Let's Talk About ...... Toilet Training

**** Please note that the advice in this post is based on our personal experience in toilet training children. I do not receive commissions of any kind for any products mentioned in this post.****

Over the last few years on our Autism journey, I've been asked for advice on many different topics. One topic that comes up in conversation on a fairly regular basis, is "do you have any tips for toilet training my child?"

Well, where do I start?!?!?! Working in the early learning industry and toilet training both of my own children, I have used a number of different strategies to toilet train both little superheroes as well as children in my care at work. But let's face it, toilet training any child, regardless of diagnosis or not, can be daunting but toilet training a child who struggles to understand their internal body signals, interoception, can make toilet training that little bit harder.

Before we get into toilet training, I'll recap on interoception for those of you who haven't heard if it before now. Interoception is one of our hidden senses and it consists of all of the internal sensations that we feel on a daily basis - including when we need to go to the bathroom. For children on the spectrum, interoception can play a big factor in struggles with toilet training.

Children who have been diagnosed with Autism Spectrum disorder may struggle with toilet training for a myriad of reasons. Their sense of interoception may still be developing and even though their body is sending all the signals that they need to go to the bathroom, they may not be able to correctly interpret these signals. Children whose communication skills are still developing may not have the skills to verbally tell you that they need to go to the bathroom. They may also lack the motor skills - both fine and gross motor - to physically use the toilet.

So what tips can I pass onto you, the reader, on teaching your child, or perhaps a child in your care, to use the toilet?

First things first, the key to toilet training of any child is patience. Depending on the child's skill and developmental level, toilet training can take some time. Be patient and calm - children pick up on this in us. If we are patient and calm, then we can assist the child to be calm. Toilet training is a big skill for any child to learn. For some children, physically sitting on a toilet can be nerve wrecking.

You also need to ensure that your child is showing signs of being ready to toilet train. These could include -

• Indicating to you that their nappy is wet or soiled - they may try to take the nappy off or they may vocalize or sign to you that their nappy is dirty.
• Your child may physically take you to where the clean nappies are stored or they may go and get a clean nappy themselves.
• Your child may be staying dry most nights while they are sleeping - this indicates that their bladder and bowel control is developing.
• They take more of an interest in the toilet.

We began toilet training both little superheroes when they started to show signs of being ready. O was relatively easy to toilet train, but in saying that she was toilet trained at day care long before she was at home.

With O we used a book called "Stress Free Potty Training." At the beginning of the book, the reader does a quick questionnaire about the personality type their child and then based on the child's personality, the book is broken down into tips for each personality. When I initially read the section based on O's personality type (she was a child who would master a skill and then not do the skill again,) I said to my husband that the book could have been written specifically about O! We were then able to toilet train O very successfully and quite quickly.

With L, however, toilet training didn't come naturally to him and for a long time we really struggled. At times, L showed an interest in that he would sign to us that he needed to be changed or he'd simply take his own nappy off but we really struggled to toilet train him, and at other times he showed no interest at all.

It was really only after he started early intervention therapy and his therapists gave us some tips and tricks of the trade, that we were able to properly begin toilet training with L.

So what did we do? Well....


We had to build L's confidence up in using the toilet. To begin with we'd simply get L to sit on the toilet (with the lid down) fully clothed, just to get him to feel comfortable. We read stories about going to the toilet - one of his favourite books was a book with the Sesame Street characters in it. We'd read this book to L while he was sitting on the toilet. One of the reasons that I think L loved this book is that the final page was interactive - he was able to flush the toilet on the last page by pulling a lever down! We'd read the book and then he'd play with the last page over and over again!

We were made aware of the fact that L's sense of interoception was probably still developing which could account for him lacking the ability to tell us when he needed to go. Whenever either myself or Daddy Superhero needed to use the bathroom, we'd encourage L to try too. We'd let him know that "my tummy feels a bit sore, maybe I need to go to the toilet," in the hope that he would begin to recognise his internal feelings. L watched us many times when either of us went to the toilet!!

L's therapists at the early intervention centre created social stories for Lachlan about using the toilet. These were personalised with photos of Lachlan in the bathroom - flushing the toilet, sitting on the toilet and so on. We also had social stories about washing hands.

We put up visuals in the bathroom on the steps involved in going to the toilet and washing hands after using the toilet. We still use these visuals just as a reminder of the steps involved as occasionally L still forgets the steps. It's not a case of L being lazy, his executive functioning skills are developing so he genuinely forgets and just needs a visual to prompt him.

Whenever we were encouraging L to use the toilet, we'd say the word "toilet" and sign the word as well. Initially L was non verbal, so by learning the key word sign for toilet, he had a means of communicating to us that he needed to use the toilet.

