Benefits of toilet training Goals of independent toileting Potty chair or

Terms to
know
When should
toilet training
be started?
Benefits of
toilet training
Goals of
independent
toileting
Potty chair or
toilet?
To sit or to
stand?
What should
the child
wear?
Home or
school?
Data
collection
Components
of rapid toilet
training
Teaching
initiations
Fading the
intensive
program
Bowel
movement
training
Nighttime
training
Teaching
related skills
Additional
research
Questions!
 Urinate, pee, peepee, weewee, tinkle, peeps?
 Bowel movement, poo, poop, kaka?
 Bathroom, toilet, potty?
 Training, teaching, toileting, learning?
“’Toilet learning’ is very different from ‘potty training.’ Old-fashioned potty training is something
adults do to children and often makes children feel bad about accidents. Toilet learning is
something children take an active part in and helps them feel good about using the toilet.”
http://www.appleton-child-care.com/toilet-learning.shtml
 Body parts
 Toileting “readiness”: Are there toileting prerequisites?
 American Academy of Pediatrics (2006)
 Dry at least 2 hours at a time during the day or is dry after naps
 Bowel movements are regular and predictable
 Actions or words reveal child is about to urinate or have a bowel
movement
 Can follow simple instructions
 Can walk to and from the bathroom and help undress
 Seems uncomfortable with soiled diapers and wants to be changed
 Asks to use the toilet
 Asks to wear underwear
 Gorski (1999)
 Walk
 Imitate behavior
 Put things where they belong
 Demonstrate independence by saying “no”
 Express interest in toilet training
 Indicate first when “going” and then when needs to “go”
 Able to pull clothes on and off
Azrin & Foxx (1974)
Bladder
Control
Physical
Readiness
Urinates a
lot at one
time
Can pick up
objects
Appears
aware is
urinating
Walk from
room to room
Stays dry for
several hours
Instructional
Readiness
Follow
simple
instructions
 http://www.avbpress.com/updates-and-downloads.html
 Current trend is toward “readiness” and later toilet training
 Neff (1998): Children toilet-trained by 30 months
 1997: 22%
 1961: 90%
 Most children achieve bowel and bladder control by 24-48 mo
(Carlson, 2012)
 1947: most children by 18 months old
 There is no scientific evidence that an early potty training age
harms children
Consider cultural differences in expectations:
Horn, Brenner, Rao, & Cheng (2006)
Caucasian parents: 25.4 months
African-American parents: 18.2 months
Parents of other races: 19.4 months
 Avoid diaper rash and diaper-related infections
 Save money and time on diapering
 Inclusion in community experiences (e.g., school)
 Environmental impact of disposable diapers
 Peer perception
 Parent perception
 Parent confidence in clinicians and ABA
 Children with developmental disabilities may not
 Respond to instructions and rules explaining contingencies
 Experience social approval and independence as reinforcing
 Respond to feelings of having to urinate/BM the same way
 May require more practice and reinforcement to acquire new
skills
 Healthy
 Consult the child’s pediatrician
 Rule out or remedy any medical conditions or additional factors that would
make starting toilet training inadvisable at that time
 Feeding issues
 Relatively cooperative
 Cicero (2007): Awareness of reinforcement contingencies for other activities
 The team is ready
 Family not experiencing major change or crisis
 Everyone is aware of their roles and time commitment
* Studies should report skill levels on signs of “readiness”
 Continence
 Initiation/ Getting to (the correct) bathroom
 Mastery of related behaviors
 Removing clothes
 Excreting into the toilet
 Wiping
 Redressing
 Flushing
 Washing hands
Kroeger & Sorensen-Burnworth (2009)
* No studies comparing these
Advantages of
Potty Chair
• Child-size
• Portable
• Doesn’t flush
Limitations of
Potty Chair
• Must transition
to regular toilet
• Doesn’t flush
Considerations
• Seat that can
be used on
both potty
chair and toilet
• Novelty potty
chairs?
