What should I know about toilet training of children with autism spectrum disorder (ASD)?

Children with autism spectrum disorder (ASD) often have slowed development, may be stuck on their own routines, or may be nervous about learning a new skill. They may not understand how to copy the steps using the toilet, or they may not understand the words parents are using. Many children with ASD may toilet train at a later age than typically developing children.

When are children with ASD ready for toilet training?

Children may be ready for toilet training when they

• Tell a parent or caregiver they need a dry diaper (or bring one to them).
• Go off by themselves to urinate (pee) or have a bowel movement (poop).
• Seem interested when others go to the bathroom.
• Stay dry overnight and for more time.

Being ready may also be linked your child’s developmental and medical challenges. If your child has a developmental delay or has a hard time communicating, he may not be able to tell you when he needs to go to the bathroom, but you may be able to set up a routine to clock train or time train him.

How should I start toilet training?

1. Children with developmental delays may not be fully ready for toilet training, but clock or time training is a good start.

For a few days, keep track of when your child has bowel movements and wet diapers. When you are ready to start clock training, you may want to have your child drink more fluids so that she will need to urinate (pee) more often.

Set up times for your child to sit on the toilet. To avoid accidents, be sure to set up times more often than your child usually wets. For example, if your child has wet diapers every 3 hours, set up a time to sit on the toilet every 2½ hours.

2. To teach your child to sit on the potty, you may need to help her with music, a story, attention, or a favorite toy. Slowly increase the time your child sits on the potty (up to 2 minutes).
3. Your child does not need to urinate (you may call it “peeing” or something else) or have a bowel movement (poop) each time she sits.
4. Your child needs to be able to relax on the toilet to go, so teach sitting as the first step. If your child is sitting on a full-sized toilet, she should put her feet on a stool so that all her muscles can relax. Think about using a special seat with side supports if your child seems shaky.
5. If your child cannot understand your words, use hand signals or pictures to let your child know it’s time to sit on the toilet. It may be helpful to show your child pictures of each step to help her learn: sitting on the toilet, using toilet paper, flushing (unless the noise upsets your child), and handwashing.

Make an activity board with each picture put in order. As each step is finished, you can take the picture off the board or place it into the “finished” section. If your child does not talk much, teach your child a sign or give a picture she can hand to you to show that she needs to use the toilet. This will help her learn to tell you when she needs to go. See the Resources section for a toolkit that has pictures you can use to help your child.

6. When your child urinates (pees) or has a bowel movement (poops) into the toilet, reward her right away with something special that you don’t give other times. Rewards can be an inexpensive grab-bag prize or a favorite toy, treat, or song, plus praise and hugs.

If your child has a bowel movement (poops) between scheduled trips to the potty, she should help put the poop into the toilet and flush it away. Never punish your child for accidents. It may take weeks to months for training to become habit.

7. After clock training is successful, work on teaching your child to tell you when she needs to use the bathroom on her own.

What are some potential roadblocks to toilet training?

• Your child may not like the sound of flushing the toilet. If that happens, flush the toilet later. Be aware that automatic flush toilets may cause sound-sensitive children to not want to use them. You might try covering the sensor with a sticky note to reduce risk of flushing while your child is using the toilet.
• Your child may be sensitive to other feelings that come with the bathroom. If your child doesn’t like the feeling of the tile floor, consider using a small mat or rug. If your child doesn’t like the feeling of the toilet seat, consider using an insert seat.
• Your child may be very active and may not be able to sit on the toilet for very long. If so, try having your child sit for less time, and save his favorite quiet toys or books for the potty. You can also let him listen to calming music to help him relax while he is sitting on the toilet.
• Your child may be able to pee on the potty but won’t poop. He may have hardened stool or be constipated. Ask your child’s pediatrician for ways to help avoid constipation. It also helps “move the process along” if your child exercises a bit before eating. Try sitting your child in a comfortable position on the toilet for up to 5 minutes after meals. Pay attention to when your child normally has a bowel movement to increase the chances of success.
• Your child may not want to have a bowel movement in the bathroom and may choose another place to poop. You can help your child by giving him a small bath mat to stand or sit on when having a bowel movement. Move the mat closer to the bathroom over time. Have your child practice sitting on the toilet at other times so he feels comfortable with it. Even if your child pees or poops in another place, do all cleanup in the bathroom.
• When your child is alone (usually at night or nap time), he may smear his poop. If this happens, have your child help clean up (even if it must be done with your hand over his hand). Remember to wash hands well if you or your child has any contact with the poop. Try not to react in a dramatic way that might encourage the smearing behavior.
• Children who like the feeling of touching poop may benefit from clothing that limits their ability to remove clothes (such as zippered one-piece pajamas placed on backward). You can also use safe toys that they like touching at times when this behavior is most likely to happen.
• Your child may learn that wetting or pooping outside the bathroom gets a strong reaction from adults. Try to respond to accidents without emotion and refer to your picture schedule to guide your child to the appropriate steps. Do all cleanup in the bathroom. Have your child help flush the toilet and wash hands. Praise and reward the behavior you want to see more of.

Resources

Autism Treatment Network, Autism Intervention Research Network on Physical Health. Toilet Training: A Parent’s Guide. New York, NY: Autism Speaks. https://www.autismspeaks.org/sites/default/files/2018-08/Toilet%20Training%20Guide.pdf.

Schaefer CE, DiGeronimo TF. Toilet Training Without Tears. Rev ed. New York, NY: Signet; 1997

Wheeler M. Toilet Training for Individuals With Autism or Other Developmental Issues. 2nd ed. Arlington, TX: Future Horizons; 2007

© 2020 American Academy of Pediatrics. All rights reserved.

 #AAP