Toilet Training In Neurodivergent Children: A Case Presentation In Readiness

Toilet training can look very different from one child to the next, and the signs of readiness are not always obvious. As a pediatric pelvic health therapist, you may work with children who indicate readiness yet struggle to become toilet independent. They can follow directions, have the motor skills to sit on a toilet, or even show interest in the potty, but they don’t have success. Knowing when to move forward or slow down, and which foundational skills to address first can make all the difference.

Simon’s* case is a great example of why toileting readiness deserves a closer look. At 3 years old, Simon, who has autism, began withholding stool shortly after his parents started potty training. What followed was a shift away from focusing on toilet use and toward helping him become regulated, comfortable, and ready for the next step.

Simon was able to squat, but he would poop while standing. Once his parents began potty training, he started withholding his stool for increasingly long periods (over a week!). At that point, the priority was no longer getting him to poop on the toilet. It was helping him establish regular, comfortable bowel movements.

Simon’s PT worked closely with his physician on a cleanout and laxative plan. His laxative dosage was increased depending on how many days he had gone without a bowel movement. This medical collaboration was an important part of his care because addressing constipation had to happen alongside the therapy interventions.

For Simon, continuing to push toilet training while he was withholding would not have addressed the underlying problem. Before expecting him to successfully transition away from diapers, the focus shifted toward helping him become well regulated and comfortable with his bowel movements again.

Simon’s case also highlights why pre-toilet training skills matter. A child may have some of the physical abilities needed for toileting but still not be ready for the demands of toilet training itself.

For Simon, this meant looking at skills such as squatting, movement, body awareness, interoception, and regulation. Rather than focusing solely on whether he could sit on the potty, therapy addressed the skills that would eventually support successful toileting.

You may find that a child is showing some signs of readiness while still needing support in other areas. That does not necessarily mean toilet training needs to stop permanently. It may mean that your role is to identify which foundational skills need attention first.

One of the recommendations for Simon was to keep him in diapers until he was well regulated. For some families, this can feel like moving backward when they have already started potty training. Clinically, however, pausing the process can create the space a child needs to develop the skills that will make toileting more successful later.

The goal was not to prevent Simon from learning to use the toilet. It was to remove the pressure to perform before his body and nervous system were ready. Withholding had already become part of his toileting experience, so creating a more predictable and comfortable bowel routine was an important first step.

This is where education can make a significant difference for parents. Helping families understand the importance of pre-toilet training skills and toileting readiness can shift the focus away from a specific deadline and toward what their child is actually demonstrating.

With the pressure to use the toilet temporarily removed, therapy could focus on helping Simon develop the skills he needed. Many of these interventions were incorporated through play and movement rather than making toileting itself the central activity.

Squat-and-blow exercises helped Simon practice the mechanics of squatting while pairing the movement with breathing. Pretend play also became an important tool. Simon participated in “poop traffic jam” play and animal pooping activities, giving him opportunities to explore the concept of stooling in a playful, low-pressure way.

His physical therapist also incorporated belly massage and core strengthening into sessions in the pediatric gym. Movement activities included the swing, rock wall, half-kneeling with rotation, bear crawls, frog jumps, and inchworms. These activities provided opportunities to work on movement, strength, coordination, and body awareness while keeping therapy engaging for a 3-year-old.

Interoceptive activities were another part of the intervention. For a child who is withholding, helping him notice and interpret internal body signals can be an important piece of the larger toileting picture. Instead of expecting Simon to immediately communicate and respond to every bowel or bladder sensation appropriately, therapy gave him repeated opportunities to build that awareness.

Simon’s progress also depended on what was happening between therapy sessions. His family was encouraged to increase his fluid intake and offer more fruits and vegetables as part of his overall bowel management plan.

These recommendations were not being used as a replacement for his medical management. Instead, they complemented the cleanout and laxative plan developed with his physician while therapy addressed the movement, regulation, and toileting-related skills that were contributing to his challenges.

This type of collaboration is especially important when a child’s bowel dysfunction is significantly affecting toileting. You may be addressing the functional and behavioral components in therapy while the physician manages the medical side of constipation. Keeping those pieces connected can help prevent the child from receiving conflicting messages.

One of the most interesting parts of Simon’s case is how his progress began to show up before he was independently using the toilet. At each appointment, Simon would announce that he had pooped. He was now having daily bowel movements and squatting to poop in his diaper.

That was a meaningful change from going 7 to 10 days without a bowel movement. His bowel routine was becoming more predictable; he was no longer withholding, and he was becoming more regulated.

His emotional regulation also noticeably improved once he was no longer constipated. This is an important reminder to look at the broader changes that can happen when a child is more comfortable and no longer caught in a cycle of withholding and constipation.

At this stage, the goal was not to rush into the next step simply because Simon was doing better. His improved regulation and daily stooling were progress in themselves.

Interestingly, Simon eventually began showing interest in toileting on his own. During bath time, he started initiating urination in the toilet. He would get out of the bathtub specifically to use the toilet and became excited about using the “big potty.”

That interest changed the picture.

Rather than creating pressure for him to use the toilet throughout the day, his family allowed him to initiate. There was no expectation that he had to start using the toilet consistently during daytime activities. He was given the opportunity to follow his own interest while continuing to maintain the bowel routine that had helped him become regulated.

This is an important distinction when you are talking with families about readiness. A child showing interest can be very different from a child being pushed toward a toileting goal before they are ready to participate.

Simon’s experience demonstrates why toilet training should not be viewed as a single skill that a child either has or does not have. His ability to squat was only one piece of the picture. His withholding, regulation, interoception, movement skills, bowel habits, and willingness to participate all mattered.

As a pediatric pelvic health therapist, your job is not simply to help a child use the toilet. It is to help identify what that child needs to get there successfully, and sometimes that means slowing the process down before moving it forward.

Want to learn more about toileting readiness?

If you want a deeper look at how to assess and support the skills that come before toilet training, check out my new mini-course “Toileting Readiness & Independence: Supporting Neurotypical & Neurodivergent Children.” It provides practical guidance for supporting children with different developmental and sensory needs while keeping toileting goals individualized and developmentally appropriate.

*patient’s name changed for privacy