White Paper: Autism

Executive Summary

Bathroom participation is a fundamental occupation that supports health, hygiene, independence, dignity and quality of life. For many individuals with autism, however, using the bathroom can present challenges due to the complex interaction between sensory processing differences, interoception, motor planning, executive functioning, communication, emotional regulation and the physical environment.

Occupational therapists are uniquely positioned to understand these challenges because they consider not only the individual’s abilities, but also the demands of the occupation and the environment in which it takes place. Using the Person–Environment–Occupation (PEO) model, therapists can identify barriers to participation and develop practical, person-centred solutions that promote independence whilst respecting each individual’s strengths, preferences and sensory needs.

This white paper explores the relationship between autism and bathroom participation through an occupational therapy lens. It brings together current evidence, clinical reasoning and practical guidance to support healthcare professionals, educators, housing providers, families and assistive device providers, in creating more accessible and neuroaffirming bathroom environments.

The document examines the sensory, cognitive, motor and environmental demands associated with toileting and personal hygiene, highlighting how factors such as lighting, acoustics, temperature, visual complexity, layout and predictability can influence occupational performance. It also outlines evidence-informed approaches to assessment, intervention and environmental adaptation, demonstrating how changes can reduce sensory load, simplify task demands and increase participation.

Whilst environmental modifications and structured routines often form the foundation of intervention, some individuals continue to experience barriers to independence, particularly in relation to personal hygiene. In these circumstances, assistive technology may play an important role in reducing physical effort, simplifying task sequences and promoting greater autonomy and dignity.

This paper explores the clinical reasoning behind considering technologies such as wash and dry toilets as part of a comprehensive occupational therapy intervention, emphasising that equipment should always be recommended following individual assessment rather than as a standalone solution.

Ultimately, this white paper advocates for a shift in perspective. Rather than asking individuals with autism to adapt to environments that do not meet their needs, it encourages professionals to design bathrooms, routines and supports that better meet the needs of the individual.

Introduction

Most people rarely think about what is involved in using the bathroom. It is an activity that becomes so familiar, it is often completed automatically. However, from an occupational therapy perspective, bathroom participation is a complex occupation of daily living, requiring the integration of sensory processing, motor skills, executive functioning, communication, interoception and emotional regulation within a physically demanding environment.

Bathroom routines require individuals to interpret internal body signals, transition away from another activity, sequence multiple steps, manage clothing, maintain balance, complete personal hygiene and adapt to a range of sensory experiences, all whilst maintaining privacy and dignity. These demands are often underestimated but are essential for promoting health, independence and participation.

For individuals with autism, the bathroom can present a unique combination of sensory, cognitive and environmental challenges. Bright lighting, echoes, extractor fans, unfamiliar smells, cold surfaces, visual clutter and unpredictable public bathrooms, can all contribute to sensory overload. At the same time, differences in executive functioning, motor planning, communication and interoception may increase the effort required to complete what appears to be a simple routine.

Occupational therapists are uniquely positioned to understand the interaction between the individual, the environment and the demands of the occupation. Drawing upon current evidence, occupational therapy models of practice and clinical experience, the document provides practical guidance for assessing bathroom environments, reducing sensory barriers, implementing person-centred interventions and considering the role of assistive technology, when appropriate.

Understanding Autism through an Occupational Therapy lens

Autism is a lifelong neurodevelopmental difference that influences how an individual experiences, understands and interacts with the world around them. Every individual with autism is unique, with their own strengths, interests, communication styles, sensory preferences and support needs. Occupational therapists consider how these characteristics influence participation in everyday occupations, including self-care, education, leisure and community life.

From an occupational therapy perspective, it is important to recognise that autism itself is not a barrier to participation. Rather, challenges often arise when there is a mismatch between an individual’s needs and the demands of the environment or occupation.

The following sections explore the occupational performance components most commonly influencing bathroom participation for individuals with autism.

Sensory Processing

Many individuals with autism experience sensory information differently. Some may be hypersensitive to sounds, lights, smells or touch, whilst others may seek additional sensory input or have reduced awareness of certain sensations, and some, a combination of all of the above. Bathrooms are naturally rich in sensory experiences, including bright lighting, echoes, flushing toilets, extractor fans, tiled surfaces, temperature changes and strong cleaning product odours.

