~ 1Pergamon

PII: S0005-7916(97)00011-6
J B e h a v T/,er & E rI~ Psychiat. Vol. 28. No 2, pp. 1~53 11~8.1997.
1997 Elsevier Science Lid, All rights reserved
Primed in Great Britain
ooo5-7<6/,. st 7.q~+III~l

TEACHING TOILET SKILLS IN A PUBLIC SCHOOL

SETTING TO A CHILD WITH PERVASIVE
DEVELOPMENTAL DISORDER

JAMES K. LUISELLI
The May Institute, Norwood, U.S.A.

Summary - - An 8-year old boy with Pervasive Developmental Disorder (PDD) was
taught toileting skills within a public elementary school. During baseline, he never
urinated successfullyin the toilet and wore a disposable diaper throughout the day. The
training program includedscheduling a toileting opportunityat a time that increasedthe
likelihood of urination and providing positive reinforcementwhen voiding in the toilet
occurred. Toileting skills were established rapidly and were maintained when another
bathroom visit was added to the toiletingschedule,primary reinforcementwas eliminated,
and the boy no longer wore a disposable diaper. Issues related to behavioral support
programming within inclusive educational settings arc discussed. (~ 1997 Elsevier
Science Ltd

Many children with developmental disabilities require systematic training to acquire toileting
skills (Burgio & Burgio, 1989; McCartney, 1990). The most comprehensive approach towards
intervention is the Rapid Toilet Training (RTT) procedure developed by Azrin and Foxx
(1971). This method includes regularly scheduled toileting opportunities, increased liquid-
intake to promote urinating, positive reinforcement of appropriate voiding, and overcorrection
contingent upon incontinence. Procedures are implemented during individualized training
sessions that typically are conducted for many hours during the day. The RTI" method usually
is recommended for children who have never urinated in the toilet successfully and experience
protracted urinary incontinence.
In addition to the influence of cognitive and learning deficits, children with developmental
disabilities also lack toileting skills due to other factors, For example, some children display a
problem of stimulus control because they have learned to withhold urination in the toilet and
instead, urinate only when they wear a diaper or undergarments (Taylor, Cipani, & (;lardy,
1994). Intervention in such cases seeks to transfer stimulus control over urinating from clothing
items to the toilet (Luiselli, 1996). Another reason for urinary incontinence is when children
have a toileting phobia. Fear and anxiety associated with urinating in the toilet generally are
overcome by in vivo desensitization procedures such as graduated exposure and reinforced
practice (Luiselli, 1977).
Finally, some children with developmental disabilities demonstrate toileting skills in one
setting but not in other environments. Behaviors and skills that are restricted to specific
locations reflect setting specificity, a problem seen commonly in children with autism and

Requests lbr reprints should be addressed to J. K. Luisell,Directorof ConsultationServices and Peer Review,The May
Institute Inc.. 220 Norwood Park South, Norwood. MA 02062, U.S.A.
163
164 JAMES K. LUISELL!
related pervasive developmental disorders. In the present single-case study, a child with
Pervasive Developmental Disorder had toileting successes intermittently at home but never
urinated in the toilet at school. Therefore, the study evaluated a training program that was
instituted in the child's classroom within a public elementary school. In addition to empirical
documentation of intervention for one type of toileting deficiency, the study also describes the
adaptation of behavioral teaching procedures to a child with developmental disabilities in an
inclusive educational setting.

Method

Participant

Don was an 8-year old boy with a diagnosis of Pervasive Developmental Disorder. His
language consisted of 1-3 word phrases that generally were used to request an object or
activity. Don's developmental skills were judged to be at a 4-4.5-year-old level. He could
complete simple preacademic tasks and self-care routines but required continuous supervision
from an adult to maintain his attention and performance. At times, he displayed noncompliance
and loud screaming but was not considered to pose serious behavioral challenges.
Don did not toilet himself in the school setting. He would enter the bathroom, sit on the toilet
when requested, and do so without distress but did not urinate appropriately. His parents
reported that Don would "go to the bathroom" occasionally at home, although the behavior was
restricted to particular situations. For example, he might urinate in the toilet if he was
encouraged to do so before he was allowed to engage in certain preferred activities (e.g., going
for a ride in the family car, taking his bath in the evening). However, his rate of success under
these conditions was inconsistent. Don's parents had him wear a disposable diaper both at home
and when he attended school.

Setting

Don attended a public elementary school located in a suburban community. He entered this
setting approximately one month preceding the study. He was integrated fully within a first-
grade classroom comprised of 20 other students and a primary teacher. An individual
instructional-assistant interacted with Don throughout the school day and was responsible for
implementing the toilet training program. Don was at school from 8 : 30 a.m. to 2 : 30 p.m., five
days per week.

