Pick of the Week: Toilet Training Books – Save 20% this week!

Toilet training can be easier! Toilet Training for Individuals with Autism by Maria Wheeler, MEd, and Toilet Training Success by Frank Cicero, PhD, BCBA, offer toilet training tips and strategies for parents and professionals to implement into their programs using the methods and principles of Applied Behavior Analysis.

Toilet Training for Individuals with Autism presents clear solutions for transitioning children from diapers to underpants, covering how to:

  • gauge readiness
  • identify and reduce sensory challenges
  • overcome anxiety
  • develop habits and routine
  • teach proper use of toilet, sink, toilet paper
  • and more!

 

Toilet Training Success introduces the reader to effective toilet training interventions for individuals with developmental disabilities, including urination training, bowel training, increasing requesting, and overnight training. The manual also addresses when to begin toilet training and how to use positive reinforcement, collect data, and conduct necessary assessments prior to training.

Use our promotional code POTTY20 at check-out this week to redeem your savings on either or both of these manuals!

* Promotion is valid until May 17, 2016 at 11:59pm EST. Offer cannot be applied to previous purchases, combined with any other offers, transferred, refunded, or redeemed and/or exchanged for cash or credit. Different Roads to Learning reserves the right to change or cancel this promotion at any time. To redeem offer at differentroads.com, enter promo code POTTY20 at checkout.

Tip of the Week: Two Essential Considerations When Toilet Training Boys

Last year, I had the opportunity to interview Gary Weitzen, the Executive Director of POAC Autism Services and the Autism Shield Program. (You can see the blog post about that interview here.) In the months since our interview, many of his comments have stuck with me, but one in particular has impacted my daily work with students. He said, “A lot more boys have autism than females but the vast majority of educators in special ed, and in particular with autism, are females.” He went on to provide examples of how this fact influences some skill development, specifically with toilet training.

Child on Toilet 2 BlogThis leads to several considerations to take into account when toilet training boys. I agree with Weitzen that some of these issues arise from the simple fact that women are predominantly toilet training boys. However, it’s also possible that such issues arise from the fact that many boys are trained in early intervention or preschool years without consideration of the implications of those training techniques several years down the line, and without further intervention or training later in life. Either way, it’s important to recognize that training of life skills should be completed in such a way as to develop effective skills that are similar to those of the child’s same-age peers. To that end, here are two considerations:

Consider hygiene. Something I had never thought about prior to my conversation with Weitzen is that after boys use the bathroom, then zip up their pants, it’s easy for a little urine to drip onto their pants. Especially once children reach upper elementary and middle school grades, a spot of urine can be socially isolating or an invitation for bullying. Weitzen acknowledges that it can be difficult to teach boys to gently shake their penis before zipping up, especially because teachers don’t want to inappropriately touch the students. However, for the long term, it’s essential that teachers find a way to teach this simple action.

Consider the topography of the behavior. When we think about topography, we basically mean, “What does the behavior look like.” When initially toilet training, teachers will typically have the student pull his/her pants down to the floor. Weitzen shared a personal experience from several years ago, when he was a chaperone on a field trip with his son who is autistic. At one point, the teachers asked him to take the boys to the bathroom, so Weitzen went in with eight 14-year-old boys with autism. He said, “They took their pants and pushed them right down to their knees at the urinal at Medieval Times. So we had seven hairy tushies in the room. Out in public! And what happens is other dads and other boys came in there and everyone’s laughing and commenting and pointing.” This is the type of situation that teachers and parents do not want students to experience. When toilet training, it’s essential to recognize that the topography of the behavior in the male restroom is to unzip the pants, and then pull the fabric aside in order to urinate in the urinal. While it may be easier to teach students to pull their pants down in the initial phases of toilet training, it’s important to continue shaping behavior until it has the appropriate topography.

If our students continue to pull their pants down completely, they become targets for bullying, or worse. Weitzen says that on multiple occasions, he’s had parents report to him that their child used the bathroom at the urinal, and when they pulled their pants to the floor, another student took a picture of them. “Four different moms told me that, and if four moms told me that, I can’t imagine how often that’s happening,” Weitzen said. “And even if they’re not sharing the photo, well now you’re the weird kid who sticks his butt out. And you’re isolated and you’re picked upon, so we have to be real. We have to realize our guys live in the real world and teach them the skills that they need.”

WRITTEN BY SAM BLANCO, MSED, BCBA

Sam is an ABA provider for students ages 3-12 in NYC. Working in education for ten years with students with Autism Spectrum Disorders and other developmental delays, Sam has developed strategies for achieving a multitude of academic, behavior, and social goals. Sam is currently pursuing her PhD in Applied Behavior Analysis at Endicott College.

