Toilet Training and Autism
A look at some study data, and how Hot Wheels helped us get to that milestone with our boy
Toilet training can be a rough road for any child (and the parents), but children on the autism spectrum may need more time to get the hang of it than other kids.
Back in 1968, researchers from Johns Hopkins University (Oppel, et al.) carried out an influential 12-year study on toilet training with 859 children that were not diagnosed with any particular delays [1]. Among many other things, they reported that 95% of kids from the general poppulation achieved “daytime dryness” by 5 years of age. Other studies have reported that the majority of typically developing children reach some version of that milestone by age 3 [2,3].
Following a similar research methodology that was used in the 1968 study, a group from the University of Houston (Faulkner, et al.) put out a 2017 study that focused specifically on children with autism. In comparison, they reported that about 79% of children with autism were able to achieve daytime dryness by age 5 [4]. Their study included data from 583 children that met specified criteria for autism spectrum disorder, and it was based on information collected from interviews with parents over time. Below, I’ve graphed the reported results for ages 3 through 12:
Earlier studies on toilet training and autism seem to align with these results. In a 1992 study out of Indiana University (Dalrymple and Ruble), the mean age that toilet training was reportedly achieved in kids with autism was 3.8 years for urination, and 4.7 years for bowel movements [5,6]. This was based on survey data from 100 participants.
It should be noted of course, that autistic or not, every kid is on their own developmental trajectory. As individuals they will be ready to take on certain challenges sooner or later than other kids, and so looking for cues that they are ready is probably more important than looking at charts and data. As with anyone else, our experience toilet training has been a unique journey and therefore maybe not a useful model for anyone else. But for what it’s worth, I’ll share a bit about how we approached it.
We came to realize that our child is on the autism spectrum around the time he turned 2. He is very limited in his communication, so in our case we couldn’t rely on him to verbalize when he needed to go potty. But at almost 4 years of age he started to show more awareness of his diaper filling up, sometimes taking it off when it got heavy or taking it off to poo. He has a really good BCBA (board-certified behavior analyst/ABA therapist) who has toilet trained dozens of kids with special needs, and thankfully she noticed these cues and was there to give us the encouragement we needed to take on this challenge when our child was ready. At home, we tried to continue the approach she was taking with him each day in the clinic.
We had to be creative and persistent in how we communicated what we wanted our boy to do with the potty. Our basic strategy at first was to periodically get him to sit on the potty chair for as long as possible. So that meant letting him play his iPad games, watch cartoons, look at a favorite picture book, eat snacks — whatever it took to keep his bum on the chair. And then we waited….until inevitably he had to pee or poo. And when he did, he got big cheers and a reward. Rinse and repeat.
At the beginning, we did this frequently — several times an hour even. It was fortunate that I was working from home at the time (due to the pandemic) so that between Zoom meetings, I could help with many potty sessions and false alarms.
If there is one thing that our boy has always loved, it’s cars, trucks, and especially tractors. So we used that as our reward system. We loaded up on cheap Hot Wheels and Matchbox cars from Walmart, and every time he went pee or poo in the potty chair, he got to open a new car. He picked up on the idea quickly, and his collection of Hot Wheels exploded as he was eventually getting rewarded several times a day. He then got bored of opening Hot Wheels (or, “satiated” as our BCBA would say), but thankfully continued using the toilet without the reward.
Early on in this process, we switched from diapers to underpants during the daytime when he was at home or at his clinic. This was a big leap of faith for me. After a few accidents though, he quickly picked up on the idea that wetting his underwear is not the same as wetting a diaper, and he learned to hold it in. We also switched from a potty chair to a toddler toilet seat along the way.
By age 4.5 our boy would routinely use the toilet all on his own, and he could control his bladder and bowels fairly well. Sometimes while being intently focused on his playtime, he’ll suddenly realize he needs to pee and then he’ll dramatically scream and run to the bathroom to take care of business. Now at the age of 5, we’ve had some success letting him go to bed without a diaper too.
One less obvious thing we’ve done to help this process is make sure that he is getting fiber, because toilet training is hard enough without constipation getting in the way. Since our child won’t eat many whole fruits or vegetables, we’ve been feeding him a smoothie-type blend with fruits, vegetables, and oat fiber every morning since he was about 2 (it doesn’t taste too bad, really).
An unusual thing about our child’s experience was that he learned to use the toilet for pooping before he started using it to go pee.
There have been moments of regression that we’ve had to work through. For instance, a period of pooping next to the toilet (instead of inside it), although he knew better.
In any case, we’re very proud of the progress our boy has made, and I’m glad we didn’t underestimate his ability to wear Toy Story underpants despite his developmental delays.
- ppel WC, Harper PA, Rider RV. The age of attaining bladder control. Pediatrics. 1968;42(4):614–626.
- Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods, clinical interventions, and recommendations. Pediatrics. 1999;103(6 pt 2):1359–1361.
- Blum NJ, Taubman B, Nemeth N. Why is toilet training occurring at older ages? A study of factors associated with later training. J Pediatr. 2004;145(1):107–111.
- Faulkner VJ, Schanding T, Fan W, Harris GE. Individuals with autism spectrum disorder: a study of the age of attaining daytime dryness. Consultant. 2017;57(7):394–398.
- Dalrymple NJ, and Ruble LA (1992). Toilet training and behaviors of people with autism: Parent views. J. Autism Dev. Disord. 22: 265–275.
- Williams G, Oliver JM, Allard A, et al. Autism and Associated Medical and Familial Factors: A Case Control Study. Journal of Developmental and Physical Disabilities 15, 335–349 (2003).
Robert Lawrence writes about science and data visualization. You can find his published work at: www.robertlawrencephd.com