For some individuals, these sensory experiences can become overwhelming, making it difficult to participate comfortably or confidently in bathroom routines. Others may actively seek particular sensory experiences, such as running water or deep pressure, which can also influence bathroom behaviour.

Understanding an individual’s sensory profile allows occupational therapists to identify environmental barriers and develop strategies that reduce sensory load whilst promoting participation.

Executive Functioning

Bathroom routines place significant demands on executive functioning. Individuals are required to initiate the activity, transition away from another task, remember each stage of the routine, complete the steps in the correct order and return to their previous activity.

For individuals with autism, differences in planning, sequencing, working memory, cognitive flexibility and organisation may make these demands particularly challenging. Breaking routines into smaller steps, using visual supports and creating predictable sequences can significantly reduce cognitive load and increase successful participation.

Motor Planning and Coordination

Successful bathroom participation depends upon coordinated and sustained movement. Tasks such as managing clothing, transferring on and off the toilet, sustaining an upright posture on the toilet while relaxing bowels and bladder, reaching for toilet paper, wiping effectively and washing hands; require postural control, balance, bilateral coordination and motor planning.

Where motor planning or coordination is difficult, individuals may require additional time, physical support or environmental adaptations to complete these activities safely and independently.

Interoception

Interoception refers to the ability to recognise and interpret internal body signals, such as hunger, thirst, pain, temperature and the need to use the toilet.

For some individuals with autism, these internal sensations may be difficult to recognise or interpret, making it challenging to identify when the bladder or bowel is full or when personal hygiene has been completed effectively. Reduced interoceptive awareness can therefore have a significant impact on continence, toileting routines and independence.

Supporting interoceptive awareness often requires consistent routines, repeated learning opportunities and a focus on helping individuals recognise and respond to their own body signals.

Communication

Communication differences may also influence bathroom participation. Some individuals may find it difficult to express that they need the toilet, ask for help or communicate discomfort within the bathroom environment. Others may communicate effectively using gestures, signs, visual supports or augmentative and alternative communication (AAC).

Occupational therapists work collaboratively with speech and language therapists, families and educators to ensure communication methods are understood and integrated into bathroom routines, enabling individuals to express their needs in ways that are meaningful to them.

Emotional Regulation

Bathrooms can become emotionally demanding environments, particularly if previous experiences have been associated with discomfort, anxiety or sensory overload. Unexpected changes to routine, unfamiliar public toilets or concerns around privacy, may further increase stress and reduce willingness to participate.

Supporting emotional regulation involves creating environments that feel safe, predictable and responsive to the individual’s needs. Reducing uncertainty, providing preparation before transitions and respecting sensory preferences can all contribute to more positive bathroom experiences.

Understanding the occupational demands of bathroom participation

For most people, using the bathroom is an automatic part of everyday life. The sequence of recognising the need to use the toilet, managing clothing, completing personal hygiene and washing hands, often occurs without conscious thought. However, bathroom participation is a demanding activity of daily living.

Importantly, every bathroom is different. Variations in lighting, noise, layout, temperature, space and equipment, mean that no two bathroom experiences are exactly the same. For individuals with autism, these changing environmental demands can increase uncertainty and make it more difficult to develop confidence and independence across different settings.

The Bathroom: A High-Demand Occupational Environment

The bathroom combines multiple occupational demands simultaneously. During a typical toileting routine, an individual may be required to:

• Recognise internal body signals indicating the need to use the toilet.
• Transition away from another activity.
• Navigate safely to the bathroom.
• Manage clothing.
• Transfer safely on and off the toilet.
• Maintain postural control and balance.
• Complete personal hygiene.
• Wash and dry hands.
• Return to their previous activity.

Each step requires the integration of multiple performance skills, often while responding to unfamiliar sensory experiences and maintaining privacy and dignity.

