Autism spectrum disorders. Autistic disorder, pervasive developmental disorder not otherwise specified (PDD–NOS), and Asperger disorder are also neurobiologically based diagnoses. Approximately 1 in 150 children have an autism spectrum disorder, and at least 50% of these children are mentally retarded. 5 Children with autism spectrum disorders have struggles in 3 areas:
- The use of language.
- Social interactions.
- Repetitive, perseverative behaviors.
To receive a diagnosis of autistic disorder, a child must have symptoms in each of these 3 areas. Symptoms in children with autistic disorder are typically more severe or intense than those seen in children with PDD–NOS. Children with PDDNOS may also have fewer symptoms and do not need to demonstrate symptoms in each of the 3 areas mentioned above. To receive a diagnosis of Asperger disorder, a child must have no history of either clinically significant language delay or cognitive delay.
Among children on the autism spectrum, 11% suffer from enuresis and 6.6% from encopresis.6 Toilet training problems in children with autism spectrum disorders are most commonly caused by developmental expectations that cannot be met in the typical time frame, rather than by symptoms specific to autism that interfere. Even for those whose cognitive levels are adequate for toilet training, typical language–based instructions may be inadequate to convey toileting requirements, because of these children’s trouble with communication.
Many children with autism spectrum disorders have GI problems, and both loose and hard stools can interfere with the successful development of continence. In addition, many of these children take psychoactive medications, which can exacerbate problems with constipation.
Like children with ADHD, children with autism spectrum disorders also have trouble with transitions; thus, shifting from one’s current activity to use the bathroom may prove difficult. The trouble these children often have generalizing activities from one setting to another may require specific training efforts in every common setting. Finally, children with autism tend to have different sensory experiences, as evidenced by sensory–seeking behavior and sensory avoidance. The feeling of “having to go” may be harder to detect or more bothersome for this population than for children who are typically developing.
In addition to properly determining the child’s developmental capacity for toilet training, the careful selection of a toilet teaching method is also helpful for successful training in children with autism spectrum disorders. Because of these children’s communication limitations, visual aids are important for indicating expectations. The Picture Exchange Communication System, a visual system commonly used in the education of children with autism, includes a number of drawings appropriate for this task.
Addressing any GI concerns is also necessary; constipation should be effectively treated to ensure that bowel movements are easily and regularly produced, and diarrhea should be treated with bulking agents so that stools are soft, formed logs that a child can feel and control.
To motivate a child with autism to sit on the toilet, it may help to allow him (as either incentive or reward) to engage in a favorite selfstimulatory activity or hold a favorite toy while sitting on the toilet. For example, a favorite train or light–up toy might be kept exclusively in the bathroom, used to make the bathroom a desirable place to be and the sitting time fun and relaxing.
If toileting is the focus of a child’s behavior or learning plan, then it may be necessary to incorporate toilet visits throughout the day (at school and at home) and to use the strongest reinforcer available. Collaborating with school providers is important and generally very helpful; experienced teachers and school therapists often have vast experience training children on the autism spectrum.
Sensory integration dysfunction (SID). Diagnosed mainly by occupational therapists, SID refers to the atypical processing of sensory information. Normally, we receive sensory input via multiple modalities, including visual, auditory, tactile, and sensory modes. Without conscious effort, we incorporate these varied signals into a whole, well–integrated experience. We use this information to understand the world around us and to respond appropriately to the environment.
Children with SID are thought to be neurologically different and to react to sensory input differently. SID is often diagnosed in children who are easily overwhelmed by noise, activity, sound, or tactile sensations, and their symptoms are attributed to an inability to integrate the sensory information smoothly. Common presentations include intolerance of the tags in shirts, the need for socks to feel a specific way, food–texture avoidance or preference, and overreaction to noises such as those produced by vacuum cleaners and blenders.
There is no clear medical model or diagnosable medical disorder that directly explains SID. A more conventional medical framework considers sensory threshold as one aspect of temperament, a child’s behavioral style or manner of interacting with the world. A child with a low sensory threshold is more reactive to sensory input, while one with a high sensory threshold is more tolerant.
Regardless of the way in which these symptoms are explained, children who respond differently to sensory information may struggle with toilet training. They may not be as aware of their body signaling the need to urinate or defecate, or they may experience these signals in a more abrasive manner than do children with normal sensory processing. Children with sensory differences may feel overwhelmed by body sensations related to toileting and then struggle to respond in an organized fashion. The tactile experience of wiping may also bother them.
If a child seems overly reactive to sensory input, then minimizing the distress he experiences with toileting is a priority. Strategies for accomplishing this may include the use of medications or dietary interventions to optimize stool comfort and regularity. Make sure the bathroom is minimally stimulating: it should be uncluttered, quiet, and calm. Some children benefit from being taught to coordinate sensations; one way to do this is to have them place a hand on the lower abdomen to feel it protrude when they are pushing stool out. Relaxation techniques, including deep breathing and positive imagery, may help prevent a child from becoming overwhelmed. Classic interventions provided by a therapist, such as desensitization to the sound of flushing or the odors of the bathroom, can be useful as well.