 Step stool – can help child be
 Independent sitting
 More comfortable sitting
* No studies comparing these
 Most boys learn to urinate sitting down and later change to standing up
(American Academy of Pediatrics, 1998)
 Starting with sitting may be easier
 Appropriate for both urination and BMs
 May need extended time on the toilet for success
 If sitting: legs apart; hands on legs or give something to hold
 But some may prefer standing
 Teaching boys to aim
 Toilet targets
 Consistency is important
Clothes
• Shorter shirt
• Just underwear or elastic-waist pants (no shoes)
• Wearing light colors (not white or black) may make
it easier to detect accidents immediately
Diapers or underwear?
•Disadvantages of diapers
Diapers or underwear?
• Disadvantages of diapers
• Advantages of underwear
• What about pullups?
 5 typically developing toddlers
 Underwear facilitated toilet
training
• Diaper while sleeping
 Decreased accidents/ increased
successes for 2
 Diapers and pull-ups: no
improvement for any
 Begin at school and transfer to other settings
 LeBlanc et al. (2005)
 Toilet training in all settings
 Consistency!
 Dunlap, Koegel, and Koegel (1987)
 Conduct an initial meeting attended by all team members
 Choose a “coordinator”: parent or professional responsible
for monitoring data collection, making changes to the
program, and coordinating communication across all settings
and caregivers
 Write out the procedures and keep a copy in all settings
 Schedule observations and supervision across settings and
providers
• Collect data on
• Urine & BM accidents
• Urine & BM successes
• Initiations
(1) Establish
individualized
sitting schedule
Baseline data
important for at
least three
reasons:
(2) Recording
occurrence of BMs
may reveal a
pattern
(3) Allows you to
evaluate the
intervention
 Most studies frequency per day
 Some studies: Percentage of urinations/BMs that were successes, accidents, self-initiated
 Cocchiola et al. (2012)
Because
 Kroeger & Sorensen-Burnworth (2010)
fluid intake
 LeBlanc et al. (2005)
may differ
 Post & Kirkpatrick (2004)
across days
 Baseline checks
 15 min: Post & Kirkpatrick (2004)
 30 min: Tarbox et al. (2004); Cocchiola et al. (2012)
 60-90 min: Didden et al. (2001); Brown & Peace (2011); Chung (2007)
 Baseline data on fluid intake?
 Can help determine appropriate increase during treatment
 Toilet training with individuals with developmental disabilities
began in 60s
 Rapid toilet training (RTT)
 Most studies on behavioral toilet-training this population use
similar components
1 – Full bladder
2 - Comfortable diaper
3 - Playing
1 – Full bladder
2 - Comfortable underwear
3 – Playing
Pee in diaper
Pee in
underwear
1 – Relaxed bladder
2 - Comfortable diaper?
3 – Still playing
1 – Relaxed bladder
2 - Wet underwear
3 – Delay in playing
1 - Full bladder
2 – Comfortable
underwear
3 - Playing
Pee in
potty
1 – Relaxed bladder
2 – Comfortable underwear
3 – Delay in playing
4 – “I’m like a grownup”
5 – Praise, sticker
Prompting
Success
Hydration
Frequent Sits
Water Prompt
Transfer of
Stimulus
Control
Decreasing
Accidents
Urine Alarm
Startle Statement
Positive Practice
DRO for dry
Intervention
Components
Increasing
Successes
Positive
Reinforcement
Negative
Reinforcement
• EO for urination; increased number of opportunities to reinforce
success
• Consult pediatrician: Don’t use if seizure disorder, hydrocephaly,
spinal cord injury, med with side effect of urinary retention (Kroeger &
Sorensen-Burnworth, 2009)
• Bladder capacity for children (Kaefer et al., 1997)
• Age (years) divided by 2 + 6 = capacity (ounces) for those 2 years
old or older
• But feeling to urinate can be perceived after a couple ounces
Azrin & Foxx (1971)
• “a large volume of fluids…each half hour as he would consume” (p. 92)
Cicero & Pfadt (2002)
• “variety of liquids were offered…verbally encouraged to drink if liquid intake was low” (p. 324)
LeBlanc et al. (2005)
• “every 5 min during the first hour, every 10 min during the second hour, every 15 min during
the third hour, every 30 min throughout the rest of Day 1” ( p. 100)
Rinald & Mirenda (2012)
• “at least 4-6 ounces of liquid per hour” (p. 937)
• Preferred, noncaffeinated, nondairy (LeBlanc et al., 2005)
• Water is ideal
• Mix juice & water
• White grape juice: More easily absorbed than apple juice? (American Academy
of Pediatrics, 2001)
• Consider variety
• If the child doesn’t want to drink
• Reinforce drinking
• Be creative…
• Best practice for hydration?
