April / May / June • Issue 2 • 2019
Toilet Training Among Young Children with
Autism: What is OT’s role?
Adaptive behavior is defined as the necessary skills
to “effectively and independently care for oneself,
respond to others, and meet environmental demands
at home, school, work, and in the community”
(Harrison & Oakland, 2015, p.1). Adaptive behavior
constitutes so many skills! What is foremost with this
definition, however, is the ability to independently
care for oneself. As occupational therapists who work
with children in clinics, schools, and communities,
we wonder how we can better focus on independence.
Like many of you, we work with families of children
with developmental conditions, including autism
spectrum disorder (ASD), and many parents are
concerned about their children’s independence,
particularly related to toilet training. Research shows
when children are independent in toilet training,
they have more opportunities for participation
(Richardson, 2016; Kroeger & Sorensen-Burnworth,
2009; Cicero & Pfadt, 2002). Parents tell us they want
their children to attend after school care, summer
camps, or dance classes. Their children, however, are
ineligible from such programs that would offer social
communication, friendship, or physical and leisure
occupation opportunities because they are not toilet
trained. When we focus on toilet training for young
children with developmental conditions, we are not
only working on self-care skills. We are opening doors
for participation across various contexts that will allow
children opportunities to practice skills that have
cascading effects on development. While many of us
may not be elated to work on toilet training (it can
be challenging and messy), we have the opportunity
to positively impact a child’s development across his
or her life. This is a critical need we must address to
support parents and their children.
Toilet training for children with ASD is
complicated by the presence of gastrointestinal (GI)
symptoms and differences in eating patterns. The
prevalence of GI issues (e.g., constipation, diarrhea)
present in up to 70% children with ASD; also, 67-
83% of parents report mealtime and eating difficulties
(Marí-Bauset et al., 2014). Since our food and liquid
intake effects our toileting behaviors, GI issues and
eating behaviors can make toilet training, especially
bowel movement training, more challenging. When
beginning a toilet training intervention for children,
be sure to understand any GI symptoms a child
is experiencing; behavioral interventions may be
most effective when complemented with medical
interventions (e.g., laxative therapy, pre- or pro-
biotics). Additionally, while research is scarce, some
studies suggest that the average amount of time for
children with ASD to reach toilet training with urine
is 1.6 years; for bowel movement training, the time
is 2.1 years (Davlrymple & Ruble, 1992). Children
and parents need support during this extended time,
because consistency and repetition is vital for toilet
training.
Successful toilet training is described as mastery
over two domains: 1) continence (i.e., the child
must learn to recognize the sensation of and for
elimination); and 2) the entire chain of behaviors
that accompany using the bathroom (i.e., managing
clothing, wiping, redressing, flushing, and washing
hands); (Kroeger & Sorensen-Burnworth, 2009).
Mastery in each domain is not a prerequisite for
beginning toilet training; as occupational therapists,
we are experts in task analysis. Therefore, we can break
down the specific components of toilet training and
work with children within each discrete activity. See
Table 1 for examples of how to break down domains
of toilet training and provide specific strategies within
each domain.
In Mary Reilly’s 1962’s Eleanor Clarke Slagle
lecture, she asked “Is occupational therapy a
sufficiently vital and unique service for medicine to
support and for society to reward?” (p.5). We would
pose this question to the occupational therapists
that work with young children across contexts.
What is your vital role in schools? What is your vital
role in early intervention? Let’s continue to be the
professionals that truly focus on independence and
Lauren M. Little, PhD, OTR/L
Anna Wallisch, PhD, OTR/L
Samantha Souza, OTD Student
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