We incorporated L's intense interest of superheroes into toilet training. Every skill that L has learnt, his superhero figurines have been there every step of the way, including sitting on the toilet. This was a huge motivator for L - if his superheroes could sit on the toilet, then he was keen to do it too!

Initially we kept a record of when L was soiling and wetting his nappy and/or clothes. When we established the times that he would generally soil or wet himself, we'd encourage him to use the toilet at roughly around those times.

We would also use a specific phrase once L was sitting on the toilet, something along the lines of "L, wees and poos go in the toilet," so that he began to understand why he was sitting on the toilet.

L likes to be in control of what is happening around him so we'd give him choices based on an outcome that we wanted. We wanted him to use the toilet so we would ask questions like "Who would you like to take you to the toilet? Mummy or Daddy?" or "Which toilet would you like to use?" Questions along these lines made him feel like he was in control. If we ever asked him "Do you want to go to the toilet?" the answer was always no!

We'd also give L a visual countdown of when he'd need to go to the toilet - we'd also let him know that in five minutes it was time to go to the toilet. This certainly helped as without a countdown, he'd become quite distressed.

Other tips that could be useful ....

• You could encourage your child to simply sit, fully clothed on the toilet and praise your child if and when they do. Start off with a small amount of time and work up to longer periods.
• Some children find the noise of the toilet flushing overwhelming - so initially, simply get them to be in the vicinity of the toilet when you flush it and work up to your child flushing the toilet. Again praise them if this is successful along every step of the way.
• Your child may have difficulty in dressing and undressing themselves so they may need your assistance in this.
• Some children may respond to reward charts - a stamp or sticker each time that they use the toilet and a reward once they get a certain number of stickers. We did try sticker charts and other rewards with both little superheroes, but neither were interested. They loved getting the sticker but it didn't help in any way with toilet training.
• Once you begin toilet training, you can encourage your child to go to the toilet every 45 minutes or so. Some children respond to this, others can be quite resistant.

And finally, if you begin toilet training your child and have no luck, stop and try again in a month or so. It could be that your child simply is not ready. Have a break from toilet training, for both of you, and try again at a later date.

Introducing Ulla! A water hydration system.

*** Please note that I do not receive commissions of any description for this review. It is simply a product that we have found incredibly useful. ***

As I have mentioned in numerous posts on previous occasions, we have always struggled to get O to drink water on a more regular basis. Through talking with her previous therapist in Perth we now know that the struggles that we had are in part due to her sense of interoception still developing.

When we first met with O's therapy team one of the managers, thank you Bianca, mentioned to us about a gadget that you could place onto a water bottle to help you to remember to drink water.

Well, I couldn't get home fast home to research this gadget.

The name of the gadget is Ulla and as their website states Ulla is a smart attachment that fits on any water bottle (plastic or glass) via a silicone band that fits around the bottle. Ulla itself is a small tear dropped shaped object that clips onto the band. Ulla comes in a range of colours and designs depending on where you order it from. The US website does have a larger range of designs than the Australian website.

The Ulla works by following an optimal hydration cycle of 40 minutes. Every time you take a drink from your bottle, or glass, Ulla blinks as it detects when the drink bottle is tilted. After 40 minutes if you haven't taken a drink, Ulla will start to blink madly at you.

When I started reading about Ulla, I immediately knew that this was exactly the type of reminder that we have been searching for for O. Ulla is discrete and would blend in with the drink bottles that O likes to use. Ulla doesn't make any noise so it wouldn't be distracting to O or to her classmates. It sounded perfect. And Ulla is powered by a battery that is replaceable - even better!

The first one that I purchased, I used myself at work just to check that it was in fact useful. Hooley dooley, I don't think that I have drunk that much water in one day - the flashing reminder was definitely useful.

Our first Ulla arrived on a Thursday afternoon and I used it on the Friday. The weekend that followed, O bugged me for the entire weekend to put Ulla onto her drink bottle - "When can I use it? Huh? Huh? Mum? Mum? When? Please?" She was super excited to start using it straight away.

I am happy to report that Ulla is paying for itself in the consumption of water that O is going through. Since putting Ulla onto O's water bottle, we've not had one day where she has not drunk enough water. Touch wood, she hasn't become dehydrated once since putting the Ulla on her water bottle.

I found Ulla so useful that I purchased another one for myself to use. It is such a great reminder and it is a product that I would happily recommend to others, especially children, who are struggling to remember to drink enough water throughout the day.

So where can I get an Ulla for myself I hear you ask? Well ....

They are available from Axon Australia and direct from their website. Just don't do what I did the second time  I ordered an Ulla - I didn't realise that I had ordered from the US website and was becoming quite cranky when Ulla took about a month to arrive. Oops! Note to self - check where you order it through!

