A parent training model for toilet training children
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Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2010.01286.x
556
pp –
A parent training model for toilet training children
with autism jir_ ..
K. Kroeger & R. Sorensen
Cincinnati Children’s Hospital Medical Center, Kelly O’Leary Center for Autism Spectrum Disorders, Cincinnati, OH, USA
Abstract day of the intervention. Participant was conti-
nent after day and completely toilet trained by
Background Azrin & Foxx pioneered an intensive
day of the intervention.
toilet training protocol for individuals with intellec-
Conclusions Long-term follow-up demonstrates
tual disability living in a residential setting. Since
maintenance of skills years post training. Social
the development of the Rapid Toilet Training
validity via parent satisfaction was assessed. Limita-
(RTT) protocol, many have replicated the efficacy,
tions to the current study and recommendations for
most notably in educational and outpatient treat-
future research were discussed.
ment settings, but often training over longer periods
of time. This study presents data from a parent Keywords autism, continence, parent training,
training model that replicates Azrin and Foxx’s self-initiation, toilet training, voiding
results and training time.
Method This multiple baseline across subjects Azrin & Foxx () made prominent gains in the
design study employs an ABA design where two remediation of incontinence in individuals with
boys diagnosed with autism were toilet trained intellectual and developmental disabilities in devel-
using a modified Azrin & Foxx intensive teaching oping the most widely cited treatment protocol for
protocol. The first subject, a -year-old boy, did not continence training. Many researchers have adapted
have a history of attempted toilet training. The minor components while maintaining the whole of
second subject, a -year-old boy, demonstrated a the programme (i.e. positive reinforcement, hydra-
history of failed toilet training attempts in both the tion where the subject is provided increased access
home and school settings. The trainings were con- to fluids, scheduled sitting) and demonstrated suc-
ducted in the home setting where a novel parent- cessful continence training across a variety of devel-
training approach was implemented. opmental disability populations (e.g. Taylor et al.
Results Participant was continent at the end of ; Luiselli ; Leblanc et al. ), with the
the second day of training, and completely toilet removal of urine alarms (e.g. Cicero & Pfadt ;
trained (including initiation and communication) by Post & Kirkpatrick ) and overcorrection and
positive practice procedures where the subjects are
Correspondence: Dr Kimberly Kroeger, ML , Burnet
typically required to clean the resultant soiled items
Avenue, Cincinnati, Ohio , USA (e-mail: Kimberly.Kroeger- and repeatedly practice walking to the bathroom
Geoppinger@cchmc.org). from the site of the accident (e.g. Cicero & Pfadt
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
557
K. Kroeger & R. Sorensen • Intensive toilet training programme
). In addition, further models of toilet training ers’ and skills with them to new settings increasing
maintaining core components such as reinforcement the likelihood of generalisation. In addition, it has
and intensity have also been developed (e.g. Didden been suggested that punishment procedures are
et al. ; Averink et al. ) [see Kroeger and not critical elements of the rapid training proce-
Sorensen-Burnworth () for comprehensive dure (e.g. Cicero & Pfadt ) and clinical anec-
review]. Most studies maintain shorter training dotal observation noted that parents are routinely
times; however, many children referenced as conti- not consistent in their delivery of punishment and
nence trained demonstrate residual issues and the its proper procedure. Moreover, with the cited
more components to the original study manipulated exponential increase in autism spectrum diagnoses,
or removed from treatment protocols, the longer the lay persons, direct care staff and professionals
training time appears to take (Kroeger & Sorensen- outside the field of autism often consider autism
Burnworth ). to be categorically different from other develop-
It would seem that parent training is a critical mental disabilities creating an increased need to
component to successful continence training and document efficacy of established intensive toilet
its maintenance over time as most individuals with training interventions on this population as well.
autism live at home with their parents as primary Because of this noted trend and in combination
caregivers. In addition, children with autism with the difficulties in communication and gener-
characteristically demonstrate difficulty in alisation inherent to a spectrum diagnosis, particu-
generalisation of skills across environments and lar attention also has been noted in generalisation
persons making parent training even more critical and communication training within the procedural
(Lovaas ). Nonetheless, most frequently toilet description.
training is still conducted in clinical and school
settings (e.g. Cicero & Pfadt ; Averink et al.
