Challenges with toilet training (e.g., frequent accidents, withholding urine or feces) and eating (e.g., food selectivity, getting sufficient nutritional intake) may have a significant impact on the child’s functioning in the home, school, community, and social events. These issues often impact the entire family. Individuals diagnosed with Autism Spectrum Disorder experience challenges related to feeding and toileting at a more significant rate than those without the diagnosis (Schreck, Williams, & Smith, 2004). When faced with these areas of concern individually, the task of increasing skill levels to age or developmental expectations for nutritional intake or “socially appropriate” ability levels can be an overwhelming task for a parent. When feeding and toileting issues are co-occurring, caregivers are often at a loss as to which area to address first, the method or progression of intervention, and how to best support their child.
When Is It a Problem?
Early challenges associated with feeding may be initially overlooked or attributed to “typical pickiness” or a “phase.” Issues with initially refusing meals, limiting intake of novel or previously consumed foods, or minor behavioral challenges may persist. These may evolve into a more substantial concern when growth and health are impacted, functioning and participation in daily activities are impaired, or social-emotional development and appropriate interactions are diminished (Mcmanus et al., 2003). While more commonly reported parent concerns regarding their child’s eating often involve selectivity, either by type or texture, there are a variety of other concerns that may exist such as:
- Phobias
- Behavioral issues
- Oral motor issues
- Packing or holding food in the mouth
- Delayed or absent chewing
- Tongue Lateralization
- Medical and behavioral complications
- Delayed gastric emptying
- Rumination
- Complications from Gastroesophageal Reflux Disease
- Chronic emesis (vomiting)
- Weaning from tube feedings
Challenges with toileting are most often identified when a child displays frequent “accidents” or fails to meet age-appropriate expectations for toilet training. Reports of “being full” or a lack of appetite, frequent abdominal pain, or irritability may be associated with a gastrointestinal or urinary tract issue. Individuals diagnosed with Autism have been shown to be more frequently referred to constipation clinics than the general population (Pang and Croaker, 2011).
Challenges related to toileting may include:
- Constipation
- Having less than 3 bowel movements a week
- Stools that are unusually dry or hard
- Inconsistent stooling (abnormal size and consistency can be an indicator)
- Diarrhea
- Having at least 3 watery bowel movements per day
- Enuresis / encopresis (urinating / defecating in places other than the toilet)
- Frequent accidents during the day
- Refusal to use the toilet
- Regression
- Stool withholding
Contributing Factors
Factors that may specifically affect feeding-related tasks include but are not limited to:
- Anatomical structures
- Oral motor functioning and development
- Motor functioning
- Genetics
- Medical issues
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- Gastrointestinal functioning
- Bowel issues
- Cardiac, pulmonary
- Sleep / sleep apnea
- Food allergies
- Environment including schedules, setting, choice, and biological state
- Dietary impact
- Behavioral challenges which may be related to a medical issue or functional skills deficit
Contributing factors to challenges with toileting may include:
- Medical challenges
- Crohn’s, Colitis, GERD, food allergies, Celiac Disease
- Motor or communication delays
- Fear of pain / aversion
- Environmental changes
- History
- Inconsistency across time, settings
- Overarching behavioral concerns
- Transition difficulty
- Noncompliance
Feeding and toileting difficulties often have significant overlap with regard to physiological or biological contributing factors to one another (Field, Garland, & Williams, 2003). These issues frequently co-occur and may affect the intake of food, hunger, the ability to pass stool, or contribute to behavioral or gastrointestinal disorders.
What Comes Next?
Careful evaluation of the previously mentioned contributing factors is both necessary and beneficial to assess the impact before intervention. This may involve a medical or specialist screening in the areas of fine or gross motor, oral motor, gastrointestinal specialist, behavioral, or psychological for example. A thorough assessment of prerequisite skills should also be assessed before intervention. If you have started working with your child at home and have plateaued, or experienced a significant regression of skills, a reevaluation of the various skills associated with your goal for your child should be conducted.
Whether you are just starting the intervention process, or you have hit a roadblock, data collection is essential. This information may be used as a guide for where to begin, for evaluating progress with goals, for deciding when to increase the expectations, to take a step back, to change your course of action, or to let you know when additional assistance is required.
