Toileting Problems in Children and Adolescents with Parent-Reported Diagnoses of Autism Spectrum Disorder

  • Geraldine Leader
  • Kady Francis
  • Arlene Mannion
  • June Chen


The current study investigated toileting problems in one hundred and twenty-seven children and adolescents with parent-reported diagnoses of autism spectrum disorder. Toileting refers to the accomplishment of various unprompted behaviors, including recognising the need to go to the toilet, and waiting before eliminating. The relationship between toileting problems and age, gender, intellectual disability, gastrointestinal symptoms, sleep problems, comorbid psychopathology, quality of life, and adaptive functioning were examined using parent-report questionnaires. The most common toileting problems were, “Does not independently perform most self-help tasks”, “Has toilet accidents during the day”, and “Parent/caregiver notices smears in underwear”. Gender, presence of intellectual disability, gastrointestinal symptoms, and comorbid psychopathology were significant predictors of toileting problems in this study. The gastrointestinal symptoms of constipation and bloating were found to be significant predictors of toileting difficulties. Specifically, constipation predicted accidents and physical problems associated with toileting, and bloating predicted social/emotional factors and physical problems. A small negative correlation was observed between total toileting problems and total health related quality of life. An increase in physical toileting difficulties was associated with lower quality of life.


Autism spectrum disorder Toileting problems Enuresis Encopresis Comorbidity 



This study did not receive research funding.

Compliance with Ethical Standards

Ethical Approval

No animals were involved in this study. This research received full ethical approval form the National University of Ireland Galway. The study followed all procedures in accordance with the ethical standards of our University and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all participants in this study.