; Leblanc et al. ), and the inclusion of Method
parents in the training component is cited as a
Participants
unique element (Leblanc et al. ). This could
be problematic in the literature as the current Marvin, a Caucasian boy, was years, months at
trend for children with autism is to spend majority the time of implementing the toilet training pro-
of their time in the home setting (as opposed to gramme. Marvin was diagnosed with autistic disor-
institutional) and demonstrate a documented der at age by a multidisciplinary team at an
history of poor generalisation of skill autism clinic in a university-affiliated children’s hos-
acquisition. pital. Marvin received a score of (cut-off score of
The current study sought to implement a for autism diagnosis) on Module of the Autism
parent-delivered, intensive training protocol imple- Diagnostic Observation Schedule – General
mented within the home setting without the use of (ADOS-G; Lord et al. ). In addition, he had a
punishment procedures, such as positive practice Vineland Adaptive Behavior Scales (VABS; Sparrow
(repeated walking from accident site to bathroom), et al. ) Composite score of (X = ,
environmental restitution (cleaning self, soiled SD = ) and Bayley Scales of Infant Development
linens and soiled areas) or verbal reprimands (ver- – Second Edition (BSID-II; Bayley ) Mental
bally telling child any version of ‘No, don’t pee in Development Index of (X = , SD = ).
your pants.’). By training parents and subsequently Marvin was functionally nonverbal and primarily
their children within the home, issues of generali- communicated through the use of the Picture
sation are circumvented in that the training is pro- Exchange Communication System (PECS; Bondy
vided in the child’s most common environment & Frost ) where he was communicating in
with the child’s most frequent caregiver (parents). phase IV (sentence construction).
Moreover, when young children leave their homes Attempts to train Marvin previously had not
they are often accompanied by parents (such as occurred and he would only tolerate sitting on the
going to a relative’s house, shopping centre or toilet for a few seconds with the lid closed. Marvin
therapy sessions), thus bringing their ‘toilet train- wore diapers on a routine basis. Marvin demon-
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
558
K. Kroeger & R. Sorensen • Intensive toilet training programme
strated one-half of one of the toileting prerequisites Setting
generally recommended by paediatricians (Brazel-
All training occurred in the first-floor bathroom of
ton et al. ). Of the seven prerequisites (stay dry
the children’s home. Both training bathrooms con-
for at least h at a time, regular bowel movement
tained a toilet and sink. For Marvin, the bathroom
schedule, follow simple instructions, demonstrate
was adjoined to the family’s laundry facility;
discomfort with dirty diapers, ask to use the toilet,
however, the child was not permitted in that section
request to wear underwear, pull pants up and
of the bathroom during the training. A small stool
down), Marvin was able to pull his pants up.
for the trainer (and subsequent parent) was
Chris, a Caucasian boy, was years, months at
included in front of the toilet. A bin of preferred
the time of the training intervention. Chris was
but not highly motivating toys was also accessible to
diagnosed with autistic disorder at age by a multi-
the trainer and parent, as well as a clipboard with
disciplinary team at an autism clinic in a university-
datasheets and edible reinforcers. An audible timer
affiliated children’s hospital. Chris received a score
was used to signal scheduled pots and cessation of
of (cut-off score of for autism diagnosis) on
breaks. Once the children were demonstrating
Module of the ADOS-G. He was also nonverbal
routine continence, the toileting skill was then gen-
and communicating in phase IV of the PECS
eralised first to other bathrooms within the home
protocol.
and then systematically to other familiar and
Previous attempts in the home and school
routine settings for each child.
setting failed to train Chris. His parents stated
that a minimum of two separate attempts were
made to train Chris at home and school. By
Data collection and interobserver agreement
verbal description, all of those attempts were pri-
marily systematically scheduled pots with the Data were collected continuously throughout the
planned consequence of verbal praise for success- baseline, training and return to baseline periods.
ful voids. By the time of intake, Chris occasionally For Marvin, baseline lasted days, training for
voided in the toilet during a scheduled sit when days and return to baseline was days recorded.