Target Behaviors and Recording Procedures

Two behaviors were monitored and recorded: In-Toilet Urination was defined as Don
urinating in the toilet during daily scheduled bathroom visits. Incontinence was defined as Don
urinating in his disposable diaper or underwear. At each scheduled bathroom visit the
instructional-assistant prompted Don verbally to "Go to the bathroom," and then escorted him
to a lavatory that was adjacent to the classroom. He was allowed to sit on the toilet for a 3-
minute duration or until he urinated, whichever came first. During this time, his diaper or
underwear were checked to determine whether incontinence had occurred. Immediately
following the bathroom visit the instructional-assistant used a precoded data sheet to record
 Toilet Training in Public School 165

whether Don did or did not urinate in the toilet and whether his diaper or underwear was wet or
dry.
For purposes of privacy, and given the unambiguous features of the target behaviors, formal
reliability checks (interobserver agreement) were not performed. The instructional-assistant
was requested to indicate any uncertainty regarding the target behaviors on the data sheet and
recordings were reviewed during biweekly consultation meetings with the author. The
instructional-assistant did not report any difficulties in detecting and recording target behaviors
throughout the course of the study.

Experimental Design and Procedures

Baseline and training phases were evaluated using a changing-criterion design (Tawney &
Gast, 1984).

Baseline. In the baseline phase Don participated in two bathroom visits that were scheduled at
l0 : 30 a.m. and 1 : 30 p.m. daily. The instructional-assistant was asked to maintain conditions
which were in effect preceding the study. They consisted of encouraging Don to "'Go to the
bathroom," and singing songs to him (a preferred activity) to create a pleasant condition, Don
wore a disposable diaper during the day and it was changed at each bathroom visit if
incontinence had occurred.

Training

Phase 1. Don continued to wear a disposable diaper each day. Several procedures were
combined in a systematic training package. First, as contrasted to the baseline phase, only the
afternoon bathroom visit ( I : 30 p.m.) was scheduled daily. This arrangement was introduced to
minimize the toileting "demands" imposed on Don. Also, by scheduling the bathroom visit at
the end of the day, there was a greater likelihood that urinating would be occasioned because
Doll had a full bladder.
The second training component was positive reinfk)rcement lk)r in-toilet urination. The
instructional-assistant reported that Don expressed an interest in drinking from a portable water
container that she used during the day. A child-size version of the container was obtained and
Don was infor.ned that he could "have a drink" from it each time he "'goes to the bathroom."
When he did urinate in the toilet he received lavish praise from the instructional-assistant and,
upon exiting the bathroom, was allowed to have a drink of water from his container. Any
occurrences of incontinence during Phase l and all subsequent phases resulted in a change into
a dry diaper or underwear.

Phase 2. All previous conditions remained in effect, but in addition, a second bathroom visit
was scheduled each day ( 1 0 : 3 0 a.m.). Don now had to urinate in the toilet at each visit in order
to have access to his water container. Thus, the criterion for reinforcement was increased from
one in-toilet urination to two in-toilet urinations.

Phase 3. In this phase, procedures were introduced to maintain toileting skills under more
"naturalistic conditions." First, during the first week of this phase (the seventh week of
training), the use of primary reinforcement was discontinued by gradually "fading-out"
presentation of the water container. Initially, every second, and then every third, in-toilet
166 JAMES K. LUISELLI
urination was reinforced with contingent access to the water container until the procedure was
eliminated by the end of the week. The instructional-assistant continued to praise Don each
time he urinated successfully in the toilet. A second change occurred during the subsequent
week (the eighth week of training) when Don began wearing regular underwear instead of a
disposable diaper.

Posttraining. Posttraining phases occurred l and 6 months following completion of the study
and consisted of recording Don's toileting behavior each day for one week. During
posttraining, he visited the bathroom two times daily ( 1 0 : 3 0 a . m . and 1:30 p.m.), wore
underwear throughout the day, and simply was praised when he urinated in the toilet.

Results

Figure l displays the average frequency of in-toilet urination and incontinence recorded
daily, each week, during baseline, training, and posttraining conditions. During the 2 weeks of
baseline, Don did not urinate in the toilet and did not demonstrate incontinence. During the
initial week of Phase 1 training, one in-toilet urination was recorded and it occurred on the
Friday of that school week. For the next 3 weeks in this phase, Don urinated in the toilet
successfully during each daily bathroom visit. At Phase 2 training when positive reinforcement
was contingent on two in-toilet urinations per day, Don achieved this criterion 100% of the
time. An average of two in-toilet urinations daily continued during Phase 3 training when
primary reinforcement was eliminated and Don no longer wore a disposable diaper. Throughout
all training phases, and similar to baseline, Don never demonstrated incontinence. The results