Why This Matters

When viewed as a whole, bathroom participation is far more than completing a toileting task. It represents the interaction of multiple occupational performance components occurring within a challenging environment. This shift in thinking forms the foundation of person-centred, neuroaffirming occupational therapy practice and guides the assessment, intervention and environmental recommendations explored throughout the remainder of this white paper. Please see in the image below the multiple skills required for bathroom participation.

The Bathroom Routine: A Task Analysis Journey

Multiple skills are required at each step to support successful bathroom participation.

Looking beyond the toilet

Occupational therapy assessment extends beyond determining whether an individual can independently complete a toileting routine. Instead, assessment seeks to understand why challenges occur by exploring the interaction between the person, the environment and the occupation.

The aim is to identify opportunities to improve occupational performance through person-centred intervention, environmental adaptation and, where appropriate, assistive technology.

Assessment Framework

A holistic assessment should consider three key components:

Gathering Information

A comprehensive assessment combines information from multiple sources.

Assessment should occur across environments whenever possible, recognising that bathroom participation may vary between home, school and community settings.

Clinical Observation and Task Analysis

Observation provides valuable information that may not emerge during interviews alone. Breaking the toileting routine into individual steps allows therapists to identify precisely where difficulties occur.

Each step can then be analysed according to:

• Motor demands
• Cognitive demands
• Sensory demands
• Communication requirements
• Environmental barriers
• Level of assistance

This detailed analysis supports highly targeted intervention planning.

Environmental Assessment

The bathroom itself should be viewed as an integral part of the assessment.

Questions to consider include:

• Is the lighting comfortable?
• Are there unexpected noises?
• Is the layout intuitive?
• Is equipment positioned within reach?
• Is there enough space for movement?
• Are colours and patterns visually overwhelming?
• Does the environment support predictability?
• Can the individual complete tasks safely?

Often, small environmental modifications can have a significant impact on occupational performance.

Sensory Assessment

Understanding an individual’s sensory profile is a fundamental component of occupational therapy assessments. Rather than identifying sensory differences in isolation, the assessment should explore how sensory processing influences occupational performance during bathroom routines and personal hygiene activities.

Information should be gathered through collaborative discussions with the individual (where appropriate), families, caregivers, alongside direct observation across environments. Particular attention should be paid to sensory experiences that may influence participation, including auditory, visual, tactile, olfactory, vestibular, proprioceptive and interoceptive processing.

Where appropriate, standardised assessments may be used to support clinical reasoning, including:

• Sensory Profile 2 (Dunn)
• Sensory Processing Measure (SPM)
• Adolescent/Adult Sensory Profile

The aim is to understand how their sensory preferences influence bathroom participation and what environmental adaptations or sensory strategies may support successful engagement.

Occupational Therapy Models of Practice

Occupational therapy models provide a structured framework for understanding occupational performance and guiding clinical reasoning. Rather than focusing solely on impairments, these models encourage therapists to consider how the individual, the environment and the occupation interact to influence participation.

Person–Environment–Occupation (PEO) Model

The Person–Environment–Occupation (PEO) model is particularly valuable when assessing bathroom participation because it recognises that occupational performance is influenced by the interaction between three key components:

• Person – physical, cognitive, sensory and emotional characteristics.
• Environment – the physical, sensory, social and cultural context.
• Occupation – the demands of bathroom routines and personal hygiene tasks.

Occupational performance improves when there is a good fit between these three elements. Difficulties often arise when there is a mismatch.

The PEO model provides a useful framework for identifying barriers and developing interventions that target not only the individual, but also the occupation and the environment.

Model of Human Occupation (MOHO)

The Model of Human Occupation (MOHO) complements the PEO model by exploring how motivation, habits, abilities and environmental influences affect occupational participation.

Within bathroom routines, MOHO encourages occupational therapists to consider:

• Volition – Does the individual understand the importance of the task? What motivates them?
• Habituation – Are bathroom routines consistent, predictable and well established?
• Performance Capacity – What physical, cognitive and sensory abilities influence task performance?
• Environment – How do the physical and social environments support or hinder participation?

Considering these components helps therapists understand why an individual may engage successfully in one environment but experience difficulties in another, supporting the development of person-centred interventions.

