Question: I have a nine-year-old who is not using the toilet to open his bowels. He can take himself to the toilet to urinate but is having constipation issues. He has been on a laxative for three weeks, and the continence nurse has encouraged us to put him back in nappies during this time.
He is fine whilst at school as he does not use the toilet unless he is urinating. He catches the bus home and usually arrives home with soiled pants. At home, he refuses to wear his undies, and when placed on the toilet to open his bowels at this time even when successful he stills soils his pants soon after.
We have tried to keep the experience positive by introducing a reward scheduled, however, he dismisses these quick enough saying he doesn’t want his tokens. Social stories have assisted in keeping him on track however we have not included any consequences. Any suggestions would be greatly appreciated. —Michelle
I am sorry to hear you are struggling. Toileting can be a complex issue; especially in older children because they often have many learned and ingrained behaviors that accompany bathroom routines. Without knowing the exact reason for your son’s difficulties I am unable to recommend the one best course of action, however, I do have some basic information to share, and it is likely you will need a combined approach of medical, behavioral, and sensory interventions.
I am glad you are working with a nurse. It is important to rule out medical causes for constipation and to work with a medical team if constipation has been long-standing. It is also important to keep in mind that when constipation has been going on for a long time, the entire digestive process may be disrupted, and this includes hunger cues, eating, and voiding (going to the bathroom).
You may need or want to also work with a nutritionist to ensure your son’s diet has adequate amounts of fiber and liquid to set him up for success. A medical provider should also rule out whether his constipation is resolved with the laxative. It may seem to be resolved, but some children have “leaking.”
Leaking makes parents think their child has loose stools when in reality it is liquid seeping out around hard stools that remain in the lower intestine. When softer stool leaks around harder stool it can soil a child’s underwear, and it seems this could be a cause of soiled underwear, daily after school for your son.
It is important to consider multiple things in regards to behavior when toilet training. I encourage parents not to punish or provide negative consequences for soiling or refusal to use the toilet. Your son may be unable to control his bowel movements and punishment or too much emphasis on whether he goes or does not go, only sets up a power struggle and possible feeling of failure.
Even if it is in his control, the more attention you give to the negative behavior (avoiding or soiling) the less likely he is to be successful at the behavior you want. I recommend positive reinforcement (providing rewards of some kind) for attempts or trying to go, vs. only rewarding him when he successfully goes. I also encourage parents to consider using rewards of your time and attention vs. concrete, tangible things like tokens or stickers.
You are the most motivating thing to your child and time with you will likely always be reinforcing. Tokens and “prizes” tend to lose their value the longer they are used, so you want something that will remain motivating to your child. I encourage parents to also stay away from using an iPad or screen during toilet training or as a reward because a child is more likely to tune out the bodily sensations of going when they use a screen.
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To master toilet training, your son needs to tune into his body vs. away from his body. By reinforcing his attempts to go, you are also encouraging a positive attitude toward the use of the bathroom. I encourage parents to set up a regular, consistent time of the day to encourage trying. By making this time consistent, he may begin to tune into the sensations he experiences at that time, and his body may begin to develop and respond to bodily cues more reliably.
Finally, if you haven’t done so already, consider having him help with clean up when he soils in his pants or underwear. This may serve as a natural consequence for soiling. It is not intended as a punishment and he should not be “scolded” while cleaning up, but instead, I suggest “teaching” by stating things like, “This is what grown-ups do if they soil their pants, even if we can’t help it. Accidents happen.” Working with an applied behavior analyst provider may be needed if some of the above behavioral suggestions do not help.
Sensory processing is about how the brain and body work together to accomplish daily tasks. Successful use of the toilet for urination or having a bowel movement requires multiple sensory systems to work together.
Many children with autism struggle to feel sensations in their body the same way as neuro-typical people might and many children with autism, may also struggle to respond in a timely manner to the sensations of voiding. Some children are under-responsive (do not feel internal sensations as strongly), and some children are over-responsive (feel internal sensations more strongly).
Both of these patterns of sensory responsiveness may lead to a pattern of avoidance when it comes to the use of the toilet. Regardless of which pattern your son may have, it will be important to engage him in a supportive way, so he is not experiencing “aversive” sensory input from the experience of using the toilet.
Teaching your son about how his body works might help him understand and be motivated to improve his skills. I have used Youtube videos previously to engage school-aged children and here is one video I suggest. I also recommend that you work with an occupational therapist (OT) if you haven’t already, on how to offer the types of input your son’s body may need in order to accurately feel the sensations of having a bowel movement.
A couple of sensory strategies that may be helpful include: movement, warmth, and positioning. Movement (running, jumping, climbing, bending) encourages proper digestive flow and doing these kinds of activities before he is being encouraged to go might help him feel what’s happening in his body. Animal walks (frog jumps, walking like a duck, or any animal position that encourages squatting and moving in/out of a squat position) may be helpful.
His age makes it harder to complete these kinds of games, but he may be interested in playing with a peer or a sibling if available. Warmth from a warm bath, or warmed (not hot) towels across the abdomen may encourage digestive flow. These are strategies to consider if his daily time for trying coincides with bedtime routines or a time when a bath is possible. Warmth tends to be calming and soothing and may assist with having a bowel movement.
Positioning so that feet are elevated on a stool, a little higher than on the floor or hanging down towards the floor (depending on how tall your son is) could encourage pelvic tilt that may facilitate digestive flow. Having feet supported also puts the body in a more upright stable position, which may facilitate other body responds such as voiding.
I have also suggested people try a lower toilet seat such as a potty seat on the floor, if your son is not comfortable sitting directly on the regular toilet. Feet supported is important, whatever seat he chooses to sit on for trying, and use of a potty seat is not a forever intervention, it is simply a tool along the way of getting your son to begin some positive pattern of having bowel movements.
I hope the above is helpful and that you can get some relief for your son. It can be a long process and working with the professionals you have on your team, or finding some to support you through this is one of the best ways to make progress. Good luck.
This article was featured in Issue 89 – Solutions for Today and Tomorrow with ASD