Parent training 2014
Toilet training PPT script
Slide 1
Toilet training in the home – a guide for parents and caregivers is a presentation designed to instruct
parents in the basics of teaching individuals with an autism spectrum disorder appropriate toileting
habits. Although text within the presentation will refer to the child or children with ASD, the techniques
described have documented utility in teaching individuals of all ages to toilet appropriately. Parents are
strongly encouraged to have the child examined by a medical doctor in an effort to identify any
potentially influencing conditions prior to starting a toilet training program. Parents are also strongly
encouraged to secure the services of an experienced and competent Board Certified Behavior Analyst to
monitor the toilet training plan’s implementation and offer direct support if complications arise.
Slide 2
While it is not possible to cover every facet of toilet training in a single presentation or training session,
the overarching goal for this presentation is to prepare parents for running a toilet training procedure at
home. So first we will examine some barriers inherent to teaching individuals with an ASD to toilet train
and then compare them with the characteristics of individuals who train successfully. We will then
explore the multifaceted roles of parents in the training process and explore some common reasons why
training programs fail. Next we will survey the toilet training research and parse out variables deemed
critical to toilet training. Lastly, we will walk through two different scenarios – one for a child who has
not undergone prior training and another for one who has and failed – exploring how the critical
components fit to become a comprehensive toilet training plan.
Slide 3
Training an individual with ASD to toilet appropriately and independently presents a number of
challenges linked to the symptomology of ASD itself. Individuals with an ASD tend to display certain
behavioral patterns that, in one way or another, will prevent the child from acquiring the skills necessary
for toileting unless the programmer makes appropriate accommodations. For example, a strong affinity
to existing routines can make the transition away from diapers or pullups to regular underwear
problematic. In fact, any changes to the manner by which the child may void currently can be a barrier
that requires individualized techniques to surmount.
Schum and colleagues (2002) pointed out that when toilet training normally developing kids, parents
reported the most difficulty with the final step of training, when kids had to stop a current activity and
transition to the bathroom. Their participant group reported high rates of accidents because the kids
either waited until the last possible second to go to the bathroom or refused to go entirely. Now
imagine how much more difficult this can be when the learner already has the transition difficulties
inherent to ASD.
Among the characteristics the CDC lists as common to ASD, differences in sensory processing are
perhaps the least understood and most difficult to address. In the arena of toilet training, muscular
bladder control is an essential skill to master as sit schedules are thinned, as is identification of the
sensation connected to the need to urinate. Poor diet can also compound the issue of bladder control,
particularly in the areas of water retention and sensation to void. However, dietary factors tend to
influence bowel training more than urination training. Unless a specific oral motor dysfunction is
indicated, kids with ASD tend not to have difficultly learning to label urination in the toilet or in their
undergarments – they experience difficulties generalizing their use of language to spontaneously
indicating the need to use the bathroom.
A tendency toward over-selectivity is characteristic to the communication difficulties present in ASDs,
and this requires very specialized procedures to remediate. Lastly, while children younger than 18
months have been taught to urinate in the toilet, the general consensus in the literature is that typically
developing kids are most likely to be successful with learning all of the skills necessary to become
independent toilet users if programs began after approximately 20 months of age. Thus developmental
delays can present significant challenges to toilet training and may require supplementary strategies to
overcome their effects in preparation for training.
Slide 4
Let’s look at the skill sets that kids who train successfully can demonstrate. As you will notice, these
skills are directly or indirectly connected to the areas of deficit characterized by ASDs. Successful toilet
users can change the method by which they urinate from a standing position in an undergarment to
either a standing position without the feel of cloth contacting his/her skin or a seated position on the
toilet and into empty space. Further, these kids can recognize the sensation in their groin and abdominal
muscular region as the need to void and, subsequently, spontaneously indicate the need to do so to an
adult. They can then proceed to the bathroom in an efficient manner. Independent toilet users also
have adequate muscular control to refrain from urinating in the presence of the sensation to do so until
reaching the toilet. Again, influencing bowel training more directly than urination training, these kids
eat a healthy diet that makes food processing and subsequent waste elimination predictable and
efficient. While not absolutely necessary for beginning training, speed of training and overall skill quality
can be increased when the child indicates ‘readiness’ by displaying a few or most of these skills. As a
final note, notice that this slide’s title includes the phrase ‘by caregivers’. By intent, this indicates that
the most critical variable in toilet training children is the parent.
Slide 5
In speaking of the parent, we must acknowledge and explore the role of the family in the training
process. Just like with any other program we must clearly define expectations for those responsible for
implementing and maintaining it, and since the majority of toileting training occurs in the home, these
responsibilities fall on the shoulders of the family. Professionals will be involved in a consultative
capacity primarily and the professional contacting the family most frequently will be the BCBA
supervising the program. As such the BCBA will be present only for limited amounts of time and serve to
troubleshoot problems and/or refine the technical abilities of those implementing the program. Thus
those family members responsible for implementing the program fall into the role of designated
interventionists and will be the people doing the lion’s share of the toilet training. It is very important
for designated interventionists to have clear channels of communication not only with one another but
with the BCBA as well. In most cases this communication first will serve to ensure that the protocols
associated with the program are being implemented consistently and second to flag any issues with
implementation. A family member designated as program coordinator will receive all information
regarding program issues, meet with the interventionists and decide whether or not to contact the BCBA
for guidance. Overwhelmingly, it is easiest to simply contact the BCBA via phone or email and let
him/her decide if further support is necessary. Lastly, data based decisions cannot be made if accurate
and consistent data are not collected. Thus, the family is also responsible for assigning someone to
monitor data collection and collapse it into a user friendly format such as line graph. The data monitor
may also be responsible for sending graphs to the BCBA for review. We have presented these roles as
distinct for purposes of clarity in explaining them, and in some cases, families do set up roles in this
manner. However, existing resources do not always afford the luxury of these distinctions and so,
realistically, one caregiver may adopt two or all three roles simultaneously. However, the process
remains mostly unchanged.
