Appropriate toileting is a basic skill that, once mastered, opens up a world of possibilities. Without being toilet trained, a person is dependent on others, restricted from partaking in community activities, has difficulty making and maintaining social relationships and overall will have a less independent and satisfying quality of life. In addition to benefits for individuals, families will maintain a higher quality of life once children master toileting. It is often reported that parents in the USA and UK begin toilet training when children are around 12-18 months of age with mastery noted between 3 and 4 years of age (Harris, 2004). Although ages vary, children with intellectual and developmental disabilities usually master continence at a later age, frequently after five (Harris, 2004). Issues with toileting are in the top ten of the most frequently reported emotional and behavioral problems in children with autism spectrum disorder (Maskey, Warnell, Parr, Le Couteur, & McConachie, 2013). Problems with incontinence past the age of expected training are reported in between 23% to 86% of individuals with intellectual disabilities with the average prevalence likely being between 60% and 65% (Van Laecke, 2008). Effective toilet training procedures, for both individuals with developmental issues and typically developing children are based on behavioral methodology. For children with developmental issues, including intellectual disabilities and autism spectrum disorder, toilet training procedures should be well structured, highly intensive and consistently implemented. Over the past 6 decades, a relatively large body of literature has emerged describing highly effective toilet training strategies for children with special needs.
What to know before you start
Toilet training should start not based on a child’s age or when he or she “says” that they are ready, but when they have mastered the following prerequisite skills:
The ability to sit on a toilet appropriately for about 3 minutes
The ability to hold urine in their bladder for about 1 hour
The understanding that rewards are linked to following directions
The absence of severe and frequent interfering behaviors (aggression, self injury, noncompliance, etc.)
For the best outcome an intensive training model should be used. This consists of:
1:1 trainer:trainee ratio
Implementation of training for 6-8 hours per day
All training taking place either within a bathroom or directly outside of a bathroom
Once started, training should be consistent 7 days per week. Plan your schedule and home life accordingly. It is ideal for trainers to consist of a combination of professionals and parents/family members.
The guidance of a board certified behavior analyst in the design, implementation and oversight of the training procedures should be obtained.
As with all behavioral interventions, the training procedure should start off with an assessment of the skill deficit or target behavior that will be the focus of treatment. With regards to toilet training it is likely that this will include a medical examination as well as baseline data collection prior to developing a training plan.
Questions for the BCBA Many behavioral methods seem very intense. How long can I expect training to take? Although it is impossible to give an exact time frame for how long training will take, I have seen training completed in as short as 2 weeks or longer than a month. Length of time will vary based on the skill level and diagnostic issues of the trainee as well as the intensity level and consistency of which the plan is implemented.
What if I am not able to implement an intensive 1:1 procedure, in a bathroom, consistently? Although your child might be successful using a less intensive intervention, you will likely significantly lengthen the training period. It may also be the case that your child needs an intensive intervention in order to be successful. Before giving up on an intensive procedure, make sure you are considering all your resources (school, home staff, family members, related services etc.) and that you are considering temporary changes in your schedule in order to make it work (such as taking off vacation time from your job to coincide with school breaks).
Can any behavior analyst guide me in the training? Whereas it is true that all behavior analysts are familiar with learning principles, not all behavior analysts have training or experience working with children, individuals with developmental disabilities or knowledge of assessment and training techniques related to toileting. It is always best to ask a behavior analyst directly about their experience and knowledge in this area before using them to develop and guide your plan.
Materials you may want to have The materials that you will need will depend on the details of the plan that you are implementing, however the following materials are most likely required:
Access to a bathroom in which training can occur (the less traffic in the bathroom the better)
Various reinforcers (rewards)
An electronic timer
Changes of clothing
Various preferred liquids
Step stool and toilet seat ring (for younger/smaller children)
Activities to do in the bathroom (you will be spending many hours in the bathroom)
Treatment decisions should always be based on objective data
Data should be collected during all training hours
Although the exact type of data collected will be determined based on the plan you are implementing, it is likely that you will take some form of data on urination or bowel movement accidents, successful elimination in the toilet and spontaneous trips to the bathroom/requests to use the bathroom.
Sometimes during the assessment phase narrative descriptions of accidents and successes are also collected in order to gather information for plan development.
With toileting, data should be reviewed daily
What to expect In most behavioral toilet training interventions you will find a combination of the following procedures and techniques:
Taking the trainee to the toilet on a timed schedule in order to try to urinate/defecate (30 minutes is often the recommended schedule)
Having the trainee drink an increased an amount of liquids during training times in order to encourage urination
Offering a reinforcer (reward) if the trainee successfully eliminates in the toilet. The reward should be something highly preferred. For urination training the reward should be something that can be delivered quickly. Because bowel movements occur less frequently, longer duration rewards can be used.
Quickly prompting the trainee to the toilet upon the start of an accident
Having the trainee learn how to communicate the needs the use the bathroom through either prompting a verbal request, picture exchange or sign language. The type of communication used will be individualized to the skills and preferences of the trainee.
Although the use of punishments for accidents can be beneficial and is included in some published training plans, research has shown that they are often not needed in many situations. The use of punishments should be done with caution and consideration. Always seek the guidance of a behavior analyst when using punishment based interventions.
Whenever you are toilet training, always expect to spend many hours in the bathroom with your child and staff.