Do you have some strategies to help us maintain toilet training when we travel with our 10-year-old who has autism? There’s no problem remembering to use the bathroom at home and school. But we still need a diaper when we travel or otherwise disrupt our usual routine.
Editor’s note: The following information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional and/or behavioral therapist.
Today’s “Got Questions?” answer is by psychologist and behavior analyst Daniel W. Mruzek, of the University of Rochester Medical Center. The medical center is one of 14 sites in the Autism Speaks Autism Treatment Network.
That’s an outstanding question that's especially timely as we enter the season for holiday travel. In particular, your question highlights a common consideration for children with autism – the variability of skilled behavior across time and settings. This includes the “on again, off again” nature of learned skills, even those that seem to be well established.
One principle to remember – for all of us – is that knowing is not the same as doing. For example, I can plainly state the key attributes of a great golf swing. However, as my sons are happy to attest, I regularly sail golf balls into nearby woods, ponds and even behind me. Of course, on other occasions, I hit the ball straight down the fairway.
“Why can’t I do that every time?” That’s variability.
This notion of “variability” is likewise a key consideration in toilet training. Children can learn the necessary skills: recognizing the need to go, sitting on the toilet, etc. But they may still commonly fail to use these skills at the right times.
This seems to be particularly true for two groups of children:
1) Those who have recently learned the skill of toileting but for whom it’s still not yet an established habit
2) Those for whom toilet accidents are a longstanding and recurring problem.
You child sounds like he falls into the second group. It includes kids who “know” the toileting routine and use the toilet with few or no accidents for days, weeks or even months at a time. Then they have periods when, for any number of reasons, they fall back into a pattern of accidents.
Some of these reasons include an illness, a period of increased anxiety or, as you describe, a disruption in regular routine.
Here are five strategies and a special consideration that may help:
#1 Practice visiting public restrooms
Toileting is a skill that’s prone to becoming what behavior analysts refer to as “stimulus bound.” In essence, this means that the probability of success increases in familiar settings and circumstances. Coaches refer to this as the “home field advantage.”
The key to expanding the home field advantage is to use skills in a variety of settings. So in preparing for an upcoming vacation, I suggest that you encourage your child to use different public restrooms. This can be during day outings such as going to the library, grocery store, etc.
As with all toileting routines, keep these practice trips “low stress.” Be sure to reward efforts with praise and compliments.
By the way, I suggest encouraging your child to drink water or another healthy beverage before or during these practice trips to increase the likelihood of needing to use a public toilet.
The goal here is to promote “generalization” of toileting skills across settings. Generalization of a skill doesn’t necessarily happen spontaneously. We need opportunities for practice.
#2 Provide positive reinforcement
Be generous with positive reinforcement immediately after your child uses a toilet outside of home and school. Complement your praise with a favorite treat or activity. It’s a powerful way to teach a new behavior.
You can gradually decrease and drop (“fade”) these rewards as your child becomes more reliable with using the bathroom in new situations. I suggest that you continue using praise to maintain the toileting behavior.
In general, I encourage you to look for instances of successful behavior to celebrate with your child. This can include remaining dry, using a public restroom or otherwise following a vacation schedule. Here are some techniques for doing so:
#3 Consider visual supports
On your next vacation, it may be helpful to use a visual support such as a schedule board with bathroom breaks listed or “First-Then” boards (e.g., “First bathroom, then trip to the restaurant”). Still other visual supports can include photographs or icons that prompt your child to think about taking a bathroom break.
Learn more about visual supports and download theAutism Speaks ATN/AIR-P Visual Supports Tool Kit here.
#4 Use prompts, but try not to nag
Establish a simple routine for prompting your child to stop and consider whether it’s time to go to the bathroom. Of course, you might just ask. (e.g., “Do you need to go now?”) But in the interest of privacy, you may want to simply use a gesture or point to a designated symbol on a communication board.
Try to avoid doing what many of us parents (myself included) do too often: nag or dwell on the negative, in this case accidents. Instead, provide brief, direct prompts in as few words as possible.
#5 Schedule bathroom breaks
When on vacation – or during other changes in the usual routine – set aside time for bathroom use. I suggest doing this in two ways:
1) A daily schedule of bathroom breaks – for example, after breakfast, lunch, etc.
2) Visiting the bathroom immediately prior to fun activities. For example, before going to the pool or beach.
Special considerations around public bathrooms
When it comes to using public bathrooms, I suggest the additional consideration that there may be something stressful about this environment for your child. In fact, many children with autism have anxiety about specific aspects of public bathrooms. The unexpected noise of an automatically flushing toilet comes to mind!
If you sense your child has related apprehensions, I recommend providing supports such as ear plugs or a calm warning about what to expect.
Additionally, a psychologist or occupational therapist may be able to work with you and your child to identify and address such sources of anxiety.
Second, when despite your best efforts, your child has an accident, react with as little fanfare and conversation as possible. Encourage a prompt changing of clothes in a matter-of-fact tone, with a brief reminder of your expectations going forward.
But I recommend against focusing on the accident. Keep your attention on celebrating and praising successes.
This certainly isn’t the final word on the subject. I invite others to contribute their ideas, so we can all learn from each other. Meanwhile, I wish you all the best for your upcoming travels.
For more helpful advice, see Autism Speaks’ATN/AIR-P Parent's Guide to Toilet Training in Autism. Follow the title link for free download.