TRAINING
BASELINE PHASE 1 PHASE 2 PHASE 3 POST-
TRAINING

2.0 -.- -,~-, m---,--m ,,,~m

u./
Q: t "
EL -- In-Toilet
>- 1 . 0 -- m~m--= [3
:37rJ' LLI --_ / Incontinence

0U.I
IT"
u_ o---~ ~ ~ ~ o----13
2 4 6 8 10 1 6
WEEKS rvlOS.
Figure l. Average frequency of in-toilet urination and incontinence recorded daily, each week, during
baseline, training, and posttraining conditions. During Phase 1 training, the criterion tbr reinforcement was
one in-toilet urination per day. During Phase 2 and Phase 3 training, the criterion for reinforcement was
two in-toilet urinations per day.
 Toilet Training in Public School 167
of both posttraining assessments revealed that Don maintained 100% success at each scheduled
bathroom visit and remained dry throughout the day.

Discussion

Toileting skills are an essential competency to be acquired by children with developmental

disabilities. In this study, the child's successful toileting, albeit intermittent, was restricted to
his home. The school-based training program was effecti\e in overcoming this setting
specificity by first establishing and then maintaining toileting skills outside of the home
environment. The training program combined antecedent control and consequence procedures
that were instituted within an inclusive educational setting. Positive results were achieved
rapidly and as demonstrated by a changing-criterion design, were clearly associated with the
training program.
Training procedures were selected based upon the outcome of baseline assessment. Because
Don did not urinate in the toilet or exhibit incontinence preceding training, it was likely that his
bladder would be full later in the day. Indeed, there was a suggestion that he was voluntarily
withholding urination at school. As noted previously, this observation resulted in a decision to
schedule only an afternoon bathroom visit as the initial phase of training. Don's interest in
drinking water from a portable container suggested that this high-preference behavior could be
used as positive reinforcement for in-toilet urination. Don did not respond immediately to these
contingencies but on the fifth day of training, experienced a loileting success. Thereafter he was
successful 100% of the time. Therefore, it was possible to transfer toileting skills to the school
setting.
Once positive results from a toilet training program have been achieved it is important to
maintain acquired skills under "naturalistic" conditions. In the present case, this objective was
addressed by first, fading-out primary reinforcement for in-toilet urinating and then, having
Don remain out of protective briefs in favor of underwear. Don responded positively to these
changes and his toileting skills continued to be exhibited at follow-up when only scheduled
toileting opportunities, identical to the baseline phase, were operative.
Because many children with developmental disabilities are being educated in their
community schools, it is likely that toilet training objectives will be incorporated into their
individualized educational plans. Because toilet training is a nontraditional goal for students in
public elementary schools, behavioral strategies will have to bc adapted to the characteristics of
these settings. The consultative model in this case involved '~hands-on" staff' training, case
review meetings, and preparation of written guidelines, The classroom teacher, instructional-
assistant, and school principal comprised the educational team and were responsible for the
day-to-day implementation and evaluation of training procedures. The scheduling of ongoing
consultation to the team provided both technical assistance and interpersonal support to
facilitate programming in the classroom. Once desired results were achieved, it was possible to
eliminate consultation and as demonstrated through the follow-up assessments, maintain Don's
newly acquired skills.

Acknowledgements

Thanks are extended to the Maeve O'Brien, Julie Silver, and Betsy Frattaroli tk~rtheir participati~m in the stu~iy.
168 J A M E S K. L U I S E L L I

References

Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied
Behavior Analysis, 4, 89-99.
Burgio, L. D., & Burgio, K. L. (1989). Bladder and bowel incontinence. In J. K. Luiselli (Ed.), Behavioral medicine and
developmental disabilities (pp. 74-91). New York: Springer.
Luiselli, J. K. (1977). Case report: An attendant-administered contingency management program for the treatment of a
toileting phobia. Journal of Mental Deficiency Research, 21, 283-288.
Luiselli, J. K. (1996). A transfer of stimulus control procedure applicable to toilet training programs for children with
developmental disabilities. Child & Family Behavior Therapy, 18, 29-34.
McCartney, J. R. (1990). Toilet training. In Matson, J. L. (Ed.), Handbook of behavior modification with the mentally
retarded (pp. 255-271). New York: Plenum Press.
Tawney, J.W., & Gast, D. L. (1984). Single subject research in special education. Columbus, OH: Charles E. Merrill
Publishing Company.
Taylor, S., Cipani, E., & CIardy, A. (1994). A stimulus control technique for improving the efficacy of an established
toilet training program. Journal of Behavior Therapy & Experimental Psychiatry, 25, 155-160.