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.CrossRefGoogle Scholar
  2. Autism Treatment Network. (2005). GI symptom inventory questionnaire, version. 3.0. New York: Autism Speaks.Google Scholar
  3. Belva, B., & Matson, J. L. (2013). An examination of specific daily living skills deficits in adults with profound intellectual disabilities. Research in Developmental Disabilities, 34, 596–604.CrossRefPubMedGoogle Scholar
  4. Belva, B., Matson, J. L., Barker, A., Shoemaker, M. E., & Mahan, S. (2011). The relationship between adaptive behavior and specific toileting problems according to the profile of toileting issues (POTI). Research in Developmental Disabilities, 23, 535–542.CrossRefGoogle Scholar
  5. Community-University Partnership for the Study of Children, Youth, and Families. (2011). Review of the Vineland Adaptive Behavior Scales-Second Edition (Vineland-II). Edmonton: Community-University Partnership for the Study of Children, Youth, and Families.Google Scholar
  6. Cox, D. J., Morris, J. B., Borowitz, S. M., & Sutphen, J. L. (2002). Psychological differences between children with and without chronic encopresis. Journal of Pediatric Psychology, 27, 585–591.CrossRefPubMedGoogle Scholar
  7. Darymple, N. J., & Ruble, L. A. (1992). Toilet training and behaviors of people with autism: parent views. Journal of Autism and Developmental Disorders, 22(2), 265–275.CrossRefGoogle Scholar
  8. Duncan, D., Matson, J. L., Bamburg, J. W., Cherry, K. E., & Buckley, T. (1999). The relationship of self-injurious behavior and aggression to social skills in persons with severe and profound learning disability. Research in Developmental Disabilities, 20(6), 441–448.CrossRefPubMedGoogle Scholar
  9. Foxman, B., Valdez, R. B., & Brook, R. H. (1986). Childhood enuresis: prevalence, perceived impact, and prescribed treatments. Pediatrics, 77(4), 482–487.PubMedGoogle Scholar
  10. Francis, K., Mannion, A., & Leader, G. (2017). The assessment and treatment of toileting difficulties in individuals with autism spectrum disorders and other developmental disabilities. Review Journal of Autism and Developmental Disorders, 4, 190–204.CrossRefGoogle Scholar
  11. Goldman, S. E., McGrew, S., Johnson, K. P., Richdale, A. L., Clemons, T., & Malow, B. A. (2011). Sleep is associated with problems behaviors in children and adolescents with autism spectrum disorder. Research in Autism Spectrum Disorders, 5, 1223–1229.CrossRefGoogle Scholar
  12. Gorrindo, P., Williams, K. C., Lee, E. B., Walker, L. S., McGrew, S. G., & Levitt, P. (2012). Gastrointestinal dysfunction in autism: parental report, clinical evaluation, and associated factors. Autism Research, 5(2), 101–108.CrossRefPubMedPubMedCentralGoogle Scholar
  13. Hattier, M. A., Matson, J. L., Belva, B. C., & Horowitz, M. (2011). The occurrence of challenging behaviors in children with autism spectrum disorders and atypical development. Developmental Neurorehabilitation, 14(4), 221–229.CrossRefPubMedGoogle Scholar
  14. Issenman, R. M., Filmer, R. B., & Gorski, P. A. (1999). A review of bowel and bladder control development in children: how gastrointestinal and urologic conditions relate to problems in toilet training. Pediatrics, 103(3), 1346–1352.PubMedGoogle Scholar
  15. Joinson, C., Heron, J., Butler, U., & Von Gontard, A. (2006). Psychological differences between children with and without soiling problems. Pediatrics, 117(5), 1575–1584.CrossRefPubMedGoogle Scholar
  16. Keen, D., Brannigan, K. L., & Cuskelly, M. (2007). Toilet training for children with autism: the effects of video modeling. Journal of Developmental and Physical Disabilities, 19, 291–303.CrossRefGoogle Scholar
  17. Kuhlthau, K., Orlich, F., Hall, T. A., Sikora, D., Kovacs, E. A., Delahaye, J., & Clemons, T. E. (2010). Health related quality of life in children with autism spectrum disorders: results from the autism treatment network. Journal of Autism and Developmental Disorders, 40, 721–729.CrossRefPubMedGoogle Scholar
  18. Kuhlthau, K., Kovacs, E., Hall, T., Clemmons, T., Orlich, F., Delahaye, J., & Sikora, D. (2013). Health-related quality of life for children with ASD: associations with behavioral characteristics. Research in Autism Spectrum Disorders, 7, 1035–1042.CrossRefGoogle Scholar
  19. Landman, G. B., Rappaport, L., Fenton, T., & Levine, M. D. (1986). Locus of control and self-esteem in children with encopresis. Developmental and Behavioral Pediatrics, 7(2), 111–113.CrossRefGoogle Scholar
  20. Lohmann, W., Eyman, R. K., & Lask, E. (1967). Toilet training. American Journal of Mental Deficiency, 71(4), 551–557.PubMedGoogle Scholar
  21. Mannion, A., Brahm, M., & Leader, G. (2014). Comorbid psychopathology in autism spectrum disorder. Review Journal of Autism and Developmental Disorders, 1(2), 124–134.CrossRefGoogle Scholar
  22. Mannion, A., & Leader, G. (2013). Comorbidity in autism spectrum disorder: a literature review. Research in Autism Spectrum Disorders, 7(12), 1595–1616.CrossRefGoogle Scholar
  23. Mannion, A., Leader, G., & Healy, O. (2013). An investigation of comorbid psychological disorders, sleep problems, gastrointestinal symptoms and epilepsy in children and adolescents with autism spectrum disorder. Research in Autism Spectrum Disorders, 7, 35–42.CrossRefGoogle Scholar
  24. Maskey, M., Warnell, F., Parr, J. R., Le Couteur, A. L., & McConachie, H. (2012). Emotional and behavioral problems in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 43, 851–859.CrossRefGoogle Scholar
  25. Matson, J. L., Dempsey, T., & Fodstad, J. C. (2010). The profile of toileting issues (POTI). Baton Rouge: Disability Consultants, LLC.Google Scholar
  26. Matson, J. L., & Gonzalez, M. L. (2007). Autism spectrum disorders – Comorbidity – Child version. Baton Rouge: Disability Consultants, LLC.Google Scholar
  27. Matson, J. L., & LoVullo, S. V. (2009). Encopresis, soiling and constipation in children and adults with developmental disability. Research in Developmental Disabilities, 30(4), 799–807.CrossRefPubMedGoogle Scholar
