“I’ve Tried Everything
with Toilet Training,
Now What?”
Strategies for supporting children,
teens and adults with gaining
independence in meeting their
toileting needs
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Parent Training Resources
www.otac.org
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“This is a
one size
does not fit
all
approach
to toileting”
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Step 1: Take a behavioral
approach: Assess
Step 2: Determine
readiness
Step 3: Develop a routine,
add supports, teach skills
Step 4: Celebrate successes,
as this is a process!!
Our Approach to
Toileting!
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• Refuses to sit on toilet
• Screams, cries during
• Doesn’t communicate need
transition
for bathroom
• Resists being cleaned
• Smears/plays with feces
• Goes to bathroom in strange
• Repeated flushing
locations
Look below the surface….
Confusion: Not sure what is expected of him/her
Fear of bathroom related to sensory processing
Seeks ways to meet own sensory needs
Diagnosis i.e. cognitive functioning, development
Communication
Chronic medical conditions
• Pain associated with using the bathroom
• Limited fine/gross motor skills
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Step 1: Assess
“This place
is scary!”
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• Gastro-intestinal issues
i.e. Constipation
• Medication side-effects
(increased thirst,
diarrhea, constipation)
• Food intolerances
Always Rule • Diagnostic factors (e.g.
out Medical!
tethered cord)
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Does your
child have
answers to the
following
questions?
• Where am I going?
• What is expected of me to
do in the bathroom?
• How long will I be in
there?
• How will I know I am
finished in the bathroom?
• What happens next?
– “When do I get to finish my
game?”
• Who will help me in the
bathroom?
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Activity
1. Think about what behaviors you “see” your child
engaging in related to toileting and describe these
above the surface
2. Describe what is going on below the surface that
may be a factor as to why your child is engaging in
the “above the surface” behaviors
Step 2: Determine Readiness
• Does your child?
– Sit and hold their body in an upright position?
– Show basic cooperation with undressing
related to toileting?
– Seem to know what is expected of him/her in
the bathroom?
– Show an interest in behaviors related to the
bathroom routine i.e. hand washing
– Act differently when their clothing or diaper is
soiled/wet?
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Is it really needed?
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Habit Training
This method can be helpful when the person….
• Does not show awareness of the need to go
• No change in behavior if soiled or wet
• Older than six years and other techniques have not been
effective
• Uneven patterns of development and not meeting
chronological age milestones in toileting
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Habit Training: Steps
• Use your data:
– select one time a day that is 5-15 minutes before your
child usually goes to the bathroom
• Increase regular exercise/movement
• Ensure your child is “dry” before starting- if they
are already wet, just wait until the next time
• Keep meal/fluid times as consistent as possible
• Follow a toileting routine
• Once your child successfully goes within 2-3
minutes upon sitting on the toilet for several days
in a row the toilet/void connection has been
established!
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Step 3: Develop Supports
• Set up a routine to help decrease confusion
• Remove barriers from the environment
• Prepare the environment for success and
your own sanity
• Teach skills needed to support independence
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Develop a Routine
• What steps does my child already know?
• Attach toileting to a current routine
– before eating, leaving the house, bedtime
• Use your data!
– Include toileting on your child’s daily schedule at
times when they are most likely to be successful
Eat
Bathroom
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Play
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Tip: Focus on teaching the whole routine
of sequenced behaviors
– check schedule, enter bathroom, undress, sit,
void/BM, wipe, flush, dress, wash/dry hands, exit
bathroom, check schedule
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“Some of the behaviors you might see…..”
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•
•
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•
Fear of the bathroom… (sensory factors)
Difficulty transitioning away from diapers/pull-ups
Urinating/defecating outside of the toilet
Behaviors to meet sensory needs i.e. smearing feces,
flushing
Resistance to using toilet paper/using too much
Needing frequent cues
Difficult transition to/from bathroom
Toileting is not generalized i.e. home/school
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Support Communication
• Object, picture, line drawing, words/sign
• Watch for signs that your child is
communicating the need to use the bathroom
or to be changed
– grabs at clothing
– goes to a specific area of the house
– increased or decreased
movements/vocalizations/distance
• Use transition objects and pair with current
communication methods
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Social Stories
• Used to support and enhance your child’s
understanding of social factors related to
toileting
• Visual way to share information
• Can help to share medical information i.e. risks
of refusing to change soiled diaper/clothes
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Environmental Support Ideas
Add familiar
images of
bathroom signs
at home which
your child will
see in the
community!
Dim the lights
Remove
distracting
items
Avoid flushing
Support
stability while
sitting
Control
temperature of
room/wipes
Support
privacy
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Stress Reducers
• Easy to access clean-up kits for home and the
vehicle (always keep a change of clothes in the car)
• Provide universal precaution kits for caregivers
• Install a bidet attachment to the toilet
• Flushable wipes
• Adaptive clothing
• Waterproof mattresses or mattress pads
• Overstock on towels and washcloths so you don’t
run out in a touch situation
• Waterproof cases for devices if entertainment is
needed for the longer sits
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Desensitization
• Allow your child to sit on the toilet with their
diaper on- slowly overtime cut away the diaper
• Keep lid closed when practicing to sit down
• Have your child touch and hold the toilet paper
or wipe prior to wiping their bottom
• Have your child stand away from toilet when
flushing, say “ready, set, flush”
• If your child is afraid of the bathroom-focus on
being in the environment without placing any
toileting demands
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Skill Development…
“How do I increase the length of time my child will sit
on the toilet?”
• Routine: Count to a specific number, sing or
use a visual timer to show how long to sit
• Keep expectations for sitting short at first
• Place a small table outside over the child’s lap
with toys and other items to keep him/her
entertained
• Place a weighted item on your child’s lap i.e.
rice/bean filled sock, lap pad (sensory)
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Teaching Strategies
• Teach bowel/bladder control:
– Show how to gently apply physical pressure on lower
abdomen to help empty bladder
– Pushing- clench fists, feet up on stool, hunch over
• Use a doll to “model” toileting behaviors if child is
unable to observe the process of others
• Take turns sitting on toilet, use visuals
• Use hand-over-hand to assist your child with
dressing and wiping
• Use “chaining” to support independence within
the toileting routine
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Things to Avoid
• Physically restrict a child’s movement while in the
bathroom i.e. holding them to sit longer on the
toilet
• Responding emotionally if an “accident” occurs
• Loud cheering/applause once the child begins to
void
• Lecturing, scolding or shameful statements i.e.
“only babies where diapers”
• Trying to “push” a child to overcome a fear or
discount the fear
• Avoid excessive increase/decrease of fluid intake
• Avoid rushing steps in the routine!
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Signs that toilet training is a success!
• Your child indicates a need to use the
bathroom
• Accesses the bathroom on their own
without relying on cues from others
• Uses the bathroom in different settings
• You notice a decrease in the amount of
diapers/pull-ups being used
• Increasing skills- no matter how big/small
or how long it takes accomplish it!
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Activity
Look at your list of possible underlying factors and
tips you have learned today. Determine 2 or 3 action
steps and support ideas.
Step 4: Celebrate
successes!!
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References
• Wheeler Maria, M.ED; Toilet Training for
Individuals with Autism or other
Developmental Issues; 2007
• TEACCH-Applying Structured Teaching
Principals to Toilet Training; 2005
• Heffner Gary J.; Toilet Training- Autism
printable article #25; 5/9/2002
• http://www.ninds.nih.gov/disorders/tethe
red_cord/tethered_cord.htm
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