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Toileting support for autistic children
Learning to use the toilet can be a challenge for some autistic children. Even though it is sometimes difficult, nearly all autistic children do become toilet trained.
Read on to learn more about some of the challenges that autistic children may experience when toilet training and how you can support them.
Behaviours and challenges
For each individual child there may be a range of behaviours and difficulties that affect them in different ways including:
- Social communication
- Repetitive behaviours and dealing with change
- Sensory differences
- Intense and highly focused interests
- Extreme anxiety
- Meltdowns and shutdowns
Children communicate their feelings and understanding with their behaviour.
- Try to consider what their behaviour is saying before thinking of solutions.
- Consider the triggers that start their behaviour
- Notice the factors that might make their behaviour continue - these may not be the same as the things that started it.
How these behaviours can impact on toileting
These challenges can affect how your child learns to use the toilet and how they develop reliable continence. There can be implications for children’s social experiences, making friends, and their education.
However, it’s important to remember that some autistic children can learn to use the toilet at the usual time and may not have any problems.
Using an individual toileting programme
For children with behaviours linked to autism an individual toileting programme tailored to their specific needs can be really helpful.
When developing their toileting programme, it’s important to think about the physical factors affecting your child as well as their their individual behaviours so that both these aspects can be included.
Autistic children and toileting problems
The causes of toileting challenges in autistic children include:
- Delayed development
- Difficulties with communication and understanding language
- Confusion around what wee and poo is and where it should go
- Becoming used to going in a nappy and finding change difficult
- Parent/carer may have been advised to delay toilet training, by friends or professionals.
- Lack of an assessment or diagnosis - for some children their difficulties may not yet be fully appreciated or evaluated.
- Sensory problems
- Other problems taking priority
- Underlying physical causes such as constipation, withholding and/or bladder problems
Physical causes of toileting problems
If you are concerned your child's bowel and/or bladder isn't working properly, book an appointment with your GP for an assessment and to discuss your concerns.
Our flowchart for children with additional needs has more information to help you navigate this process. Children with developmental delay may have associated genetic and physical factors that affect their bowel and bladder.
Bowel Problems
Constipation is very common in all children, and it is important to monitor your child’s bowel movements to see if this may be a factor.
Constipation won’t get better on its own – it needs to be treated and treatment needs to be continued to make sure it it doesn’t come back.
Autistic children may become constipated for the following reasons:
- Constipation is common in all children
- Restricted diet
- Restricted fluid intake – most young children do not have a very good awareness of thirst.
- Anxiety linked with poo coming out of their body, often associated with withholding.
- Sensory issues such as difficulty identifying bowel signals that they need a poo (understanding body signals is known as interoception). Other sensory factors are often related to the environment such as toilet sitting on a hard, cold toilet seat, bright lights, and sounds in the toilet and bathroom environment.
- Anxiety in bathrooms and sitting on toilets, so they prefer the security of a nappy.
Once diagnosed and given laxatives, your child may find taking medication every day challenging. They may not like the taste or feel scared of passing loose poos.
Read more about how to help autistic children with constipation.
Bladder problems
Bladder problems may be linked to the following:
- Poor fluid intake which leads to concentrated wee, which can irritate the bladder and cause wetting accidents - use our wee checker to see how diluted your child's wee is.
- Constipation – a bowel full of poo can press on the bladder and cause irritation.
- Withholding wee is often linked to anxiety about bathrooms and using toilets.
- Sensory issues – your child isn’t able to identify a full bladder feeling.
- If your child is nonverbal or has limited verbal skills it will be difficult for them to communicate their needs.
Tips for supporting toilet training
Before you get going with a toileting programme, we would recommend using our bladder and bowel assessment chart to record your child’s bowel and bladder activity for a few days.
This information will be really helpful as you develop a toileting programme and work out timings that will suit your child.
It’s important not to delay toilet training. Children with autism do not like changes so by delaying it may make it more difficult for your child to get used to using potties and toilets.
Here are some top tips to help with toilet training:
- Start early, and help your child get used to being in the bathroom. Learning skills such as sitting on a potty, and washing their hands will help later.
- Reward your child’s effort as much as their success
- Break down the task into easy steps
- Include toileting in your child’s regular daily routines, for example, by going to the toilet 20 minutes after meals, before bedtime and after waking up
- Teach words and signs for toilets and wee and poo, using pictures too.
- Make going to the toilet fun – and not scary!
Things to consider as you design a toilet training programme
One of the most important things to consider is how your child’s sensory issues may affect toilet training. We have lots more information and tips on this and also ways to reduce toilet anxiety, and other stresses.
Help your child to understand toileting and become used to going to the toilet in different places such as nursery, friend’s houses, and public toilets. Remember signs can be different in public toilets and other settings outside your home.
Try to use the same words and language to talk about wee and poo and going to the toilet.
Use our Toileting Social Script and Toileting Visual Schedule as part of the programme.
You can also download this social story created by one of ERIC's Trustees, Dr Eve Fleming, about understanding how children can learn to use the toilet.
