Toilet Training

Toilet training children with autism poses unique problems for parents and professionals. Lack of intervention by specially trained educators can extend their dependence on caregivers. Remaining untrained as they age can inhibit children's independence, limiting future habitation and employment options.

The Autistic Disorder

Toilet training is one of the earliest tasks of the developing child. It is a task for which specific teaching techniques exist which are widely accepted and commonly practiced. When a child is hindered in this task by a developmental disorder, it is necessary to alter the techniques to address his or her specific deficits. This proposal aims to address the challenges involved in the toilet training of autistic children and provide a viable solution. To accomplish this goal, a description of autistic disorder as it is currently defined in the fields of education and psychology will be outlined. A review of the current trends in accepted toilet training methods recommended for typically developing children will follow. These two topics will then be discussed in terms of how the particular traits of autism require special adaptations to these methods. Finally, I will propose a pilot program designed to train parents and caregivers of children with autism to effectively toilet train their children.

Autism is a spectrum disorder, falling under the umbrella of pervasive developmental disorders (American Psychiatric Association, 1994), which is brought on by a dysfunction of the central nervous system. It is usually diagnosed in the first three years of life with noted symptoms occurring as early as 18 months. Traits common to autism include the following three symptoms: impairment of social readiness (Thiemann, Howard & Goldstein, 2001), verbal and nonverbal communication delays and disorders (Pickles, 1996; Sarakoff, Taylor, & Poulson 2001), and stereotypical, repetitive behavior patterns. The more symptoms a child displays, the more severely impaired the child is considered to be. The DSM-IV considers milder cases not meeting every criterion for autism to be pervasive developmental disorder-not otherwise specified. For a child to receive a diagnosis of autism, the three core impairments must be present.

Impaired social interaction can be demonstrated by "the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction." Impaired social interaction can also be regarded as a "failure to develop peer relationships appropriate to developmental level" as well as " a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people" and a "lack of social or emotional reciprocity (American Psychiatric Association, 1994, p. 70)". Often autistic children are happiest when left alone, not seeking out connections with parents or peers. Autistic children may actively avoid interactions with others, straining away to avoid eye contact or being held. An autistic child does not get pleasure, as typically developing children do, from making their parents happy or proud. They may be taught to say, "I did it!" or "Look at me!" but rarely think to do this on their own.

Impairments in communication are demonstrated in autistic children by "a delay in, or total lack of the development of spoken language...marked impairment in the ability to initiate or sustain conversation with others...stereotyped and repetitive use of language or idiosyncratic language...(and) lack of varied, spontaneous make-believe play as well as lack of social imitative play appropriate to developmental level."(American Psychiatric Association, 1994, p. 70) Often autistic children show abnormalities in the use of gestures and other non-verbal communication. With the help of intervention, autistic children may develop some language skills, while others never use verbal communication effectively. Often, their speech patterns do not contain the intonations that are commonly paired with language to convey mood or feeling when speaking, giving their speech a halting quality that can be described as robotic. Some people with autism use augmentative communication devices such as computers or "cheap talk" devices or picture symbols (Capps, Losh & Thurber, 2000).

Autistic children display some form of self-stimulatory behavior which is a repetitive, stereotypical motor or verbal action. Some common examples are hand flapping, rocking, tracking objects with their eyes, spinning, and repetitively waving or twirling objects. Extreme attachment to routines is very common. For example, an autistic child might insist on taking the same route from the kitchen to the bathroom and making the same sounds and gestures each time around. This behavior is described as a "compulsive adherence" to routines and rituals (Capps, Losh & Thurber, 2000). When playing with toys, their actions may seem on the surface to be appropriate but when closer attention is paid, one may notice that they are lining up the same objects over and over or repeating the same action such as picking up a play phone and saying hello repeatedly with no variance in words or behavior.

In addition to the symptoms listed in the DSM-IV, other sources noted that autistic children might demonstrate unusual responses to stimuli. Autistic children may be very sensitive to their environment, such as sounds, the amount of light, smells, etc. Conversely, they may be oblivious to changes in their environment. They can also have very strong reactions to seemingly innocuous objects, songs or visual stimuli (Dettmer, Simpson, Myles, & Ganz 2000).

Autistic children can have extreme difficulty attending to non-preferred activities. They are often constantly moving and may be seen as hyperactive. They can be extremely sensitive to changes in their environment (Copps, Losh & Thurber, 2000). Some children may also engage in self-injurious or aggressive behaviors. They may bite or hit themselves or others as well as engage in head-banging. It is unclear whether this behavior occurs out of frustration, anger or because abnormalities of sensory experience may result in pleasurable stimulation from self-injury. Some autistic children may show an aptitude for certain skills while exhibiting extremely low functionality in other areas, although true autistic "savants" are rare (Hendriks 1998). When all of the characteristics unique to autism are looked at, it is understandable that toilet training would pose particular problems for autistic children.