Slide 6
Before examining components of toilet training programs deemed critical according to the research
base, it may help to set a context by reviewing some typical reasons these programs fail. This way, the
procedures and their importance will take some shape. Although occurring less frequently these days,
parents may take an approach to training their child with ASD that is similar or identical to that taken
with typically developing children. Given the characteristics of ASD and their potential impact on
training we have already reviewed, you should be able to see that this approach accounts neither for the
differences in developmental level or learning styles, nor the use of the evidence based practices that
have been so successful to date. Another reason children can fail at toilet training is when parents or
other consultants without proper education or training attempt to create and implement the training
program. Without a thorough understanding of the critical components and the behavioral processes
associated with implementing a toilet training program significant training errors can occur causing
problems that are extremely difficult to reverse and, in some cases, physical harm. Under these
conditions, parents will frequently give up on trying to toilet train and inadvertently establish additional
maladaptive routines. Lastly, parents can become overwhelmed with the sheer resistance displayed by
their children when they attempt to change the prevailing conditions under which the children void
currently. This resistance can manifest as problem behaviors such as tantrums, aggression, self-injury or
other forms of refusal to comply with these changes. Of paramount importance is the parent’s ability to
communicate these issues with the consulting BCBA and have him/her make programmatic revisions if
necessary. This is where the assistance of a qualified professional makes the difference between
achieving success and creating new, maladaptive routines that make successful training in the future
much more difficult.
Slide 7
So what exactly are the variables deemed critical to successful toilet training? A survey of the peer
reviewed research body yields 7 items proven effective directly and an 8th that has early, indirect
support. These are: systematic prompting, preference assessment, scheduled sittings, use of mild
punishment for accidents, manipulation of learner motivation, stimulus control strategies, discontinued
use of protective undergarments and modeling. We will cover each of these in more detail in the slides
that follow.
Slide 8
Systematic prompting is a strategy that is used to teach a wide variety of skills in behavior analysis.
When a new skill is introduced, the learner will need support to perform the skill. This support allows
the learner to practice the skill properly and repeatedly, and the trainer to deliver reinforcement
contingent on the skill, in an effort to increase its future occurrence. When it comes to toileting Azrin
and Foxx developed a systematic prompting technique called ‘Graduated Guidance’ designed to be used
with task analyzed behavior chains such as toileting. The instructor provides a degree of initial support
to ensure that the learner performs the skill correctly and then progressively and systematically lessens
this support over time as the learner begins to perform the skill with greater confidence and
independence. While graduated guidance can be compared to most to least prompting, Azrin and Foxx
noted a primary distinction as the use of manual support when implementing graduated guidance.
Support begins with hand over hand guidance to ensure correct practice of the skills in the behavior
chain. As the instructor feels the learner initiating the behaviors, she provides less directed guidance
and moves her hand up the learners arm to what is known commonly as an ‘elbow prompt’. The
instructor then positions himself out of the visual field of the learner and fades support up the arm to a
‘shoulder prompt’. Once the instructor relinquishes physical contact altogether, she remains in close
proximity for a bit longer to address any learner error. Once the learner is able to complete the chain
accurately and independently for several trials, the instructor removes herself from the learner’s
proximity entirely. Please note that this process can vary considerably in length based on a number of
factors including learner characteristics, environmental features and reinforcer potency. Also note that
failure to fade prompts in a timely manner can produce learner dependency on instructor support, a
problem that will require specialized strategies from a BCBA.
Slide 9
As the name implies, preference assessment requires an instructor to determine the items and/or
activities for which the learner displays high preference. Research has yielded several different formats
to identify learner preference, each having varying degrees of efficacy and characteristics lending them
to use in different contexts. When training toileting skills we want 1 or 2 items that are highly
motivating to the learner and can be used exclusively for training. Thus be sure that the items are not
those that your child must have other times throughout the day, such as juice or essential food items. Of
the different types of preference assessment, paired stimulus procedure tends to be best suited for
toilet training because it yields rank order of items as a reflection of learner preference (i.e. most highly
preferred, second highest preferred, etc.). Once we have these items, we can make their availability
contingent only upon performance of the toileting behavior chain. Again, please understand this means
that you will ONLY allow the child access to these items when toilet training and ONLY as per the
applicable step in his training plan. You will use a chaining procedure, most often total task
presentation, to teach the toileting chain. By keeping the 1 or 2 highly preferred items exclusively for
toilet training you can establish each step in this chain as a conditioned reinforcer for the next,
ultimately culminating in access to the preferred item. This not only teaches the child appropriate
toileting skills but establishes the toileting chain and the bathroom in general as a desirable condition.
For cases in which the child has not acquired the toileting chain properly, a consulting BCBA may
recommend using negative reinforcement as the primary contingency to teach proper toileting skills. In
these cases, sitting on the toilet has become an aversive event due to poor training or medical
contraindications, and the value of leaving the bathroom far exceeds the value of any competing
positive reinforcers you will have. Thus the child is allowed to leave the bathroom only after voiding on
the toilet. Negative reinforcement is to be utilized only with proper guidance from a qualified BCBA.
Slide 10
The next critical variable we will discuss are sit schedules. Sit schedules determine how frequently and
for how long the child will sit on the toilet for purposes of voiding. As you might suspect, sit schedules
can have a profound influence on the success of a toilet training program. Essentially, there are 3 ways
to determine sit schedules: arbitrarily, based on elimination schedule findings and based on a fluid
consumption schedule. Each has its own strengths and weaknesses and each is predicated on a
different philosophy. Arbitrary schedules are based on convenience and simplicity. The programmer
selects sit frequency and duration without considering existing elimination patterns or fluid
consumption. With a shorter interval between sits and a longer time on the toilet, you can increase the
probability that voiding will occur properly. The drawback of this approach is that you must bring the
child to the bathroom very frequently during training sessions and ensure that he remains on the toilet
for the entire sit duration. This can sometimes evoke resistance from the child in the form of
problematic behaviors such as tantrums, eloping and/or aggression. While they can be successful, we do
not recommend using arbitrary schedules for kids with ASD.