 Increased opportunities to reinforce success
 Use a timer or vibrating pager to cue the caregiver
 May decide to stay in the bathroom (e.g., Cicero & Pfadt, 2002)
 As successes increase and accidents decrease, time between sits
is increased & time sitting is decreased
 According to a predetermined criterion
 Terminal goal of every 2 hours is ideal for daycare/preschool
settings
 Access to moderately preferred toys/video while sitting
 What should the schedule be?
Cicero &
Pfadt (2002)
• Sit every 30 min
• For 3 min
• Scheduled sits d/c
on the following
day if child made
independent
initiation
LeBlanc et al. (2005)
• Day 1: 1 level each hour
• Days 2,3: 1 level each half day
• 1 level every 2 days
Kroeger & Sorensen
(2010); Rinald &
Mirenda (2012)
• 30 min on/5 min
break for success
• 25 min on/10 min
break for success
• 20 min on/15 min
break for success
* Most efficient scheduling?
 9-year-old boy with profound MR
 Severe SIB
 Other toilet training ineffective
 Water prompting: “slowing pouring approximately 5 oz. of lukewarm water over the client’s genitalia
for 3 to 5 s immediately after he was seated on the toilet” (p. 473)
 Warm water may relax external sphincter muscle
 Need replications. Measure temperature carefully!
 Luiselli (1996)
 7-year-old girl
 PDD
 Other toilet training ineffective
 Began by reinforcing urination in diaper while sitting on
the toilet
 Would have continued by cutting progressively larger
holes in the diaper, but she became independent
 Need replications
 Negative Reinforcement
 Allow off the toilet contingent upon success
 Positive Reinforcement
 Stimulus preference assessment
 Identify several highly preferred items: food, drinks, toys, videos
 Items for toilet training only
 Potty Party
 Fun box: Keep in opaque container out of reach, in the bathroom
 Deliver immediately contingent upon success
 Deliver praise in way child prefers, don’t interrupt flow of urine
 Keep box closed until delivering?
 If child does not have success, neutrally help up from toilet
 Accidents can set the stage for frustration for caregivers
 If using reduction procedure, provide training and supervision; monitor stress of
caregiver
 Clean up accident calmly
 Have needed materials ready to go, second person
 Startle Statement (Cicero & Pfadt, 2002)
 When child begins to have accident, delivered a statement to startle and interrupt
the flow of urine
 “no, no, no, hurry up, you pee on the potty”
 Rush to sit on toilet: Opportunity to reinforce success
 Neutral to firm tone of voice
 Need replications
 Urine Alarm (LeBlanc et al., 2005)
 Functions?
 Various types available
Wet Stop 3: https://www.youtube.com/watch?v=92C2Km7yTmM
 More research
 Prompt request before each scheduled sitting opportunity
 Select method based on
 Caregiver preference
 Child’s skills
 Sign, picture exchange, vocal
 “Potty”, “I need the bathroom”
 Durable, waterproof picture (laminate, baseball card holder)
 https://www.youtube.com/watch?v=C7Fym1W5XuA
 Praise and trip to the bathroom contingent upon all requests
 Once toileting goal has been reached, components of the intensive program
can be removed
 Cicero & Pfadt (2002): 3 consecutive days with initiations & no accidents
 Post & Kirkpatrick (2004): 80% of urinations successes for 3 consecutive days
 Cocchiola et al. (2012): 100% of urinations successes for 3 consecutive days
 Differential reinforcement
 Only successes paired with dry pants are reinforced
 Only reinforce successes from self-initiations
 Wear regular clothing
 Fluid intake returned to normal
 Decrease reinforcement
 Delay: start to wait until he has gotten up and pulled up his
pants….then until he has pulled up his pants and
flushed…then until he has pulled up his pants, flushed, and
washed his hands…
 Intermittent reinforcement
 Most efficient method?
