Teaching your child to use the toilet correctly can be a difficult task, whether they are on the autism spectrum or not. But if your child is autistic, the process of developing a toilet routine can take longer, and involve its own particular challenges. This guide provides some useful steps that will hopefully make your toilet training a success.

When to start 

There is a temptation to delay toilet training with autistic children. However, clinical experience and research is now saying that starting earlier is better (before the age of two). However, it is vital to say that it is never too early or too late to start the preparation for toilet training. The ERIC website has some great tips around this. 

Developing a toileting routine 

Remember that independent toileting is the ultimate aim and may take many months but there will be many small steps and successes along the way. As well as physical factors associated with toilet training, there are social factors to consider. It is rare for an autistic child to have the social motivation to want to be like mummy/daddy/friend and use the toilet. After using nappies for a number of years, your child might not see the point in starting to use the toilet. It's important to remember that all children are different and they will not all respond to the same teaching techniques.  

Children on the autism spectrum often like routine. You can build upon this desire for predictability to develop a successful toilet training routine. 

• When changing your child's nappy, do this where the toilet is so they can start relating toileting activities to the bathroom. 
• Your child may behave differently than normal when their routine is changed so let everyone who cares for them know why there could be a change in behaviour. It is often easier not to use a potty as part of toilet training to avoid a possibly difficult change from potty to toilet. 
• Ensure everyone working with your child starts toilet training at the same time and follows your agreed approach. Send in any equipment to nursery/school which you use at home, for example a toilet seat they may use to make the seat smaller. Also remember to send spare clothes, plastic bags to put any wet clothes in and wet wipes. It is important that you have clear lines of communication during this time so having a home/school book to share concerns and successes is vital. 
• Observe your child over a few days to see when they do a wee or a poo. Identifying a regular pattern can help you take your child to the toilet with an increased likelihood of them doing a wee or poo. This then leads to positive reinforcement. 
• Continue to take your child at set times based on your observations. If they wet themselves at another time, take them to the toilet as quickly as possible and try to get them there so some of the wee goes into the toilet. Ignore the wetting and positively reinforce that the wee has gone into the toilet and continue the rest of the toileting routine. 
• Use a visual sequence beside the toilet to help your child understand what is expected of them, for example: trousers down, pants down, sit on the toilet, wee/poo in the toilet, wipe (you may need to show how many squares of paper to take), pants up, trousers up, flush toilet, wash hands. The sequence can either be in the form of photographs, pictures or the written word - whatever is most suitable and motivating for your child. You may need to create a way of removing or covering over each symbol as the step is completed to show that it is finished and to move on to the next step. There are some examples of visual supports on the Do2Learn website.  
• Make sure any pictures or instructions are very clear so there is no misunderstanding. For example, if you are teaching your son to stand and wee in the toilet, show an outline drawing of him standing and weeing in the toilet. If you are teaching sitting, show a picture of him sitting and weeing in the toilet. 
• Show your child a photo or drawing of the toilet and say 'your child's name, toilet', take them into the toilet, follow your visual sequence for undressing and sit your child on the toilet. Even if they do not open their bowel or bladder, continue to follow the visual sequence as if they had. 
• Use a laminated visual sequence above the sink at eye level for hand washing. 
• Teach toileting as a whole routine from communicating the need to go to the toilet, using the toilet, to drying hands, rather than just sitting on the toilet. 
• Keep the sequence of behaviours the same every time. Often when an activity is anticipated, the child is more receptive to it.  
• Concentrate on tackling one behaviour at a time; it's very difficult to change two behaviours at once. 
• Decide whether or not and how to praise your child for successfully following the toileting routine. Some children enjoy and respond to social praise ('well done', or a tickle), others respond better to an object. Some children find praise difficult and keeping a calm, structured routine with a preferred activity after toileting may work better.
   

Dressing and undressing 

• Dress your child in comfortable clothes they can easily manage themselves such as elasticated waistbands on trousers and skirts or dresses that are not too long.  
• Motivate your child to wear underwear by buying pants with their favourite cartoon or television programme characters on them. 
• Use 'backward chaining' to teach new skills. This involves breaking a skill down into smaller steps, teaching the last stage of the sequence first. So if you were teaching your child to pull up his trousers, you would pull them up to his hips and then he would pull them up to his waist. Next time, you would pull them up to just under his hips and he would pull them over his hips and waist. This is a particularly good way of teaching new skills as it raises your child's self-esteem as they have taken the final step of the task themselves to complete the sequence.  
   

Hand washing 

• Follow the same steps each time: sleeves up, tap on, wet hands, squirt soap, rub hands together, rinse hands, turn off tap, shake hands, dry hands. 
• Stand behind your child and physically prompt them if necessary, slowly withdrawing. 
• Avoid using verbal prompts as your child can become dependent on these without you realising. Instead let your child refer to a visual sequence as a reminder. 
• You may wish to teach your child to use the cold tap only. Beware that if you teach them to use the hot tap independently at home, when they go into other settings and wash their hands, the water may be too hot and could burn them.
   

Boys - sit or stand? 

When deciding whether to teach a boy to sit or stand to urinate, ask yourself the following questions: 

• Can they distinguish between when they want to wee and poo? 
• Do they have the co-ordination, focus and control needed to aim? 
• If they learn by imitation, is there someone they can watch? 

