Toilet Training Children With Autism and Developmental Delays - An Effective Program For School Settings
Toilet Training Children With Autism and Developmental Delays - An Effective Program For School Settings
Toilet Training Children With Autism and Developmental Delays - An Effective Program For School Settings
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
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
105
120
45
60
75
90
correct urination. 100
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
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