Goal Setting

Sensory-friendly bathroom design

The physical environment plays a fundamental role in shaping bathroom participation. For individuals with autism, environmental characteristics can either support independence or create unnecessary sensory, cognitive and emotional barriers.

Sensory-friendly bathroom design focuses on designing environments that are predictable, calming, accessible and adaptable to a range of sensory preferences and functional abilities. Small, thoughtful environmental changes can reduce anxiety, simplify routines and promote greater independence, participation and dignity. Occupational therapists play an important role in identifying environmental barriers and recommending practical adaptations that improve the fit between the individual, the environment and the occupation. Working collaboratively with families, architects, housing providers and manufacturers enables bathroom environments to support meaningful, occupational performance, rather than creating additional challenges.

Sensory-friendly Bathroom Checklist

Small changes can make a big difference

Intervention Planning

Effective intervention begins with understanding the individual’s strengths, goals and occupational priorities. Following a comprehensive assessment, occupational therapists develop interventions that reduce barriers to participation by addressing the interaction between the person, the environment and the occupation.

Successful intervention is highly individualised and should reflect each person’s sensory profile, motor abilities, communication style, cognitive strengths and support needs. Equally, intervention should recognise the importance of dignity, autonomy and choice, ensuring that support is meaningful, respectful and individual.

Intervention planning should aim not only to increase independence with bathroom routines, but also to improve confidence, predictability, emotional regulation and participation across home, school and community environments. Please see the following adaptations below:

✔ Environmental Adaptations

Creating bathroom environments that support participation, independence and dignity.

✔ Sensory Strategies

Supporting regulation and reducing sensory barriers during bathroom routines.

✔ Routine Supports

Structure and predictability help reduce anxiety and support independence during bathroom routines.

✔ Family Education

Empowering families with knowledge and strategies to support independence at home.

✔ Skill Development

Building the skills needed for independence through structured teaching and practice.

Some individuals may continue to experience barriers despite environmental adaptation and therapy intervention alone. In these situations, assistive technology may further enhance independence, reduce support requirements and improve dignity. The role of wash and dry toilets, including the Closomat system, is explored in the next section.

Assistive technology

Assistive technology can play an important role in supporting bathroom participation by reducing physical, sensory and cognitive barriers that may limit independence. Within occupational therapy, assistive technology is not viewed as a replacement for skill development or environmental adaptation, but rather as one component of a holistic intervention plan.

When carefully matched to the individual, this has the potential to increase independence, improve hygiene, reduce caregiver support and promote dignity.

What is a Wash and Dry Toilet?

A wash and dry toilet is an assistive technology that combines the functions of a toilet, bidet and warm-air dryer into a single unit. Following toileting, the system automatically flushes, cleans using warm water and dries with warm air, reducing or removing the need for manual wiping.

Unlike traditional toileting, which relies on reaching, balance, fine motor coordination and sequencing multiple hygiene steps, a wash and dry toilet simplifies the personal hygiene component of the toileting routine. This has the potential to reduce physical demands, improve consistency and support greater independence.

Why might this be beneficial for individuals with autism?

For some individuals with autism, difficulties with bathroom participation are not solely related to toileting itself, but to the combination of sensory processing differences, executive functioning challenges, motor coordination, interoception and anxiety that influence successful completion of the routine.

A wash and dry toilet may reduce these barriers by:

• Simplifying the number of task steps required to complete personal hygiene.
• Reducing the fine motor and postural demands associated with wiping.
• Decreasing the need for reaching, twisting and balance adjustments.
• Reducing tactile discomfort for individuals who find wiping aversive.
• Increasing privacy by reducing reliance on caregiver assistance.
• Supporting greater independence and dignity.

Clinical Reasoning

A wash and dry toilet should not be viewed as the first intervention for every individual. Instead, occupational therapists should consider this type of equipment when barriers remain despite appropriate environmental adaptations, sensory strategies and skill development.

The decision should always be collaborative, involving the individual, their family or caregivers and the wider multidisciplinary team where appropriate.

When might an OT consider a wash and dry toilet?

A wash and dry toilet may be appropriate when assessment identifies ongoing barriers despite environmental adaptations, sensory strategies and skill development.

