs elimination patterns dont seem to be linked to time or activities, you might consider toileting your child every 2 hours. Other similar plans suggest toileting every hour and a half. Pick which interval seems to work best for your lifestyle (6). If you find your child typically goes for longer or shorter periods between accidents, adjust the time interval between toilet trials(3). Schedule your childs first toilet trial of the day for 15 minutes before the earliest time he urinated or defecated over the last two weeks of records (15). If you want to increase the chance your child will have a successful scheduled trial try increasing

his liquid intake 7-30 minutes before the scheduled trial (4, 2). If your child is having multiple accidents decrease the time between intervals to no less than 1 hour. However, if your child is toileting every two hours, dont suddenly decrease to 1 hour between toilet trials; instead try decreasing by 20 minutes. Once youve got your child toileting at an interval that allows him to have less than one accident per day begin expanding the time between toilet trials by 15-30 minutes a day (6).

13

Putting the Plan into Action:

Should I teach my child all the potty routines as a whole right off the bat? Or, should I teach my child the initial steps and then build up to completing the whole routine? Some pros suggest teaching your child all the steps of the potty routine as a whole, while others

suggest adding steps to the potty routine one at a time as your child masters the basics. Because potty training has no guaranteed results and all children are different, both ways are correct, but both may not be correct for your child.

Does your child benefit from consistent routine, dislike change and/or respond well to sequential learning?

If this sounds like your child, teach all the bathroom steps from the beginning (2, 7). Toilet Training Individuals with Autism and Related Disorders promotes training autistic children by teaching the whole routine at the same time including steps such as wiping and hand washing. If your child responds well to routine, youll probably be more successful introducing the potty training process as a set of steps organized into a set routine instead of teaching one step at a time. If your child doesnt respond well to change, continuously adding new steps may end up overwhelming him. If your child benefits from sequential learning make the most of this by using a visual schedule (4). In the bathroom present a visual schedule of the potty training routine broken down into small steps. Remember, once you introduce a routine or sequence stick with it and make sure that your childs caregivers and family members stick with it too.

Does your child learn better when tasks are broken down into smaller steps, responds well to change and/or doesnt get frustrated when new tasks are introduced?

If your child is fairly easy going but learns better when tasks are broken down and time is allotted to learn one step before moving onto the next, then teaching toilet steps separately may be the best bet. Most sources that promote this method suggest teaching your child first how to eliminate on the toilet and secondly how to practice good hygiene and wipe herself (10, 15,8). This may also be a better plan if your child seems overwhelmed by tasks with a lot of different steps. If your child has a fear of the toilet, refer to the section on rewards to potty train your child using a reward process called shaping.

How do I deal with accidents? Accidents happen. Having an accident helps your child to learn what it feels like to be wet and how her body works. However, after the first few days, accidents can make you and your child

frustrated. The best way to deal with accidents is to act completely neutral (7,3). Many professionals say that even negative attention can be reinforcing, so by acting anything but neutral you may actually be rewarding the negative behaviour (15). When an accident happens, clean it up immediately - never let your child stay in her wet clothing as this will only get her used to feeling wet. Always change your child in the bathroom so that she can begin to form the connection between the potty and elimination.

14

Positive Practice While the majority of professionals agree caregivers should remain neutral after an accident, there are a few differing opinions. Some professionals suggest using positive practice rather than

simply remaining neutral. When your child has an accident, tell him to feel his underwear and confirm they are wet. Next let him know that big boys wet on the potty, take your child to the toilet and have him sit. As soon as your child is sitting, praise him and offer him a reward (5). Even though your child already eliminated in his diaper, this will help him to form the potty-elimination connection.

What happens if my child doesnt go during a scheduled toilet trial? For Habit training there are two choices regarding what to do when your child just doesnt go during a toilet trial. Decide whether timed toileting or distributed practice will work best for your

lifestyle and your child based on the information below:

Timed Toileting: The basis of timed toileting is to simply put your child on the toilet for five minutes at scheduled times of the day. If after 5 minutes your child has not eliminated, remain neutral, prompt your

child to get off the toilet, redress and wait until the next scheduled time to go back on the potty (16). It is very important that you do not reprimand your child or show any signs of disappointment. For some children getting attention (even if negative) will act as reinforcement for negative behaviour. If your child eliminates a few minutes after taking them off the toilet and they dont seem to have any problems sitting on the toilet or longer, its okay to extend the five minute sitting time.

Distributed Practice: Distributed Practice is quite similar to timed toileting. The only difference occurs when your child fails to eliminate while on the toilet. Take your child to the potty at the scheduled time. If your child

does not eliminate after 5 minutes remove your child from the toilet (5). After youve taken your child off the toilet in a neutral manner allow him to go back to playing. Ten minutes later take your child back to the toilet for another 5 minute sit. If at this point the child does not urinate or defecate, take your child off the toilet in a neutral manner and allow him to play again until his next schedule potty trial (5). If hes already overwhelmed by the toilet training process the extra trials needed for distributed practice may just further overwhelm him. However, for distributed practice it is okay to decrease the number of toilet trials to 2-3 (6).

