Helping Children with Moderate-Profound Cognitive Disability Achieve Continence: A Classroom Based Behavioral Protocol

1. Helping Children with Moderate-Profound Cognitive Disability Achieve Continence: A Classroom Based Behavioral Protocol Cindy Myers Comprehensive Behavior Specialist cindy.myers@slc.k12.ut.us

2. Add/scan spectrum

3. Who can be toilet trained using this protocol? • 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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?

11. 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

13. Materials List • 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

14. 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

16. Prompting Strategies • Promote independence • Least to most prompt hierarchy • Graduated guidance when physical prompting is required • Consider time delay prompting strategies for dressing skills

17. 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

18. 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

19. 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

20. 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

21. 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!

22. 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

23. 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

24. 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”

25. 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