If the answer to any of the above is 'yes', then they are probably able to be taught to stand to urinate. To start teaching them to aim, it can be useful to put a piece of cereal (preferably one they don't eat as this could lead to confusion) down the toilet so they have something to aim for and concentrate on. You can also purchase a variety of fun toilet target stickers online.
 

Bowel control 

Bowel control is usually learnt after bladder control. Some children can find bowel movements very frightening and not understand what is happening. It can help to get a book with pictures to explain the digestion process. 

• Some children find the feel of a full nappy comforting, and may enjoy the sensory feeling of the weight of the nappy. Find alternative ways to replace these feelings so you can continue toilet training. Give your child a means of requesting the activity eg being wrapped in a warm, heavy blanket and fit it into their routine. 
• Sit your child on the toilet, keep the nappy on but with a hole cut in the bottom, slowly cut away the nappy each time until they are able to go without the nappy at all. To start with, they will still have the feeling of a security around their waist which in turn will enable them to feel relaxed enough to poo on the toilet.  
   

Habit training 

Some children are toilet trained through habit. Habit training is effective for children who may: lack awareness, not understand the significance or meaning related to physical sensations, be limited by decreased or absent physical sensations or have unsuccessfully tried toilet training before. 

• Habit training involves training the body to go at set times. Take your child to the toilet at set times throughout the day, every day. 
• As before, observe your child to discover the best times to take them to the toilet. 
• Make sure your child feels relaxed enough to open their bladder/bowels while they sit on the toilet. Having the tap running in the background can help enable your child to wee for example. 
• Sometimes having a toy to handle - not one which causes excitement - can be useful to both keep your child on the toilet and relax them. Keep certain toys/books for just when they are sitting on the toilet. 
• If your child lacks awareness or sensation, they may have to be taught a strategy before getting off the toilet, to avoid accidentally weeing on the floor. Encourage them to slowly count to ten out loud when they have finished weeing before allowing them to get up, or give them a sand timer to look at. 
• To help your child to independently manage their own toileting routine when they are older, you can buy watches which you can set to vibrate at certain times throughout the day. You can then teach your child when the watch vibrates, they are to go to the toilet.
   

Environment 

• Ensure the bathroom is a calm, relaxing environment to encourage independence and success with the complete toileting routine. 
• Remove all distractions which are not associated with toileting to help your child understand what is expected of them while in the toilet. 
• Make the bathroom as comfortable as possible, adding foot supports, side rails and a smaller toilet seat if necessary. 
• Encourage independence by ensuring that everything in the bathroom is at the right level for your child eg soap and towels. 
• Think about your child's sensory needs and make changes to reduce their anxiety. Does the soap smell too strong for them? Does the noise of the extractor fan bother them? Does the water temperature need to be adjusted? Is the lighting too bright? 
• Make sure your child can sit comfortably on the toilet with hips and knees flexed at a 90 degree angle and have feet flat on a secure object.
   

Night-time 

Once your child is mostly dry during the day you will be able to start night-time toilet training. 

• Have a set bedtime routine which does not change with weekends or holidays. 
• Limit the amount your child eats and drinks before bed, having no fluid an hour before bedtime, but ensuring your child has enough fluid throughout the day. 
• Take your child to the toilet before they go to bed. They then may need to be taken once during the night. You could fit this in with your routine by taking them before you go to bed. 
• If they are unable to keep dry during the night, you may need to try different times in the night to take them. 
• Use products to protect bedding.
   

Schools and early years settings 

Admission to school should not be refused simply because a child has difficulties with continence. A school that does this may be at risk of disability discrimination (alternative legislation operates in Northern Ireland). 

Further tips 

• Giving a drink 10 to 15 minutes before toileting can help increase the chances of your child successfully doing a wee on the toilet but avoid giving too much as this creates an unnatural routine. 
• Decide if you are going to teach your child to shut the door as part of the whole toileting routine or only in certain situations. 
• Avoid using childlike terms for toileting as your child may find it difficult to change language later in life.  
• If your child has a fear of flushing the toilet, you may wish to remove this from the visual sequence and leave it until the end of the routine - after your child has dried their hands. They then may need to stand in the doorway while you flush the toilet and gradually stand closer each time until they are able to flush for themselves. Playing calming music to drown out the noise of the flush or explaining with pictures what makes the noise when the toilet is flushed may also help. 
• When your child is in a car, ensure they have a protector to sit on to stop the car seat from being soiled by accidents. Avoid drinks before long car journeys. 
• Be aware that some children will hold onto their wee/poo until they have their nappy put on, for example if they know they always have a nappy on before going in the car they may wait until it is put back to release their bowel/bladder. 
• A range of absorbent pants and swimwear for older children is available. 
• Once your child is toilet trained at home, you will want to teach them to use toilets when out. When visiting new places, show your child where the toilets are and use the same routine as you do at home. Use the same picture and toy or book they may have for toileting at home. 
• Some children smear their poo. Read our guide on smearing for strategies to try (link to new guide in behaviour section).  

Further information 

• ERIC the children's bowel and bladder charity helpline, information, message boards and products. Their website includes a kids’ zone for explaining about continence. 
• Bladder and Bowel UK provides links to organisations which sell toilet-related products including swimwear, absorbent pants and toilet seats for older children. 
• NICE Guidelines: Bedwetting in children and young people, Constipation in children and young people. 
• Autism and continence, training for professionals. 
• Profesional practice article: Toileting and autistic children, Author: Lorraine MacAlister.