15

Alternative Plans: The following two plans can be executed without going through the monitoring stage.

1) Activity linked toilet trials:

Indiana Resources Center suggests toilet training children with special needs by linking toilet trials to everyday activities. These can be activities such as waking up, going to school, coming home from school or eating. This will form a correlation between elimination and specific activities. Scheduled toilet trials based on your childs elimination patterns instead of your lifestyle can mean having to toilet your child during the busiest time of your day (21). This can rush the toilet teaching process and cut back on the quality time needed for your child to learn how to use the toilet. If you choose this method, pick out a few activities which can be followed up which can be followed up by bathroom visits. The best type of activities to correlate with potty trials are eating and drinking. Stooling most likely occurs with exercise following a meal often just arising from getting up from the table after eating. Down Syndrome: From Birth to Adults also suggests a similar method of taking your child to the bathroom at times when you know your child will have a full bladder such as, [in the] morning upon rising, after meals, mid-morning, mid-afternoon and before bedtime (107). Using a method of activity linked toilet trials doesnt mean that you dont have to stick to a schedule. You should be toileting your child after the same activities everyday (8). In order to remember to do this, and help your child understand, add these trials to your childs visual schedule. If you want to increase your childs chances of having a successful toilet trial, try increasing his liquid intake 7-15 minutes before his scheduled potty time (21, 2, 4, 7). If your child begins displaying outward signs of having to void, dont immediately rush your child to the bathroom. Sudden rushing will cause them to tense up (8). Instead approach your child and tell them they need to go to the bathroom, even if its not after a specific activity. By letting them know that they have to go to the bathroom, they will begin to understand the feeling of having to go. Be aware that if your child doesnt seem to be having many accidental successes on the toilet you may end up having to start again at the monitoring stage.

2) Generic Timed Toileting:

The following toilet training program is suggested for children with autism by Thames Valley Childrens Center. This program is not based on your childs elimination patterns but rather on toileting your child every 90 minutes. Set a timer for 90 minutes and every time the timer goes off prompt your child to sit on the toilet. If your child seems to be having a lot of accidents and is not voiding at the 90 minute trials, decrease the interval to one hour. If at the one hour mark your child is voiding regularly, try to lengthen the time between trials to 90 minutes again. Avoid taking your child to the bathroom more than once an hour. Toileting too often may not allow your child to learn how to properly hold his urine. Once your child is having less than one accident a day its time to extend the time interval between each potty trial. Try by lengthening the time between potty trials by 15-30 minutes at a time. Once your child seems to be accident free move onto the independence stage (cite).

16

Independence stage: 1) Put your child on a chair next to toilet without pants on 2) Praise your child frequently for good sittings 3) If the child gets off of the chair and moves onto the potty be ecstatic with praise and offer reward 4) If the child has an accident on the chair do not reprimand or prompt. Next time just start your child

off on the potty 5) After the child can move from the chair to the toilet without prompting start to move the chair further

and further from the toilet and start your child on the chair with his clothing on 6) Eventually your child should be able to self-initiate toilet training

Intensive Training Intensive training is a shorter term training method as compared to habit training, however, it requires a lot more daily work than habit training. Most intensive training plans suggest setting aside a period of three to five days for the toilet training program, however, there is no guarantee that this type of training will necessarily work that quickly for children with disabilities.

Here are a few possible plans:

Plan # 1: 1) During the short term intensive potty plan its a good idea to increase your childs intake of liquids. This will increase the number of times your child urinates in the day, giving her more chances to have a potty success! Increase your childs chance of going during a toilet trial by having her drink something shortly beforehand. 2) Prompt your child to get to the bathroom for her potty trial. Once your child is seated and on the toilet, wait 10 minutes to see if she will eliminate while on the potty. If your child does not eliminate take the child off neutrally and let her go play. If your child does eliminate on the potty praise and reward her and then let her go play. 3) After 15 minutes of play bring your child back to the toilet. Once your child has had a few successes on the potty the time between trials can be extended gradually throughout the day. 4) In the event of an accident tell your child not to wet his pants and then prompt him to change himself with help. If youre training an older child you can also prompt him to help to clean up any mess that was a result of his accident. 5) Begin to do dry pants checks to see if your child is staying dry between potty trials. If your child is dry praise and reward him for having dry pants. 6) Follow this plan for 4-8 hours a day until your child gets the hang of it.

17

Plan # 2:

This plan, unlike the one above, is only used over a three day time period. In preparation, restrict your childs favourite drinks a week before beginning your intensive potty program (this will encourage your child to drink more when you offer her her favourite drinks during the potty program).

