Goals of independent toileting. Benefits of toilet training. Components of rapid toilet training. Data collection. Teaching related skills

Transcription

1 Terms to know When should toilet training be started? Benefits of toilet training Goals of independent toileting Potty chair or toilet? To sit or to stand? What should the child wear? Home or school? Data collection Components of rapid toilet training Teaching initiations Fading the intensive program Bowel movement training Nighttime training Teaching related skills Additional research Questions!

2 Urinate, pee, peepee, weewee, tinkle, peeps? Bowel movement, poo, poop, kaka? Bathroom, toilet, potty? Training, teaching, toileting, learning? Toilet learning is very different from potty training. Old-fashioned potty training is something adults do to children and often makes children feel bad about accidents. Toilet learning is something children take an active part in and helps them feel good about using the toilet. Body parts Toileting readiness : Are there toileting prerequisites? American Academy of Pediatrics (2006) Dry at least 2 hours at a time during the day or is dry after naps Bowel movements are regular and predictable Actions or words reveal child is about to urinate or have a bowel movement Can follow simple instructions Can walk to and from the bathroom and help undress Seems uncomfortable with soiled diapers and wants to be changed Asks to use the toilet Asks to wear underwear

3 Gorski (1999) Walk Imitate behavior Put things where they belong Demonstrate independence by saying no Express interest in toilet training Indicate first when going and then when needs to go Able to pull clothes on and off Azrin & Foxx (1974) Bladder Control Physical Readiness Instructional Readiness Urinates a lot at one time Appears aware is urinating Stays dry for several hours Can pick up objects Walk from room to room Follow simple instructions

4 Current trend is toward readiness and later toilet training Neff (1998): Children toilet-trained by 30 months 1997: 22% 1961: 90% Most children achieve bowel and bladder control by mo (Carlson, 2012) 1947: most children by 18 months old There is no scientific evidence that an early potty training age harms children

5 Consider cultural differences in expectations: Horn, Brenner, Rao, & Cheng (2006) Caucasian parents: 25.4 months African-American parents: 18.2 months Parents of other races: 19.4 months Avoid diaper rash and diaper-related infections Save money and time on diapering Inclusion in community experiences (e.g., school) Environmental impact of disposable diapers Peer perception Parent perception Parent confidence in clinicians and ABA

6 Children with developmental disabilities may not Respond to instructions and rules explaining contingencies Experience social approval and independence as reinforcing Respond to feelings of having to urinate/bm the same way May require more practice and reinforcement to acquire new skills Healthy Consult the child s pediatrician Rule out or remedy any medical conditions or additional factors that would make starting toilet training inadvisable at that time Feeding issues Relatively cooperative Cicero (2007): Awareness of reinforcement contingencies for other activities The team is ready Family not experiencing major change or crisis Everyone is aware of their roles and time commitment * Studies should report skill levels on signs of readiness

7 Continence Initiation/ Getting to (the correct) bathroom Mastery of related behaviors Removing clothes Excreting into the toilet Wiping Redressing Flushing Washing hands Kroeger & Sorensen-Burnworth (2009) * No studies comparing these Advantages of Potty Chair Child-size Portable Doesn t flush Limitations of Potty Chair Must transition to regular toilet Doesn t flush Considerations Seat that can be used on both potty chair and toilet Novelty potty chairs?

8 Step stool can help child be Independent sitting More comfortable sitting

9 Most boys learn to urinate sitting down and later change to standing up (American Academy of Pediatrics, 1998) Starting with sitting may be easier Appropriate for both urination and BMs May need extended time on the toilet for success If sitting: legs apart; hands on legs or give something to hold But some may prefer standing Teaching boys to aim Toilet targets Consistency is important * No studies comparing these Clothes Shorter shirt Just underwear or elastic-waist pants (no shoes) Wearing light colors (not white or black) may make it easier to detect accidents immediately

10 Diapers or underwear? Disadvantages of diapers Diapers or underwear? Disadvantages of diapers Advantages of underwear What about pullups? Diaper while sleeping 5 typically developing toddlers Underwear facilitated toilet training Decreased accidents/ increased successes for 2 Diapers and pull-ups: no improvement for any

11 Begin at school and transfer to other settings LeBlanc et al. (2005) Toilet training in all settings Consistency! Dunlap, Koegel, and Koegel (1987) Conduct an initial meeting attended by all team members Choose a coordinator : parent or professional responsible for monitoring data collection, making changes to the program, and coordinating communication across all settings and caregivers Write out the procedures and keep a copy in all settings Schedule observations and supervision across settings and providers Collect data on Urine & BM accidents Urine & BM successes Initiations Baseline data important for at least three reasons: (1) Establish individualized sitting schedule (2) Recording occurrence of BMs may reveal a pattern (3) Allows you to evaluate the intervention