seated by an adult; he wore pull-up diapers on a Chris had a recorded baseline of days, training
routine basis. Of the recommended toileting pre- period of days and return to baseline data
requisites, Chris demonstrated three readiness recorded for days. Across all study phases, data
behaviours on a routine basis including staying dry were collected on frequency of in-toilet voids, self-
for at least h at a time, a regular bowel move- initiations to use the toilet and accidents. For the
ment schedule, demonstrating discomfort with purposes of this study, an in-toilet void was
dirty diapers via removal of the soiled linen, and recorded when urine or faeces were directly depos-
pulling pants up and down. ited into the toilet, a self-initiation was indicated
The participants were selected as a sample of when the participant child independently went to
convenience. They were selected for study post- the bathroom and subsequently voided without the
training given their completeness of datasets use of verbal or physical prompts at any point in
(including follow-up data) and anecdotal reported the behavioural sequence, and an accident was
similarity to children with autism most frequently noted to occur any time a void occurred away from/
presenting to developmental disabilities clinics off of the toilet. Data were recorded on both
requesting toileting services. The selected partici- number of accidents and self-initiations as a child
pants provide a sample of () children with autism may not have accidents, however, also may not be
not attempted to train (Marvin); and () children independently toilet trained in that all or most voids
with autism who fail to train without professional are prompted by another person or event (such as a
intervention (Chris). schedule).
Permission to publish archival clinical data from Reliability was assessed during the first day of
which these cases were derived was obtained treatment only for the time when the trainer and
through the governing children’s hospital institu- parent were both physically involved in the training.
tional review board. Data were recorded for voids, initiations and acci-
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
559
K. Kroeger & R. Sorensen • Intensive toilet training programme
dents. Interobserver agreement (IOA) during the school and other), as well as recorded for all
training time was % (calculated using the exact in-toilet voids and self-initiations. Data demon-
agreement method) for both subjects and continued strated a reliable pattern of primary incontinence,
reliability was not obtained in accordance with hence treatment was initiated. Treatment (formal
reasons cited in Cicero & Pfadt () including training) ended when the children were reliably
the obviousness of the operationally defined behav- continent (one or less accidents per day) and self-
iour, historically high IOA associated with toilet initiating use of the toilet more than half the time
training and high current IOA for the -h training for voids (% or greater). Leblanc et al. ()
periods. Long-term follow-up data with IOA were noted the higher occurrence of parental prompting
not collected as parent report was considered a reli- to use the restroom when training younger children
able source. (i.e. the younger the child the more likely the
parent to prompt or remind to use the restroom).
Procedure Follow-up data were collected at weeks, months
and years post-training in order to assess for long-
Medical consent and clearance were ascertained term maintenance of continence and initiation of
from the children’s attending developmental paedia- toilet use, as well as overall consumer satisfaction
tricians before beginning the intensive training pro- and social validity.
cedure. The procedure used was adapted by the
second author from Leaf & McEachin () based
Intensive toilet training programme components
on the Azrin & Foxx () intensive training
approach. Training occurred upon waking in the The intensive training treatment components con-
morning and continued until the child went to bed sisted of the following: () increased fluids; ()
in the evening (all waking hours). scheduled sitting on toilet; () positive and negative
reinforcement for target behaviour (in-toilet voids);
Stimulus preference assessment () redirection for accidents; and () scheduled
sitting on a chair (as opposed to toilet) to increase
The participant children’s mothers were inter- self-initiations.
viewed prior to baseline data collection using a
reinforcer interview modified from the Reinforcer
Increased fluids
Assessment for Individuals with Severe Disabilities
(RAISD; Fisher et al. ). Based upon interview Parents were instructed to increase the children’s
findings, Marvin’s target potent reinforcers were access to fluids for days prior to implementing the
identified as popsicles, candy-coated chocolate training in order to assure they were well-hydrated
candies and access to a computer (preferred and to provide for maximum opportunity for
website/game), while playing on the outside swing- voiding success when beginning to implement the
set and fish-shaped cheese crackers were identified protocol. It was recommended to consult with their
as principal reinforcers for Chris. The families were paediatricians to determine a safe volume of liquids
asked to restrict the children’s access to these rein- in order to avoid over-hydration and the minimal
forcers for a minimum of days prior to imple- potential risk of hyponatremia. Increased fluid
menting the intensive training treatment protocol. intake was continued until : h on day of
training.