The Hidden Sense of Interoception

One of the things that I have learnt on our Autism journey thus far is that you never stop learning. Never!

Since O started her therapy sessions we have begun yet another learning journey.

But before I get onto the topic of this post, there is some background information that you need to know about first, otherwise you may become slightly confused.

Ever since O started Kindy, we have always struggled to get her to drink water regularly, eat her recess and lunch at school and go to the bathroom on a more regular basis.

I am sure that she has a hidden camel hump somewhere, as on some days she will rarely drink water during the day but then she loads up in the afternoon and evening. I also wonder if she has a bladder of steel as this little superhero can hold on for a very, very long time!

We've always put these struggles that we have down to O just simply being too busy at school or simply forgetting. Now the issue with not drinking enough water or eating enough food throughout the day leads to other more serious complications. On more occasions than I would like, we have ended up in the emergency department of our local hospital with a very dehydrated child.

It was only in talking to O's key therapist and the school age services coordinator that we realised that perhaps, just perhaps, O's sense of interoception hasn't fully developed.

I can now hear you asking, what on earth is interoception?

I have talked briefly about interoception in a previous post, but let's go into a little more detail.

First we need to go back to basics. We all know about the five senses - hearing, sight, smell, touch and taste. But there are three others that are considered our hidden senses. Senses that we don't consciously think about or are aware of on a daily basis.

The sixth sense is our vestibular sense - this sense provides our bodies with information as to where our head and body are in space. It helps us to keep our balance as we move about.

Then we have the seventh sense which is proprioception. This is our body sense that tells us where our body is in relation to the rest of us. It also tells us how much force to exert when performing different activities like hugging someone, shaking hands, cracking an egg open and so on.

Then we have an eighth sense - our interoception sense. This is a relatively unheard of internal part of the sensory system and consists of all of the internal sensations that we may feel on a daily basis when we're hungry, thirsty, anxious, nervous or when we need to go to the bathroom. Any sensations that originate from within our bodies all stem from the sense of interoception. Receptors in our body organs and skin, are constantly sending information about the inside of our bodies to our brain.

Our sense of interoception is always there in the background and it isn't something that we are generally consciously aware of.

In some individuals, particularly those who have sensory processing difficulties, this hidden sense may still be developing. And as with sensory processing difficulties, individuals may be under-responsive, over-responsive or a combination of both.

Some specialists consider that individuals with sensory processing difficulties may not know how to verbally label the data that their brains receive from the interoceptive sense. If they are not receiving enough data, the sensations that they receive may be confusing. And likewise if their brains are receiving too much data from the interoceptive sense, the sensations may become very overwhelming.

In O not feeling the need to drink water regularly in essence means that this part of her interoception sense is under-responsive - she simply isn't receiving enough data to register that she is thirsty.

In O being in a constant state of anxiety at times in essence means that this part of her interoception sense is over-responsive. Her brain is receiving too much information and the data becomes a distraction so she is unable to focus on anything else and enters into an anxious state.

The tricky thing about our sense of interoception is that the data that it sends to our brain, is required for a range of basic and advanced functions. These functions range from breathing, being hungry or bring full, needing to go to the bathroom, being aware of our own emotions, being able to manage our own emotions and everything else in between.

So it makes sense then that if a child's sense of interoception is still developing, then they may struggle with recognising and responding appropriately to their own emotions and to those of others.

If an individuals brain has difficulties in making sense of the information that it receives, then the individual may not be tuned into their internal body cues that assist others to interpret emotions. They may have difficulty "feeling" the different emotions that they experience. If an individual is not able to interpret their own different body sensations, then they may have difficulty in identifying their own and others emotions.

So how can we help children whose sense of interoception may still be developing?

One of the activities that O's key therapist has been working on with O is labelling different emotions and talking about what some of the external AND internal feelings that she may feel that are associated with these emotions. We have quite a number of body outlines with different sensations written around them - anger, nervous, happy, sad, you get the picture. This has been incredibly beneficial and very effective as O is now starting to recognise the early warning signs of her different emotions and can now verbally tell us how she is starting to feel.

Earlier this year, I developed a social story called "My Book About My Feelings" to assist O in labelling her own emotions. The story started to assist O to identify how she felt inside when she was sad or anxious.

We regularly read books and talk about how the characters might be feeling in particular situations.

When we see the little superheroes experiencing different emotions, we will verbally assist them to label their emotions - "Oh you look very excited....." or "I can see that you are becoming angry/frustrated by ..............." This not only assists them to label their own emotions but it also provides them with the appropriate language so that the next time, they may be able to verbally express themselves.