1) Begin by prompting your child to sit on the toilet. 2) Once your child is seated on the toilet offer her a drink. 3) Wait 5 minutes to see if your child will eliminate. If your child does eliminate praise and reward your

child. If your child doesnt eliminate, act neutral and allow him to go back to playing. 4) Time 10 minutes from the end of the last potty trial. When the ten minute timer goes off, take your

child to the bathroom for his next toilet trial. 5) Continue this process 30 minutes - 2 hours. Constant potty trial will help your child to make the

connection between elimination and the potty. 6) Once you feel your child understands this connection, stop the constant trials. 7) Begin bringing your child to the bathroom every 90 minutes. Do not prompt her to sit on the toilet. 8) Have your child sit on a chair next to the toilet without underwear. 9) Do not prompt her to get up off the chair and move to the potty. 10) If she urinates on the chair, remain neutral, clean it up and next time start her off on the potty 11) If she moves from the chair to the toilet offer a huge amount of praise and a reward. 12) Once your child is able to move from the chair to the toilet, move the chair farther away. Have your

child start seated with her underwear on. 13) Every time your child masters a new distance, extend the distance even farther and begin your child

in pants rather than underwear. 14) If your child is toileting fairly successfully, begin randomly checking his pants to see if hes dry. If he

is dry praise and reward him. If he isnt dry remain neutral and help him to get changed in the bathroom.

How do I incorporate both intensive training and habit training into my childs toilet training plan? Heres an alternative plan developed by M. Beattie based on the work of Azrin and Foxx. This

plan incorporates the scheduling pattern of habit training and the routine of intensive training plan. 1. Follow the habit training toileting instructions that explain how to monitor and set out scheduled potty trials. If your child has no real pattern, toilet him every 2 hours and adjust the interval based on the length of his periods of dryness. 2. When its time for your childs potty trial, prompt him to the bathroom and put a chair next to the toilet. 3. Seat your child on the chair (without underwear) for one minute while having your child drink as much liquid as possible. 4. Prompt your child to get off the chair, take down his pants and sit on the

toilet. 5. Have your child sit on the toilet for 3-5 minutes or until he eliminates. 6. When your child eliminates, praise him and offer him an immediate reward. 7. If your child does not urinate, stay neutral and let him go back to playing for 30 minutes. After 30 minutes put him back on the toilet. If the second time on the toilet your child still doesnt go, remove him neutrally and wait to toilet again until his scheduled potty trial.

18

Rewards Picking the proper reward method is one of the most important keys to successful potty training. There are three main reward methods to choose from based on your childs level of development: immediate food or small prize rewards, sticker charts or natural rewards. Rewards will not be effective if you offer them for tasks that are too large or overwhelming. Instead make sure that you start off by offering rewards for simple things like sitting on the potty or doing a good job relaxing. Whatever type of reward method you decide on, always offer your love, support and verbal praise at the same time. When you phase out the tangible reward be sure not to phase out your love and support.

Immediate Food or Small Prize Rewards: This reward method works well for most children with a developmental age of 5 and under, but may also work for some older children. Immediate food or small prize rewards are just that, small rewards given to your child as soon as she completes a desired task. In order to make the reward method as effective as possible do a reward preference test on your child by giving her a series of reward options to see what one she chooses most often. Remember: when it comes to food, if you pick a reward that your child doesnt love, the chances of it being an effective motivator are slim. Instead, choose rewards that your child really likes but limit the portion size. You can also try to increase your childs motivation further by picking out a special reward and offering it only for potty training. If you decide to keep a certain reward special to potty training make sure that all of your childs caregivers follow the same plan. Once you come up with a reward plan it is most important to break the larger task (going to the bathroom) into small steps to be rewarded first (e.g. Sitting on the toilet for five seconds).

19

Shaping A reward method known as shaping can be used for children with a fear of the bathroom (5). Shaping is used to overcome your childs fears by rewarding him for taking very small, baby steps that will build up to the final goal. The example below demonstrates how shaping can be used with immediate rewards.

Example: Todd was terrified of the toilet. Although Todd was non-verbal, his parents knew that he was afraid of the bathroom by his reaction to it. As soon as Mum and Dad attempted to get Todd to enter the bathroom, he freaked out. Mum and Dad had tried offering Todd a few Smarties for defecating or urinating on the toilet but this didnt work. They couldnt even get him to sit on the toilet let alone relax enough to eliminate on it. Mum and Dad heard about using a technique called shaping. Along with Todds support staff they set out a list of goals for Todd to accomplish toileting bit by bit:

1) walk towards the bathroom 2) touch the bathroom door 3) open the bathroom door 4) stand in the doorway of the bathroom 5) enter the bathroom 6) touch the toilet 7) sit on the toilet (fully clothed, lid down) 8) sit on the toilet (just diaper, lid down) 9) sit on the toilet (just diaper, lid up) 10) sit on the toilet (diaper unattached but draped over the toilet hole) 11) sit on the toilet for 3 seconds (no diaper) 12) sit on the toilet for 5 seconds 13) sit on the toilet for 30 seconds The list continued to build up to the final goal which was for Todd to defecate or urinate on the toilet.