Experimental design and baseline
Toilet scheduled sitting
This study collected data across two subjects in an
ABA design in that baseline data were collected, the The boys were undressed from the waist down and
training programme implemented and then training continuously seated on the toilet with planned
components were removed and the children left to escape for appropriate voids or brief time-outs from
initiate and pot on their own. Baseline data for fre- sitting in order to stretch and move their legs
quency of voids were manually assessed via wet/dry during non-void intervals. As they increased their
checks and collected across environments (home, number of appropriate voids, the time for scheduled
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
560
K. Kroeger & R. Sorensen • Intensive toilet training programme
Table 1 Toilet scheduled sitting fade schedule Chair scheduled sitting
If the children were successful at voiding in the
30 min on toilet 5-min break for successful void toilet on a -min on/-min break schedule but
25 min on toilet 10-min break for successful void
20 min on toilet 15-min break for successful void
not yet self-initiating, the initiation training compo-
nent of the treatment protocol was then imple-
mented; this occurred midday of day for Marvin
and in the late morning of day for Chris. A chair
was placed next to the toilet and the child seated
sitting on the toilet was systematically reduced and there instead of on the toilet for the scheduled sits.
time off of the toilet increased. Time on the toilet When beginning a void, if the child did not move
was reduced and time on break increased when the from the chair to the toilet, he was provided the
children successfully voided three times during a least intrusive, minimal, physical prompt. When he
given time ratio. Table summarises the sitting independently moved from the chair to the toilet to
schedule and time on/off ratios. The children were void three consecutive times, the chair was system-
permitted to play with preferred (but not highly atically moved away from the toilet in -feet incre-
reinforcing) toys while seated on the toilet in order ments. Once the chair was feet from the toilet,
to prevent boredom and potential inappropriate time was again systematically decreased for sched-
behaviours associated with the prolonged sits. If the uled sits by min and break time increased by
child did not void during the allotted scheduled sit min. When the time ratio was at -min break/-
time, he was permitted off the toilet for min but min scheduled sits and self-initiations were % of
restricted to remain in the bathroom until the the time or greater, protocol was discontinued.
-min break elapsed. If the child successfully voided
in the toilet, he immediately was permitted a longer Planned generalisation
break off of the toilet and outside of the bathroom.
Once the children demonstrated reliable continence
as outlined above, they were introduced to planned
Reinforcement for continent voids
generalisation in order to increase the likelihood of
If the children successfully voided while on a sched- successful toilet training as well as positive skill
uled sit, they were provided immediate reinforce- transfer. They were first shown and required to use
ment (primary edible reinforcement and planned another toilet in the home setting and then system-
escape to a preferred activity). If the child self- atically generalised to other bathrooms in their
initiated a void while on break, he was provided routine settings outside the home. For Marvin, this
immediate reinforcement and a new break time was occurred on day for different toilet within the
begun after the self-initiated void (e.g. if he was home and days (therapy sessions and school) and
min into a break and self-initiated use of the (public library) for settings outside the home.
toilet, his break was then restarted for the full break For Chris generalisation probes occurred on days
time after the void was complete). Both of these (different toilet within home), (school setting) and
situations were accompanied by verbal praise and (grandparent’s house).
behaviour-specific labelling of the target behaviour.
