Toilet Skills in children with special needs: Personal hygiene and activities of daily living

Toilet training is extremely important and children with autism might need extra support and aid to develop toilet skills. They make take longer due to certain concerns, such as:

1. Sensory Processing differences: Bathrooms can be scary for children, and the added sensitivity towards bright lights, the noise of water and or the flush, the temperature of water can further make it difficult to participate and engage in the activity. Addressing these concerns can help make the child comfortable and prepared to gradually get used to the toilet training routine.
2. Communication Delays: A major concern in toilet training children with autism is a delay in their communication. 

• Parents can work closely with speech therapists on improving communication skills. The child can be slowly introduced to different means of communication to let the caregivers know that they have to use the toilet. 
• This can be through sign language, using Picture Exchange Communication System (PECS) or simple, short words. 
• Remember, it is important that the same signs, words or phrases are used consistently so as to not confuse the child. 
• These gestures or words should be such that it can also be used in public places and can be easily understood. 
• They should be appreciated for using it when they do so successfully and encouraged to use it each time they would like to use the toilet. 

3. Difficulty in transition: Children with autism often have some difficulty in transitioning from activity to other. Therefore, learning a new skill that is a change from the ‘usual’ may often be overwhelming. Positive reinforcement and constant encouragement can help children slowly participate in the activity.

 Step-by-Step process:

Break down toilet training into simple and sequential steps for gradual and effective learning. Always follow the same sequence. Knowing what to do will motivate children and create a comfortable environment. Going to the toilet can be broken down into simple steps.

1. Going to the toilet, opening the door and closing it behind them. It is important that we remind the child to undress and use the toilet only in privacy. However, if the child is not old enough or not ready, it is important they do not lock the door. 
2.  Undressing: Teach them to undress or lower their pants and underwear. Only after they close the door. Similarly, they should be reminded to pull their pants up or dress up before they open the door. Children should be encouraged to always wear undergarments. Undressing and dressing should be also taught to children as an independent skill. 
3. Dress the child in comfortable and easily removable clothing such as pants or skirts with elastic waistbands.
4. Using the toilet: The child should be taught to squat or sit on the toilet. Initially, they can be asked to sit in front of the toilet before they are confident enough to sit on one. While squatting, help can be offered by holding the child by the shoulders and standing next to the child for support. Once the child gains confidence, this help can be decreased. To make the child more comfortable, start by using a toilet training seat on the toilet. Toilet seats with railings on both sides can also be helpful.
5. Cleaning: Cleaning should be explained to the children as an important part of the toilet training. Initially, parents can start by physically assisting them. To overcome the sensitivity of the loud sounds of the flush, explain to the child about the importance of flushing the toilet. They can also practice flushing other times of the day as well, this can help desensitise them towards the loud sounds. If there is no flush or if it is easier, teach them to empty buckets of water into the toilet, instead.
6. Washing Hands: Guide the child through the steps of washing their hands. Follow the same order each time. 
   • Open the tap and wet palms
   • Take the soap and lather it onto the hands
   • Wash hands thoroughly to rinse off any soap, close the tap
   • Dry the hands on a towel

Customized teaching:

Each child learns differently and it’s important to choose the method that suits your child’s preferences. 

• Since many children with autism learn visually, using visual aids helps them learn faster.
• A visual schedule or PECS can be used demonstrating the steps involved. It can be placed on a wall close to the toilet to remind the child of the steps. 
• Going through the visual schedule at other times of the day helps establish consistency. 
• Similarly, video modelling can also be used by playing videos on toilet training during the day.

Follow a routine:

Be consistent and have a regular routine. Predictability helps the child to understand the activity and what can be expected.

• Follow a strict routine even on weekends and holidays.
• Ensure all members who are involved in toilet training follow the same routine. This holds good even for teachers or helpers if the child attends school regularly.
• If any additional materials are needed like the potty seat etc., it is a good idea to have a spare at the school as well. 
• Observe for particular times when the child is most likely to use the toilet and make it a practice to go there at those set times. 

Forming strong habits will be effective in teaching the child.

Positive reinforcement: 

Praise and encourage progress to build confidence and motivation in the child.

• It is important to acknowledge and praise the child as they start using the toilet.
• Even indicating that they want to use the toilet, sitting them for a few minutes initially should be positively reinforced. This encourages the child to gradually follow the toileting routine.
• Even if they have an accident, positively reinforcing any use of the toilet and continuing with the remaining routine can be effective.

Positive reinforcement can be in form such as verbally praising the child, offering their favourite toy or snack or even a preferred activity.

Toilet train without punishment:

As the child learns and masters the skill, there are bound to be a few accidents. It is important to ignore these accidents and to not scold or punish the child. This will act as a major deterrent in the learning process. In case of a toileting accident, it can be effective to ignore the accident and remind the child of the routine calmly.

You may also seek tips from Ms. Snehal Vaidya, Occupational Therapist about activities of daily living.

The Jai Vakeel Foundation has helped us compile a step-by-step process to help in understanding toilet skills in children with special needs.

Do you want to teach your child bathing skills as well? Refer to the link here to learn.

If you have questions about Autism, Down Syndrome, ADHD, or other Intellectual Disabilities, or have concerns about developmental delays in a child, the Nayi Disha team is here to help. For any questions or queries, please contact our FREE Helpline at 844-844-8996. You can call or what’s app us.

DISCLAIMER: Please note that this guide is for information purposes only. Please consult a qualified health practitioner for proper guidance.