FAQs: Verbal Behavior | Potty Training

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Frequently Asked Questions Regarding Potty Training

By Mary Barbera, RN, MSN, BCBA

The following are my answers to some Frequently Asked Questions regarding potty training.

What age should I start?

Consider the child's developmental age. If a child with autism just turned 3 but has a developmental age of 18 months, it is probably too early to start an official program. However there are some steps you can do prior to potty training: 1) Keep the child dry and clean by changing diaper frequently; 2) Comment—"you're very wet;" 3) Place the child on a potty in the morning and at bath time—reward heavily if he is successful; 4) Boys should sit on the potty for urination until they are fully bowel trained.

My child is 3 and just got diagnosed with autism. Potty training is a priority as I am expecting our second child next month. Should I start a program?

If a newly diagnosed child is starting a school or home program, you probably want to begin with easy programs so that you can gain attention and compliance and build on your successes. You also want to establish a good positive behavior program (without any negative reinforcement or consequences) before attempting potty training. This is obviously a very stressful time for you and your child so I would put it off for a several months, if possible, since stressful times are not conducive to successful potty training. You have to be committed and have good carry-through for a program to work. You need at least 2 solid weeks to be home a lot and be committed to working almost solely on potty training in order to be successful. Also, I would look at the 3 months that follow the start date of your program and avoid planned events like the birth of a sibling.

My child urinates on the potty if I put him on at bath time but never shows interest throughout the day. How can I motivate him to initiate using the potty?

A child is usually trained for urination using a schedule before he starts to initiate using the potty on his own. Another key to potty training is determining what will motivate your child. Choose a reinforcer that your child goes crazy over. "Good job!" usually isn't enough to motivate any child. If your child loves m&m's, only give him this special reinforcement after a successful trip to the potty. Another option is to go to the Dollar Store and fill a bag so your child can pick a toy after each success. I would not recommend using long-term reinforcers for potty training for any child, especially those with autism (for example, "I'll buy you a train set when you go pee on the potty for one week"). Make sure rewards are immediate, tangible and motivating to your child.

My child is 5 but I don't think he has the verbal or cognitive ability to be trained. Are there some cases when potty training is just not feasible?

Azrin and Foxx suggest that by 5 years of age, even severely retarded children (IQ of about 30) can be successfully toilet trained.

Are there books or videos I should get to prepare myself and/or my child?

Yes, there are many books and videos on the subject. My favorite is Once Upon a Potty (for Him or Her). For parents, Toilet Training in Less than a Day by Foxx and Azrin is a great place to start and is available for under $7 at amazon.com. Another great resource is Toilet Training for Children with Severe Handicaps by Dunlap, Koegel and Koegel available for under $5 by calling 304-696-2332. Finally, if you are attempting to train adults or children on the severe end of the spectrum, a good resource is Toilet Training Persons with Developmental Disabilities: A Rapid Program for Day and Nighttime Independent Toileting by Richard Foxx.

Our child has always worn diapers. Should he continue to wear diapers or pull-ups during training?

No. One of the keys to successful toilet training is for the child to wear regular underwear during the day. The child needs to feel wet when they urinate and you need to spot the accident promptly during the training. During the initial weeks of training, if you prefer, the child can wear only underwear (no pants) and a shirt if you are at home. You can get waterproof pants or use a diaper or pull-up to put over underwear if needed when you take the child out. Unless the child wakes up consistently dry, putting a diaper or pull-up on at bedtime is acceptable both in the short term and in the long term since many children with and without autism have nighttime accidents. First thing after waking, the child should be taken to the potty and the diaper removed. Of course, if the child wakes up dry he should receive lots of reinforcement.

OK, I think I'm ready. What are the components of a formal toilet training program?

There are five basic steps as outlined in both the Azrin and Foxx book as well as the one by Dunlap, Koegel, and Koegel. Because of space limitations, I will only briefly describe each step.

1) Extra Drinks: The child should be given salty foods and extra drinks to allow more opportunities for toileting during the training period.

2) Scheduled Toileting: This should happen at least 1-2 times per hour. Tell the child "Time to go to the bathroom/potty?" Have them say or sign "toilet/potty" and take them. The child should be heavily reinforced if he urinates or has a BM. Once the child starts initiating, the schedule should be dropped.

3) Dry Pants Checks: There are 2 purposes for this. One is to allow for detection of accidents. The other is to reward the child for having dry pants. The child should be asked "Are your pants dry?" These dry pants checks can be done at intervals of 5 minutes to an hour depending on the level of success. If you notice an accident, a dry pants check should be done immediately.

4) Positive Practice (or at least a neutral tone) for Accidents: Some toileting experts such as Dr. Richard Foxx suggest that Positive Practice is a very important step in the toilet training process. Positive practice involves taking a child quickly from the spot of the accident to the toilet and back again 5-10 times. For more details on this step, read Toilet Training in Less than a Day by Azrin and Foxx. I usually don't recommend this step initially, especially if the child is larger or if he is in a setting outside the home where the positive practice procedure can be stigmatizing. If you chose not to implement this step of the procedure when you toilet train, make sure you are do not laugh, smile or give your child positive attention after accidents. Have the child participate in the clean up procedure as much as possible and re-direct him or her to a neutral activity.

5) Data Recording: You will need to record all successful trips to the potty as well as urine or BM accidents. This will help indicate the length of time between urination as well as the usual times for BM's. Keeping data will also help you measure the success of you toileting program.

How long will the toilet training process take?

Some children with severe disabilities train completely in a week and some take months. If your child regresses and starts having accidents after being trained, start implementing the steps of the formal program to get him back on track. Some children and adults with disabilities who are very difficult to toilet train or who regress with toileting need a toileting plan developed and coordinated by a medical practitioner or behavior analyst. Don't be afraid to seek assistance from a qualified professional if you are having difficulties with toileting.

For more information on potty training, read Chapter 11 of my book: The Verbal Behavior Approach: How to Teach Children with Autism and Related Disorders. The information in this paper is not intended to serve as professional advice nor as a substitute for consultation with medical and behavioral professionals.