When working with a specialist provider, information regarding your child’s bowel or bladder habits (e.g., accidents, meal schedule, food/calorie intake, behavioral data) is beneficial in helping guide your appointments, provide concrete and objective information to the provider, and determine the next steps.
Key Points for Intervention
One of the key features of Autism is a preference or insistence on sameness as well as rigidity with routines. This may result in a fearful approach to new things, expectations, or even new foods (Patrick & Nicklas, 2005). Taking small steps, repeating opportunities for practicing the skill, and gradually increasing the expectations based on previous success are a few of the hallmark features of successful intervention in these areas. Intervention and assessment in these areas should begin as soon as possible. Research has shown that smaller issues, such as your child’s “pickiness,” especially in children with Autism are far less likely to resolve on their own (Williams, Gibbons, & Schreck, 2005; Mascola, Bryson, & Agras, 2010). Data has also shown that children on the autism spectrum often experience delays in solidifying daytime toileting skills (Faulkner et al., 2017), further emphasizing the need for more immediate attention.
Supporting your child in the area of feeding and toileting often involves a significant commitment of time and attention and a high degree of consistency. As a parent or caregiver, it is important to consider if this allocation of focus and resources is feasible for your family. This decision will impact your next steps of intervention and the decision to include other professionals in your intervention plan. Support for the caregiver may also be needed in these cases.
Managing goals and expectations related to your goals for your child should also be carefully considered and frequently reevaluated. Just as interventions should not be a “one size fits all,” neither should our expectations for an individual. What is reasonable, healthy, and appropriate for your child may not be the case for another. Setting attainable goals that focus on the overall health and well-being of your child and the functioning and nature of your family should be prioritized.
Important Considerations
Consideration of the various levels of care and support options related to your child’s areas of difficulty is essential. While specialized support is available for in-home intervention and consultation, it is important to consider the need for utilizing outpatient or inpatient providers, such as a dedicated clinic, to provide additional oversight, training, guidance, and caregiver support if the need arises. If you are experiencing a lack of or plateaued progress, significant increases in maladaptive behavior, and difficulty with intervention implementation and consistency, you may need to consider modifying the approach to supporting your child.
Immediate medical consultation should be obtained if you suspect potential medical complications arising from frequent bladder infections or chronic or severe impaction or constipation. For concerns related specifically to feeding, careful attention should be paid to weight loss or gain to ensure nutritional needs for growth and development are being met.
Dr. Bianca Coleman, PhD, NCSP, BCBA-D, is a licensed psychologist in the state of New Jersey, Nationally Certified School Psychologist, and a Board-Certified Behavior Analyst at Behavior Therapy Associates located in Somerset, New Jersey. To contact Dr. Coleman, email bcoleman@behaviortherapyassociates.com or call (732) 873-1212.
References
Faulkner, V.J., Schanding, G.T., Fan, W., & Harris, G.E. (2017). Individuals With Autism Spectrum Disorder: A Study of the Age of Attaining Daytime Dryness. Consultant. 56. 394-398.
Field, D. & Garland, M., & Williams, K. (2003). Correlates of specific childhood feeding problems. Journal of paediatrics and child health. 39. 299-304.
Mascola, A. J., Bryson, S. W., & Agras, W. S. (2010). Picky Eating during Childhood: A Longitudinal Study to Age 11 Years. Eating Behaviors, 11, 253-257.
McManus, M., Derby, K. M., Dewolf, E., & McLaughlin, T. F. (2003). An evaluation of an in-school and home-based toilet training program for a child with fragile X syndrome. International Journal of Special Education, 18, 73–79.
Pang, K.H., & Croaker, G.D. (2011). Constipation in children with autism and autistic spectrum disorder. Pediatric Surgery International, 27, 353-358.
Schreck, K.A., Williams, K., & Smith, A.F. (2004) A Comparison of Eating Behaviors between Children with and without Autism. Journal of Autism and Developmental Disorders, 34, 433-438.
Williams, K. E., Gibbons, B. G., & Schreck, K. A. (2005). Comparing Selective Eaters with and Without Developmental Disabilities. Journal of Developmental and Physical Disabilities, 17(3), 299–309.
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