12 Most studies frequency per day Some studies: Percentage of urinations/bms that were successes, accidents, self-initiated Cocchiola et al. (2012) Kroeger & Sorensen-Burnworth (2010) LeBlanc et al. (2005) Post & Kirkpatrick (2004) Because fluid intake may differ across days Baseline checks 15 min: Post & Kirkpatrick (2004) 30 min: Tarbox et al. (2004); Cocchiola et al. (2012) min: Didden et al. (2001); Brown & Peace (2011); Chung (2007) Baseline data on fluid intake? Can help determine appropriate increase during treatment

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14 Toilet training with individuals with developmental disabilities began in 60s Rapid toilet training (RTT) Most studies on behavioral toilet-training this population use similar components

15 1 Full bladder 2 - Comfortable diaper 3 - Playing Pee in diaper 1 Relaxed bladder 2 - Comfortable diaper? 3 Still playing 1 Full bladder 2 - Comfortable underwear 3 Playing Pee in underwear 1 Relaxed bladder 2 - Wet underwear 3 Delay in playing

16 1 - Full bladder 2 Comfortable underwear 3 - Playing Pee in potty 1 Relaxed bladder 2 Comfortable underwear 3 Delay in playing 4 I m like a grownup 5 Praise, sticker Prompting Success Hydration Frequent Sits Water Prompt Transfer of Stimulus Control Decreasing Accidents Urine Alarm Startle Statement Positive Practice DRO for dry Intervention Components Increasing Successes Positive Reinforcement Negative Reinforcement

17 EO for urination; increased number of opportunities to reinforce success Consult pediatrician: Don t use if seizure disorder, hydrocephaly, spinal cord injury, med with side effect of urinary retention (Kroeger & Sorensen-Burnworth, 2009) Bladder capacity for children (Kaefer et al., 1997) Age (years) divided by = capacity (ounces) for those 2 years old or older But feeling to urinate can be perceived after a couple ounces Azrin & Foxx (1971) a large volume of fluids each half hour as he would consume (p. 92) Cicero & Pfadt (2002) variety of liquids were offered verbally encouraged to drink if liquid intake was low (p. 324) LeBlanc et al. (2005) every 5 min during the first hour, every 10 min during the second hour, every 15 min during the third hour, every 30 min throughout the rest of Day 1 ( p. 100) Rinald & Mirenda (2012) at least 4-6 ounces of liquid per hour (p. 937)

18 Preferred, noncaffeinated, nondairy (LeBlanc et al., 2005) Water is ideal Mix juice & water White grape juice: More easily absorbed than apple juice? (American Academy of Pediatrics, 2001) Consider variety If the child doesn t want to drink Reinforce drinking Be creative Best practice for hydration? Increased opportunities to reinforce success Use a timer or vibrating pager to cue the caregiver May decide to stay in the bathroom (e.g., Cicero & Pfadt, 2002) As successes increase and accidents decrease, time between sits is increased & time sitting is decreased According to a predetermined criterion Terminal goal of every 2 hours is ideal for daycare/preschool settings Access to moderately preferred toys/video while sitting What should the schedule be?

19 Cicero & Pfadt (2002) Sit every 30 min For 3 min Scheduled sits d/c on the following day if child made independent initiation LeBlanc et al. (2005) Day 1: 1 level each hour Days 2,3: 1 level each half day 1 level every 2 days Kroeger & Sorensen (2010); Rinald & Mirenda (2012) 30 min on/5 min break for success 25 min on/10 min break for success 20 min on/15 min break for success * Most efficient scheduling? 9-year-old boy with profound MR Severe SIB Other toilet training ineffective Water prompting: slowing pouring approximately 5 oz. of lukewarm water over the client s genitalia for 3 to 5 s immediately after he was seated on the toilet (p. 473) Warm water may relax external sphincter muscle Need replications. Measure temperature carefully!

