Toilet Training Children With Autism and Developmental Delays - An Effective Program For School Settings

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The document describes a study that evaluated a public school-based toilet training procedure for children with autism or developmental delays implemented by paraprofessional staff with minimal clinical support. The procedure was effective across all 5 cases in increasing continent voids and bladder control.

The goal of the study was to explore the effectiveness of a formal toileting procedure to increase continent voids as well as bladder control for expanded periods of time in a public school program with minimal clinical oversight.

The procedure included: removal of diapers during school hours, scheduled time intervals for bathroom visits, a maximum of 3 min sitting on the toilet at each visit, positive reinforcement of urination in the toilet, and gradually increasing time intervals for bathroom visits as each student progressed through training.

Toilet Training Children With Autism and Developmental Delays:

An Effective Program for School Settings


Michael A. Cocchiola, Jr., Gayle M. Martino, Lisa J. Dwyer, and Kelly Demezzo
Capitol Region Education Council:
CREC River Street Autism Program

ABSTRACT
Current research literature on toilet training for children with autism or
developmental delays focuses on smaller case studies, typically with con-
centrated clinical support. Limited research exists to support an effective
school-based program to teach toileting skills implemented by public
school staff. We describe an intervention program to toilet train 5 children
with autism or developmental delays who demonstrated no prior success in
the home or school setting. Intervention focused on (a) removal of diapers
during school hours, (b) scheduled time intervals for bathroom visits, (c) a
maximum of 3 min sitting on the toilet, (d) reinforcers delivered immedi-
ately contingent on urination in the toilet, and (e) gradually increased time
intervals between bathroom visits as each participant met mastery during
the preceding, shorter time interval. The program was effective across all
5 cases in a community-based elementary school. Paraprofessional staff
implemented the program with minimal clinical oversight.
Keywords: autism, paraprofessional staff, school setting, toilet training

S kill deficits in the areas of self-help


may be a significant hurdle for
people diagnosed with autism and
other developmental disabilities. Indeed,
toilet training for children with devel-
A seminal article written by Azrin and
Foxx remains a staple in current practice
for toilet training; more recent literature
follows the underpinnings of their find-
ings though points toward less focus on
Even with the vast body of informa-
tion available regarding toilet training,
there are few studies that deal directly
with the issue of toilet training in school
settings (see Luiselli, 1997) and even
opmental disabilities was (Konarski & the concept of rapid training and instead fewer that remove direct, ongoing
Diorio, 1985) and continues to be one of concentrates on a durable life skill read- clinical support during training. This
the most frequently researched self-help ily implemented in nonclinical settings study evaluated a public school-based
skills. Blum, Taubman, and Nemeth (Cicero & Pfadt, 2002; Kroeger & toilet training procedure implemented
(2004) defined effective daytime toilet Sorensen-Burnworth, 2009; Kroeger & by paraprofessional staff with minimal
training as when a child has less than four Sorensen, 2010; LeBlanc, Carr, Crossett, clinical support. The goal of the study
wetting accidents per week. For the vast Bennett, & Detweiler, 2005; Stadtler, was to explore the effectiveness of a
majority of typically developing children Gorsky, & Brazelton, 1999). formal toileting procedure to increase
in the United States, 98%, meet this Since the inception of The continent voids as well as bladder
criterion by their third birthday (Blum, Individuals with Disabilities Education control for expanded periods of time in
Taubman, & Nemeth, 2003). Act, 2004 (IDEA; U.S. Department of a public school program with minimal
The field of applied behavior Education, 2004), school districts are clinical oversight. The procedure in-
analysis provides an ample body of required to teach skills that are beyond cluded multiple components, including
literature that spans over four decades the scope of straightforward academic the following: removal of diapers during
and describes effective toilet training goals; a focus on and accountability for school hours, a scheduled time interval
programs in applied settings. Early functional life skills is a requirement as for bathroom visits, a maximum of 3
models (e.g., Azrin & Foxx, 1974; Van well. Education of children who require min sitting on the toilet at each visit,
Wagenen, Meyerson, Kerr, & Mahoney, specialized services needs to address positive reinforcement of urination in
1969) relied on intense yet short periods broad issues of learning including adap- the toilet, and gradually increasing time
of intervention coupled with direct tive skills that support inclusion (Bryson, intervals for bathroom visits as each
clinical support to maximize learning. Rogers, & Fambonne, 2003). student progressed through training.