Todds parents began by asking Todd to walk towards the bathroom. When Todd didnt follow the prompt, Mum gently used hand over hand to guide Todd towards the bathroom. When this action was complete she praised Todd and offered him a reward. The next time, when asked, Todd was able to do this all by himself. After he was able to complete this action without guidance 3-4 times, Mum moved onto the next step. As usual, Mum asked Todd to walk towards the bathroom door. Once he completed this action, Mum then told Todd to touch the bathroom door. When he didnt follow their instruction, Dad used hand over hand, praised him and offered him the reward. Todd only received the reward when he completed the first two steps in order. After he was able to complete the first two steps in order, 3-4 times without guidance, Mum added the next step. Using shaping to teach Todd to use the toilet was a very long process. However, Mum and Dad felt it was well worth it once they got to step five and Todd actually entered the bathroom on his own. They continued with this plan until Todd was able to complete all of the actions in the list without guidance. By breaking the task of eliminating on the toilet into smaller steps with immediate rewards, Todd was less overwhelmed and able to complete each step in good time.

Sticker Charts: Sticker charts work well for children with good comprehension, an older developmental age (5 or above) and a good understanding of cause and effect. This plan can also be used for shaping, but only when working with developmentally older children. If your child is the type of child who likes to work towards earning things, and understands long-term concepts, this is probably the best plan for your child. Break the potty training process down into a set of hierarchical steps and assign sticker sizes to the goals based on the level of difficult. Create a sticker chart. Choose a large prize that your child may like (e.g. Going to a favourite restaurant, getting a special book etc.) which will be the grand finale prize. For example, let your child know that if she has a clean month shell get to go to a favourable restaurant, or if he has two stickers on every day by the end of the week he gets to pick a toy out of the special toy bag. Personalize the reward plan so that the stickers act as the immediate motivator to complete an action, whereas the grand finale prize acts as a motivator to keep having consistent progress.

20

Example:

Elaine was displaying all of the signs signalling potty readiness. Elaine was well aware of when she needed to defecate and would take the first few steps of self initiation by walking into the bathroom when she needed to go. However once in the bathroom, Elaine would position herself on the floor and then defecate in her diaper. It seemed as if Elaine really had no real motivation to sit on the potty. Pooping on the floor was comfortable and being changed really didnt bother Elaine. Mum and Dad tried offering Elaine immediate food rewards for pooping on the toilet. However, this didnt seem to motivate Elaine to go. Elaine had good communication skills, a high level of comprehension and was assessed as having a developmental age of 5 years old so Mum and Dad decided that the best reward method would be to use a sticker chart. They then spoke with Elaines support team and put together the following list of hierarchical goals:

1) sit on the potty with the lid closed and clothing on 2) sit on the potty with the lid up and clothing on 3) sit on the potty with the lid up and her diaper on 4) sit on the potty with the lid up and without a diaper 5) poop in the toilet 6) have a clean day 7) have a clean week 8) have a clean month

For each of Elaines 8 goals, Mum and Dad assigned a specific sticker size -the harder the step, the larger the sticker. Elaines parents then let her know that when she got the biggest sticker of all shed receive a special prize. The sticker chart helped Elaine gain immediate rewards for her positive actions while also increasing her motivation. It worked by breaking down the desired action (going poop in the toilet) into smaller steps that Elaine felt confident about and capable of doing. This gave Elaine the ability to have daily successes which helped her to get excited about the potty training process.

Natural Rewards: Natural rewards are great for a child who has a fascination with something bathroom related (e.g. flushing the toilet, using soap dispenser, putting down the toilet seat)(4). For some autistic children, rewards that do not have an obvious connection to the action may be overwhelming instead of reinforcing (21). If you find your child seems stressed by exaggerated praise or rewards, try using natural reinforcers (21). For natural rewards such as flushing the toilet, its fairly straight forward that if the child doesnt use the toilet he doesnt get to flush(7) However, make sure to include this reward as a separate entity on the childs visual schedule. If your child really likes to use the soap pump, allow him to wash his hands even if hes not successful on the toilet (for hygienic reasons). If he is successful on the toilet let him use an extra squirt of soap or lotion.

Natural Reward Ideas: Water play in the sink, using the mirror, flushing the toilet, getting to use special soaps or lotions, turning on and off the taps

21

Phasing out Once your child is able to complete the full potty process by herself without prompting, it is time to begin phasing out your bathroom presence and the rewards.

