By Matt Harrington, BCBA · Behaviorist Book Club · April 2026 · 12 min read

Bowel Movement Difficulties and Evidence-Based Toilet Training: A Clinical Guide for Behavior Analysts

Overview & Clinical Significance

Toileting — and specifically bowel training — is among the most frequently requested and clinically demanding services that behavior analysts provide in school and home settings. While urinary continence training has received substantial attention in both the literature and in practitioner training programs, bowel training and the management of defecation-related difficulties present distinct challenges that are often underaddressed in BCBA preparation programs.

Constipation is highly prevalent in school-age children, affecting approximately one-third of children between four and eleven years old, with five percent experiencing chronic constipation lasting more than six months. In children with autism, gastrointestinal difficulties including constipation and functional bowel disorders occur at even higher rates than in the general population, with some estimates suggesting that up to 70 percent of autistic children experience significant GI symptoms. These medical factors interact directly with the behavioral aspects of toilet training in ways that behavior analysts must understand to avoid implementing behavioral interventions that are contraindicated by an underlying medical condition.

The Azrin and Foxx rapid toilet training method, developed in the early 1970s, established a behavioral foundation for toilet training that has been widely adapted and applied across populations for more than five decades. Behavior analysts working in special education and early intervention contexts are regularly asked to design and oversee toilet training programs, manage regression, and troubleshoot cases where standard procedures are not producing expected progress.

The clinical significance of this topic extends beyond functional skill acquisition. Toileting difficulties are a major source of caregiver distress, restrict social participation and educational access, and can lead to school refusal, social isolation, and significant hygiene and health complications. Behavior analysts who are competent in this area address a genuine need that overlaps the domains of behavior science, pediatric health, and family quality of life.

Background & Context

Azrin and Foxx's 1971 study on dry pants training established the prototype for behavioral toilet training: intensive schedules of trips to the toilet, positive reinforcement for successful elimination, mild correction procedures for accidents, and graduated independence as the child demonstrates competence. Their subsequent 1974 book made these methods accessible to parents and practitioners and drove widespread adoption. Subsequent research has refined and adapted these procedures for children with intellectual disabilities, autism, and complex medical histories.

Functional constipation — the most common form of constipation in children — is defined by the Rome IV criteria as a functional disorder involving infrequent, hard, or painful stools, often accompanied by fecal retention and sometimes stool withholding. Stool withholding is a particularly important concept for behavior analysts because it has both a physiological component (the retained stool becomes harder and larger, making defecation more painful and increasing avoidance) and a behavioral component (escape from the aversive experience of painful defecation reinforces withholding behavior). The two components create a self-perpetuating cycle that behavioral interventions alone cannot fully address.

Encopresis — the passage of feces in inappropriate locations, typically occurring as a consequence of fecal impaction and overflow incontinence — is a related condition that behavior analysts may encounter in school-based practice. Encopresis is primarily a medical condition requiring medical management as the first line of treatment; behavioral interventions support the treatment protocol but cannot substitute for appropriate medical evaluation and intervention.

For children with autism, toilet training is complicated by the presence of sensory sensitivities, communication differences, ritualistic behavior around toileting routines, and the high rates of GI comorbidities already noted. Behavioral toilet training programs for autistic children typically require more individualization, longer training timelines, and closer collaboration with medical providers than programs for typically developing children.

Clinical Implications

Before implementing any behavioral toilet training program, behavior analysts should conduct a thorough assessment that includes medical history and current GI status. The BACB Ethics Code (2022) Section 2.03 requires that behavior analysts recommend seeking professional consultation from other disciplines when such consultation is in the best interest of the client. For toileting cases with any indication of constipation, pain during defecation, unusual stool patterns, or suspected medical involvement, a referral to the child's pediatrician or a pediatric gastroenterologist is not optional — it is ethically required.

For children without significant medical complications, a behavioral toilet training program based on Azrin and Foxx's foundational procedures remains the evidence-based starting point. Key components include: a schedule of regular toilet sits at biologically appropriate intervals (typically every 30-60 minutes), differential reinforcement of successful elimination with highly preferred reinforcers, brief and neutral correction procedures for accidents without unnecessary emotional response, and active practice trials following accidents to build the skill of traveling to the toilet and completing elimination there.

For bowel training specifically, additional considerations apply. The timing of bowel movements is substantially influenced by biological rhythms — the gastrocolic reflex, for example, typically produces colonic activity 20-30 minutes after eating. Scheduling toilet sits following meals (especially breakfast) capitalizes on this biological pattern and can significantly increase the rate of successful bowel elimination during toilet sits.

Stool withholding behavior requires a multicomponent approach. Modifying the antecedent conditions — diet, fluid intake, physical activity, and in consultation with the physician, stool softeners to reduce the aversive properties of defecation — is often necessary before behavioral intervention can gain traction. Simply reinforcing toilet sitting or placement is insufficient if defecation itself remains highly aversive due to pain or fear.

