Toilet  Training  for  Individuals  with  ASD  

Presented  by  Laura  O’Rourke,  MS,  BCBA  

Description  

Ê In  this  presentation,  participants  will  learn  how  to  effectively  identify  readiness  skills  associated  with  successful  toilet  training  of  individuals  with  ASD,  how  to  set  up  and  monitor  a  toilet  training  program,  and  how  to  trouble  shoot  different  challenges  that  may  occur  along  the  way.    This  training  will  be  geared  toward  toilet  training  younger  children,  but  is  also  applicable  to  older  learners  into  adulthood  wanting  to  establish  more  independent  toileting  skills.    

Agenda  

Ê Definitions  

Ê Toilet  training:  Definition,  Readiness  &  Implications  

Ê Planning  the  toilet  training  program  

Ê  Initiating  the  toilet  training  program  

Ê Monitoring  the  toilet  training  program  

Ê Fading  the  toilet  training  program  

Ê Troubleshooting  

What  does  ‘Toilet  Trained’  Mean?  

Ê  Child  is  able  to  remain  dry  for  a  period  of  1  month  without  accidents  (excludes  night  training).  

Ê Without  reminders,  child  is  able  to:  (1)  Communicate  a  need  to  go  to  the  bathroom,    (2)  Walk  independently  to  the  bathroom,    (3)    Pull  down  pants  and  underwear,    (4)  Urinates  and  or  passes  a  bowel  movement  in  the  toilet,    (5)  Wipes  self  clean,  and  (6)  Pulls  up  underwear  and  pants.  

Why  is  Toilet  Training  Important  Ê  Anderson  (2011)  Questionnaire:  

Ê   Featured  adult  individuals  with  developmental  disabilities  in  the  South  Sound  area.  Ê  Questionnaire  looked  at  the  most  common  needs  of  adult  residents  in  local  agencies.      

Ê  Support  for  Challenging  Behaviors  Ê  Dressing  Ê  Medication  Administration  

Ê  Making  Appointments  Ê  Arranging  Transportation  Ê  TOILETING  Ê  Grooming  

Ê  Preparing  Meals  Ê  Selecting/Communication/Engagement  in  Community  Ê  Feeding  

Ê  THE  MORE  INDEPENDENT  THE  INDIVIDUAL  AS  AN  ADULT,  THE  MORE  ACCES  TO  SERVICES  WILL  BE  AVAILABLE  TO  THEM.  

Typical  Toilet  Training  Readiness  

Ê  Children  typically  begin  to  show  readiness  for  toilet  training  from  12-­‐30  months  (American  Academy  of  Pediatrics)  as  seen  by:  

Ê  Stay  dry  for  up  to  2  hours  at  a  time.    

Ê  Imitates  motor  actions.    

Ê  Refuse/say  ‘no’  (verbally  or  non-­‐verbally).  

Ê  Can  request    

Ê  Sit  for  3-­‐5  minutes.    

Ê  Pull  up  and  down  underwear/pants.    

Ê  Shows  discomfort  with  being  soiled  

Ê  Has  preferred  items  or  reinforcers.    

Ê  Interest  in  cleaning  up.  

Set  the  Stage  for  Success!  

Ê  Use  Incentives!  What  will  your  child  do  anything  for?  

Ê  Make  items  readily  available  (everything  in  one  room).    

Ê  Let  your  child  pick  out  special  soap  or  towels,  underwear!    

Ê  Provide  child  access  to  special  activities  geared  to  increase  sitting  (books,  game,  etc.).  

Ê  Identify  behavior  cues  child  has  for  when  they  need  to  go.    Model  and  teach  cues  to  child  through  books,  videos,  etc.  

Ê  Get  a  baseline.    

Diapers,  Pull  Ups  or  Underwear,  oh  my!  

Ê  Using  absorbent  diapers  has  shown  to  increase  amount  of  incontinence  in  children  (Tarbox,  Williams,  &  Friman,  2004;  Oorsouw  et.  al,  2009).  

Ê  Consider  using  underwear  (make  sure  you  have  lots  of  changes).      

Ê  If  this  is  too  much,  consider  wearing  underwear  under  the  diaper,  or  using  a  modified  approach  such  as  a  cloth  diaper  or  nighttime  ‘underwear’.    

Establishing  a  ‘Baseline’  

Ê  PRIOR  TO  STARTING  TOILET  TRAINING  INTERVENTION:    Ê Record  for  3-­‐5  days.  Ê Record  every  hour  for  6-­‐8  hours.  Ê Record  any  urinary  and  bowel  accidents  which  occur  at  

hourly  checks.    Ê Record  fluid  intake  times  and  amounts.    Ê  Change  diaper  immediately  if  wet/soiled  (if  in  between  

hourly  checks,  record  time  of  accident  as  well).      

