1. Toilet Training Tips for your Child with Special Needs Lori Warner, PhD, BCBA Director, HOPE Center Jamie McGillivary MS, LLP, BCBA Clinical Manager, HOPE Center Veronica J. McAtee, MS, LLP, BCBA Limited License Psychologist Board Certified Behavior Analyst Center for Human Development Beaumont Children’s Hospital

2. When do I start training?  Average age = 18-24 months  Key signals: The child is aware that his/her diaper is soiled and may request to be changed The child shows an interest in using the toilet The child’s bladder muscles are developed enough to hold urine (remain dry for at least 1 ½ to 2 hours) The child can communicate his/her needs (verbally or nonverbally) The child can follow simple instructions and assist in dressing The parent/caregiver has time to devote to training

3. Preparation  Use the bathroom for all toileting activities  Watch videos and read books about toilet training  Allow the child to watch parents/siblings using the toilet  Use a doll to model the toileting process  Use words that the child understands  Practice sitting on the toilet; provide praise

4. Beginning Training  This is a learning experience that requires practice and may take time  Consistency is important!  Dress the child in loose clothes; have the child pull up/down pants  Goodbye diapers!  Select rewards for the child (may need to be more than praise)

5. Materials Needed for Training  Potty seat that fits over toilet  Foot stool  Timer  Data on urination (taken week before)  Multiple pairs of underwear  Favorite drinks and snacks  Rewards, Rewards, Rewards!

6. Rewards – why do we use them?  Increase the likelihood that the behavior will occur again  Rewards are fun!  Child should be rewarded for all appropriate toileting behavior Pulling up/down pants Walking to toilet independently Recognizing the need to use the toilet Remaining dry in between sittings

7. How to select rewards  Observe your child during free time  Limit access to preferred foods/toys to increase motivation  Start with powerful rewards – not just stickers!  What is motivating one minute, may not be the next  When starting training rewards will be delivered frequently  Rewards are faded as the child is successful

8. Intensive Toilet Training Toilet Learning Center (TLC)  Increase fluids  Scheduled sits: Example: child sits on the toilet for 10 minutes then given a 5 minute break for the first hour (or until urination)  Child is prompted to do all steps; increase independence  When the child urinates in the toilet s/he is rewarded with access to toys and highly preferred food items; takes a break from sitting

9. Intensive Toilet Training Toilet Learning Clinic (TLC)  Time spent on the toilet is decreased until the child urinates quickly after sitting  Break time is increased  Child wears pants alarm, goes off as soon as child urinates in pants  Consistent Procedure for accidents

10. Accidents – Uh Oh!  Remain calm & neutral! Do not punish the child!  Try to get the child to the toilet to finish  Tell the child “Uh-oh! Wet pants. You go on the potty.” (Use words he/she understands)  Practice going to the toilet, pulling down pants, and sitting (“This is where you go potty”)  Include child in clean up and have him/her change into clean pants  Have a schedule (after meals, before school) so that the child learns to use the toilet frequently, may also consider using pants alarm

11. How do I train my child to use the toilet? (Less intensive approach)  Take data to ensure that your child is ready to begin training  Put your child on the toilet at times when he/she typically urinates  Have the child do the steps on his/her own  In the beginning stages, the child may need to sit for up to 5 minutes; provide praise for sitting on the toilet, use timer if necessary  Sittings should take place every 30 minutes to increase success

12. How do I train my child to use the toilet? (Less intensive training)  As training progresses, sittings should be spaced further apart  Take data on each sitting so you know when the next one takes place (increase amount of time if child urinates in toilet)  Reward the child when he/she urinates in toilet!!

13. Bowel Movements  Determine times when the child is most likely to have a bowel movement (look at data)  Watch for signals  Put the child on the toilet as soon as you detect these signals  Provide a reward for eliminating on the toilet  Scheduled sits for a longer amount of time  Larger rewards  Positive practice for accidents  Social stories/de-sensitization

14. Initiation Training  An important part of toilet training at all times  Child should be prompted to request to use the toilet before being taken to the toilet ASL, PECS, vocal, typing  Requesting to use the toilet is often not motivating for children; may need additional rewards  Some children continue to require prompts to request and it may take awhile for the child to initiate  Some children may be trained on a schedule

15. Rewarding Dry Pants  Once the child has learned to urinate in the toilet and is doing so on a fairly regular basis, the training is not over!  Check for dry pants in between toileting times (about 6-7 per day)  Reward the child for remaining dry – let the child know why it’s important to stay dry

16. Rewards  In the beginning of training, rewards should be frequent and strong enough to maintain the behavior – this will speed up the training  As the child is using the toilet regularly, rewards for going on the potty should be faded and the child should be rewarded for remaining dry  A daily chart may be used to track progress; child can work towards bigger reward

17. Nighttime Training  This may happen at the same time if the child is already remaining dry at night  Cut liquids by 6:00 pm (or 2 hours before bed)  Have a bed time routine that includes going potty  As soon as the child wakes up, have him/her use the toilet  Reward dry nights

18. This isn’t working!  My child does not want to use the potty Is she/he ready? Are you ready to work on training? Can you be consistent? First step is to practice sitting on the potty (don’t require urination); reward all potty related activities Gradually work up to training Are rewards strong enough? Are you delivering them frequently?

19. This isn’t working!  My child has too many accidents Are you putting him/her on the potty at the right times? Take data on sittings and if he/she urinated; helps you start the sitting at the correct time Put the child on the potty frequently (every 15 minutes) until he/she urinates Is your child in diapers? Are you checking for dry pants and rewarding? Are rewards strong enough?

20. Bed-wetting  Common during training time  Some causes The bladder is not developed enough to hold urine The child is not able to awake in response to a full bladder  Could be due to stress or changes in life (especially if the child used to remain dry)  Could be due to a medical problem or side effect of medications

21. Bed-wetting  Cut fluids at night  Have the child use the toilet before bed  Consider waking the child to have him/her use the toilet (1 - 2 hours after going to sleep)  Use an alarm to condition the response of awakening to a full bladder Alarm senses wetness and goes off to alert the child to awake and use the bathroom  Overcorrection procedure  Rewards when the child wakes up dry

22. Summary  Toilet training is not easy  It takes time, effort, consistency, and most of all…patience!  Do not be afraid to get help  Remember that it is a learning process; it doesn’t just happen  Parents need to make sure that they are prepared to begin training

23. Resources  Toilet Training in Less Than a Day by Nathan H. Azrin, Ph.D. and Richard M. Foxx, Ph.D.  Self Help Skills for People with Autism: A Systematic Teaching Approach by Stephen R. Anderson  Steps to Independence by Bruce Baker & Alan Brightman  Materials: www.bedwetting.com www.pottytrainingsolutions.com

24. Contact information  HOPE Center 1695 W. 12 Mile Road Suite 110 Berkley, MI 48072 (248) 691-4772 https://www.beaumonthospitals.com/hope  Dr. Lori Warner, Director HOPE Center (248) 691-4774