Helping Children with ModerateProfound Cognitive Disability
Achieve Continence: A
Classroom Based Behavioral
Protocol
Cindy Myers
Comprehensive Behavior Specialist
[email protected]
Add/scan spectrum
Who can be toilet trained using this
protocol?
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Mild to profound cognitive disability
Ambulatory
Verbal or non-verbal
Physical and/or orthopedic disabilities
including CP, TBI
• Students with autism
• Once toilet trained, but regressed
Exclusions & Cautions
• Fears and phobias (treat fears first)
• Children with medical conditions which
proscribe excess fluids or toilet training
• Children on neurogenic bowel and bladder
programs
• Children under the age of 4 years
Determining Readiness
 Shows discomfort or recognition of
wet/soiled diaper
½ hour or more of dryness while in
diaper
Age (over 4 ½ years old)
Shows interest in the toileting activities
of others
Displays no fears of being in, on, or
around the bathroom or toilet (if fears
exist, deal with them first with behavioral
desensitization program
Determining Readiness cont.
• Physician’s exam to rule out
medical/physical causes
• Parental interest or request
• Positioning, adaptive equipment
addressed and in place before beginning
program
Prioritizing in a Classroom
• Students who show multiple signs of
readiness
• Student who stays dry for prolonged
periods of time
• Older students who show any signs of
readiness
• Students with good gross motor and
adequate fine motor skills
• Encouragement from home
General Philosophy
• Increased fluid intake to maximize opportunities
for practice
• Pre-determined, time based toileting schedule
• Use of positive reinforcement
• No punishment component
• Modified version of Foxx & Azrin’s toileting
procedure
• Training occurs in the classroom and is then
later generalized to home
• Minimizes stress to families and caregivers for
training responsibilities
Getting Started
• Review and understand each procedure in
the training protocol
• Train assistants and others who will be
sharing toilet training duties
• When ready, schedule a conference with
parents or guardians
Parent Conference
• Present you proposal to toilet train the
student
• Provide a copy of the protocol to parent to
keep
• Explain the procedures
• Do you need to modify the student’s IEP to
include a toileting goal?
Parent Conference cont.
• Obtain written permission
• Agree on a starting date and review date
• Discuss and agree on terminology that will
be used
• Provide parents with a materials list of
items you want them to supply
Materials List
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6 pairs of conventional underwear. NO PULL UPS!!!!
3 changes of elastic waisted, loose, easy to manipulate pants
2 to 4 changes of socks
Washable, easy on/off footwear
Variety of preferred liquids (approximately 30 ounces)
Variety of preferred thirst promoting treats & snacks
Highly prized reinforcer to be used only for toilet training
Activities or items for entertainment while toilet sitting
Two washable chairs
Cleaning supplies
Disposable diaper wipes, disposable gloves
Plastic bags timer
Data sheets, clipboard, pencil
Data Sheet
• Review protocol and data sheet
• Mark data sheet as you go
• Use data to make programming decisions
– Latency between being placed on toilet &
production
– Ability to remain dry until taken to the toilet;
how long?
– Times that accidents/successes occur;
patterns
Prompting Strategies
• Promote independence
• Least to most prompt hierarchy
• Graduated guidance when physical
prompting is required
• Consider time delay prompting strategies
for dressing skills
The Training
• 30 minute Training
Intervals
• 8:00 – 8:05
encourage fluid intake
• 8:00 – 8:15 sitting on
the toilet
• 8:15 – 8:30 dry pants
check
Training Intervals
• 8:00 – 8:15 sitting on the
toilet
– May be looking at books or
singing songs
– 15 minutes
• 8:15 – 8:30 dry pants
checks
– Sitting in chair face to face
with trainer
– May be looking at books or
playing with toys
– Check every 5 minutes
until 8:30
If Success Occurs:
• Praise and reward with highly prized
reinforcer while still on the toilet
• With least amount of prompting necessary,
direct student to stand up from toilet, pull
up pants, walk to chair
• Begin dry pants checks at 5 minute
intervals until the next ½ hour training
interval begins
• Start new training interval on the ½ hour
If an accident occurs:
• Calm or neutral voice for informational feedback,
“Your pants are wet. You need to use the toilet.”
• Direct student to the toilet using the least
amount of prompting necessary
– Student pulls down & takes off wet clothing
– Sits on the toilet for the remainder of the 30 minute
interval (or 15 minutes, whichever is less)
– Student picks up wet clothing & puts it in bag
– Adult cleans are (with neutral affect!)
• Begin new training interval on the ½ hour
Dry Pants Check
• Student and trainer sit in chairs in
bathroom or just outside bathroom door
• Trainer sets timer for 5 minutes
• When timer rings, trainer prompts student
to lightly touch underwear in crotch area
(optional) and verbally reinforces dry pants
– Caution: touching crotch area may not be
appropriate for many students!
Dry Pants Check cont.
• Trainer gives
desirable, thirst
promoting treat along
with verbal/social R+
• Trainer sets timer for
next 5 minute dry
pants check
Expanding the Environment
at School
• After 2 days of no accident while training in the
bathroom, bring the student back into the
classroom and continue ½ hour training intervals
– Accidents will happen. Be prepared to clean up
• Student participates in pleasant table tasks
within the classroom
– Present easy, familiar work tasks
– No new learning
• Toilet training is still the main focus
Increase the Time Between
Toileting Trips
• When data are stabilized for dry pants at ½ hour
intervals, discontinue offering fluids
• Take student to the toilet at ½ hour intervals
• Decrease dry pants checks
• Decrease reinforcement as indicated by data
• After >3 days of no accidents, begin increasing
toileting schedule as appropriate
• After 2 weeks of success at 1 ½ hour intervals,
toilet on “class schedule”
Generalizing to Home
• Meet with parents & review progress at
school
• Ask parents to toilet student at 1 ½ hour
intervals at home
• Use social praise or small edible treat
• Continue to use diapers at night
• Use diapers in social situations or outings