60 TOILET TRAINING CHILDREN WITH AUTISM Behavior Analysis in Practice, 5(2), 60-64
was provided, which was separated into 30-min increments
Method each day (go to http://www.abainternational.org/Journals/
bap_supplements.asp for a copy of the data sheet). Staff
Participants and Settings documented the occurrence of urination immediately in the
Participants were 5 boys ranging in age from 3 to 5 years cell corresponding with the time of day. The coded format on
old and were diagnosed with either autism or a developmental the scatter plot included C for correct, A for accident, and I for
delay (see Table). None of the participants demonstrated urinary incomplete. Correct was defined as the release of urine while
continence, even though parents reported at least one attempt seated on the toilet. Accident was defined as release of urine at
to teach toileting skills at home, and the school also attempted any other location. Incomplete was defined as when the child
to toilet train the participants. All 5 participants were assigned neither urinated in the toilet nor had an accident during a 30-
to the same preschool classroom, intended to deliver services to min interval. At the end of each day, the percentage correct was
children identified with autism or developmental delays. determined by a simple C/A+C equation (number correct over
All participants were enrolled in a preschool setting in the number correct plus accidents). This allowed for a simple
Connecticut and had active individualized educational plans conversion to a percentage correct per day.
(IEPs) in place. Their school day consisted of direct instruc- The data collected also allowed for detection of reliable times
tion as well as inclusionary time with peers, based on each each participant was more likely to produce urine throughout
participant’s ability and individual needs. The classroom had the day. These data were readily available by plotting the times
an assigned special education teacher, and each participant had of the day over a more extended period of time (e.g., 1 week or
1:1 support throughout the day. The 1:1 staff held at least an longer) and determining a pattern of urination.
associate’s degree and received ongoing training and oversight
Interobserver Agreement and Program Fidelity
from a Board Certified Behavior Analyst (BCBA). The partici-
pants attended school 5 days per week, 6 hours per day. A second observer collected data for the purpose of assess-
The toilet training program occurred in the same preschool ing interobserver agreement (IOA) and participated in an aver-
classroom for each child. The classroom provided a small area age of 37% of all bathroom visits (range, 31% to 45%) across
for discrete trial instruction, a play area, an area for morning all 5 participants during baseline and intervention phases. IOA
circle, and a snack area. A bathroom adjoining the classroom was 100% across all subjects during baseline, intervention, and
had a small toilet designed for preschool-aged children, allowing post-treatment data collection.
for a smooth transition from the classroom into the bathroom Training for paraprofessionals began with a 1-hr in-service
throughout the day. training before the start of the program. This training consisted
of a PowerPoint presentation to explain procedures, a review
Response Definition and Measurement of data collection systems, and role playing of the procedure.
The dependent variable (DV) was the percentage of cor- A BCBA provided didactic training and oversight of the staff
rect urinations in the toilet. Correct urination for the purpose for the first day of program implementation. Following this
of this study was defined as the release of urine while seated on initial training, the consulting BCBA or special education
the toilet. The independent variable was the school-based toilet teacher intermittently completed direct observation of pro-
training program. Assigned 1:1 staff were responsible for all gram implementation, at least weekly. Any steps performed
data collection. Data were generated by recording each child’s incorrectly were reviewed with the direct care staff and cor-
urinary status throughout the day. A monthly scatter plot rected at the time of the observation. The density of clinical

Table. Age, Diagnosis, and Length of Treatment for Each Participant

Age at Onset of Number of School Number of Calendar


Participant Treatment Diagnosis Days for Mastery Days for Mastery
Cal 5 years, 1 month Developmental Delay 65 110