Ê Optional:  if  concerned  about  diet,  constipation,  or  diarrhea  are  evident,  may  want  to  also  record  food  intake.      

Baseline  Data  Sheet  Example  

*  OPWDD    Targeting  the  Big  3-­‐  Toilet  Training  by  Dr.  Helen  Yoo  2012  

Baseline  Data  Sheet  Example  

*OPWDD    Targeting  the  Big  3-­‐  Toilet  Training  by  Dr.  Helen  Yoo  2012  

Initiating  a  Toilet  Training  Program  

Ê  Initiate  when  child  is  well.    

Ê  Initiate  when  child  is  calm.  

Ê  Initiate  when  child  is  not  experiencing  major  transition  or  change.    

Ê  Initiate  when  the  whole  team  is  on  board-­‐  CONSISTENCY  IS  KEY.    

Planning    A  Toilet  Training  Program  

Ê  Child  Oriented  Method  (Brazelton,  1962)  Ê  Gradual,  developmental  approach.  Ê  Respond  to  child’s  signals  of  toileting  readiness.  Ê  Formal  research  on  this  approach  is  lacking.      Anecdotal  evidence  

indicates  this  approach  is  more  favored  by  pediatricians,  however  delayed  ages  of  toilet  trained  children  as  well  as  increased  toilet  training  problems  (NY  Times,  Erica  Goode,  1999).    

Ê  Parent  Oriented  Method  (Azrin  &  Foxx,  1971)  Ê  Goal  oriented  Ê  Teaching  behavioral  chains  of  independent  toileting  behaviors.  Ê  Follow  up  research  shows  repeated  success  over  time  using  this  

approach,  with  modifications  that  are  equally  successful  geared  toward  reducing  aversive  procedures  such  as  overcorrection.    

A  Modified  Caregiver  Oriented  Approach  (Azrin  &  Foxx,  1971;  LeBlanc  et.  al,  2005,  Ardic  &  Cavkaytar,  2014)  

1.  Set  aside  one  entire  weekend  (2-­‐4  days)  for  toilet  training.    

2.  Block  out  time  for  toilet  training  only  (no  phone  calls,  childcare,  other  children,  cooking,  chores,  etc.)  

3.  Eliminate  distractions.  

4.  Minimize  interruptions.    

5.  Decide  on  a  “word”.    Consider  age-­‐appropriateness.  

6.  Gradual  Fade  Sit  Schedule  

Gradual  Fade  Sit  Schedule  (LeBlanc  et.  al,  2005)  

Level   Schedule   Day  

1   10  min  sit  on  toilet,  5  minutes  off  of  the  toilet   Day  1,  hour  1  

2   10  min  on,  10  min  off   Day  1,  hour  2  

3   5  min  on,  15  min  off   Day  1,  hour  3  (stay  here  until  met)  

4   5  min  on,  25  min  off   Day  2,  am  

5   5  min  on,  35  min  off   Day  2,  pm  

6   5  min  on,  45  min  off   Day  3,  am  

7   5  min  on,  60  min  off   Day  3,  pm  

8   5  min  on,  90  min  off   Day  4-­‐5  (or  until  met)  

9   5  min  on,  2  hours  off   Day  6-­‐7  (or  until  met)  

10   5  min  on,  2.5  hours  off   Day  8-­‐9  (or  until  met)  

11   5  min  on,  3  hours  off   Day  10-­‐11  (or  until  met)  

12   5  min  on,  4  hours  off   Day  12-­‐13  (or  until  met)  

Increasing  Fluid  (LeBlanc  et.  al,  2005)  

Ê  1st  Hour:  Prompt  to  drink  liquid  every  5  minutes  

Ê  2nd  Hour:  Prompt  to  drink  liquid  every  10  minutes  

Ê  3rd  Hour:  Every  15  minutes  

Ê  Rest  of  Day  1:  Every  30  minutes  

Communication  Training  

Ê  Communication  training  should  be  used  prior  to  each  visit  to  the  bathroom.      Ê  Verbal  request  Ê  Picture  cue  exchange  Ê  Signal  or  sign    

Ê  Praise  for  correct  use  of  the  communication  cue.    

Communication  Training  

Ê  The  same  schedule  should  be  used  for  toileting  every  time:    1.  Enter  bathroom  2.  Pull  pants  down  3.  Sit  down  4.  Pee/poop  5.  Get  toilet  paper  6.  Wipe    7.  Pull  up  pants  8.  Flush    9.  Wash  hands  (this  is  a  whole  separate  chain  of  skills)  10.  Leave  bathroom  

What  to  Do  While  Sitting!    