If you feel that it makes more sense to be strategic in establishing a sit schedule, then doing so based on
elimination or fluid intake schedules may be better for you. Elimination and fluid intake schedules focus
on times in which you might catch the child voiding naturally, and then planning scheduled sits around
those times. An elimination ‘study’ is when you track the times and amounts of food and fluid intake
and the times of voiding without making any other changes to the child’s daily routine. The goal of this
study is to determine how quantity of food and fluid intake influences times of voiding. Revealing
patterns such as average length of time between ingesting foods and voiding allows you to perform
toilet training at an optimal time and thus greatly increase the probability of capturing voids on the
toilet. One common complaint about this procedure is the amount of effort required by the family to
accurately determine voiding times. Although this process has been made easier through technological
advances such as urine alarms, it still requires frequent and consistent undergarment checks at
predetermined intervals. Further, families may find difficulty with recording all foods and all mealtimes
consistently for what can be extended periods of time.
Fluid consumption schedules rely on contriving, not capturing, the need to void. As such, they are run
concurrently with fluid intake schedules. Fluid consumption schedules allow adjustment of sit frequency
and duration according to how much fluid the child drinks and the timing of programmed fluid intake
during the day. Scheduled sits do not begin until the child has had some time to ingest fluids. Over time
as her bladder becomes increasingly full, the need to void becomes greater and sits become more
frequent. Because the child is on the toilet more often under conditions of motivation to void, the
probability of his voiding on the toilet increases greatly. The sit schedule thins accordingly as you slow
down fluid intake, stopping about an hour or so after the child drinks her final sips of fluid to ensure her
bladder empties fully. While fluid consumption schedules tend to be the most effective of the three
we’ve discussed, they require careful planning and monitoring. Thus, this procedure requires
consultation by an experienced BCBA and as such limits the independence with which parents can
implement the procedure.
Slide 11
The current political climate surrounding the use of aversives, seclusion and restraint discourages the
use of punishment procedures in favor positive behavioral supports. While this does not prohibit their
use, it mandates that programmers have sufficient support for their inclusion in a training program both
from the existing peer reviewed literature base as well as actual empirical findings. That said, surveys of
the toilet training literature revealed that punishment, while used in all but one published study on
toilet training, was the least frequently reported behavioral component.
Remember that a punisher is defined by its decremental effect on behavior, not the form that it takes.
In other words, although stating “no wet pants” in response to an accident may not appear to be a
punisher in form, it may reduce the rate of accidents quickly and as such function as a punishing
consequence for accidents. As prescribed in their RTT protocol, Azrin and Foxx established a procedure
called restitutional overcorrection. With this procedure the child restores the environment after a
soiling accident by cleaning an area larger than the actual soiled area, cleaning self, removing and
replacing clothing and cleaning clothing. While this procedure can act as an effective inhibitor for future
accidents, it often produces countercontrol in learners such as aggression, tantrums and other types of
physical and emotional resistance.
Contemporaries to Azrin and Foxx exploring variations of the RTT procedures replaced the restitution
component something called ‘positive practice’. Upon occurrence of a voiding accident, the instructor
guides the learner through the toileting chain for a fixed number of ‘practice trials’ consecutively, stating
“No wet pants” on each trial. In comparison to the restitution procedure, this practice procedure is
designed to ‘remind’ the child of the proper toileting sequence through repeated practice, so it
emphasizes correct toileting behavior rather than clean up skills. Further, because the sequence is
already familiar to the child, it tends to evoke less countercontrol.
Both restitutional overcorrection and positive practice have demonstrated tremendous efficacy as part
of toilet training packages. Paradoxically, the strongest feature of both of these procedures, the
accompanying avoidance contingency they establish, is also their most questionable because of its roots
in negative reinforcement. Both procedures involve increased response effort on the learner, and as
such, are intended to be unpleasant. Thus, the learner refrains from toileting accidents as a means to
avoid the overcorrection or positive practice procedure. And generally, positive reinforcement
procedures are favored in lieu of negative reinforcement procedures to increase behavior.
However, inclusion of these procedures warrants further consideration not just for their effectiveness in
suppressing voiding accidents but for those on program maintenance and spontaneous requesting.
Learners can become reliant on positive reinforcement and sit schedules such that their overuse can
promote dependence on them and a failure to achieve independent toileting. In fact the overarching
goal of toilet training is for the learner to self-monitor and self-initiate the chain without parent support.
Thus thinning of the sit and reinforcement schedules is mandatory.
Unfortunately, kids with disabilities can periodically regress and toileting accidents can recover over
time. Aside from being highly labor and time intensive, reintroducing schedules may actually promote
further regression. Further, when teaching kids to spontaneously communicate the need to use the
bathroom we want to establish a clear connection between the sensation of a full bladder, the
spontaneous request and the relief of the bladder emptying. This way the request comes under the
control of the sensation of a full bladder. Having a RO or PP procedure in place when accidents occur
better facilitates spontaneous requesting by enhancing contrast between appropriate and inappropriate
toileting components and can preclude the need to reinstitute a toileting schedule if accidents resurface
once formal training has concluded.
Presently, most studies forgo the RO procedure in favor of the PP procedure because of the emphasis on
practicing appropriate toileting behaviors. In the few studies that attempted to teach toileting without
using PP, none maintained successful training once the schedule and positive reinforcer was removed.
Thus at this point, PP seems to be a necessary component in an intensive toilet training intervention.
However, further research is in the works.