  28. Matson, J. L., Horovitz, M., & Sipes, M. (2011a). Characteristics of individuals with toileting problems and intellectual disability using the profile of toileting issues (POTI). Journal of Mental Health Research, 4, 53–63.Google Scholar
  29. Matson, J. L., Neal, D., Hess, J. A., & Kozlowski, A. M. (2011b). Assessment of toileting difficulties in adults with intellectual disabilities. An examination using the profile of toileting issues (POTI). Research in Developmental Disabilities, 32, 176–179.CrossRefPubMedGoogle Scholar
  30. Matson, J. L., LoVullo, S. V., Rivet, T. T., & Boisjoli, J. A. (2009). Validity of the autism spectrum disorder-comorbid for children (ASD-CC). Research in Autism Spectrum Disorders, 3(2), 345–357.CrossRefGoogle Scholar
  31. Mazefsky, C. A., Schreiber, D. R., Olino, T. M., & Minshew, N. J. (2014). The association between emotional and behavioral problems and gastrointestinal symptoms among children with high functioning autism. Autism, 18(5), 493–501.CrossRefPubMedGoogle Scholar
  32. Mazurek, M. O., Vasa, R. A., Kalb, L. G., Kanne, S. M., Rosenberg, D., Keefer, A., et al. (2013). Anxiety, sensory over-responsivity, and gastrointestinal problems in children with autism spectrum disorders. Journal of Abnormal Child Psychology, 41(1), 165–176.CrossRefPubMedGoogle Scholar
  33. McElhanon, B. O., McCracken, C., Karpen, S., & Sharp, W. G. (2014). Gastrointestinal symptoms in autism spectrum disorder: a meta-analysis. Pediatrics, 133(5), 872–883.CrossRefPubMedGoogle Scholar
  34. Oliver, C., & Richards, C. (2010). Self-injurious behavior in people with intellectual disability. Current Opinion in Psychiatry, 23(5), 412–416.CrossRefPubMedGoogle Scholar
  35. Owens, J. A., Nobile, C., McGuinn, M., & Spirito, A. (2000). The children’s sleep habits questionnaire: construction and validation of a sleep survey for school-aged children. Sleep, 23(8), 1043–1051.CrossRefPubMedGoogle Scholar
  36. Owens-Stively, J. A. (1987). Self-esteem and compliance in encopretic children. Child Psychiatry and Human Development, 18(1), 13–21.CrossRefPubMedGoogle Scholar
  37. Pierce, K. L., & Schreibman, L. (1994). Teaching daily living skills to children with autism in unsupervised settings through pictorial self-management. Journal of Applied Behavior Analysis, 27, 471–481.CrossRefPubMedPubMedCentralGoogle Scholar
  38. Richdale, A. (2001). Sleep disturbance in children and adolescents with disorders of development: Its significance and management. London: Cambridge University Press.Google Scholar
  39. Richdale, A. L., & Schreck, K. A. (2009). Sleep problems in autism spectrum disorders: prevalence, nature, & possible biopsychosocial aetiologies. Sleep Medicine Reviews, 13(6), 403–411.CrossRefPubMedGoogle Scholar
  40. Schum, T. R., Kolb, T. M., McAuliffe, T. L., Simms, M. D., Underhill, R. L., & Lewis, M. (2002). Sequential acquisition of toilet-training skills: a descriptive study of gender and age differences in normal children. Pediatrics, 109(3), 48–54.CrossRefGoogle Scholar
  41. Shahid, A., Wilkinson, K., Marcu, S., & Shapiro, C. M. (2012). STOP, THAT and One Hundred Other Sleep Scales, Chapter 31: FACES (Fatigue, Anergy, Consciousness, Energy, and Sleepiness). Springer Science+ Business Media, 200, 155-156.Google Scholar
  42. Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity and associated factors in a population-driven sample. Journal of the American Academy Child and Adolescent Psychiatry, 47(8), 921–929.CrossRefGoogle Scholar
  43. Smith, P. S., & Smith, L. J. (1977). Chronological age and social age as factors in intensive daytime toilet training of institutionalized mentally retarded individuals. Journal of Behavior Therapy and Experimental Psychiatry, 8(3), 269–273.CrossRefGoogle Scholar
  44. Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland Adaptive Behavior Scales (2nd ed.). Circle Pines: American Guidance Service.Google Scholar
  45. Szyndler, J. (2007). Toileting problems in a group of children with autism. Child and Adolescent Mental Health, 1(1), 19–25.CrossRefGoogle Scholar
  46. Taylor, A. M., Schreck, K. A., & Mulick, J. A. (2012). Sleep disruption as a correlate to cognitive and adaptive behavior problems in autism spectrum disorders. Research in Developmental Disabilities, 33(5), 1408–1417.CrossRefPubMedGoogle Scholar
  47. Taubman, B. (1997). Toilet training and toileting refusal for stool only: a prospective study. Pediatrics, 99(1), 54–58.CrossRefPubMedGoogle Scholar
  48. Van der Wal, M. F., Benninga, M. A., & Hirasing, R. A. (2005). The prevalence of encopresis in a multicultural population. Journal of Pediatric Gastroenterology and Nutrition, 40(3), 345–348.CrossRefPubMedGoogle Scholar
  49. Varni, J. W., Seid, M., & Kurtin, P. S. (2001). PedsQL™ 4.0: reliability and validity of the pediatric quality of life inventory™ version 4.0 generic core scales in healthy and patient populations. Medical Care, 39(8), 800–812.CrossRefPubMedGoogle Scholar
  50. Varni, J. W., Seid, M., & Rode, C. A. (1999). The PedsQL (TM): Measurement model for the pediatric quality of life inventory. Medical Care, 37(2), 126–139.CrossRefPubMedGoogle Scholar
  51. Williams, K. C., Christofi, F. L., Clemmons, T., Rosenberg, D., & Fuchs, G. J. (2012a). Association of chronic gastrointestinal symptoms with sleep problems may help identify distinct subgroups of autism spectrum disorders. Gastroenterology, 142(5), (Suppl.1)), S-714.CrossRefGoogle Scholar
  52. Williams, K. C., Christofi, F. L., Clemmons, T., Rosenberg, D., & Fuchs, G. J. (2012b). Chronic GI symptoms in children with autism spectrum disorders are associated with clinical anxiety. Gastroenterology, 142(5), (Suppl. 1)), S-79–S-80.CrossRefGoogle Scholar
  53. Williams, K. C., Fuchs, G. J., Furuta, G. T., Marcon, M. A., & Coury, D. L. (2010). Clinical features associated with GI symptoms in autism spectrum disorders (ASD). Gastroenterology, 138(5), (Suppl. 1)), S-74.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.National University of IrelandGalwayIreland
  2. 2.East China Normal UniversityShanghaiChina

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