Intensive toilet training caregiver training protocol
Redirection for accidents
The children’s parents were the primary caregivers
If an accident occurred on break, the children were and trained in the toileting protocol as described
administered a neutral verbal redirection (i.e. ‘We above on day of the intervention. At the beginning
go pee-pee on the toilet.’) and physically redirected of day , protocol details were verbally reviewed
back to the toilet. Once on the toilet a scheduled sit with each child’s parents, including operational
was initiated. If they finished voiding in the toilet definitions for both successful and accidental voids,
after the physical redirection, they were reinforced component strategies of the training protocol, data
and the void treated as a successful void. collection and prompt fading techniques. The
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
561
K. Kroeger & R. Sorensen • Intensive toilet training programme
trainer was present in each child’s home for six completely faded and removed. The additional
consecutive hours. The first h the trainer coordi- prompts were discontinued on day of the training;
nated and modelled the intensive training while the however, it could not be ascertained that they did
parents observed, and the following h the parents not inadvertently occur on occasion until the
implemented the training while the trainer observed -week follow-up. Therefore, the treatment compo-
and coached the parents. At the conclusion of the nents that taught and maintained the continent
-h trainer visit, written protocol was provided for behaviour were discontinued at the conclusion of
the family reviewing the above and including imme- day of training and all residual parental prompts
diate contact information for the trainer. Verbal and reminders were discontinued previous to the
directions were then additionally provided for con- -week follow-up.
tinuing the child in protocol from his current level. It should be noted that percentages (number of
The families were instructed to contact the trainer accidents or self-initiations divided by total voids)
with any additional questions or concerns. Marvin’s were reported. Therefore, due to the decrease in
parents contacted the trainer five times for the fol- overall number of voids after the discontinuation of
lowing concerns: concern on redressing for outside increased fluids, the number of accidents appears
play (day ), concern regarding prompt dependency slightly inflated. Beginning with day and continu-
on auditory component of the timer (day ), review ing for all remaining consecutive data collection
of protocol to fade chair prompt use and discon- days, Marvin only had one accidental void when
tinue protocol (day ), review of protocol to discon- accidents were indicated. By the -week follow-up
tinue verbal prompts for use of toilet (day ) and Marvin did not have any accidents and this zero-
review of protocol to fade all prompts (day ). accident rate continued at the -month and -year
Chris’s parents also contacted the trainer five times follow-ups. Table provides the raw data ratio of
for concerns regarding review of accident protocol in-toilet voids to accidents for the participants.
during initiation training (day ), reduction of On day of training, the void accident was faecal
physical prompts during initiation training (day ), incontinence (first bowel movement since training
reduction of unobtrusive prompts (eye contact) implementation) and was behaviourally managed as
during initiation training (day ), runny bowel with urinary incontinence (i.e. verbal and physical
movements during training (day ) and removal of redirection). On day , the audible timer to signal
chair from initiation protocol and fading training break and scheduled sitting times was removed in
protocol overall (day ). order to dissuade auditory prompt dependency.
Beginning day , removal of the chair prompt and
return to typical home activities were implemented.
Day was reintroduction to routine activities
Results
outside the home (e.g. school, speech therapy) and
Figure illustrates the accident and self-initiation generalisation of toileting skills outside the home
percentages of daily voids for Chris across baseline, setting. It should be noted that self-initiations did
treatment and follow-up phases. At the beginning of not occur on this day and follow-up probes indi-
the fifth day, all treatment components, including cated that the participant’s mother reverted to
scheduled sits, reinforcement and prompting for delivering routine verbal prompts (e.g. asking ‘Do
independence, were discontinued. Beginning day you have to go to the bathroom?’) to initiate use of
(return to baseline period), Chris was indepen- the restroom. This is not an uncommon phenom-
dently potting and requesting to use the restroom enon when skills are generalised to settings where
(via PECS). incontinence carries higher social stigma and more
Figure illustrates the accident and self-initiation complex restitution routines (e.g. cleaning, chang-
percentages of daily voids for Marvin across study ing). Marvin’s mother was again instructed to
phases. By the beginning of the fifth day, all treat- remove all verbal and physical prompts beyond
ment components, including scheduled sits and what was deemed appropriate given child’s chrono-
reinforcement, were discontinued and by the logical age (it was permissible to provide a toileting
-week follow-up physical and verbal prompts were reminder before car/bus trips and going to bed).
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
562
K. Kroeger & R. Sorensen • Intensive toilet training programme
120
Baseline Treatment Return to Baseline Follow-Up
100
80
Percentage of Voids
Accidents
60 Self-Initiations
40
20
0
1 2 3 4 1 2 3 4 5 6 7 8 2 weeks 6 months 3 years
Day
Figure 1 Percentage of daily accidents and self-initiations for voids for Chris.