We also verbally label our own emotions and our internal sensations to the little superheroes. If they recognise that they too experience these internal sensations then they will begin to connect the dots!

Interoception issues are not as well known as other sensory processing difficulties and as such, medical professionals are still developing strategies to further develop this sense in those who need it.

The great thing about being on a learning journey with the little superheroes is that as we have an awareness of and basic understanding of the possible causes behind the little superheroes behaviour and/or functional limitations, means that we are helping the little superheroes. Just having an awareness of the sense of interoception and implications of this sense still developing means that we are able to trial different strategies to see what works best for them. It means that we are more understanding when we see them struggle with skills that everyone seems to take for granted.

So the next time you see a child who can't seem to get the hang of toilet training, or they never seem hungry or thirsty, or they fly off the handle at the drop of a hat, keep in mind that perhaps their sense of interoception is still developing.

Behaviour is not done on purpose. Behaviour is done for a Purpose.

Just recently I read a comment on a social media site that disturbed me on so many levels. The comment was:

"Do you know what I can't stand? Children who hit their parents. It's absolutely disgraceful. You are the parent, where is the respect."

Now I don't know the background to this comment or the family involved, but the person who made it is an Early Childhood Educator and this alone worries me.

It appears to me that the person who made this comment did not take the psychology and development of children into consideration before passing judgement on the child and family involved and that is very disconcerting.

They haven't examined the actions of the child from another angle prior to passing judgement.

All children, regardless of whether they have autism, another special need or none at all, ALL children are still learning to recognise and manage their BIG emotions.

BIG emotions that can be incredibly overwhelming at times.

BIG emotions that do cause children to lash out in frustration.

When a child lashes out, there could be an array of reasons and possibilities as to why they have lashed out and quite often it is not due to a lack of respect towards their parents.

Children lash out when they are tired, when they are feeling unwell, when they haven't yet grasped the concept of sharing and turn taking......

Lashing out at others, including their parents, isn't an excusable action but there is generally a reason behind the child's actions.

I am constantly reminding myself that a child's behaviour is not done on purpose, it is done for a purpose.

My role as a Mum and as an Educator is to work out what that purpose is and to provide and equip the child, be it my own children or the children in my care at work, with the skills that they need to be able to communicate their needs and wants. 

O and L often lash out at myself and Daddy Superhero and when they do it is not due to disrespect on their part, it's often due to their frustration at being unable to convey their feelings at that point in time. They lash out when they enter into sensory overload. They lash out when they enter into meltdown mode.

And when there is an underlying reason as to why they have lashed out, I show O and L compassion and understanding. I get to the bottom of why they have lashed out. I end up with much happier children when I do this. I can only imagine what would occur if I jumped to conclusions and condemned their behaviour.......

When others who were following the thread started commenting about children with autism and how they struggle to understand their own emotions and that they do lash out at times, others started chiming in with comments such as:

"Even children with additional needs should not hit their parents."

"Parents still need to set boundaries for children with autism."

"Children with autism need to learn from an early age that hitting is not okay."

When I read these comments, the only thing that I could say was WTF??? Plus a few other expletives that I will not repeat.

Really? So much judgement from education professionals who should know better.

Individuals with autism will often lash out when they are in sensory overload, when they are in meltdown mode and when they are unable to communicate their needs and wishes. They mean no maliciousness, they are simply communicating in the only manner that they know how.

I would love to know how these people would get through to a non-verbal child with autism that "hitting is not okay." How do you explain this to a child whose executive functioning is still developing?

How do you explain this to a child who does not understand or recognise their own emotions, let alone the emotions of others? How do you explain this to a child whose sense of interoception ** is still developing?

Yes individuals with autism do need to understand that violence is not okay but when an individual is in meltdown mode, all sensibilities really do go out of the window. An individual in meltdown mode is not aware of their actions.

I have felt the judgemental stares and have heard the judgemental comments from others when O and L have been in such an emotional state that they've lashed out at me.

These stares and comments are not helpful in any way shape or form.

And when the comments and stares are from education and medical professionals, they hurt much more deeply.

Over time O and L will come to understand that hurting others is not an acceptable behaviour but in the meantime I will keep reminding myself that -

Behaviour is not done on purpose. Behaviour is done for a purpose.

Note:
** The sense of Interoception is a relatively unheard internal part of the sensory system in which the internal physical and emotional states of the body are detected, recognised and responded to. Interoception skills are required for a range of basic and advanced functions - functions such as breathing, hunger, going to the toilet, being aware of your own emotions which includes being able to manage your emotions proactively. When children have not yet developed interoception skills they will struggle with their own emotions. They will struggle with being able to respond appropriately to their own and others emotions and in social interactions.