 For some children, BM training is more challenging and takes longer
 When children are not having BMs on a regular basis, it is important
to speak with the child’s pediatrician to ease constipation and
establish better regularity
 For some children, use of laxatives or suppositories may be
indicated to supplement behavioral toilet training procedures; this
must always occur under the direction and supervision of the child’s
pediatrician
 When children are having frequent BMs but are not going in the toilet,
identify a separate, very powerful item to reinforce BMs on the toilet
 Track times when the learner tends to have BMs (more frequently and
sitting for longer durations during time periods when BMs are probable)
 Overcorrection procedures may also be added contingent on BM
accidents
 Some children will start to stay dry through the night on their own
 When the child regularly wakes up dry, nighttime diapers can be removed
 After continent during the day, if not dry during the night
 Reduce liquids before bed
 Trip to the bathroom right before bed
 Night-time alarm
 Parent may wake child to go to the bathroom
 Consider the entire process of toileting, from start to finish
 Teaching related skills can improve the learner’s level of independence
 Gerhardt (2007) suggested five “survival skills” for individuals with autism
that are essential to “look the part” for successful inclusion in the
community:
 Restroom skills
 Meal skills
 Sexual behavior
 Hygiene skills
 Age appropriate clothing
 Create a task analysis (detailed list of
steps necessary to complete the task)
 Each step should be in clear,
observable terms
 Example: skill acquisition program for
washing hands
This program is meant to serve as an example
and should always be customized for the
individual!
MATCHES GENDER-APPROPRIATE RESTROOM DOOR SIGNS
Behavioral Goal: When presented with a picture of a public restroom door sign representing the
learner’s gender, and the verbal instruction, “Find ___(e.g., men’s room),” the learner will match the
picture to a corresponding picture or restroom door.
Teaching Procedure: Give the learner a picture of a public restroom door sign representing the
learner’s gender, and give the verbal instruction, “Find ___(e.g., men’s room).” If the learner places the
picture on top of a corresponding picture or brings the picture to the appropriate restroom door (in the
school building) provide verbal praise (e.g., “Great, that’s the men’s room!”), and access to a tangible
reinforcer (e.g., token or edible). If the learner does not match to the correct picture or restroom, or
does not respond, immediately provide manual guidance and verbal correction (e.g., “This is the men’s
room”). Vary the materials and the location, using many different exemplars of pictures and bathrooms
on all floors of building. Use a most to least prompting hierarchy. Differentially reinforce responses
demonstrated with lowest level of prompting. Fade prompts across subsequent teaching trials.
Teaching Steps:
Teach the learner to match identical pictures of public restroom doors using pictures representing the
learner’s gender (e.g., if the learner is a male, teach the learner to match identical pictures of men’s
room doors).
Teach the learner to match non-identical pictures of public restroom doors using pictures representing
the learner’s gender.
Teach the learner to match identical pictures of public restroom doors to an appropriate bathroom door
in the school building (e.g., if the learner is a male, teach the learner to match pictures of the boys’
restroom doors at school to the actual boys’ restroom doors at school).
Teach the learner to match non-identical pictures of public restroom doors to an appropriate bathroom
door in the school building, when presented with multiple exemplars of gender appropriate pictures and
restrooms.
Teach the learner to respond to a verbal instructions only (e.g., “Go to the Men’s room”) when pictures
are faded.
Program for generalization to restrooms within community settings (e.g., restaurants and shopping
malls).
Measurement: Per Opportunity Measure
The instructor will record a plus (+) for each correct, independent response, and a minus (-) for each
prompted response. Data will be summarized as a percentage of correct responses per session and will
be graphed daily on a skill acquisition graph.
Criterion: 100% for 3 consecutive sessions
The following sample skill acquisition program uses a stimulus fading procedure to teach appropriate eye gaze
½ inch dot
¼ inch dot
KEEPS EYES FOCUSED FORWARD WHILE USING A URINAL
Behavioral Goal: When standing at a urinal, the learner will keep his eyes focused forward at the top/center of the urinal.