Phasing out your presence: Reference 15 suggests phasing out your presence by following these simple steps: 1) act distracted by something in the bathroom so youre not paying direct attention to the child 2) pay attention to things that are closer and closer to the bathroom door 3) after your child responds well to this, put your child on the toilet and stand in the doorway 4) if your child responds well to this try exiting the room next time and coming back to help your child wipe and washing their hands

Phasing out immediate rewards: The best way to phase out immediate rewards is to begin randomly removing them once your child seems to be consistently using the toilet. Begin by offering rewards to your child only after hes completed the whole potty process (including hand washing and hygiene). For the next 1-3 days (depending on how your child reacts) only offer the reward every second or third time he completes the potty process. After your child has adjusted to decreased rewards begin offering the reward at a random time once a day. At the same time as decreasing rewards for completing the potty process, begin offering rewards for having dry pants. Throughout the day randomly do a couple of dry pants checks by prompting your child to check if they are dry. If they are, praise him and offer him a reward. If they are not dry, stay neutral and change them in the bathroom. After your child seems to be using the toilet well and is dry most of the time, phase out the dry pants checks as well.

Personalizing the Plan You know your child better than anyone. You know what she likes and what she doesnt like; what sets her off and what helps her to calm down. With all of your expert knowledge regarding your child, personalize her potty plan with the help of the following information:

Communication:

How does your child best communicate with you? How do you most effectively communicate with your child? Communication works both ways. In the beginning, the most important thing is for you to be able to communicate prompts in a way that your child will understand. Once your child begins to self-initiate youll have to be able to understand what hes trying to tell you. If your child is verbal make sure to explain body words and potty words to him not only so that he can understand you, but so that he can one day use them to self-initiate. Some children who are verbal also benefit from the use of picture exchange, symbols or signs especially when communicating their needs to you. If you feel that visual cues may help your child communicate with you, make these accessible. If your child is non-verbal, update his picture exchange cards by making available cards that deal with the potty process. When introducing new symbols or pictures, pair up the visual cue with the verbal words youre explaining. If your child only uses visual cues, make sure he has a travel size cue book to use when out in public or when he has to go to the bathroom quickly.

22

Communicating the process: In order to communicate the potty training process with your child, use a visual schedule. Using the

toilet is a task that is made up of a lot of little baby steps that all need to come together in the right order. By providing your child with a visual schedule youll help her to understand the process and become more independent. Its best to customize three visual schedules:

1) Master Visual Schedule: this is the schedule that outlines your childs activities for the whole day. Add in the bathroom symbol based on the toilet trial schedule youve set up for your child. Also add in a reward visual to the schedule directly after the bathroom symbol.

2) Toilet Schedule: Place a special schedule in the bathroom that covers all the steps of using the toilet (e.g. Take down pants, sit on toilet)

3) Hygiene Schedule: include a special hygiene schedule in the bathroom that will help your child master the steps of washing his hands. For actions in the bathroom that your child likes to repeat (e.g. Flushing or soap pumping) use a 1 only picture exchange card (which can be either handed to the child or taped on the object e.g. Toilet handle). Make sure that the schedules are posted where your child can see them. If your child does a step wrong in the process (e.g. Begins to wash his hands before pulling up his pants) do not simply restart the wrong action (e.g. Do not begin pulling up pants). Instead, go back to the last correct step the child completed (e.g. Wipe again before having the child pull up his pants). For children that comprehend and communicate best using verbal or written word, feel free to make a schedule for them as well -- this will simply remind them of the proper order of the steps. Besides a verbal schedule to prompt your child to use the toilet, you can use a visual cue or object exchange to indicate what youd like them to do.

Lets get Literal:

If youre toilet training an autistic child, its very important to keep your communication as literal as possible (21). Autistic children will often take the most literal meaning of the word. For example, if you use the term going to the bathroom to prompt your child to urinate or defecate your child may think youre asking them to walk into the bathroom and not actually eliminate. Make sure your child comprehends the intended meaning of your prompts by pairing up your verbal cues with visual cues.

Assessing your childs abilities: Go through the following steps. For each step address whether or not your child is physically

capable of completing the step. If not, make the necessary environmental adjustments or talk to your childs physical therapist. For each step also consider whether your child may have behavioural problems completing the step. Before you even begin the potty process, troubleshoot to avoid your childs tactile sensitivities or behavioural problems. Think of how you could use your childs abilities to get around any problems (14). This may mean being completely realistic and reassessing whether or not your child will be able to complete all of the potty training steps (14). Based on this assessment you may need to modify the goals you had originally had in mind (14). Troubleshooting examples have been added in brackets to certain steps in the checklist below.

23

Can indicate the need to go to the bathroom (e.g. Visual cue put into picture exchange book which indicates need to go to the bathroom) Can walk to the bathroom Can pull down pants and underwear Can get onto toilet (e.g. step stool needed to get onto toilet) Can sit on toilet (e.g. Bag of tactile toys offered to keep child on toilet) Can relax enough to eliminate (e.g. Calming music played, lights lowered) Can wipe himself (e.g. Physically difficult task so mum or dad aids child in wiping) Can pull up his pants Can flush the toilet (e.g. Visual cue taped to handle to indicate one flush only) Can stand at the sink (e.g. Step stool needed) Can wash his hands (e.g. Sensory sensitivities - soft soap used instead of bar or soap,

wet wipes or hand sanitizer used instead of water (from citation)

Environment:

If your child doesnt feel comfortable in her environment, chances are no matter what potty program you use its not going to be successful (14). Modify your childs environment based on her sensitivities and likelihood of distraction. The following section offers suggestions to how to change your childs environment

to combat their sensitivities and likelihood of distractions.