Slide 12
Anytime we can make a behavior occur more frequently, we increase our opportunities to alter its
consequences, and hence, its future frequency. Thus if we want to rapidly increase a given behavior, we
want it to occur as frequently as possible so we can deliver positive reinforcement upon each
occurrence. In most cases, the only constraints upon producing the target behavior is the willingness of
the child to play along. When it comes to toilet training though, there is the added constraint of having
waste that is ready for release. In other words, if a child does not feel or recognize the sensation of
needing to void, it is unlikely that he will engaging in voiding, regardless of the time or place. When
learning about sit schedules, we discussed the idea of contriving opportunities for the child to void by
manipulating timing and fluid intake interactively. The manipulation to which we were referring falls
into the realm of what Jack Michael termed Motivating Operations or MOs in 2000. A more thorough
discussion of MOs can be found in the presentation on behavioral principles, but for now, it is sufficient
to understand that MOs have two basic functions: they temporarily increase the value of an item,
activity or condition as a reinforcer and they temporarily increase the frequency of any behavior that
has produced that item, activity or condition in the past. So in terms of toilet training increasing fluid
intake significantly will serve as an MO for releasing waste through voiding. Two points of note: first,
increased fluids do not act as an MO for the reinforcer you found via preference assessment. The
reinforcer attached to the MO for voiding is the physiological relief voiding produces, particularly under
the sensation of a full bladder. In other words, MOs in toilet training occur in conjunction with negative
reinforcement contingencies primarily. Second, if an increased MO establishes the value of voiding as a
negative reinforcer, then by definition the child will void more often. Now that the opportunity to
reinforce frequently is contrived sufficiently, you must be diligent with getting the child to the bathroom
and sitting on the toilet. Extra effort here will translate into increased opportunity for yoking positive
reinforcement for voiding on the toilet with the naturally occurring negative reinforcement for voiding.
This will enhance greatly the effectiveness and efficiency with which you train your child to toilet
appropriately. Lastly, you must check with your child’s medical doctor to see if there are any
contraindications to increasing fluid intake significantly. Typical red flags are certain types of
medication, seizure disorders and other medical conditions.
Slide 13
Parents often switch from diapers to pull ups for typically developing children when starting toilet
training so the child can practice the undress / redress component of the toileting chain independently.
These children understand where the waste has to go and just need time to develop volitional control
over the muscles contributing to waste retention and release. In contrast, the child with ASD clutches
to routine and sameness and lacks the social awareness of stigmas associated with inappropriate
toileting. In other words, this child is very comfortable with voiding in the pull-up and will happily
continue to do so in absence of specific training otherwise. Paradoxically, studies examining the effects
of these protective undergarments on toilet training show that they are associated with increased
voiding accidents and decreased appropriate voiding on the toilet in BOTH neurotypical children and
those with an ASD. So clearly, when toilet training you should say goodbye to pull-ups. However, during
times when you are not training such as during nocturnal hours, it may be advisable to continue with the
pull-ups to avoid messy urine and/or bowel accidents. Consult your BCBA when making these
determinations.
Slide 14
Modeling is a general name for a category of antecedent interventions in which some form of
illustration of a targeted behavior is presented to the learner in hope that she will perform it. Models
can take many forms, for example as videos, scripts, or illustrated stories. While variations on modeling
have a base of peer reviewed research to support them, very few studies targeted toilet training
specifically. While preliminary research shows promise in teaching toileting skills to learners with ASD,
these skills did not prove durable over time in comparison to those taught using other techniques
discussed in this presentation. Thus, presently it appears that modeling may be effective during
acquisition phases of toileting skills as part of a multi-element intervention package. When using
modeling techniques, consider a few key points. First, the model should be tailored to the preferences
and of the target child. For example, if a child with ASD typically earns watching videos as a reinforcer
for other behaviors, he may offer resistance when you try to play a video model for toilet training.
Second, incorporate a model that matches the child’s learning style. For example, using text based
scripts with a child that has limited or no reading skills likely would be less meaningful than pictures or
illustrations of the toilet chain steps. Lastly, ensure compliance with child safety and privacy laws when
recording video samples or lending personal video samples for others to use. You must choose an
appropriate actor in the instructional video, maintaining your child’s and the actor’s dignity when
selecting samples of behavior to record.
Slide 15
Stimulus control occurs when a given condition, item or activity comes to reliably predict a specific
consequence and, hence, reliably evokes a given behavior consistently over time. Every time you teach
your child something using behavior analytic techniques, you are using stimulus control strategies.
However for toilet training, they have some very specific uses.
First, when toilet training a previously untrained child we want the sit schedule signal to acquire
stimulus control over the toileting chain during early phases and motivational variables to control the
chain later on. But sometimes things go wrong, and the child fails to acquire the toileting skills
appropriately. This is where specific stimulus control strategies come in; their application allows you to
remove the errors and retrain the proper skill set. Second, a consulting BCBA may wish to augment
existing training strategies to increase their efficiency. For example, perhaps the child is resisting
proceeding to the bathroom upon a timer signal; the BCBA can bring appropriate transitions back under
control of the timer by introducing a lesser reinforcer for appropriate transitions to the bathroom in
addition for that provided contingent upon urination in the toilet. Yet another application of SC
techniques may be to provide additional strategies for training bowel movements. The child may
require a modified toilet or seat or a systematic way to remove diapers and a specific stimulus fading
procedure to accompany. As you might surmise, selection and application of stimulus control strategies
is a highly complex process. Improper application of corrective stimulus control procedures can lead to
more serious problems for the child. It is essential that qualified BCBAs evaluate prevailing conditions
comprehensively, make appropriate recommendations for remedial strategies and monitor their
implementation closely.
Slide 16
Typically developing children require a great deal of support from their families when learning to toilet
appropriately, and children with an ASD require even more. Thus, the most critical variable in any toilet
training intervention is YOU. You must be unequivocal in your decision to toilet train your child. There
will be emotional and physical tumultuousness – are you ready? You will need to commit fully focused
time and attention – are you ready? You will need the direct and indirect support of your family and
decide who will participate actively and who will provide peripheral support. You will need to make this
your priority for as long as it takes – are you ready? Perhaps these statements make training seem more
daunting than it is in reality; but in truth far too many parents walk into training thinking they can do it,
only to bail out when things get difficult. This causes much larger problems later on. The take away
message is this: if you read this slide and answer “No” to any of the questions, then you and your child
are better served waiting until you can answer all “Yes”.