Teaching Procedure: Preteach in the learner’s school building. Each time the learner uses the urinal, if the learner keeps his eyes focused at the
top/center of the urinal while urinating, without averting his eyes for longer than one full second, provide verbal praise (e.g., “Good looking here!”)
and access to a tangible reinforcer (e.g., a token or an edible). If the learner averts his eyes for longer than one full second, provide graduated
guidance from behind to look at the top/center of the urinal. Use a most to least prompting hierarchy. Differentially reinforce responses
demonstrated with lowest level of prompting. Fade prompts across subsequent teaching trials.
Teaching Steps:
Teach the learner to keep his eyes focused at the top/center of the urinal when marked with a ½ inch dot prompt.
Teach the learner to keep his eyes focused at the top/center of the urinal when marked with a ¼ inch dot prompt.
Teach the learner to keep his eyes focused at the top/center of the urinal when marked with a 1/16 inch dot prompt.
Teach the learner to keep his eyes focused at the top/center of the urinal when marked with a 1/32 inch dot prompt.
Teach the learner to keep his eyes focused at the top/center of the urinal when no stimulus prompt is present.
Teach the learner to keep his eyes focused forward at the top/center of the urinal when no stimulus prompt is present when the instructor is 1 ft
away.
Teach the learner to keep his eyes focused forward at the top/center of the urinal when no stimulus prompt is present when the instructor is 3 ft
away.
Teach the learner to keep his eyes focused forward at the top/center of the urinal when no stimulus prompt is present when the instructor is 5 ft
away.
Teach the learner to keep his eyes focused forward at the top/center of the urinal when no stimulus prompt is present when the instructor is out of
the room.
Program for generalization to novel instructors and community settings.
Measurement: Per opportunity measure
For each opportunity, the instructor records a plus (+) if the learner keeps eyes focused forward without averting eyes for less than one full second, in
the absence of graduated guidance. If the learner averts eyes for longer than one full second or graduated guidance is necessary to prompt
appropriate orientation of eyes, the instructor scores a minus (-). Data are summarized percentage of correct responses per day and summarized on
a skill acquisition graph.
Criterion: 100% for 3 consecutive sessions
MINIMIZES EXPOSURE WHILE USING A URINAL
Behavioral Goal: When the learner enters the bathroom and approaches the urinal, he will follow the designated steps to minimize exposure
while standing at the urinal.
Teaching Procedure: Run teaching sessions at the learner’s school. Teaching procedures should only be carried out by a male staff member,
and will be used for all restroom opportunities, including initiations and scheduled opportunities. If the learner follows the designated steps of
the task analysis to open and replace pants, provide verbal praise (e.g., “Nice job using the bathroom!”) and access to a tangible reinforcer (e.g.,
a token or an edible). If the learner does not follow the steps correctly or does not respond, provide graduated guidance from behind as
necessary. Use a most to least prompting hierarchy. Differentially reinforce responses demonstrated with lowest level of prompting. Fade
prompts across subsequent teaching trials.
Whole task presentation should be used to teach this skill.
Teaching Steps:
Teach the learner to unbutton/unzip pants and push down the front of the waistband with nondominant hand OR pull down the front of
pants/underwear simultaneously (depending on the type of pants the learner is wearing).
Teach the learner to remove and hold penis with dominant hand.
Teach the learner to hold penis aimed at the center of urinal with dominant hand.
Teach the learner to pull up front of underwear and pants and button/zipper pants (if applicable) when he has finished urinating.
Teach the learner to complete steps 1-4 with an instructor 1 ft away.
Teach the learner to complete steps 1-4 with an instructor 3 ft away.
Teach the learner to complete steps 1-4 with an instructor 5 ft away.
Teach the learner to complete steps 1-4 with an instructor out of view.
Program for generalization to community settings.
Measurement: Task Analysis
For each step listed on the task analysis, observer records a plus (+) if the learner completes the step correctly. If any step is not completed, is
completed incorrectly, or is completed with prompts, the observer scores a minus (-) for that step. Data are summarized as percentage of steps
completed correctly and graphed on a skill acquisition graph.
Criterion: 100% for 3 consecutive sessions
Caregiver training
Use of a multiple-schedule arrangement to reduce
toileting requests maintained by escape
Programming for and assessing generalization
Social validity

[email protected]
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