20 Luiselli (1996) 7-year-old girl PDD Other toilet training ineffective Began by reinforcing urination in diaper while sitting on the toilet Would have continued by cutting progressively larger holes in the diaper, but she became independent Need replications Negative Reinforcement Allow off the toilet contingent upon success Positive Reinforcement Stimulus preference assessment Identify several highly preferred items: food, drinks, toys, videos Items for toilet training only Potty Party Fun box: Keep in opaque container out of reach, in the bathroom Deliver immediately contingent upon success Deliver praise in way child prefers, don t interrupt flow of urine Keep box closed until delivering? If child does not have success, neutrally help up from toilet

21 Accidents can set the stage for frustration for caregivers If using reduction procedure, provide training and supervision; monitor stress of caregiver Clean up accident calmly Have needed materials ready to go, second person Startle Statement (Cicero & Pfadt, 2002) When child begins to have accident, delivered a statement to startle and interrupt the flow of urine no, no, no, hurry up, you pee on the potty Rush to sit on toilet: Opportunity to reinforce success Neutral to firm tone of voice Need replications Urine Alarm (LeBlanc et al., 2005) Functions? Various types available Wet Stop 3: More research

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24 Prompt request before each scheduled sitting opportunity Select method based on Caregiver preference Child s skills Sign, picture exchange, vocal Potty, I need the bathroom Durable, waterproof picture (laminate, baseball card holder) Praise and trip to the bathroom contingent upon all requests

25 Once toileting goal has been reached, components of the intensive program can be removed Cicero & Pfadt (2002): 3 consecutive days with initiations & no accidents Post & Kirkpatrick (2004): 80% of urinations successes for 3 consecutive days Cocchiola et al. (2012): 100% of urinations successes for 3 consecutive days Differential reinforcement Only successes paired with dry pants are reinforced Only reinforce successes from self-initiations Wear regular clothing Fluid intake returned to normal Decrease reinforcement Delay: start to wait until he has gotten up and pulled up his pants.then until he has pulled up his pants and flushed then until he has pulled up his pants, flushed, and washed his hands Intermittent reinforcement Most efficient method?

26 For some children, BM training is more challenging and takes longer When children are not having BMs on a regular basis, it is important to speak with the child s pediatrician to ease constipation and establish better regularity For some children, use of laxatives or suppositories may be indicated to supplement behavioral toilet training procedures; this must always occur under the direction and supervision of the child s pediatrician

27 When children are having frequent BMs but are not going in the toilet, identify a separate, very powerful item to reinforce BMs on the toilet Track times when the learner tends to have BMs (more frequently and sitting for longer durations during time periods when BMs are probable) Overcorrection procedures may also be added contingent on BM accidents Some children will start to stay dry through the night on their own When the child regularly wakes up dry, nighttime diapers can be removed After continent during the day, if not dry during the night Reduce liquids before bed Trip to the bathroom right before bed Night-time alarm Parent may wake child to go to the bathroom

28 Consider the entire process of toileting, from start to finish Teaching related skills can improve the learner s level of independence Gerhardt (2007) suggested five survival skills for individuals with autism that are essential to look the part for successful inclusion in the community: Restroom skills Meal skills Sexual behavior Hygiene skills Age appropriate clothing Create a task analysis (detailed list of steps necessary to complete the task) Each step should be in clear, observable terms Example: skill acquisition program for washing hands This program is meant to serve as an example and should always be customized for the individual!

29 MATCHES GENDER-APPROPRIATE RESTROOM DOOR SIGNS Behavioral Goal: When presented with a picture of a public restroom door sign representing the learner s gender, and the verbal instruction, Find (e.g., men s room), the learner will match the picture to a corresponding picture or restroom door. Teaching Procedure: Give the learner a picture of a public restroom door sign representing the learner s gender, and give the verbal instruction, Find (e.g., men s room). If the learner places the picture on top of a corresponding picture or brings the picture to the appropriate restroom door (in the school building) provide verbal praise (e.g., Great, that s the men s room! ), and access to a tangible reinforcer (e.g., token or edible). If the learner does not match to the correct picture or restroom, or does not respond, immediately provide manual guidance and verbal correction (e.g., This is the men s room ). Vary the materials and the location, using many different exemplars of pictures and bathrooms on all floors of building. Use a most to least prompting hierarchy. Differentially reinforce responses demonstrated with lowest level of prompting. Fade prompts across subsequent teaching trials. Teaching Steps: Teach the learner to match identical pictures of public restroom doors using pictures representing the learner s gender (e.g., if the learner is a male, teach the learner to match identical pictures of men s room doors). Teach the learner to match non-identical pictures of public restroom doors using pictures representing the learner s gender. Teach the learner to match identical pictures of public restroom doors to an appropriate bathroom door in the school building (e.g., if the learner is a male, teach the learner to match pictures of the boys restroom doors at school to the actual boys restroom doors at school). Teach the learner to match non-identical pictures of public restroom doors to an appropriate bathroom door in the school building, when presented with multiple exemplars of gender appropriate pictures and restrooms. Teach the learner to respond to a verbal instructions only (e.g., Go to the Men s room ) when pictures are faded. Program for generalization to restrooms within community settings (e.g., restaurants and shopping malls). Measurement: Per Opportunity Measure The instructor will record a plus (+) for each correct, independent response, and a minus (-) for each prompted response. Data will be summarized as a percentage of correct responses per session and will be graphed daily on a skill acquisition graph. Criterion: 100% for 3 consecutive sessions