Lou 3 years, 9 months Autism 88 135

Job 4 years, 2 months Autism 46 72

Tom 4 years, 2 months Developmental Delay 51 86

Cam 4 years, 1 month Developmental Delay 32 79

TOILET TRAINING CHILDREN WITH AUTISM 61


support provided was based on the success of each participant. the participant to the bathroom with graduated guidance and
If the child was successful, weekly review of data occurred and social praise for cooperation.
the time between bathroom visits was increased. If the child Bathroom task analysis. Once in the bathroom, staff deliv-
demonstrated limited success, clinical staff more carefully ered verbal cues to move through the program procedures. The
monitored and assessed the effectiveness of reinforcer, accuracy cues included: Go to bathroom, lights on, close door, pants
of the bathroom visit schedule, the clarity of staff prompts, and down, sit on toilet, stay on toilet [as needed], all done [upon
suggested changes as warranted. sound of timer or upon urination], pants up, wash hands,
lights off. Cues were succinct, upbeat, and were posted on the
Preference Assessment
bathroom wall for staff to reference. Social praise followed all
Before the start of intervention, clinical staff interviewed attempts to comply with each step. Once seated on the toilet,
each participant’s parents and direct care staff to identify highly the staff set the timer for 3 min. At the start of the interval,
preferred items for use in the toilet training program. Once the staff held the reinforcer in the participant’s field of vision. In an
team compiled a list of high preference items for each partici- upbeat manner, staff stated, “First pee, then X” (X = reward).
pant, direct preference assessments were conducted (Paclawskyj This statement occurred at least 2 to 3 times during the 3-min
& Vollmer, 1995). The participants had no access to the nomi- interval. Positive social interaction occurred when the par-
nated items outside of the toilet training program. Four of the ticipant remained seated. Staff gently redirected the participant
5 participants selected edible rewards (e.g., M&Ms, crackers, back onto the toilet if needed.
etc.), and one participant selected a handheld, battery-operated Consequences for voiding in the toilet. Staff carefully ob-
spin toy. Access to the toy was limited to 15 s directly following served for any urinary output. If the participant urinated even a
correct urination. drop when on the toilet, staff delivered the reward, enthusiastic
social praise within 0.5 s (e.g., “You peed on the potty! Time
Procedures
for X!”), and allowed the child to get off of the toilet. Clinical
A concurrent multiple baseline across participants design judgment was used to gradually increase the amount of urinary
was used to detect the effect of the training program on correct output required for reinforcement, after substantial improve-
urinations. The baseline consisted of keeping the child in their ments in urination on the toilet were initially established. If
regular diapers throughout the day, checking the diaper to de- the participant excreted no urine at the end of 3 min, the timer
termine if it was wet or dry every 30 to 60 min, and scheduled sounded and the staff member guided the participant to pull
visits to the bathroom every 60 to 120 min. The teacher based his pants up, wash his hands, and exit the bathroom.
this schedule on typical bathroom reminders that occurred in Consequence for urinary accidents. Staff responded to wet-
the inclusionary preschool program. Positive verbal and social ting episodes with a neutral notification to the participant that
interaction were delivered contingent on the presence of a dry he was wet (e.g., “You wet your pants. You need to change”).
diaper as well as for urination in the toilet. Staff immediately guided the child to the bathroom and as-
A multicomponent toilet training procedure was then sisted him in changing his clothes in a neutral manner. Upon
implemented by paraprofessional staff. exiting the bathroom, the staff reset the timer for 30 min.
A countdown timer, a soft child-sized potty seat, a foot- Adjusting the schedule of bathroom visits. Once the participant
stool for leg support, three clean sets of clothes, and individual- reached 100% correct urination for at least 3 consecutive days,
ized reinforcers were used while implementing the following the duration of time between trips to the bathroom increased
program. by 15 min increments. In some instances, the child went well
Diaper removal. At the beginning of the school day, the beyond the 3 consecutive day criterion. This occurred for two
participant’s diaper was removed, and he wore regular under- reasons. First, if criterion was met on a Friday, we preferred to
pants and sweatpants for the remainder of the day. extend criterion to ensure that the skill remained intact after a
Fluid offering. At the beginning of the day, students were weekend recess from program. Second, staff were instructed to
given 8 oz of water or high preference beverage, preferably in- maintain the bathroom visit schedule until data were reviewed
gested within the first 90 min of the day. Additional fluids were by the clinical team. At times, data reviews were limited to
offered if limited urinary output occurred. After participants several days beyond meeting criterion due to the availability
successfully urinated in the toilet at least every 90–120 min, of the clinician on site. Schedule changes continued until the
fluid offering was discontinued and typical fluid intake (e.g., participant was able to remain dry all day and urinate on the
snack time, lunch time) remained in place for the remainder of toilet with 100% accuracy when visits to the bathroom were
the intervention. scheduled every 120 min.
Bathroom visits. Upon entering the classroom, participants Thinning the reward schedule. Social praise continued to
were immediately taken to the bathroom. Participants sat on occur for every checked instance of dry pants and for correct
the toilet for a maximum of 3 min. Staff reset the timer for urinations on the toilet; however, a gradual thinning of the
another 30 min interval, immediately after each trip to the edible rewards with 4 participants and the tangible reward
bathroom. At the end of every 30 min, the timer sounded, the with 1 participant occurred throughout the process. Once the
staff delivered the instruction “Time for Potty” and directed participant urinated appropriately in the toilet on a 60 min

62 TOILET TRAINING CHILDREN WITH AUTISM


schedule, the reward was provided for every second or third BL Treatment Follow-up