Slide 17
You are ready to toilet train, but is your child? This is a common question and unfortunately when
researching the answer parents come across much misinformation. Back in slide #4 we covered the
characteristics of children who are properly toilet trained. And within the discussion of this slide you
learned that all but one of these are the GOALS of training. Many unsupported sources on the internet
will claim that a child must be “ready” to toilet train by displaying these characteristics. Can you see the
contradiction? Truth be told, the only justifiable prerequisite to toilet training is to refrain from starting
until the child achieves a developmental age >24 months; and this is more of a recommendation by
developmental psychologists and pediatricians than a prerequisite, having to do with muscle control and
durability of training gains later on. In fact, there is only one requirement to starting training – YOU
must be ready.
Slide 18
So you have created training times, established roles and are ready to train. Step one is to gather some
baseline data using daily toilet training sheets. The purpose of baseline data is to establish your child’s
voiding patterns prior to training so we have something to which you can compare patterns during and
post training. By continually making these comparisons you can determine if the training methods are
working. To record the data, you will make entries on daily toileting data sheets. Please note that these
will be the same sheets you will use during training; however during baseline, you will record only the
frequency and times of voids per day and possibly the amount of liquid your child drinks. The consulting
BCBA may ask you to do soiling checks on fixed time schedules to detect voids more efficiently if your
child is wearing diapers or pull-ups and doesn’t let you know when she voids. This will entail physically
checking your child’s undergarments at each scheduled interval. These checks will be frequent, often
times every 5 or 10 minutes throughout the designated training period. Baseline data also have uses
other than comparing pre and post treatment effects. By evaluating the frequency and times at which
your child voids, the consulting BCBA can establish the sit schedule that you will use during program
start up. Perhaps the most critical element of baseline data collection is keeping things the same
throughout the collection period. Remember, we are not training yet; any changes you make will
constitute a training intervention and likely skew the data, rendering them unusable. So respond to
accidents as you have been doing, do not give your child any more or less fluids than normal, do not
switch to regular underwear if he is currently wearing diapers and do not begin a sit schedule. If you
keep things consistent, you should expect to collect baseline data for approximately a week, or less if
patterns emerge quickly.
Slide 19
The second step is to establish the highly preferred items you will use as reinforcers during training. You
will accomplish this through conducting preference assessments. To keep things moving forward as
efficiently as possible, you can perform preference assessments while you are collecting baseline data
for step one. As discussed previously, you will use a paired item format to perform the assessments.
You will perform separate assessments for food and leisure items; and for each set of food and leisure
items you will run the assessment twice. Specific details regarding how to perform the assessments are
listed in a manual located in a resources folder accompanying this presentation. In preparation for the
assessments, you will need to gather at least 6 different preferred foods and 6 different preferred
leisure items. Each assessment will yield a rank order of preference with 1 being the highest preferred
and 6 being the lowest. When you run multiple assessments using the same group of items, you will
compare the results and look for repeatability in your child’s preferences. The more often an item
achieves a high ranking the higher preferred it is. Items that consistently rank in the top three are those
you will want to set aside for toilet training reinforcers.
Slide 20
Now it is time to set up the sit schedule for your child, and remember there are three basic schedules to
consider: arbitrary, elimination and fluid consumption. But before deciding, consider a few factors
overriding all three and then base your decision on the characteristics that best suit your needs.
First, food and liquid ingestion works interactively with waste elimination as a basic phylogenic process.
In other words, the more we eat and drink the more we eliminate; the more consistently we eat and
drink the more we eliminate according to a predictable schedule. So, for example, if your child has
feeding issues such as a severely restricted diet, you may consider treating that issue before tackling
toilet training. Sitting a child on the toilet frequently or for extended periods without reinforcement
will only serve to establish the bathroom as worsening set of conditions and cause problems down the
road.
Second, kids new to toilet training need many opportunities to practice the toileting chain. Your choice
of schedule should afford these opportunities and you and your BCBA should monitor acquisition data
to ensure proper learning is occurring.
Lastly, when training urination, we want motivation to urinate to be very high. As such you will want to
ensure you have potent positive and negative reinforcement for urinating. Run preference assessments
periodically to keep positive reinforcers highly preferred and ensure sufficient liquids to keep the
inclination to urinate equally high.
Within the context of these factors, you can establish your preferred schedule based on your needs.
Conceivably, arbitrary schedules can be used for both urination and bowel training, although in practice
professionals tend to use them for urination exclusively. Remember, arbitrary schedules are easy to
understand and follow, but do not factor in motivation to void and can cause kids to avoid the bathroom
due to sitting frequently and not voiding. Elimination schedules tend to be even more user friendly for
families due to training times surrounding naturally occurring times during which the child voids.
However, the fact that most people urinate several times per day and the frequency of urination is
dependent upon what and how much the person eats and drinks naturally generally precludes use of
elimination schedules for urination training. Fluid intake schedules require increased technical
proficiency on the part of the family but best take into account motivational variables. However, care
must be taken to avoid too much fluids and to ensure ample ramp up and tapering off of fluid intake.
Slide 21
So which schedule is best? That depends on what set of behaviors you are trying to teach. Until now,
we have not made a distinction between urination and bowel training. However, the unique
characteristics of the three schedules better lends some to specific types of training. For example,
provided there are no medical contraindications, fluid intake schedules work best with urination training
by ensuring many opportunities to practice the toileting chain, the highest probability of urination on
the toilet and receiving reinforcement. The research literature and our experience shows that for
training purposes, increasing the MO for urination requires only moderate increases fluid intake in the
short term; it is the cumulative effects over time that actually evoke it. Thus the risk of hyponatremia in
actual practice is small provided that a properly experienced BCBA providing guidance. In contrast,
recommending the use of stool softeners or enemas to evoke bowel movements without explicit
medical reasons and recommendation by a medical doctor is unethical due to associated side effects
and risks. So for bowel training, we recommend an elimination schedule based on an elimination study
and train only during those times in which data show bowel movements to be most likely.