Ê Watch  a  moderately  preferred  video  for  Levels  1-­‐2  

Ê May  use  access  to  a  moderately  preferred  activity  to  reinforce  sitting  behavior  and/or  relaxation.    

 

 

What  to  Do  With  SUCCESS!  

Ê Successful  Urination/BM:    Ê Immediate  access  to  highly  preferred  toys,  praise,  food,  drinks!    

Ê Let  them  get  up  and  leave  the  bathroom/toilet!    

Ê Successful  Initiation:  Ê Praise  and  immediately  go  to  the  toilet.  

Preferred  items  only  if  urination/BM  follows  the  initiation.  

What  to  Do  With  An  Accident  Ê  Minimize  Attention  Approach  (Ardic  &  Cavkaytar,  2014)  

1.  Provide  minimal  attention.    2.  Change  clothes  immediately  with  as  little  socialization,  eye  contact,  

talking,  etc.  as  possible.  3.  Remove  any  items  child  was  playing  with,  say  “you  are  not  dry”.    4.  No  reinforcement  for  10  minutes.  

Ê  Positive  Practice  Approach  (LeBlanc  et.  al,  2005)  1.  Say  “no  wet  pants”  in  a  firm  voice.  2.  Return  to  bathroom,  sit  for  1  minute.  3.  If  completes  urination  in  toilet,  continue  on  with  normal  schedule.  4.  If  no  urination  completion  in  toilet,  stand  up,  pull  up  pants,  return  to  the  

accident  location,  and  repeat  this  sequence  4  times.  

Ê  Do  not  punish.    Avoid  negative  tones  or  making  accidents  ‘gross’  or  otherwise  negative.    Do  not  mimic,  joke,  or  express  anger.  

Monitoring  the  Program  

Ê  Alarms-­‐  To  use  or  not  to  use.      Ê  Use  of  alarms  can  help  increase  the  success  of  the  program  as  it  

will  help  ‘catch’  all  of  the  opportunities  as  they  occur  in  real  time.    

Ê  Wet  Stop  http://wetstop.com/  

Ê  Dry  Easy  Bed  Wetting  Alarm  

Ê  Potty  Time  Potty  Watch  

Ê  Malem  Ultimate  Bed  Wetting  Alarm  

Ê  Chummie  Premium  Bed  Wetting  Alarm  

Ê  Check  your  DATA  (yeah,  you  should  still  be  doing  that-­‐  it  helps).    Ê  Data  that  shows  progress-­‐  Keep  it  up!    

Ê  Data  that  shows  no/slow  progress-­‐  Change  it  up!    

Fading  the  Toilet  Training  Program  Ê  Once  child  has  shown  consistent  periods  of  

dryness,  allow  periods  where  child  wears  underwear.    Have  them  pick  out  special  underwear  of  their  own  for  increased  success.  

Ê  Gradually  reduce  the  reinforcers  and  praise.  Ê  Reduce  from  highly  preferred-­‐  moderate-­‐  low-­‐  none  

items.  

Ê  Reduce  praise  from  high-­‐  medium-­‐low-­‐no  praise.  

Ê  Gradually  reduce  the  amount  of  prompts  to  go  on  a  schedule  as  self-­‐initiation  increases.    

Nighttime  Training  

Ê  Night  dryness  often  takes  several  months  or  years  after  initial  daytime  dryness.    This  is  expected.      

Ê  Once  child  routinely  (7  days  in  a  row)  wakes  up  dry,  begin  nighttime  training.    Ê  Have  a  change  of  bedding  available.    Ê  Encourage  going  to  the  bathroom  immediately  before  bed.    Ê  You  may  want  to  wake  the  child  before  you  go  to  bed  to  have  them  

go  once  more  for  initial  few  weeks.    Ê  You  may  want  to  use  a  bed-­‐wetting  alarm.  

Ê  If  child  continues  to  have  night  time  incontinence  after  age  6  or  7,  seek  medical  guidance.    

Troubleshooting  

Ê  Behavioral    Ê  Noise-­‐  dryers,  flushing  Ê  Tactile  stimuli-­‐  toilet  paper,  wipes,  paper  towels  Ê  Refusal  to  sit  Ê  Does  not  want  to  wipe  Ê  Masterbation/touching  genitals  Ê  Digging  Ê  Smearing  Ê  Playing  with  water  

Ê  Rigidity  and  Predictability  Ê  Fear  of  where  it  all  goes.      Ê  Unclear  on  what/how  to  do  it.    Ê  Resistance  to  unfamiliar  or  different  bathrooms  (public,  stalls,  upstairs  

vs.  etc.)  