Data collection is essential and should capture the frequency, location, and approximate time of urinations and bowel movements across all settings. This level of data allows the behavior analyst to identify patterns, track progress, detect regressions, and adjust the schedule of toilet sits with precision rather than guesswork.

Ethical Considerations

Toilet training involves intimate physical assistance with bodily functions, making it one of the most sensitive areas of ABA service delivery from a dignity and rights standpoint. The BACB Ethics Code (2022) Section 2.07 requires behavior analysts to treat clients with dignity and respect their right to privacy. Toilet training procedures must be implemented with explicit attention to the child's comfort, physical safety, and dignity throughout the process.

Informed consent for toilet training programs should be thorough and specific. Caregivers should understand the procedures that will be used — including any correction procedures, the use of scheduled sits, what will happen during accidents, and how success will be reinforced — before the program begins. For school-based programs, consent from parents or guardians is required, and the program should be communicated to educational team members who will be involved in implementation.

The use of any aversive procedure during toilet training — including overcorrection, positive practice, or scheduled sitting that involves physical prompting on the toilet — requires careful justification, documentation of the least restrictive alternatives considered, and ongoing monitoring for side effects. Physical guidance toward or onto the toilet should be implemented with the least amount of physical contact necessary and should be faded as quickly as the child's responsiveness permits.

Behavior analysts must be alert to signs that a toileting difficulty has a medical basis that has not been adequately assessed. Proceeding with behavioral toilet training when a medical condition is undiagnosed or untreated could cause harm. The Ethics Code (2022) Section 2.03 and the broader obligation to act in the client's best interest both point toward consultation with medical professionals when clinical indicators suggest a health component.

Confidentiality considerations are also relevant. Toileting data, medical history, and descriptions of bathroom behavior are sensitive personal information. BCBAs should handle this documentation with appropriate care, limit access to those with a need to know, and store records securely.

Assessment & Decision-Making

A comprehensive toileting assessment covers multiple domains. Medical history should document any GI diagnoses, medications that affect bowel function, dietary habits, fluid intake, and prior toilet training attempts and their outcomes. Behavioral history should capture the child's current toileting skills (can they indicate need, manage clothing, complete the act independently, flush, wash hands), the environments where training has been attempted, and the consistency of caregiver implementation.

Baseline data collection is essential before beginning any training program. A minimum of three to five days of baseline tracking — recording the time and location of all urinations and bowel movements — provides the foundation for scheduling toilet sits at the intervals most likely to produce success, identifies patterns in timing, and establishes the comparison point for evaluating training effects.

Readiness assessment for bowel training specifically should address: the child's awareness of the urge to defecate (or observable behavioral indicators of that awareness), the presence or absence of stool withholding behavior, the consistency of the child's stool, and the frequency of bowel movements. Children who are currently withholding stools due to pain or fear are not ready for behavioral bowel training without concurrent medical management of the underlying aversive condition.

Decision-making during training should be driven by data. If a child is not producing successful eliminations on the toilet after a specified number of training days, the BCBA should review: whether the toilet sit schedule is aligned with the child's biological patterns, whether the reinforcers being used are actually preferred, whether medical factors are interfering, and whether implementation fidelity is adequate. Each of these variables requires a different response.

Regression — a return to accidents after a period of independent toileting — requires its own assessment. Regression is commonly associated with environmental change, illness, dietary change, increased stress, or the transition to a new setting such as a new school or home. Brief retraining protocols based on the original successful procedures are typically effective when regression is situational rather than medically driven.

What This Means for Your Practice

BCBAs designing toilet training programs must approach each case as an integration of behavioral and medical factors. The most common clinical error in this area is implementing a purely behavioral program without adequate medical screening — a mistake that can delay resolution and in some cases cause harm when the underlying issue is constipation, GI pain, or a medical condition that responds to treatment.

Practically, this means building strong communication channels with the child's medical providers from the outset of every toilet training case. A brief consultation letter describing the behavioral program and requesting information about any GI concerns is appropriate standard practice. When medical providers identify constipation or other GI issues, the behavioral program should be paused or modified until medical management is underway and the aversive properties of defecation are reduced.

For school-based BCBAs, toilet training requires close coordination with educators and paraprofessionals who will implement the program during school hours. Written protocols with clear instructions for toilet sit schedules, data collection, reinforcer delivery, and accident procedures are essential. Training and performance feedback for school staff on these procedures should be documented.

Caregiver coaching is integral to generalization. Parents and family members must implement consistent procedures across home, community, and other settings for the skill to fully generalize. BCBAs should provide clear written protocols, demonstrate procedures directly, observe caregiver implementation, and provide specific and supportive feedback.