Slide 22
Here is day one of a sample toilet training program for a previously untrained child. In this program, our
family has decided to dedicate mornings from 8-12 for toilet training. They begin increased fluid intake
with breakfast at 8AM, and start scheduled sits approximately 30 minutes later at 8:30AM. This gives
the child some time to process the fluids and decreases the probability that he will sit without urinating
when the sit schedule starts.
Critically, the family monitors the child closely in the minutes leading up to 8:30, watching for any signs
of urination. Should the child begin to have an accident, the family will attempt to interrupt it and rush
the child to the toilet to sit. If he urinates on the toilet, family will reinforce. Since this is day 1, step 1 of
training, the family will not run positive practice for accidents but attempts to interrupt them and get
the child on the toilet as quickly as possible. Once the child leaves the bathroom, the family will follow a
5 minutes on, 5 minutes off sit schedule.
They will end increased fluids at 11AM, approximately 1 hour before the training segment ends, to give
the child time to release residual fluids on the toilet. They continue with the 5 on / 5 off from 11AM until
the child sits and does not urinate. At that point they will adjust the schedule to 5 on / 15 off to account
for less motivation to urinate and decrease sits without contacting reinforcement. Again, if the child
begins to have an accident at any point, parents will interrupt and bring to the toilet. After the two final
sits, they end training for the day. Importantly, if the child has been wearing diapers prior to starting
training, the family will change from underwear to diapers again. The tapering of the sit and drinking
schedules exemplifies the benefits of the fluid intake schedule.
Slide 23
Some of the most common questions we get from families when toilet training are, “What type of fluids
do I give my child?” or “How much fluids do I give her when training? In response to the first question,
water is by far the best fluid to use. However, if your child drinks only juice, then you must water down
the juice to a 1 part juice to 3 parts water ratio or less. Too much concentrated juice can cause other
issues such as insulin spikes and loose stool. If your child is resistant to the watered down juice, spend
some time teaching her to drink it before starting toilet training. Your consulting BCBA will have some
recommendations about how to do this. Do not use other liquids such as soda. The toilet training
literature is not conclusive about how much fluids to give children when toilet training, but warn against
inducing a state of hyponatremia. In reality, most individuals who drink to the point of hyponatremia
have other conditions such as Prader-Willi Syndrome and will consume gallons of liquid per hour if
allowed; so truth be told, while cautious, we tend not to be too concerned when implementing our
training protocols. As a launching point, we would start with 6-8 ounces per hour for a child of about 40
pounds and 6 years of age. We drop to 4-6 ounces for a smaller child and adjust upward to 10-12
ounces for pre-teens. We do not look to “flood” kids quickly; as previously mentioned we harness the
cumulative effects of fluid intake, hence the reason we delay sitting for approximately 45 minutes after
starting fluid ingestion. As with intake, this range can vary depending on the age and size of the child.
As our training protocols are structured, this drink schedule thins out pretty quickly as the child learns
the toileting chain and can withhold urine until sitting on the toilet. Once the child learns the skills, the
need to establish strong motivation to urinate decreases. But understand that keeping motivation to
urinate high during the initial phases of training is critical. Lastly, it is perfectly acceptable for your child
to eat if your training sessions encompass a meal time. However, it is best to avoid larger amounts of
salty foods during training as increased sodium levels promote water retention, not release. A chip as a
reinforcer for urinating on the toilet is fine; a bag of salty chips as a snack during training is not.
Slide 24
While not having sufficient research to be called an evidence based strategy for purposes of toilet
training, modeling is an intervention with a low risk, potentially high reward ratio. The only real
drawback to modeling is the minimal effort it takes families to develop the materials. However, as
discussed previously you must take the time to ensure matching of the modeling format to the learning
style of the child. In practice, there are two times during which you can use modeling with your child,
those in which she is seated on the toilet and those when she is off. Intra-trial training gives the child
something to do while waiting to urinate and has the advantage of defining in vivo performance
expectations and goals. For example, if using an illustrated children’s potty training book, you can point
out to your child what the character does when on the toilet while your own child is sitting. This makes
for a stronger connection potentially. On the down side, if your child loves to look at books, you may
inadvertently reinforce sitting only, and not urinating. In this case using the book for intra-trial modeling
is contraindicated; but you can switch gears and use the potty book as a reinforcer for urinating should
you choose. Inter trial periods can also be a valuable time to use modeling for similar reasons except
that you do not have the in vivo connection. Research does not yet specify if one is better than the
other.
Slide 25
The move to step 4 of initial training requires that you utilize ABA techniques to increase your child’s
independent and accurate execution of the toileting chain. This step is where you establish a clear
contingency showing your child how he can get the item you found to be most preferred. Remember,
he should not have had access to this item for a while, so he should be highly motivated to do whatever
it takes to get it. You will use graduated guidance to ensure that he is able to successfully perform the
motor movement portions of the chain, from proceeding to the bathroom when time to washing hands
when done. Mostly you will use verbal praise to reinforce your child’s execution of the chain when she
requires your assistance. However, once she begins to perform the steps with less assistance, you can
deliver a small portion of the item or activity that ranked number 2 or 3 in the preference assessments.
The first few times your child does the chain independently, you can deliver larger portions; afterwards,
you can deliver it sporadically to maintain independence. As general rules, if using a leisure item reward,
give 30 seconds for less prompted skill demonstration and 1-2 minutes for independence; for food items
¼ portion and whole portion respectively. Offer verbal praise for sitting properly on the toilet. When
your child voids on the toilet, follow the same reinforcement guidelines for independent responding
above.
Slide 26
Believe it or not, early accidents are a good thing when toilet training. For the child, they are necessary
to provide clarity regarding the contingency for appropriate urination. Until recently, the restitutional
overcorrection of Azrin and Foxx’s RTT procedure was the only evidence-based consequence for
addressing toileting accidents during training that produced rapid and durable reductions. However,
more recent studies have favored positive practice in response to accidents because it produces the
same rapid reductions in toileting accidents but allows the child to practice the behaviors designed to
replace accidents rather than collateral chains. Even more recently, several studies investigated toilet
training programs with neither restitutional overcorrection nor positive practice.