Avoiding Tactile Defensiveness:

Responds poorly to taking off diaper: If your child responds poorly to having his diaper removed or sitting on the toilet bare bottomed, consider the room temperature. After having a diaper on almost every moment of the day, having it taken off can be a big sensory shock. Try increasing the temperature in the bathroom or buying a padded toilet seat that doesnt get so cold (20). If changing the temperature of the room doesnt work, you may need to slowly transition your child out of having their diaper on. First have him get comfortable with sitting on the toilet fully clothed, then have him sit on the toilet with his diaper on, then have him sit on the toilet with his diaper off but spread across the hole in the toilet and finally take off his diaper completely (7).

Child responds poorly to flushing the toilet: Many children are initially afraid of the toilet. In order to combat your childs toilet fear, try to figure why it bothers her so much. If she is visually sensitive of flushing the toilet, teach her to put down the toilet seat first. If she doesnt like the sound of the toilet flushing, Toilet Training children with. suggests tape recording the flush noise and let your child listen to it at various volume levels. The same book also suggests prompting your child to open the door before flushing in order to give her an immediate escape route allowing them to feel less trapped. If your childs flushing fear is getting in the way, teach your child to potty train now and work on flushing later.

Child seems to feel unstable on the toilet: for some children, especially children with autism, making a few minor changes to your childs environment may help him to feel more stable while on the toilet. Feel free to add grab bars around the toilet for him to hold onto, and buy a step stool so that hell have somewhere to place his feet (20). Placing a plastic table in front of your child may also help him to feel more stable by giving him somewhere to rest his arms. If your child benefits from tactile stimulation you can place toys on the table or books. However, never restrain him to the toilet.

Comment [MSOffice1]: Put in s=citation

Comment [J2]: is this outside of the toilet area

24

Child wont sit still long enough to go: Put together a bag of toys or books that can keep your child distracted while shes on the toilet. For children with autism this bag may include objects that will provide your child with tactile distraction. If your find that your child seems stressed while on the toilet, use various calming techniques. If your child relaxes when music is played get a CD player to keep in the bathroom and try turning down the lights a little bit. In order for your child to urinate or defecate, they must relax. Think of your childs strengths by making a list of all of the things that typically help her to calm down. If your child seems impatient sitting on the toilet, or constantly asks how much longer she needs to sit, get a visual timer and put it next to the toilet. This way your child is constantly aware of the time, and can concentrate more on eliminating, and less on asking you how much longer she must sit.

Sensitivity to Smells: There are a lot of smelly products in the bathroom and most soaps have very strong odours. If you know that your child has a sensitivity to strong smells, check out hypoallergenic bathroom products that are usually perfume-free. Make the bathroom a scent free zone. Ask other family members to put on perfume or use deodorant in their bedrooms so that perfumes are not unique to the bathroom

Sensitivity to the feeling of soap or toilet

paper: Typically the two main feelings that cause problems in the bathroom are the feeling of the soap and the feeling of the toilet paper. If your child doesnt like the feeling of soft soap try using a bar or vice-versa. If your child is still having problems try hand sanitizer or wet toilettes. If your child doesnt like the feeling of toilet paper, try wetting the paper with warm water or using wet toilettes that have been run under warm water (be aware that wet toilettes are often very cold).

Child responds poorly to wearing underwear: For some children the weight of the diaper becomes comforting. If your child seems upset by having to wear underwear instead of a diaper, or panics when you take off the diaper, you may have to wean your child out of it. In order to do this you want to gradually take away the weight and pressure the diaper creates. There are four ways to do this:

1) Cut away method: 1) place the diaper overtop of the childs underwear 2) cut a small hole in the crotch of the underwear 3) every day expand the hole 4) the last part of the diaper remaining should be the waist band because this provides the most deep pressure

2) Loosen method: Keep your child in diapers but put the childs underwear on underneath the diaper. Everyday make the diaper a little bit looser by not attaching it as tightly. Eventually hardly do up the waist band at all so that the diaper falls off on its own. Typically by this point the child no longer feels bothered by not wearing a diaper.

3) Mixed Method: Begin setting aside time in your childs day that he can spend without his diaper on. At first this may be for only a few minutes. Gradually increase the time your child spends daily in underwear without a diaper on overtop and use positive reinforcement.

25

3) Slit Method:

Cut a slit in the bottom of the childs diaper big enough that the childs feces can fall through into the toilet. Have the child use the toilet with her diaper on. Gradually make the hole bigger and bigger. Once the hole is fairly large, have your child put on his underwear underneath the diaper. Cut away the diaper until just the waistband is left and then get rid of it all together.