105

120
45

60

75
90
correct urination. 100

The formal program ceased once the participant demon- 75


strated the ability to correctly urinate in the toilet with 100%
accuracy on a 120-min schedule of bathroom visits. At this 50

point, the participant was cued with a more natural schedule 25


(e.g., typical bathroom breaks with preschool-aged children).
Cal
Social praise for correct urinations remained in place in the 0

school setting. Daily data collection continued at least 5 days

105

120
45

60

75

90
100
after mastery and occurred at 2-hr intervals to assess mainte-
nance of the skill. 75

50
Results and Discussion
Figure 1 depicts data for Cal, Lou, Job, Tom, and Cam. 25

Baseline for Cal revealed 38% correct urination in the toilet 0


Lou
over 16 days in baseline. Cal required 65 days of training to

105
120
45
60
75
90
reach the mastery criterion (100% continent voids in the 100

% Correct Urination
toilet during bathroom visits scheduled at 120 min intervals). 75
Baseline for Lou revealed 8% correct over 24 days. Lou required
88 days of training to reach the mastery criterion. Baseline for 50
Job revealed 34% correct over 40 school days. Fluctuation in
25
the data appeared to be related to spring recess and a short
Job
summer break (1-week each), causing short-term regression, 0
though Lou’s performance quickly recovered. Job rapidly moved

105

120
45
60
75
90
100
through the sequence of increased time intervals and had no ac-
cidents throughout the treatment, requiring a total of 46 days 75
to reach the mastery criterion. Baseline for Tom revealed 14%
50
correct in the toilet over 12 days of baseline. Like Job, Tom
moved quickly through the training requiring 51 days to meet 25
the mastery criterion. Baseline for Cam revealed 9% voiding Tom
0
in the toilet over 15 school days. In the beginning of treat-

105
120
45
60

75
90
ment, Cam had multiple accidents from 11:30 am to 12:30 100
pm. Based on these data, Cam was brought to the bathroom
75
every 15 min from 11:15 am to 12:30 pm. The remainder of
the day continued with a 30 min schedule for bathroom visits. 50
Cam reached the mastery criterion after 32 school days. Table 1
25
summarizes the number of school days as well as calendar days
Cam
required for each student to move from diaper dependency to 0
25 50 75 100 125
100% mastery criterion with a 2-hr bathroom visit schedule
School Days
in place.
The purpose of this study was to investigate the efficacy Figure 1. The percentage of correct urinations per school day is
of a toilet training program for children with autism and de- represented for 5 participants. Breaks in the x-axis refer to seasonal
velopmental delays in a public school setting with minimal vacations and data labels denote time between bathroom visits.
clinical oversight and with the intervention implemented by
paraprofessional direct care staff. Results from this study dem- to 88 school days with an overall mean of 56 school days. The
onstrated that all 5 participants were able to retain urine in number of calendar days (to include weekends, holidays, and
their bladder for periods of 2 hrs or more and urinate in the breaks) across all 5 participants ranged from 72 days to 135
toilet after implementation of this program in school. days with an overall mean of 96 days, or just over 3 months.
This study differs from prior research as it describes a method Toilet training can be a developmental obstacle for par-
that can be implemented in a school setting by paraprofessional ticipants diagnosed with autism or developmental delays, yet
staff. It implements toilet training in a nonclinical setting with toileting skills are an important part of a person’s development
minimal clinical support, and good effects were observed that allows for greater independence and enhances dignity in
without the use of procedures like restitution or overcorrection the social domain (McManus, Derby, & McLaughlin, 2003).
for incontinence. All 5 participants succeeded, though each Paraprofessional staff, who are often available in school districts
took varying time periods to meet criterion, ranging from 32 serving children with autism and developmental delays, were