Kroeger & Sorensen replaced restitutional overcorrection and positive practice procedures with
increased sit times as an avoidance contingency for urinary continence. In their study, these authors
had the children remain on the toilet for as long as it took them to void which, in the early stages of
training, were quite extended periods. If a urinary accident occurred during non-sit periods, the child
returned to the toilet until she voided on it. While this produced appropriate toileting initially, the
results proved fragile and at follow up the children did not maintain toileting skills. Further, parents
reported that study participants displayed resistance whenever they were made to go to the bathroom
used during training, not only if prompted to void in the toilet but for bathing as well.
Cicero & Pfadt ran the basic RTT protocol with only a verbal reprimand as a consequence for
incontinence. They verbalized, “No wet pants” when participants had accidents and, with everything
else being constant, saw rapid reductions in accidents and increases in appropriate voiding. When
exploring their results, they concluded that the verbalization functioned as an S-delta condition,
signaling the unavailability of reinforcement. However, when other independent review researchers
examined this study as part of a larger meta-analysis, they challenged these findings, concluding that the
response curve associated with the rapid drop in responding established verbal reprimands not as an Sdelta but as a punisher. Furthermore, the results achieved during the training protocol were not
maintained during follow up and the program had to be reinstated.
While these studies may act as a torchlight for more promising, future research, the degree of
contingency manipulation required to implement these protocols is likely far beyond the skillset of
anyone other than highly trained professionals. In other words, the positive practice procedure is user
friendly for families and produces consistent, durable results, even during maintenance phases. Thus,
while the use of positive practice can be replaced by accident interruption during initial acquisition of
the toileting chain, it remains the most effective component to address accidents later on, when
toileting independence is a primary goal.
Slide 27
A child toilet trained to independence will initiate the toileting sequence without direct support or
signaling from others. This begs the question – should you teach your child to communicate the need to
use the bathroom to you or other caregivers? On one hand, you probably don’t tell people in your
home when you are going to use the bathroom. And perhaps, it would be appropriate for your child
with an ASD to do the same at home. But, think about the potential safety concerns – cleaning supplies,
bath water, razors, etc. And what about when you are in places other than your home? Further, what if
your child defecates while urinating? Have you trained the skills associated with cleaning after bowel
movements? As a general rule, we recommend teaching children to communicate the need to use the
bathroom, and it does not have to take away independence.
Slide 28
‘Spontaneous’ communication implies verbal behavior that is under the control of specific motivating
operations or naturally occurring cues. In the case of teaching children to inform others of their need to
use the bathroom, we want the communication response to take the form of a mand, i.e. verbal
behavior under the control of the MO associated with voiding. The most commonly utilized response
forms are icon exchanges and sign language. Both of these forms lend themselves to errorless teaching
through prompting, so you can ensure execution at the appropriate time during initial training. Another
advantage to these forms are their portability, meaning that your child can use them across
environments. While voice output devices such as IPads using ProloQuo or other software can also
meet the same criteria, they have the additional requirements of maintaining proper programming and
charging, both of which can be challenging day to day and if not met, render the device useless for
communicating. All things considered, we recommend the lower tech options first and then moving to
the higher tech options later on if desired. In some cases, we may recommend using icons or sign even if
your child has a vocal repertoire for the same reasons of errorless execution. There are several
evidence-based ways to embed the communication response into the toileting chain. The easiest of
these is to simply make the communicative exchange the first step. So before proceeding to the
bathroom, prompt your child to perform the exchange. In cases where the exchange is not occurring
spontaneously, time delay and chain interruption tactics have also proven effective. However, they
have additional technical requirements that you must ensure are present if they are to work. First, you
must ensure that the child has both a high MO to void and the bladder control necessary to refrain from
accidents for a short period. Additionally, the child must have mastered the steps in the toileting chain
so that the steps following the interruption has been established as a conditioned reinforcer. Since
completion of the chain has been successfully correlated with the terminal reinforcer, interruption
serves as a condition of extinction which will motivate the child to perform the communication response
you will prompt errorlessly. After some repetition over time, any pause (i.e. time delay) in the chain
should evoke the communication response, which sets the conditions for you to pause the chain at the
first step and embed the communication response as the initial response in the chain. Please note that
these procedures are sophisticated and require guidance by a qualified BCBA.
Slide 29
Once the child is manding for the toilet at the start of the chain on a reliable basis, you are ready to
remove the sit schedule. Upon initial removal you will deliver positive reinforcement each time your
child spontaneously requests to use the bathroom and completes the toileting chain. Continue this for
the first 6-10 times he does so and then begin to thin the reinforcement schedule (e.g. reinforce every
other time, approximately every 3rd time, etc.) until you can remove the schedule completely. You have
now reached the maintenance phase of toileting which will last indefinitely. Unfortunately, virtually
every child has some recovery of toileting accidents in the absence of the sit and reinforcement
schedules. For this reason, we keep the positive practice in place and implement it upon every
occurrence of toileting accidents. As a general rule, be ready to run the positive practice for at least 6
months after your child is fully trained. Remember, if she never has any accident recovery, you will
never have to run the practice. Think of the positive practice as an insurance policy that protects against
accidents recovering fully and having to start the toileting process all over again. Immediately notify
your BCBA of any recovery of accidents; more than 1 accident in a week or so, may require additional
strategies to prevent regression.