If you are a professional working with a child and their family, remember that families and education settings often need regular and ongoing support. It is always helpful to have a clear plan and explanation, with regular reviews of progress.
Behavioural approaches:
- Try to see toileting experiences from your child’s perspective. Help your child to become comfortable in bathrooms and sitting on toilets.
- Think about anxiety and how to reduce this. Children often need a great deal of reassurance, games and songs.
- Keep the toilet experience fun and relaxed. Consider using special fiddle toys, or books to practice sitting on the toilet.
- Check your child’s position on the toilet. Let them use a footstool so their knees are raised, and often leaning forwards. This makes sure the large bowel is at a good angle for emptying.
- Some children may like a toilet seat with padding, or a different shaped toilet seat to feel secure.
- Help your child understand about weeing and pooing in the toilet. Pictures stories and picture cards will help your child to understand how their body works, and where wee and poo comes from.
- Break up the toileting programme into small steps.
Lots of children withhold their poo, by tightening their abdominal and bottom muscles. The triggers for this are constipation and anxiety, and both very common in autistic children.
Look out for signs of straining while your child is sat on the toilet or standing up. Usually, they are not trying to pass their poo, but trying to stop it from coming out. They may cross their legs and lean backwards, making all their muscles become tight to hold the poo in.
Children don’t do this on purpose or to be naughty. Withholding is a learned reaction which usually happens after a child passes a poo which they found uncomfortable or painful.
Get more information about withholding poo and how to support your child so the cycle of holding on can be broken.
For autistic children, it is essential to treat the physical causes of constipation in combination with strategies to help their anxiety. Once their poo is helped to be soft, it is easier to help them relax and let it go. Read more about supporting austistic children with constipation.
Sensory needs
Sensory differences/needs are very common in autistic children and may be linked to distress if your child is upset by too much sensory stimulation.
Anxiety is often a cause of avoidance of toileting, bathrooms and toilets. It’s important to try to find out what makes your child uncomfortable in bathrooms and make adjustments to make the environment feel safer and more comfortable.
Lack of sensation often leads to the child seeking additional sensations to help give adequate feelings and awareness, which are needed to develop toileting skills.
Think about the different sensations and profile of your child. A detailed sensory assessment by an Occupational Therapist may be very helpful for creating a programme that meets your child’s need.
Pausing toilet training
Sometimes if you or your child are so stressed about learning to use the toilet, it can be best to have a pause in toilet training.
It is essential to have a plan to return and continue the toilet training and make sure your child understands too. Explain to them for example: “We will leave toilet training for today and try again next week/month/before Father Christmas comes.”
Older children and teenagers
It is never too late for older children to learn toileting skills. They may need to start from the beginning, but try to include them in working out a programme they can follow.
Look at their individual interests and what motivates them. Children and young people often enjoy the ‘being a scientist’ approach. Encourage your child to keep a record of their bowel and bladder pattern using a chart. It is often a good idea to review how the bowel and bladder are working.
Teenagers often are motivated to make changes to enable them to have other opportunities.
Toileting behaviours
Compliance problems may be linked to number of factors:
- Understanding and communication - different adults may use different words for wee, poo and toilets.
- Instructions may be too complicated
- There may be more fun in continuing playing
- Your child may prefer to do something they are used to
- Your child may have got very skilled at avoiding instructions and requests
- Your child is too worried to do the request at present.
- Your child needs to feel in control.
- Your child may have demand avoidance or PDA. Get more information and help from the Pathological Demand Avoidance Society
Getting used to other toilets:
Adapting to new situations is often difficult for autistic children.
Try to anticipate this by trying to get your child used to using other toilets outside your home from an early age.
Remember toilets and bathrooms have different smells, lighting, and floor surfaces. Children may like the security of walls beside the toilet and find the space of a bathroom difficult to cope with.
They may need to start by visiting and inspecting toilets, and then gradually learn and gain confidence in the steps they need to use the toilets.
Preferring to poo in a nappy
This is very common and there are several reasons why a child will do this.
- It feels more comfortable for your child
- They’ve learnt from birth that this is where their wee and poo goes
- Doing it gets adult attention - grown ups may pull faces when they are cross which are funny
- Your child may get to go in the bath, and enjoy the reward of this
Use our resources to move your child away from using their nappy for poos and towards the toilet or potty.
Bottom wiping
This is another important skill you will need to teach your child.
Here are some tips for bottom wiping:
- Use a picture prompt to remind your child to wipe
- Your child may need to learn how to wipe their bottom; pictures or guiding their hand may help. Often children do know where their anus is
- They may need to learn to wipe other things to gain the skill, such as wiping up jam
- They may need to learn how to twist their body and arms into the right position
- They often need to learn how much paper to use. A line under the toilet roll may be helpful
Constipated poo is sticky and more difficult to wipe. Try using different types of paper, moist toilet roll or wet wipes.
More help
Watch Dr Eve Fleming talk about supporting autistic children with toileting.
Read the National Autistic Society's parents guide to toileting
Read the National Autistic Society's guidance for professionals on austism and toileting
The Pathological Demand Avoidance Society - a charity offering support and information on PDA
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