Bathroom Distractions: For some children being easily distracted can prolong the potty process. Overcome a childs tendency to become distracted easily, by removing all known distractions from the potty training process right from the get go. This may mean having to hide or remove objects from the bathroom that may distract your child (such as bath toys, toilet paper, soap). If possible, make potty trials a one-on-one experience. Some children may be distracted by having too many people in the room or having the door kept open. Especially for older children, privacy can become important. If your child seems nervous or embarrassed while in the bathroom, do all that you can to give him the privacy he needs to become comfortable. Never leave your child unattended on the toilet if they have special needs that may endanger him, or if he has a history of fecal smearing.

Example: Emmy was easily distracted. The moment Mum walked her into the bathroom she was immediately excited. She loved to look in the mirror, turn on and off the taps and flush the toilet. While Mum taught Emmy not to turn on and off the taps and flush the toilet by using visual cues, she could not get Emmy to stop looking in the mirror. Even when she was on the toilet, she had no success because she would try to angle herself to catch a glimpse in the mirror. Besides just her interest in the mirror, every time one of Emmys two brothers would walk into the bathroom to ask Mum a question or tell Mum something important Emmy wanted to join the conversation and became distracted again. While Mum was lucky and had no problem getting Emmy on the toilet, she just could not get her to concentrate and relax enough to go. The next day, Mum covered up the mirror with a big sign that said reward. Instead of reprimanding Emmy for wanting to look in the mirror while on the toilet, she used her natural interest in looking in the mirror as a reward. If Emmy eliminated on the toilet, Mum would take down the paper sign while Emmy was washing her hands. Mum continued to cut out distractions by explaining to Emmys brothers that bathroom time was private for Emmy and Mum. In order to make sure that her boys didnt feel left-out, after every toilet trial with Emmy, Mum let Emmy play solo while she spent ten minutes reading to her boys.

26

Relaxation: Relaxation is key to potty training. Once your child is sitting on the toilet, your child needs to relax enough to let her sphincters open and eliminate.

Here are some tips to try to get your child to relax once on the potty:

Play some calming music

Read your child his favorite book

If your child is easily excited by chatting, keep conversation to a minimum

To help your child go you can press gently on her lower abdomen

Try turning on the water (as long as hes not distracted by it)

Some children have a habit of getting too excited and jumping off the toilet either mid pee or right after. This can lead to dribbles and accidents on your bathroom floor. After your child feels shes finished urinating either count to ten with them calmly and slowly before they get off the potty or sing a special song together. This will help you to make sure that shes completely emptied her bladder and shes ready to get off the toilet

Place a table over your childs lap while on the toilet and place some tactile toys that tend to calm him down.

Dressing for Success: During toilet training, your child has to hold back and wait to eliminate until seated on the toilet. For the first time ever, your child has had to actually have to stop himself from urinating or defecating immediately. At first, it can be hard for many children to hold back long enough to make it to the bathroom in time. It becomes important during toilet training to dress your child in clothing that can be taken off easily (2) even if this means you may have to sacrifice his style for a while.

27

Diapers vs. Pull-ups vs. Big Kid Underwear:

There are many different opinions regarding whether diapers, pull-ups or underwear are best to use during toilet training. Even the experts dont all agree. Potty training has no definitive answers, so instead you have to choose whats right for your child. Whatever option you choose, remember to always change your child in the bathroom. This will help him develop the connection between elimination and the potty.

1) Diapers: - Makes potty training less messy - Often necessary if your child goes to school or daycare - Best for the family thats busy and doesnt have time to clean up constant messes

If you choose to keep your child in diapers: Diapers are great for keeping messes to a minimum, but they dont allow your child to get that necessary feeling of being wet. Feeling wet helps your child understand that shes in control of elimination. Feeling wet can also motivate a child who prefers to be clean and dry to stay clean and dry. So if youre choosing to keep your child in diapers, set aside some time everyday to allow her to great a feeling of being wet. If youre training a younger child, waterproof a section of your childs diaper and allow her to go bare bottomed for a short period of time everyday. If youre training an older child the place a disposable non-absorbent liner in his diaper and prompt him every hour to check if hes dry or wet.

2) Pull-ups: - Depending on the type they may allow your child to get a chance to feel a little bit wet, however

most (similar to diapers) pull the moisture away fairly quickly. - Easier to get on and off when rushing to the toilet - Pull-ups may give your child a feeling of being a big kid, however, most soon learn that pull-ups are

very similar to diapers and that they can use them the same way.

3) Underwear: - provides the child with a feeling of wetness which is necessary for learning how to stay dry - accidents help your child to understand the difference between wet and dry, so accidents in the beginning can actually be a very positive thing in the training of your child - if your child doesnt seem bothered by wetting or soiling her diaper, this is a good indicator that you should switch your child over to underwear.

