Toilet Training- There's Method to the Madness!
By: Elizabeth Zeppernick, M.Ed., BCBA, LBA
Behavior Analysts often address toilet training when working with clients with intellectual and developmental disabilities. This can be a skill deficit in early intervention settings, with adolescents and even with adults.
Perez et al. (2020) studied treatment options for addressing toileting skills with children with Autism Spectrum Disorder (ASD). Their purpose was to replicate a study by Greer et al. (2016), who studied toilet training for typically developing children and to assess the extent to which more intensive interventions were necessary for children with ASD.
In their work, which took place in a day support center, Perez et al. (2020) studied 13 children diagnosed with ASD with ages ranging from two to thirteen years old. At the beginning of each week, researchers conducted a preference assessment to determine the children’s top preference for both edible and leisure items to use as rewards for toilet training for the remainder of that week. The study followed the following package:
Phase One- While wearing a pull-up or diaper, the children were assessed for their ‘starting point’ with data being collected on their response to a 90-minute schedule of prompting to the restroom for a three-minute sit and concurrent checks for dampness every 30 minutes. After five sessions with no change to the data, Phase Two of the treatment protocol was introduced.
Phase Two- The children were changed into underwear when they arrived at the center. They were brought to the restroom every 30 minutes and were required to sit for three minutes, receiving checks for dryness before every toilet-sit. They received verbal praise and access to their preferred leisure item for 30 seconds in addition to one preferred edible if they were dry during the scheduled check, if they urinated on the toilet and if they self-initiated the toilet-sit. Mastery of Phase Two was considered to be no accidents for at least three consecutive days at the center.
Phase Three- For children who did not reach mastery in Phase Two, an individualized plan was developed. This entailed a more detailed analysis of the times of day the accidents were occurring so that a denser or more frequent schedule of toilet-sits could be implemented. For two children, the more intensive approach included putting a potty chair into the therapy room for easier access and to limit the transition time to the actual restroom. For all children who required the more intense approach of this last phase, the schedule was gradually reduced and the potty chair was gradually removed so that they transitioned back to the more general intervention described in Phase Two.
After the children reached mastery (three consecutive days at the center without accidents), the schedule of planned sittings was stretched to longer periods of time and the rate of reinforcement (praise, edibles, and leisure items) was also thinned or reduced over time. For those who demonstrated a back-slip in skills, the schedule was returned to more frequent trips with more reinforcement until they could advance again to the next level of training.
With the intervention described above, in the study conducted by Perez et al. (2020), 12 out of 13 children successfully demonstrated daytime continence or a lack of accidents with urination. Only two of the children required the more intensive level of training described in Phase 3. It is important to note that, although it wasn’t the focus of the study, the majority of the children also improved their rate of self-initiation to use the restroom and demonstrated increased continence with bowel movements by the end of the study. In addition, although training occurred only at the center, several caregivers reported that they saw increased independence with toileting in the home which shows the valuable generalization of this training across settings and caregivers.
Appropriate toileting skills are essential for dignity, inclusion in the community, and general quality of life for the individual and caregivers. The study described herein outlines one effective treatment protocol for teaching these skills to our clients and loved ones with intellectual and developmental disabilities.
Sources:
Greer, B. D., Neidert, P. M., & Dozier, C. L. (2016). A component analysis of toilet‐training procedures recommended for young children. Journal of Applied Behavior Analysis, 49(1), 1– 16. https://doi.org/10.1002/jaba.275
Perez, B.C., Bacotti, J.K., Peters, K.P. & Vollmer, T.R. (2020). An extension of commonly used toilet-training procedures to children with autism spectrum disorder. Journal of Applied Behavior Analysis, Advance online publication. Retrieved from https://doi.org/10.1002/jaba.727
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