Tip of the Week: Stop Behavior Early in the Behavior Chain

Recently I was working with a family to toilet train their son Jonathan, a six-year-old with autism. (Names and identifying characteristics have been changed to protect confidentiality.) When he eliminated in the toilet, part of his reinforcement was getting to watch the water go down the toilet after flushing. At some point, he developed the behavior of putting his hands into the toilet water as it was flushing.

When I went in to observe the behavior, one of my goals was to identify the steps in the behavior chain. Pretty much everything we do can be viewed as part of a behavior chain, in which one action is a cue for the following action. For Jonathan, each time he placed his hands in the toilet water, the behavior chain looked like this:

Pulled up pants
Stepped towards toilet
Pressed button to flush toilet
Stepped back
Watched water as it flushed
Stepped forward again
Leaned down
Put hands in water

Behavior chains can be even more detailed than the one above, depending on the needs of your learner. Identifying the steps in the behavior chain for an undesirable behavior can have a huge impact on your interventions. For Jonathan, we were able to stop the behavior of putting his hands in the toilet water by interrupting the behavior early in the behavior chain. It’s too late and unsafe to stop him once he’s leaning forward to put his hands in the water. Through prompting, which we faded as quickly as possible, we changed his behavior chain to this:

Pulled up pants
Stepped towards toilet
Pressed button to flush toilet
Stepped back
Watched water as it flushed for 3-5 seconds
Stepped towards sink
Leaned forward
Turned on water
Put hands in water

Instead of waiting for him to engage in the inappropriate behavior, we redirected him several steps earlier in the chain, providing a gestural prompt toward the sink and had him start washing his hands 3-5 seconds after he had started watching the water flush. This was ideal for two reasons: first, it was the expected step in an appropriate toileting behavior chain and second, it provided an appropriate and similar replacement behavior since Jonathan was still able to put his hands in water.

This behavior chain was relatively easy to change. While it may not be as easy in some interventions you may try, it’s essential to remember to stop the behavior early in the behavior chain. It’s much easier to give a child an activity that requires use of their hands as soon as you see them lift their hands out of their lap than it is to remove their hand from their mouth if they’re biting it. And it’s much easier to redirect a child to put their feet back under their desk than it is to get them to stop once they’re sprinting out of the classroom. Looking at the behavior chain and considering when to intervene as a part of your intervention plan is quite possibly the extra step that will make your plan successful.


WRITTEN BY SAM BLANCO, MSED, BCBA

Sam is an ABA provider for students ages 3-12 in NYC. Working in education for ten years with students with Autism Spectrum Disorders and other developmental delays, Sam has developed strategies for achieving a multitude of academic, behavior, and social goals. Sam is currently pursuing her PhD in Applied Behavior Analysis at Endicott College.

How to Assess and Address Pants-Wetting Behavior—A Response to a Teacher’s Question

Sometimes we get specific questions from teachers and parents about managing problem behaviors that are quite common. In these cases, we think it can be helpful to share the question and response, so that others in similar situations might benefit from the suggestions offered. Bed and pants-wetting can be an enormously challenging issue both at home and at school, so when we received the following question from a teacher in Australia about her student, we thought it was a great opportunity to offer some suggestions and strategies on how to address the behavior.

PantsWettingQA

This is definitely a difficult behavior to address. It’s also challenging to provide accurate advice without directly observing the behavior, instead here are a few questions to consider and potential resources.

  • First and foremost, this is a behavior in which you should consult with a Board Certified Behavior Analyst for assistance. You can find BCBAs in your area by going to this webpage: http://www.bacb.com/?page=100155. If possible, reach out to more than one to find the BCBA who is the best fit for you and your learner.
  • Second, you should conduct a functional assessment to clearly determine the reason for the behavior. It may be for attention, but you may discover there is a different cause. It is best to perform a formal functional analysis, but if that is not possible, you may consider using the Functional Assessment Screening Tool (FAST). To get the best results from this, you should have more than one person fill it out, and, if possible, one person who observes the behavior but is unfamiliar with the child. Compare results to see if you are in agreement, then make a behavior intervention plan based on the function of the behavior. For more information about the FAST and its reliability compared to a formal functional assessment, you should refer to the study by Iwata, Deleon, & Roscoe (2013).
  • If indeed the behavior is for attention, consider how to provide minimal attention for pants-wetting. You mention that he receives high-level attention right now. What qualifies as high-level for him? Is it eye contact? Physical touch? Proximity? There are ways to remove each of these types of attention while also making sure you address the behavior hygienically.
  • While your son is continent, some of the strategies that are used in toilet training may prove helpful in intervening with this behavior. Take a look at this article by Kroeger & Sorenson-Burnworth (2009), which “reviews the current literature addressing toilet training individuals with autism and other developmental disabilities.” It may provide potential solutions that you have not attempted.