30 The following sample skill acquisition program uses a stimulus fading procedure to teach appropriate eye gaze ½ inch dot ¼ inch dot KEEPS EYES FOCUSED FORWARD WHILE USING A URINAL Behavioral Goal: When standing at a urinal, the learner will keep his eyes focused forward at the top/center of the urinal. Teaching Procedure: Preteach in the learner s school building. Each time the learner uses the urinal, if the learner keeps his eyes focused at the top/center of the urinal while urinating, without averting his eyes for longer than one full second, provide verbal praise (e.g., Good looking here! ) and access to a tangible reinforcer (e.g., a token or an edible). If the learner averts his eyes for longer than one full second, provide graduated guidance from behind to look at the top/center of the urinal. Use a most to least prompting hierarchy. Differentially reinforce responses demonstrated with lowest level of prompting. Fade prompts across subsequent teaching trials. Teaching Steps: Teach the learner to keep his eyes focused at the top/center of the urinal when marked with a ½ inch dot prompt. Teach the learner to keep his eyes focused at the top/center of the urinal when marked with a ¼ inch dot prompt. Teach the learner to keep his eyes focused at the top/center of the urinal when marked with a 1 / 16 inch dot prompt. Teach the learner to keep his eyes focused at the top/center of the urinal when marked with a 1 / 32 inch dot prompt. Teach the learner to keep his eyes focused at the top/center of the urinal when no stimulus prompt is present. Teach the learner to keep his eyes focused forward at the top/center of the urinal when no stimulus prompt is present when the instructor is 1 ft away. Teach the learner to keep his eyes focused forward at the top/center of the urinal when no stimulus prompt is present when the instructor is 3 ft away. Teach the learner to keep his eyes focused forward at the top/center of the urinal when no stimulus prompt is present when the instructor is 5 ft away. Teach the learner to keep his eyes focused forward at the top/center of the urinal when no stimulus prompt is present when the instructor is out of the room. Program for generalization to novel instructors and community settings. Measurement: Per opportunity measure For each opportunity, the instructor records a plus (+) if the learner keeps eyes focused forward without averting eyes for less than one full second, in the absence of graduated guidance. If the learner averts eyes for longer than one full second or graduated guidance is necessary to prompt appropriate orientation of eyes, the instructor scores a minus (-). Data are summarized percentage of correct responses per day and summarized on a skill acquisition graph. Criterion: 100% for 3 consecutive sessions

31 MINIMIZES EXPOSURE WHILE USING A URINAL Behavioral Goal: When the learner enters the bathroom and approaches the urinal, he will follow the designated steps to minimize exposure while standing at the urinal. Teaching Procedure: Run teaching sessions at the learner s school. Teaching procedures should only be carried out by a male staff member, and will be used for all restroom opportunities, including initiations and scheduled opportunities. If the learner follows the designated steps of the task analysis to open and replace pants, provide verbal praise (e.g., Nice job using the bathroom! ) and access to a tangible reinforcer (e.g., a token or an edible). If the learner does not follow the steps correctly or does not respond, provide graduated guidance from behind as necessary. Use a most to least prompting hierarchy. Differentially reinforce responses demonstrated with lowest level of prompting. Fade prompts across subsequent teaching trials. Whole task presentation should be used to teach this skill. Teaching Steps: Teach the learner to unbutton/unzip pants and push down the front of the waistband with nondominant hand OR pull down the front of pants/underwear simultaneously (depending on the type of pants the learner is wearing). Teach the learner to remove and hold penis with dominant hand. Teach the learner to hold penis aimed at the center of urinal with dominant hand. Teach the learner to pull up front of underwear and pants and button/zipper pants (if applicable) when he has finished urinating. Teach the learner to complete steps 1-4 with an instructor 1 ft away. Teach the learner to complete steps 1-4 with an instructor 3 ft away. Teach the learner to complete steps 1-4 with an instructor 5 ft away. Teach the learner to complete steps 1-4 with an instructor out of view. Program for generalization to community settings. Measurement: Task Analysis For each step listed on the task analysis, observer records a plus (+) if the learner completes the step correctly. If any step is not completed, is completed incorrectly, or is completed with prompts, the observer scores a minus (-) for that step. Data are summarized as percentage of steps completed correctly and graphed on a skill acquisition graph. Criterion: 100% for 3 consecutive sessions Caregiver training Use of a multiple-schedule arrangement to reduce toileting requests maintained by escape Programming for and assessing generalization Social validity