TOILET TRAINING CHILDREN WITH AUTISM 63


capable in the current study to implement an effective out- Bryson, S. E., Rogers, S. J., & Fombonne, E. (2003). Autism
come with minimal support from supervising clinicians. These spectrum disorders: Early detection, intervention, education,
results are encouraging because they suggest that this procedure and psychopharmacological management. Canadian Journal of
may be practical enough for educational staff to implement in Psychiatry, 48, 506–515.
classroom settings. Cicero, F. R., & Pfadt, A. (2002). Investigation of a reinforcement-
Nevertheless, the amount of time dedicated to the process based toilet training procedure for children with autism.
of toilet training does have an inherent cost in terms of time Research in Developmental Disabilities, 23, 319–331.
lost to teaching other important skills. Before implementing Konarski, E. A., & Diorio, M. S. (1985). A quantitative review of
the program, the school-based team met with the parents and self-help research with the severely and profoundly retarded.
clearly described the amount of time that toilet training would Applied Research in Mental Retardation, 6, 229–245.
take. In the beginning, an average of 5 to 10 min per ½ hr was Kroeger, K. A. & Sorensen-Burnworth, R. (2009). Toilet training
used to transition to the bathroom, sit on the toilet, and return individuals with autism and other developmental disabilities.
to work. As the interval between bathroom visits expanded, the Research in Autism Spectrum Disorders, 3, 607–618.
impact of other programming was less of a concern. Parents Kroeger, K. A., & Sorensen, R. (2010). A parent training model
were informed of this issue and understood and agreed to the for toilet training children with autism. Journal of Intellectual
impact on academics before enrolling their child in this study. Disability Research, 54, 556–567.
Future research should attempt to determine the impact that LeBlanc, L. A., Carr, J. E., Crossett, S. E., Bennett, C. M., &
allocating time to toilet training has on academic learning Detweiler, D. D. (2005). Intensive outpatient behavioral
rate. treatment of primary urinary incontinence of children with
There are several limitations of this analysis that should be autism. Focus on Autism and Other Developmental Disabilities,
considered. First, although the procedures were applied across 20, 98–105.
multiple children and paraprofessionals, additional applica- Luiseli, J. (1997). Teaching toileting skills in a public school setting
tions of these procedures should be researched in other schools to a child with pervasive developmental disorder. Journal of
to determine the generality of the program. In addition, the Behavior Therapy and Experimental Psychiatry, 28, 163–168.
generality of the program would also be better understood by McManus, M., Derby, K. M., Dewolf, E., & McLaughlin, T.
measuring the effects of the school-based program on in-home F. (2003). An evaluation of an ın-school and home based
continence. Once mastery was attained in the school setting toilet training program for a child with fragile X syndrome.
in the current study, the special education teacher met with International Journal of Special Education, 18, 73–79.
the parents to review procedural guidelines and encouraged Paclawskyj, T. R., & Vollmer, T. R. (1995). Reinforcer assessment
the parents to monitor program implementation in the school. for children with developmental disabilities and visual
Parents of the participants reported successful toileting in the impairments. Journal of Applied Behavior Analysis, 28, 219–
home environment following the successful training at school. 224.
Nevertheless, objective measurement of these sorts of outcomes Stadtler A., Gorsky, P., & Brazelton, T. B. (1999). Toilet training
are necessary to predict the likely generality of school-based methods: Clinical interventions and recommendations.
toilet training programs. Pediatrics, 103, 1359–1361.
A second limitation of this study was the omission explicit U.S. Department of Education. (2004). Building the legacy: IDEA
procedures to train and detect self-initiations to use the bath- 2004. Retrieved August 20, 2009, from http://idea.ed.gov/
room during the toilet training treatment program. The skill of archive.
self-initiating toileting is important and future research should Van Wagenen, R. K., Meyerson, L., Kerr, N. J., & Mahoney,
replicate this toilet training program and add procedures for K. (1969). Field trials of a new procedure in toilet training.
teaching self-requesting of bathroom visits. Journal of Experimental Child Psychology, 8, 147–159.
Despite the limitations presented here, the data across par-
ticipants provide strong evidence that paraprofessionals readily Authors’ Note
available in an inclusionary school system can effectively imple- Many thanks to the parents who willingly agreed to include
ment a data-based toilet training program with lasting effects. their children in this study. They remain anonymous to ensure
the confidentiality of the children, though their cooperation is
References deeply appreciated. Also, we are indeed grateful to the special
Azrin, N., & Foxx, R. (1974). Toilet training in less than a day. education teachers, ABA therapists and the school district, all of
New York: Simon and Schuster. who worked as dedicated staff to meet the needs of the children
Blum, N. J., Taubman, B., & Nemeth, N. (2004). Why is toilet and provide empirical evidence to forward to the scientific and
training occurring at older ages? A study of factors associated educational community at large. Correspondence regarding this
with later training. Journal of Pediatrics, 145, 107–111. paper should be addressed to Michael A. Cocchiola, Jr., Capitol
Blum N. J., Taubman B., & Nemeth N. (2003). Relationship Region Education Council-River Street Autism Program, 601
between age at initiation of toilet training and duration of River Street, Windsor, CT 06095. Email: mcocchiola@crec.
training: A prospective study. Pediatrics, 111, 810–814. org.
Action Editor Jonathan Tarbox
64 TOILET TRAINING CHILDREN WITH AUTISM

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