Day introduced communication training to the occur otherwise during the remainder of training or
participant child via PECS. When going to the at follow-up probes. This reduced need to train for
bathroom, he was prompted to construct the com- faecal continence was likely circumvented due to
munication sentence ‘I want bathroom’ using the the intensity of training in that the children were
corresponding icons. Data collection was discontin- not long away from the toilet during the initial
ued after day as the parents reported that the phases of training.
participant child was independently initiating use of
the toilet (with exception of two verbal reminders
Social validity measure
per day when getting on the bus to and from
school) with an absence of accidental voids. After training and follow-ups were complete, a
Faecal continence was not trained for separately social validity measure was sent to the participants’
in this protocol. Both participants had faecal acci- parents for completion and return in order to assess
dents on the first and second days of training, the procedures acceptability, feasibility and adverse
which were consequated the same as urinary acci- events. The Treatment Evaluation Inventory – Short
dents, and demonstrated in-toilet voids for bowel Form (TEI-SF; Kelley et al. ) results yielded
movements by midday on the second day of train- that the families were highly satisfied with the treat-
ing. Residual issues were not noted or reported to ment, procedures, acceptability and effectiveness,
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
563
K. Kroeger & R. Sorensen • Intensive toilet training programme
120
Baseline Treatment Return to Baseline Follow-Up
100
80
Percentage of Voids
60
Accidents
40 Self-Initiations
20
0
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 9 10 11 2 weeks 6 months 3 years
Day
Figure 2 Percentage of daily accidents and self-initiations for voids for Marvin.
Table 2 Ratio of frequency of in-toilet voids to accidents per day for and did not associate the protocol with related
participants child discomfort. Per parental reports, the intensive
training procedure used was deemed to be high in
Day Marvin Chris social validity.
1 30:6 20:6
2 27:1 12:2 Discussion
3 28:4 10:4
4 27:1 10:0 The results for this study indicate that the outlined
5 24:1 12:0 intensive training protocol was highly successful in
6 14:1 7:0 providing caregiver training to effectively toilet train
7 15:1 9:0
8 10:1
two children with autism to independently use the
9 12:0 toilet in a relatively short amount of time and main-
10 8:1 tain the skill over time. The model appears to be
11 10:1 promising for children who are both newly intro-
12 4:0 duced to toilet training as well as resistant to train-
13 5:0
14 5:0 5:0
ing attempts. These results are also hopeful in that
the described model could reduce the clinical time
spent with professionals in training continence
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
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K. Kroeger & R. Sorensen • Intensive toilet training programme
(allowing accessible training to more children), While it was suggested that the removal or
increase parental self-efficacy in working with their manipulation of the original components to the
children with autism, reduce the need for home Azrin & Foxx () protocol could account for
generalisation training and achieve independent toi- longer training times, this study counters that such
leting in a short time while accounting for resolu- a statement would appear to be untrue. Again exists
tion of residual issues (i.e. initiation, bowel the possibility that the setting and primary caregiver
movement training and communication) as well. In as trainer are critical components to successful and
addition, children with autism are characteristically brief training reminiscent of RTT protocol. The
impeded by issues restricting generalisation of skills current study varied from the RTT protocol in the
newly learned and communication in general. This use of urine sensing devices, delivering differential
study successfully trained the two participants for reinforcement of alternative behaviours (DRA) for
continence while also accounting for and success- remaining dry during off-toilet times, and imple-
fully achieving generalisation and communication in menting the use of punishment.