Clinical indicators may include:

• Ppersistent dependence on others for personal hygiene.
• Significant fine motor or motor planning difficulties affecting wiping.
• Poor balance or postural control during toileting.
• Reduced body awareness or difficulty reaching the perineal area.
• Sensory distress associated with toilet paper or manual wiping.
• Executive functioning difficulties affecting sequencing and completion of hygiene routines.
• Goals focused on increasing independence, privacy and dignity.

Autism-Specific Considerations

Additional accessories and postural support systems

For some individuals with autism, particularly those with co-occurring physical disabilities, hypotonia, motor coordination difficulties or postural instability, a wash and dry toilet may be most effective when combined with additional postural support equipment.

Occupational therapists should consider not only the individual’s ability to complete personal hygiene, but also their sitting posture, stability, balance and safety throughout the toileting routine. Appropriate support systems can improve comfort, reduce physical effort and enable more effective participation in personal care tasks.

Fixed Support Systems

Fixed support systems, such as lateral body supports and drop-down supports, can provide additional trunk stability for individuals who have reduced postural control, muscle weakness or poor core stability.

These supports may:

• Improve sitting balance during toileting.
• Reduce the physical effort required to maintain an upright posture.
• Increase feelings of safety and security.
• Free the upper limbs for functional activities, such as operating the toilet controls or adjusting clothing.
• Improve positioning for bladder and bowel evacuation and personal hygiene.
• Adjustable footplates.

Foot support

Appropriate foot support is often overlooked but plays an important role in both toileting posture and sensory regulation.

Where an individual’s feet do not make firm contact with the floor, a footplate or footstool should be considered to provide a stable base of support. Alternatively, adjusting the toilet height, if installing an adapted wash and dry toilet, mentioned above.

For autistic individuals, appropriate foot support may:

• Improve postural stability.
• Increase body awareness and proprioceptive feedback.
• Promote relaxation of the pelvic floor muscles.
• Improve comfort and confidence during toileting.

Providing a stable sitting position may reduce the effort required to maintain balance, allowing the individual to focus more effectively on completing the toileting routine.

Looking ahead

Occupational therapy continues to evolve alongside advances in research, technology, inclusive design and neuroaffirming practice. As the understanding of autism grows, there is increasing recognition that successful bathroom participation is influenced not only by an individual’s abilities but also by the environments, products and systems designed to support them.

Future developments should continue to prioritise meaningful participation, autonomy and dignity by creating bathroom environments that are flexible, accessible and responsive to individual needs. Collaboration between occupational therapists, autistic individuals, families, designers, manufacturers, architects and researchers will be essential in achieving this goal.

Neuroaffirming Practice

As occupational therapy practice continues to evolve, there is increasing emphasis on neuroaffirming approaches that recognise and respect neurodiversity.

Within bathroom participation, this means:

• Respecting sensory preferences rather than encouraging individuals to tolerate distressing experiences.
• Providing choices wherever possible.
• Collaborating with autistic individuals and families when setting goals and developing interventions.
• Recognising that independence may look different for different people.
• Focusing on meaningful participation rather than conformity.

Final Reflections

Bathroom participation is far more than the ability to complete a toileting task. It is an occupation that influences health, well-being, confidence, social participation and quality of life. For autistic individuals, successful bathroom participation often depends upon understanding the interaction between sensory processing, motor skills, executive functioning, emotional regulation and the physical environment.

As research, technology and inclusive design continue to advance, there is an opportunity to rethink how bathroom environments are designed and how assistive technology is integrated into occupational therapy practice. By combining evidence-informed practice with collaboration, innovation and neuroaffirming principles, we can create bathroom environments that support greater independence, dignity and participation for autistic individuals across the lifespan.

References

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• Skillicorn, B. (2025). Impact of the Messy Chef Program in expanding foods tolerated by primary-aged autistic children based on parental reports (Master’s dissertation, University of Birmingham).
• Stacey, N., Turtle, B., & Daly-Lynn, J. (2026). An Investigation of Factors Affecting Bowel Movement Hygiene in Autistic Children. Occupational Therapy International, 2026, Article 5464138. https://doi.org/10.1155/oti/5464138

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