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33 Averink, M., Melein, L., & Duker, P. C. (2004). Establishing diurnal bladder control with the response restriction method: Extended study on its effectiveness. Research in Developmental Disabilities, 26, Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied Behavior Analysis, 4, Azrin, N. H., & Foxx, R. M. (1974). Toilet training in less than a day. New York: Pocket Books. Cicero, F. R., & Pfadt, A. (2002). Investigation of a reinforcement-based toilet training procedure for children with autism. Research in Developmental Disabilities, 23, Didden, R., Sikkema, S. P. E., Bosman, I. T. M., Duker, P. C., & Curfs, L. M. G. (2001). Use of a modified Azrin-Foxx Toilet Training Procedure with Individuals with Angelman Syndrome. Journal of Applied Research in Intellectual Disabilities, 14, Dunlap, G., Koegel, R. L., & Koegel, L. K. (1987). Toilet training for children with severe handicaps: A field manual for coordinating training procedures across multiple community settings. Huntington, WV: Marshall University. Gerhardt, P. F. (2007, May). Embracing and including individuals with autism: Strategies for success. Keynote address presented at the 25 th Annual Meeting of the New Jersey Center for Outreach and Services for the Autism Community (COSAC), Atlantic City, NJ. Hagopian, L. P., Fisher, W., Piazza, C. C., & Wierzbicki, J. J. (1993). A water prompting procedure for the treatment of urinary incontinence. Journal of Applied Behavior Analysis, 26, Horn, I. B., Brenner, R., Rao, M., & Cheng, T. L. (2006). Beliefs about the appropriate age for initiating toilet training: Are there racial and socioeconomic differences? The Journal of Pediatrics, 149, Kaefer, M., Zurakowski, D., Bauer, S. B., Retik, A. B., Peters, C. A., Atala, A., & Treves, S. T. (1997). Estimating normal bladder capacity in children. The Journal of Urology, 158, Kroeger, K. A., & Sorensen-Burnworth, R. (2009). Toilet training individuals with autism and other developmental disabilities: A critical review. Research in Autism Spectrum Disorders, 3, Kroeger, K. A., & Sorensen-Burnworth, R. (2010). A parent training model for toilet training children with autism. Journal of Intellectual Disability Research, 54, LeBlanc, L. A., Carr, J.E., Crossett, S. E., Bennett, C. M., & Detweiler. D. D. (2005). Focus on Autism and Other Developmental Disabilities, 20, Luiselli, J.K. (1996). A case study evaluation of a transfer-of-stimulus control toilet training procedure for a child with pervasive developmental disorder. Focus on Autism and Other Developmental Disabilities, 11, MacDonald, R., Clark, M., Garrigan, E., & Vangala, M. (2005). Using video modeling to teach pretend play to children with autism. Behavioral Interventions, 20,

34 Martin, J. A, King, D. R., Maccoby, E. E., & Jaklin, C. N. (1984). Secular trends and individual differences in toilet-training progress. Journal of Pediatric Psychology, 9, Neff, J. (1998). Kids take longer to train; Diaper business swells. Advertising Age, 69, 3. Post, A. R., & Kirkpatrick, M. A. (2004). Toilet training for a young boy with pervasive developmental disorder. Behavioral Interventions, 19, Rinald, K., & Mirenda, P. (2012). Effectiveness of a modified rapid toilet training workshop for parents of children with developmental disabilities. Research in Developmental Disabilities, 33, Schum, T. R., Kolb, T. M., McAuliffe, T. L., Simms, M. D., Underhill, R. L., & Lewis, M. (2002). Sequential acquisition of toilettraining skills: A descriptive study of gender and age differences in normal children. Pediatrics, 109, 48. Siegel, R. K. (1977). Stimulus selection and tracking during urination: Autoshaping directed behavior with toilet targets. Journal of Applied Behavior Analysis, 10, Wilder, D. A., Higbee, T. S., Williams, W. L., & Nachtwey, A. (1997). A simplified method of toilet training adults in residential settings. Journal of Behavior Therapy and Experimental Psychiatry, 28,