I hope this information is helpful! And good luck as you plan and implement your intervention.


WRITTEN BY SAM BLANCO, MSED, BCBA

Sam is an ABA provider for students ages 3-12 in NYC. Working in education for ten years with students with Autism Spectrum Disorders and other developmental delays, Sam has developed strategies for achieving a multitude of academic, behavior, and social goals. Sam is currently pursuing her PhD in Applied Behavior Analysis at Endicott College.

Simplifying the Science: Parent-Conducted Toilet Training for Kids with Autism

For many of the families I work with, toilet training their child with autism becomes a long, painful process. I typically recommend the Rapid Toilet Training (RTT) protocol developed by Azrin & Foxx (1971) but many parents struggle to maintain implementation without the presence of a behavior therapist or toilet training specialist. And while Azrin & Foxx’s results have been replicated in other studies, RTT has primarily been used in educational and outpatient settings, and the amount of time it has taken to complete toilet training has been longer than in the initial study.

This is why I was especially excited to come across the study by Kroeger & Sorensen (2010) about “A parent training model for toilet training children with autism,” which is based on Azrin & Foxx’s initial study with some key modifications. This study focuses on parent-conducted toilet training in the home and was completed with two children with autism.

As mentioned in previous blog posts, the best interventions usually are multi-pronged approaches. This is no different. While there are multiple steps involved, it’s important to recognize that one of these children was fully toilet trained in 4 days, and the other in 11 days. Both children maintained toilet training skills when researchers checked in at 2 weeks, 6 months, and 3 years. Setting aside a few days or a couple of weeks to complete this intensive protocol may be intimidating at first, but achieving similar results as the two children in the study has a huge impact on the life of your child and the entire family.

Prior to starting the intervention, they received medical consent and clearance from the children’s attending developmental pediatricians. They then performed a preference assessment (the RAISD) to determine reinforcers. The study then states that “The families were asked to restrict the children’s access to these reinforcers for a minimum of 3 days prior to implementing the intensive training treatment protocol.”

The intensive toilet training program had 5 components:

Increased fluids: In consultation with a pediatrician, the study states that “parents were instructed to increase the children’s access to fluids for 3 days prior to implementing the training.” This increase in fluid intake continued until 6:00 PM on the first day of training.

Toilet scheduled sitting: Since the protocol was completed in the privacy of the children’s homes, the children were able to remain undressed from the waist down while being toilet trained. The children were continuously seated on the toilet, then able to leave the toilet for voiding in the toilet, or for brief “stretching” breaks. As they achieved higher frequency of appropriate voiding in the toilet, the amount of time spent on the toilet decreased and the amount of time escaping the toilet increased. (The schedule for fading out time seated on the toilet is detailed in Table 1 of the study.) Also, while seated on the toilet, the child was able to play with preferred items, but not the most preferred items.

Reinforcement for continent voids: According to the study, “If the child successfully voided while on a scheduled sit, they were provided immediate reinforcement (primary edible reinforcement and planned escape to a preferred activity). If the child self-initiated a void while on a break, he was provided immediate reinforcement and a new break time was begun after the self-initiated break.”

Redirection for accidents: When accidents occur, a neutral verbal redirection was provided, such as “We go pee on the toilet” and then the child was physically redirected back to the toilet. Once they were on the toilet, a scheduled sit was begun.

Chair scheduled sitting: Once the child began to experience success with voiding on the toilet, a chair was placed next to the toilet. During scheduled sits, the child would sit on the chair. If he began to void on the chair, the study states that he “was provided with the least intrusive, minimal, physical prompt. When he independently moved from the chair to the toilet to void three consecutive times, the chair was systematically moved away from the toilet in 2-feet increments.”

The study goes into further detail on each of these five components, as well as how to generalize the skill and how parents were trained in the protocol. The study made modifications to the Azrin & Foxx study to make it easier to apply in the home setting for parents, and it removed any form of punishment.

While this is a comprehensive toilet training program that requires a high level of time and attention from the parents, it is set up to help parents achieve results in a relatively short period of time.

The study states, “Parents of incontinent children with developmental disabilities report higher personal stress and distress likely related to the toileting problems presented by their children than parents of toilet trained children with developmental disabilities. It could be deduced then that continence training not only increases associated hygiene factors and access to activities and placements, but also increases the quality of life for the parents by reducing stress and subsequently for other family members such as siblings as corollary recipients of the distress” (Macias et al., 2006).

The potential to improve the quality of life for both your child with autism and your entire family is worth the challenge of implementing this protocol.

WRITTEN BY SAM BLANCO, MSED, BCBA

Sam is an ABA provider for students ages 3-12 in NYC. Working in education for ten years with students with Autism Spectrum Disorders and other developmental delays, Sam has developed strategies for achieving a multitude of academic, behavior, and social goals.