A Highly-Effective Toilet Training Program Based on Applied Behavior Analysis Principles

By Jordan Hulass, MA, BCBA, LBS and Kristine Quinby, MEd, BCBA, LBS

Learning to use the bathroom independently is a critical life skill for any child, but especially for children with autism spectrum disorder. It boosts their self-confidence, enhances their quality of life, and enables a deeper integration into educational environments, social gatherings, and society as a whole.

Yet, several studies have shown that children with autism are consistently late in developing these habits, and some never acquire them at all. A number of factors can affect when a child develops the necessary skills to use the bathroom on her own, but non-autistic children generally do so at two- to three-years-old. Children with autism, by contrast, need a few years of training before they attain independence, if they attain it at all.

An extended period of toilet training can take a physical, mental, and emotional toll on both the child and parents. But as autism has become more pervasive in our society, the lack of effective training methods for children with autism has grown more pronounced. However, we’ve found promise in an intensive toilet training program that we largely developed around the applied behavior analysis practices outlined in the now-seminal 1971 study by Nathan H. Azrin, PhD, and Richard M. Foxx, A rapid method of toilet training the institutionalized retarded. (In 1974, the pair also wrote Toilet Training in Less Than a Day, which went on to sell more than two million copies. It was updated and rereleased in 2019 by Gallery Books.)

We’ve observed anecdotally a success rate of more than 90 percent with our plan. Not only are autistic children learning to use the bathroom on their own, they’re doing so in a matter of only a few days. Being able to accomplish that within such a relatively short period buoys the child’s self-esteem and helps parents remain compliant with the program, which, admittedly, can be a challenge for all involved. The disruption is short-lived, though. And on the other side of it, there’s the promise of a greater sense of freedom.

The distinctive features of Azrin and Foxx’s procedure were:

• “Artificially increasing the frequency of urinations;
• Positive reinforcement of correct toileting, but a delay for accidents;
• Use of new automatic apparatus for signaling elimination; 
• Shaping of independent toileting;
• Cleanliness training; and 
• Staff reinforcement procedures.”

With our own intensive program, a behavior analyst visits the family’s home prior to embarking on the training. At this point, the analyst will conduct an indirect assessment of the child and their toileting skills, along with the parents, to see how they interact with the child, how they handle problem behavior, and their capacity to accommodate the intensive training ahead. 

What the behavior analyst is looking for to determine the child’s readiness is:

• Whether the child is medically cleared to be toilet trained.
• The child’s mode of communication.
• The child’s ability to follow simple one-step instructions.
• Whether the child can remain dry for two hours.
• The child’s ability to tolerate denied access and flexibility in their routine.

Assuming the analyst determines the family is ready to begin the program, she’ll return for the first day of training. Her presence is meant to serve two purposes: First, the analyst will be able to describe, firsthand, the sequence of toileting benchmarks and the accompanying procedures. And second, the analyst will be well-positioned to troubleshoot any issues that may arise throughout the day, such as the child refusing to sit on the toilet. In doing so, we’re able to individualize the program to a large extent.

One of the features that makes the program so effective is that we get the child, from the start, to drink a lot of fluids in a short period, which then creates a lot of opportunities for them to be successful. The child will quickly become familiar with the sensation of having a full bladder, which is what needs to become their cue for using the bathroom, not prompting from a parent or a teacher.

From requiring the child to ask to use the bathroom after the first day of training to teaching the parents how to respond to the inevitable accidents, each facet of the program is geared toward a singular goal: getting the child to recognize that their bladder is full and, upon that recognition, seek out and sit on a toilet on their own.

After the first day, the parents will be responsible for beginning to gradually phase out the things that helped their child be successful the day before, including providing positive reinforcement for voids and prompting their child through the complete toilet routine, though they’ll receive daily and, eventually, weekly guidance from the analyst.

In the final formal phase of our program, the child will ask to use the bathroom in a public setting. By that point, every other incentive (and disincentive for accidents) that was used earlier in the training will have been completely phased out. 

As with any type of toilet training, and any type of child, some regression is to be expected. When that time comes, parents will have learned how to analyze their child’s behavior in relation to their bathroom routine, which will position them to make informed decisions to limit the setback. Where the rigidity of the training may cause some chafing initially, it will provide a solid infrastructure in the weeks and months that follow.

An analysis of the relevant literature makes it clear that toilet training programs are conducted within the framework of the behaviorist approach, the primary features of which are positive reinforcement and operant conditioning principles. Our program, specifically, has proven to be effective because its foundation includes motivating operations, reinforcement, protocols, and contingencies, which enables the behavior analyst to problem-solve and assure the learner’s success.

Kristine Quinby, MEd, BCBA, LBS, is Founder, President and CEO of Potential. She can be reached at Potentialinc.org, kquinby@potentialinc.org, or 215.579.0670.