regard to toileting. The current study eliminated the use of urine-
This protocol replicates Azrin and Foxx’s rapid detecting apparati, including in-pants and in-toilet
toilet training (RTT) protocol original training sensors. In-pants sensors were not necessary for
time (matched -day training time with median urine detection as the children were (initially) naked
-day training). More recent studies focused on from waist down (clothing was systematically
training children with autism (e.g. Cicero & Pfadt redressed as the children demonstrated incremental
; Leblanc et al. ) were slightly longer in success with maintenance of low accidents). This
training time (– days and – days, respec- was possible because the training was conducted in
tively) despite utilising similar training procedures. the privacy of the children’s homes where it would
Cicero & Pfadt () called into question the be acceptable to remain unclothed. The urine alarm
chronic difficulty in replicating the Azrin/Foxx was required in the RTT trials due to the shared
RTT training time. Perhaps, the discriminating public space and unethical ability to disrobe the par-
factor lies instead in the trainer, or implementer, ticipants. In the home setting, the use of a urine
of the protocol. Both the current study and origi- alarm is rather an unnecessary, additional and costly
nal Azrin and Foxx study trained the primary car- step. Moreover, in-toilet sensors were not required in
egivers for the target participants (parents and this study due to the nature of the caregiver. Parents
direct care institution staff, respectively) as would be more comfortable visually observing their
opposed to ‘part-time’ primary caregivers (e.g. child’s genitalia in anticipation of voids (as opposed
trained support staff or teachers). The advantage to paid support staff working with adults in the RTT
of primary caregivers is twofold: () the motivation studies) thus again removing the need for costly,
for the participants to achieve continence could be additional materials. Therefore, the same result was
greater in persons who are primarily responsible achieved in the two different training protocols albeit
for changing, cleaning and maintaining the living using different methods due to the change in persons
areas of the participants as cited by Azrin & Foxx used as primary trainer.
(), as well as () the primary caregivers are Another variation in protocol was the removal of
also going to be the most aware of subtle cues, DRA during dry periods off of scheduled sits in the
responses and behaviours of the participants current training protocol. This change likely main-
leading to potentially faster reaction time or hyper- tained the training time in that different from the
vigilance to potting behaviours and occurrences. In RTT studies was the extended scheduled sit times in
addition, the training was also implemented in the the current study. The participants had less time to
primary setting for the participants (home and void while on break reducing the need to differen-
institution living ward again, respectively) where tially reinforce the absence of the incontinent behav-
the participant is most familiar and adept in iour. Hence, the longer sit time may have resulted in
manipulating. Perhaps person and place could be more frequent reinforcement for target behaviour
more important factors than originally suspected and ultimately similar reinforcement schedules when
in the speedy training of children with autism. the DRA was used with the RTT participants.
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
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K. Kroeger & R. Sorensen • Intensive toilet training programme
Another variation in protocol is the implementa- not socially valid it would be rendered a useless
tion of punishment procedures, notably restitution treatment protocol due to lack of implementation.
and positive practice. While more recent publica- Dalrymple & Ruble () generated survey
tions cite reduced and/or varied use of punishment results that indicated % of individuals with
procedures (e.g. Duker et al. ; Cicero & Pfadt autism who were toilet trained regressed in training
; Averink et al. ; Leblanc et al. ) most at some later point in time. Hyams et al. ()
also demonstrate increases in training time. The additionally noted regression in reference to self-
current study is the least restrictive and essentially initiation in a review of long-term follow-up of
‘punishment-free’ in protocol design. Planned con- toilet training in developmental disabilities. The
sequences for accidents were providing a simple current participants have maintained continence as
verbal redirection (‘We pee on the toilet.’) and well as void self-initiation for over years at the
walking the participant to the toilet. However, it time of publication. Perhaps the currently demon-
should be noted that after the occurrence of the strated resistance to regression is again with the
(first) bowel movement accident for Marvin, his parents as primary trainers in that they have the
parents restricted access to the computer post- tools necessary (as direct executors of the initial
accident since he was playing on the computer training protocol) to prevent regression in toileting.
when the accident occurred. While this was not a That is, since they provided the original training,
planned protocol consequence, it was indeed a form they additionally have the training tools on hand to
of negative punishment and could most certainly prevent any subsequent regression or backslide in
have influenced subsequent incontinent behaviour. toileting.
