SM is an 8 year old boy who was referred to Middletown Centre for Autism to support the development of independent self-care skills including toileting in the home setting. At home SM would urinate anywhere inside or outside the house. SM also defecated outside. 

At home SM requires supervision for toileting. When SM is left alone to toilet, he tends to urinate in the surrounding toilet area. SM will also urinate anywhere in the house or outside. SM is not yet toilet trained at night-time and will use continence wear during the night or when traveling in the car. In school SM can independently use the toilet and follow all the steps within the hygiene routine. 


When SM engaged in behaviours of concern including urinating in the house or defecating outside it was important that SM’s parents followed the low arousal approach. It is recognised that these behaviours of concern are very difficult and upsetting for parents not to respond too, however based on the assessment and analysis completed, SM behaviours were more likely to escalate or re-occur when parents reacted to behaviours of concern. SM’s parents instead focused on positively acknowledging and praising positive behaviours that SM engaged in. 

SM use of language and literacy skills are developing and when he is calm, he can make appropriate requests, comment, say people’s names and interact with adults. SM is proficient in following a visual schedule using both photos and symbols. 

Link here for more information on the Low Arousal Approach 


A range of sensory, behaviour and social emotional regulation assessments were completed with SM, his parents and school staff. Observations were carried out at home and school. Analysis was combined with the assessment results from the specialist occupational therapist and input from psychologist and behaviour therapist.

A number of strategies were implemented with the aim of teaching SM appropriate behaviour around toileting and promoting independence with self-care. There were three specific objectives with a number of strategies implemented for each. 

Objective one: Increasing SM’s understanding of expected behaviour during toileting. Strategies included:

  • A visual support in the form of a motivating toilet sticker in place to help SM target successfully when standing to toilet. This improved this skill and helped SM to stay on task.   
  • Visual supports outlining clearly what is expected in the bathroom. Link  here for example visual supports
  • Parental supervision was encouraged as the presence of the parent encouraged SM to urinate in the toilet. Parent’s praised SM when he urinated in the toilet to make it clear to SM that he had done a good job. When the parents supervised from a distance this also supported SM’s independence. Overtime the parents gradually increased the distance from the toilet while SM was urinating

Objective Two: Remove the use of continence wear during the night and while travelling in the car. Strategies  included:

  • Every morning SM’s parents checked if SM had urinated during the night while sleeping
  • When SM was demonstrating a readiness for night-time toilet training (consecutive number of nights when SM had remained dry), it was recommended to remove continence wear at night
  • SM was prompted to use the toilet prior to going to bed and in the morning. A toilet picture was added to SM’s visual night-time schedule and morning schedule
  • Based on SM’s progress during the night-time, parents then removed continence wear while travelling in the car. SM was prompted to use the toilet prior to travelling in then car and when he arrived at the destination

Objective Three: There would be a decrease in SM defecating outside. Strategies included:

  • Introducing a social story around expected toileting behaviour
  • Supervised messy play 2-3 times for short periods throughout day with textures that looked and felt like poo (e.g. porridge oats, chocolate spread, chocolate ice cream). Parents played and modelled fun and excitement with these activities including smearing it and make shapes
  • Prior to going outside parents explained  what is expected outside by setting up a visual schedule for outside play. 
  • SM and his parents read a social story about what was expected on the walk prior to its start

Responding to an incident: Parents cleaned up quickly while giving little attention to SM or reacting to what had happened. SM was not invited to have a nice bath instead he was washed down with a cloth or whatever it took to get him clean as quickly as possible and then returned to normal routine as if this had not happened. It was important that there was no pay-off for SM including a reaction from parents or access to bath.