Slide 30
The final step of training is generalization, although you can teach your child to generalize toileting skills
far sooner than this point. Thus far we have spent considerable time and effort training your child to
respond in a very specific manner to very specific stimuli. Paradoxically, during generalization we are
weakening some of the stimulus control we have established with your child’s toileting skills so that
other stimuli can come to control them too. As discussed previously, typically developing children
generalize skills inherently, that is, any skills they learn tend to be inherently ‘portable’. As a core
deficit, the child with an ASD fails to do this and, as such, must be taught to do so explicitly. Stokes and
Baer (1977) posited that generalization is not a byproduct of training but an exclusive process containing
implicit technology deserving of serious study and consideration by the behavior analysis community. As
such, analysts would have to actively program generalization of skills across stimuli, responses and
contexts if functional and socially significant change were to occur. Thus for toilet training, your child
must be able to perform the skills not only with you, in your home and in the specific bathroom in which
she was trained but with other people (e.g. friends, family, teachers), in other settings (e.g. at friends’
homes, mall, or school), in other forms (e.g. standing at urinal) and in other contexts (e.g. overnight). For
purposes of simplifying content, generalization is placed as a final step in this presentation. However in
practice, you can program for generalization much earlier in the training process. The only caveat is that
training can take longer if you vary the stimuli that will ultimately control toileting from the start. Once
you decide to start generalization programming, it is best to limit variation to one dimension or
component at a time. In other words, if you want to have people other than you run training sessions
with your child, include only one other person at a time. In this case you will hold all other dimensions
constant. As an actual final step in programming, you will want to perform generalization probes to
truly assess if your child has generalized toileting skills. This would entail having him in a novel location
such as when in the car or community, and seeing if he will spontaneously request the toilet when
needed. Once she is able to do this successfully 2 or 3 times, you can consider her successfully trained.
Slide 31
Thus far you have learned about the tools and techniques to toilet train a child who has not undergone
prior training. But what of children who have failed during prior attempts? These kids often have
idiosyncratic and maladaptive response patterns resulting from incorrect training. In the initial RTT
study, a portion of the test group comprised kids who failed at prior attempts to train; and these kids
were successfully trained using the RTT procedures. However, Azrin and Foxx did not report the specific
toileting issues with which the subjects presented, so it is unclear exactly as to how or why the RTT
procedure worked. Fast forwarding to present times, we know that 1977 predated formal efforts to
standardize functional analysis procedures and when diagnosing toileting issues, formal functional
analysis of the precise conditions and contingencies maintaining maladaptive toileting repertoires is the
gold standard. In other words, if we understand exactly what went wrong and how the maladaptive
behavior is being maintained through functional analysis, we can devise and implement functionally
matched treatment strategies to replace it with appropriate alternatives. Please note that unless you
are a BCBA, you will not be able to perform this analysis safely or ethically without guidance from one.
Slide 32
So what are the common reasons for program failure? In many cases, the child becomes dependent
upon the schedule because it was not thinned quickly enough. The child will not spontaneously initiate
the need for the bathroom and/or will have repeated accidents upon schedule thinning or removal.
Another schedule induced scenario occurs when the child develops a conditioned aversion to the
bathroom because she sat for too long on the toilet. This typically occurs in conjunction with too little
fluid intake when the child sits for extended periods without feeling the need to void. In contrast,
another fluid intake problem occurs when the child continues to drink large amounts of fluid as the
schedule is being thinned. In most cases the child has not yet learned to initiate toileting so he is able
neither to request the bathroom nor refrain from releasing a very full bladder during extended periods
off the toilet. In other cases, earlier stages of training see a child learn the toileting chain but fail at
spontaneously requesting because the trainer embedded himself or the timer in the chain. This occurs
particularly frequently when the trainer prompts the child to begin the toileting chain by speaking to
her. Lastly, there may be a combination of reasons for program failure. As you might suspect, these are
the most difficult to diagnose and treat due to significant complexity and severity of maladaptive
patterns.
Slide 33
Most problems associated with program failure can be linked to errors in prompting, scheduling or fluid
intake. While these issues can be relatively easy to diagnose, they can be difficult to fix if left
unaddressed for long periods of time. When caught early, your BCBA will address the issues through
retraining or modifications to the existing procedures.
Issues involving combined factors are an entirely different animal. Commonly, combined issues are left
unaddressed for long periods due to their eventual severity. Thus, the maladaptive behavioral patterns
resulting from them are strongly embedded in the child’s repertoire. The consulting BCBA must conduct
a thorough functional analysis of the variables surrounding the problem(s), first to accurately identify
them and second to reveal the reinforcement contingencies responsible for maintaining them. Once
clarified, the BCBA can determine the appropriate strategies to remediate the problems, which in most
cases, will be variations on stimulus control strategies. Your child may require desensitization to stimuli
or conditions that have become conditioned aversives to her. In these situations, strategies such as
respondent extinction or systematic desensitization may be employed.
Additionally, the BCBA may recommend strategies designed to retrain your child to respond to salient
discriminative stimuli within the toileting environment. These types of strategies are particularly helpful
when children learn to void on the toilet but do not respond to the positive practice procedure.
When the issues surround deviations in the behavioral topographies associated with proper toileting,
some reshaping may be needed. The BCBA may ask you to readminister preference assessments and
make subsequent changes to the positive reinforcement schedules or behavioral contingencies
surrounding the problem topographies. Further, the BCBA may recommend adjusting the negative
reinforcement contingency associated with leaving the toilet in cases where children intentionally refuse
to void on the toilet.
Lastly, in cases of defecation issues where the health and safety of the child is compromised through
distended bowels and other dangerous conditions, the BCBA may recommend manipulation of
motivating operations through the use of enemas or stool softeners under advisement of an MD.
However, these conditions can also be symptomatic of larger, more serious medical conditions, and thus
warrant evaluation by the child’s medical doctor.
Slide 34
I’d like to leave you with a few final thoughts regarding toilet training children with an ASD. The greatest
likelihood for successful toilet training occurs the first time you try to train. Therefore, it is in your and
your child’s best interest to do it correctly the 1st time. Not only is it considerably harder to fix problems
or retrain your child, it will require extra time and effort both on the part of you and your consulting
BCBA. The basic procedures required to train your child are well within your capabilities to implement,
and implementing them with due diligence should ensure successful training. You must commit; the
most critical variable in the success or failure of a toilet training program, especially at home, is you.
Lastly, your most effective tool in training your child is knowledge; knowledge of the procedures,
knowledge of the concepts behind them and an understanding of how to identify when things are going
well and not so well. By reviewing this presentation you are taking a step in the right direction.