Cicero & Pfadt () cite that parental involve- The current study could be criticised that it is
ment in current training protocols is likely higher not a ‘true’ ABA treatment design in that while
and more socially acceptable due to reductions in most of the treatment procedures were definitively
positive punishment procedures. Perhaps the use of discontinued and returned to baseline conditions
negative punishment procedures could be useful as (scheduled chair sits, tangible reinforcement and
the one-time occurrence of it in the current study timer removals), verbal and physical prompting
was indeed parent initiated. In addition, current were significantly reduced but still faded over time.
parent rearing practices are more characteristic of Still, those named core treatment components that
negative (e.g. grounding, privilege restriction) signal the intensive training protocol were removed
versus positive punishment (e.g. spanking, overcor- leaving the child to pot independently. It is hard to
rection) use. conceive that the participant children would sponta-
Parents of incontinent children with developmen- neously become continent during this time as they
tal disabilities report higher personal stress and dis- had not spontaneously voided on the toilet previ-
tress likely related to the toileting problems ously and toilet training was not successful or
presented by their children than parents of toilet attempted (depending on the participant child)
trained children with developmental disabilities across settings. Similar conclusions were made by
(Macias et al. ). It could be deduced then that Cicero & Pfadt () in their study. The current
continence training not only increases quality of life study’s findings instead suggest a behavioural trap
factors for the child by increasing associated as described by Baer et al. () where the toilet-
hygiene factors and access to activities and place- ing skills developed through the applied interven-
ments, but also increases the quality of life for the tion (subsequently removed) were maintained by
parents by reducing stress and subsequently for the natural environment in that the children were
other family members such as siblings as corollary internally rewarded (i.e. comfort and cleanliness)
recipients of the distress. Toilet training could then for the continent behaviour and the behaviour itself
be one source of long-term stress reduction for became a learned/automatic behaviour.
families with individuals with pervasive develop- Areas of future research for this protocol would
mental disorders. Therefore, the social acceptability be to investigate its effectiveness in additional
of this intensive protocol is key in that the protocol training-resistant children and adults with autism.
is parent-delivered in the child’s home and were it Only two children’s datasets were presented limiting
© The Authors. Journal Compilation © Blackwell Publishing LtdJournal of Intellectual Disability Research
566
K. Kroeger & R. Sorensen • Intensive toilet training programme
the ability to generalise the results and procedure. Cicero F. R. & Pfadt A. () Investigation of a
In addition, as the treatment resources for children reinforcement-based toilet training procedure for chil-
dren with autism. Research in Developmental Disabilities
with autism nationwide are limited, it may be of
, –.
benefit to test this protocol in a group treatment
Dalrymple N. J. & Ruble L. A. () Toilet training and
setting where the parents are provided training in behaviors of people with autism: parent views. Journal of
the intensive protocol, video clips of training sce- Autism and Developmental Disorders , –.
narios shown, and then sent home to implement Didden R., Sikkema S. P., Bosman I. T., Duker P. C. &
with their children. Such a group treatment would Curfs L. M. () Use of a modified Azrin-Foxx toilet
even further reduce the clinical hours of profes- training procedure with individuals with Angelman-
sional time while servicing more individuals with Syndrome. Journal of Applied Research in Intellectual Dis-
abilities , –.
autism in this critical area of self-sufficiency and
independent behaviour. Duker P. C., Averink M. & Melein L. () Response
restriction as a method to establish diurnal bladder
In conclusion, however, is the promising result control. American Journal on Mental Retardation ,
offered by the current study in that a parent- –.
training protocol was successfully implemented in Fisher W. W., Piazza C. C., Bowman L. G. & Amari A.
the home environment, leading to reduced profes- () Integrating caregiver report with a systematic
sional time while maintaining high social validity choice assessment to enhance reinforcer identification.
with the caregivers. This study contributes to the American Journal of Mental Retardation , –.
currently growing body of toileting research investi- Hyams G., McCoull K., Smith P. S. & Tyrer S. P. ()
gating the effectiveness of established training pro- Behavioural continence training in mental handicap: a
-year follow-up study. Journal of Intellectual Disability
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Research , –.
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Kelley M. L., Heffer R. W., Gresham F. M. & Elliott S. N.
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early intervention in general, the earlier the children inventory. Journal of Psychopathology and Behavioral
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community events and mainstream educational training individuals with autism and other developmen-
placements. tal disabilities: a critical review. Research in Autism Spec-
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Leaf R. & McEachin J. () A Work in Progress: Behavior
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