If you choose to change to underwear: Some children may have a problem switching from diapers to underwear (especially children with autism who find that diapers provide them with a comforting heavy feeling and deep pressure touch). During the transition period you can put diapers overtop of your childs underwear if he seems resistant to letting go of his diaper (21). This way your child can get that feeling of heaviness while learning what it feels like to be wet. Because night time urine continence is acquired later than daytime urine continence, keeping your child in diapers at night is a good idea until youre ready to start night time training (15). Once your child is using underwear it is very important to change them as soon as you notice theyre wet (21). Your child may come to tolerate or prefer being in dirty or wet diapers if hes not changed frequently enough.

Suggested Reading: For more tips on personalizing your childs potty plan check out the book Toilet Training Individuals with Autism and Related Disorders by Maria Wheeler. It offers some great ideas for troubleshooting with real life case study examples!

28

Dealing with Real Life: All of the effort in the universe cant keep real life from interfering with your childs potty training. There are sports and extracurricular activities, school, work, siblings and a whole whack of other responsibilities on your plate as a parent. Thats why, when designing a potty training plan the most important thing to take into consideration is how your real life will affect the plan. The key to potty training success is CONSISTENCY, so dont create a really great plan if you can only follow it on the nights when your child doesnt have soccer or music class. Instead, create a plan that fits your childs needs and is do-able whether your child is at school, at mums house or dads house, or on nights when they have extracurricular activities. It can be even harder to maintain consistency when your child is in daycare, goes to school or alternates between homes. In the sections below there are some tips to help you maintain consistency throughout various situations.

The School or Daycare Partnership: If your child is in school or daycare, its important that you form a friendly partnership with the school. It can be hard to find a happy medium in the midst of school administration power struggles, however, its not impossible. If you adopt a team mentality instead of an us against them attitude from the get go youre guaranteed to have more success! Here are some tips:

1) Compromise to make a plan that may not be perfect but will

definitely be consistent: In conjunction with your childs support staff, design the potty plan that will work best for you. Write up all of the details of the potty plan. Instead of simply handing this over to the school and demanding they follow it, request a meeting with your childs teachers, support staff and administration to discuss whether or not the plan can work at school too. Work with the school to make the changes necessary for the plan to be followed while at school. Distribute the plan to all your childs caregivers.

2) Provide the school with all the tools theyll need: Create a shared binder which will follow your child from home to school. Heres what to include in your childs potty binder:

- a sheet for tracking potty progress along with their potty training schedule - a breakdown of the order of the potty training steps if youre teaching your child the whole process

using a specific routine - a recap of how you give rewards and respond to accidents - your childs visual schedule and visual cue (if you use this to prompt your child) - any necessary aids to help your child communicate her need to go the bathroom with her teacher - a page for your childs teacher or support staff to note any unusual events which may have

disrupted your childs potty progress for the day (ex. An assembly, bullying, a change in diet etc.)

29

How to deal with divorce:

In North America divorce is a common occurrence. Divorce may make it more difficult to potty train your child but it is not impossible. The keys to achieving potty training success in the midst of divorce are:

BE CONSISTENT: Come together with your ex-partner to have a civil meeting to design a potty plan which can be executed at both Mums and Dads house. At this time youll also want to decide on a reward program, how to deal with accidents and what your childs visual schedule will look like.

OPEN COMMUNICATION: Open communication between divorced parents can sometimes get a little messy. If youve recently ended your relationship and things are still stressful, all the messy phone calls and meetings will just stress your child out further. Instead create a shared communication binder that outlines the plan, allows each parent to track potty progress and events which may have disrupted the potty plan (e.g. Eating something new, illness etc.). Share this pamphlet with your ex.

MAKE YOUR CHILD FEEL SAFE: Too many divorced parents fight through their children. This causes the child to become more stressed and more stress leads to potty training reluctance. While you and your ex may disagree on many things, you both probably agree that you want the best for your child. Therefore, make a peace pact and stick to it.

Sudden Regression: Many parents complain that their childs progress suddenly comes to a halt, or that their potty training progress begins to go downhill. If this happens to you and your child dont be alarmed. Instead of stressing out about it, try to get to the root of your childs sudden potty regression by looking for any changes which may have occurred recently. If your child is able tell you what the problem is thats great! However, even if your child is communicative, he may not be conscious of the issue, so dont push it. Toilet Training Your Special Child, a book put out by Thames Valley Childrens Centre, suggests investigating the following possible regression causes:

Is there a physical cause? Is your child having painful or hard stools? Have your childs bowel or bladder habits changed? Is there blood in your childs urine or do they complain of painful urination? If your child is presenting with any unusual physical symptoms, consult your physician.

Has there been a recent increase of or new stress in your

childs life? Has your family become blended? Did you have a new baby? Have you recently moved? Are you going through a divorce? Added stress can cause your childs potty training progress to go downhill. If you figure out whats bothering your child and can make a change to help alleviate the problem thats great! Whether or not you figure out whats bothering your child, dont push the toilet training issue. If you feel your child would benefit from a toilet training break thats okay! Make sure that if you choose to take a break not to put your child back into diapers if your child is currently using pull-ups or underwear as this may become confusing.

30

Valuable Resources