When  to  Seek  Medical  Advice  Ê  Encopresis  (chronic  fecal  soiling  at  age  4  or  older).  

Ê  Enuresis  (at  least  twice  per  month  involuntary  voiding  during  day  or  night  in  children  over  5).  Ê  Boys  are  twice  as  likely  as  girls  to  have  nocturnal  

enuresis.    

Ê  Recurrent  episodes  of  diarrhea  lasting  longer  than  3  weeks.  

Ê  Frequent  constipation  or  withholding  (for  longer  than  3  weeks  despite  healthy  diet).    

*Tabbers  et.  al  (2014),  Issenman  et.  al  (1999)  

Recap  Ê  Take  baseline.  

Ê  Get  a  Physical:  Rule  out  medical  conditions.    

Ê  Make  a  plan.    

Ê  Commit  to  the  plan.    

Ê  Execute  the  plan.  CONSISTENCY  IS  KEY!  Track  progress.    

Ê  Reinforce  successes!    Fade  artificial  reinforces  gradually.  

Ê  Don’t  give  up.    

Ê  Seek  medical  assistance  for  concerns.    

Last  Thoughts  (I  promise…)  

Ê  Independence  is  key.  

Ê  Consider  modesty.  

Ê  Self-­‐Initiation  is  best.      Ê  If  not  possible,  try  to  create  a  time  based  schedule  the  individual  

can  complete  independently,  and  focus  on  increasing  independent  skills  in  the  process  (pants  up/down,  wiping,  hand  washing,  etc.).    

Resources  Ê  Toilet  Training  Caregiver  Manual  by  NYS  Office  for  People  with  Developmental  Disabilities-­‐  

http://www.opwdd.ny.gov/opwdd_community_connections/autism_platform/behavior_management/targeting_the_big_3  

Ê  Toilet  Training  Information  for  Autism  from  The  Children’s  Guild  Foundation-­‐  http://www.kaleidahealth.org/services/pdfs/wchob/autism/ASD-­‐Toilet-­‐Training-­‐6-­‐12.pdf  

Ê  Little  Friends  Center  for  Autism-­‐  http://www.theautismprogram.org/wp-­‐content/uploads/tips-­‐for-­‐daily-­‐life-­‐toilet-­‐training.pdf  

Ê  http://www.do2learn.com/picturecards/printcards/selselp_toileting.htm    

Ê  http://www.brighttots.com/Toilet_training_and_autism.html  

Ê  Ardic,  A.,  Cavkaytar,  A.  (2014).  Effectiveness  of  the  modified  intensive  toilet  training  method  on  teaching  toilet  skills  to  children  with  autism.  Education  and  Training  in  Autism  and  Developmental  Disabilities.  49(2),  263-­‐276.    

Ê  LeBlanc  et.  al  (2005).  Intensive  Outpatient  Behavioral  Treatment  of  Primary  Urinary  Incontinence  of  Children  with  Autism.    Focus  on  Autism  and  Other  Developmental  Disabilities.  Summer  20(2).  

Resources  Ê  American  Academy  of  Pediatrics:  

https://www2.aap.org/sections/scan/practicingsafety/module7.htm  

Ê  Anderson  (2011).  Current  Trends  in  Occupational  Therapy  Services  for  Adults  with  Developmental  Disabilities  in  Small  Community  Living  Settings.  Master’s  Thesis.  University  of  Puget  Sound.    

Ê  Stadtler,  Gorsky,  Brazelton  (1999).  Toilet  Training  Methods,  Clinical  Interventions,  and  Recommendations.    Pediatrics  vol.  103  supplement  3.        

Ê  Azrin,  Foxx  (1974)  Toilet  Training  in  Less  than  a  Day.    New  York,  NY:  Simon  &  Schuster.      

Ê  Brazelton,  B.  (1962).  A  Child  Oriented  Approach  to  Toilet  Training.  Pediatrics  vol.  29  no.  1,  121-­‐128.    

Ê  Isseman,  R.,  Filmer,  R.,  &  Gorski,  P.  (1999).  A  Review  of  Bowel  and  Bladder  Control  Development  in  Children:  How  Gastrointestinal  Conditions  Relate  to  Problems  in  Toilet  Training.  Pediatrics  vol.  103,  no.  6.    

Ê  Tabbers,  M.M.  et  al.    (2014).  Evaluation  and  Treatment  of  Functional  Constipation  in  Infants  and  Children:  Evidence-­‐Based  Recommendations  from  ESPGHAN  and  NASPGHAN.    JPGN  vol  58,  no.  2.