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How the areas of difficulty for someone with Autism link with toileting

Social Communication
Children and young people might fail to understand the words used to describe toileting. They might be unable to understand what they are being asked to do. They might take language literally, for example “Put the toilet roll in the toilet”. They might be less likely to communicate the need to go to the toilet and they might need instructions or information to be presented visually using PECs or symbols. They might not like being told what to do by another and may experience a meltdown when asked to do something. This can be extremely frustrating for parents and carers and put strain on the parent/child relationship, turning toilet training into a bigger issue for the family.  
Social Interaction
Children and young people with an ASD might lack the motivation to make the transition from nappies to pants or use the toilet as their peers do. They might be less likely to copy others to learn new skills. They might lack the motivation to please others by urinating or defecating in the right place. They might be unconcerned about wetting or soiling themselves and they might go to the toilet in inappropriate places.
Social Imagination
Children and young people with an ASD sometimes assume you know they need help and do not always realise they need to communicate this. Sometimes they lack the understanding that soiling themselves may have an impact on others. This specifically links with a child/young person with ASD’s difficulty and sometimes inability to emphasise with others. They might have difficulty in changing routines. They might be unable to transfer their toileting knowledge to unfamiliar toilets and they might develop fear and anxiety around using the toilet.
Sensory Differences
Some children and young people might not register that their bowel or bladder is full or do not feel the need to go to the toilet. Some might not be aware of urine and faeces in their nappy/pants while others might enjoy the sensation. Balancing on the toilet may be challenging for some; for others a splash or urine or water on themselves or their clothes may causes distress. Some children and young people may find the bathroom a very overwhelming room or they may love it but be interested in putting things down the toilet or flushing it.

Could there be an underlying medical issue affecting the toileting?

A child or young person with toileting difficulties could be in pain from a medical reason but that child or young person may not be aware of it or may not be able to communicate it. Autism spectrum disorder (ASD) and incontinence (nocturnal enuresis (NE), daytime urinary incontinence (DUI), faecal incontinence (FI)) are relevant disorders in childhood. In general, children with special needs such as intellectual disability (ID) or ASD are more often affected by incontinence than typically developing children. Autism spectrum disorder is an incapacitating disorder with significant impairment in social functioning. In most cases, psychological symptoms and disorders co-occur. Additionally, children with ASD are at a greater risk of being affected by different forms of incontinence and LUTS. Therefore, screening for incontinence and, if indicated, treatment of these disorders is recommended.2
There might be a concern around Constipation. Constipation and soiling is often blamed on their disability and sometimes not picked up or treated appropriately. They are less likely to have investigations to rule out any possible underlying problems. Constipation means that bowel movements are less frequent and are difficult or painful to pass. Generally we should open our bowels no more than three times a day and no less than three a week. Constipation is present in 5 – 30% of all children and the exact cause is not fully understood.

If you are concerned about constipation you can talk to a healthcare professional (it could be the school nurse, health visitor or GP). They will ask about the symptoms of the child or young person. This will help them to diagnose constipation and check that there is no serious underlying cause. They should also do a physical examination. Your healthcare professional may then do some tests. You should only have tests if they think there may be another condition that is causing the constipation. In this case they should also offer referral to a specialist. If the examination and tests do not find a cause for the constipation, your child has idiopathic constipation. Your GP or the specialist should explain what this means, reassure you that there are treatments and discuss any treatments they recommend.

Could there be an underlying medical issue affecting the toileting?

Make sure you take the time to prepare. Preparation could include considering choosing what words everyone is going to use, planning a visual routine, getting a child or young person used to going in the bathroom, observing the behaviour they are doing and thinking what alternatives could be provided to replace this.
 Talk to everyone involved -  because every person in the child/young person’s life needs to be clear and consistent  
Make sure you have covered the following:

- Does the child or young person have the ability to go into the bathroom

- Do they understand what a toilet is for

- Have you considered a reward system

- Have you got strategies to ensure the child/young person is able to cope with changes in their routines 

- Have you addressed the child/young person’s anxiety and stress levels
Key Questions 

Does the child or young person have an awareness of wee/poo? 

Are things associated with toileting/nappy changes in the bathroom? 

Have you tried changing the child/young person standing up and putting the poo into the toilet afterwards

Have you tried explaining to the child/young person how the body works, what poo is and where it goes?
Environmental questions
 Have you thought about clothing and ease of removal?  Do they need an alternative from the potential sensory input they are getting from wearing a nappy?  Have you made the bathroom safe and comfortable with equipment such as a toilet seat, foot stool or toilet frame?  Have you practiced sitting on the toilet as part of their daily routine  
Visual Aids
Have you thought about how they might understand the process?   Could you use visual aids to help understanding?
N.B make sure you use pictures/symbols or photos that the child/young person will understand to help them learn what they are asked to do
Sensory needs 

Have you considered the following factors?

- The toilet flush -

-Reflective mirrors

- Cold tile floors 

-Noisy fans

- Strong smelling cleaning products

- Splashes in the toilet

- Introducing a fiddle toy

- A weighted lap blanket

- Installing grab rails

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