Behavioral Interventions

Behav. Intervent. 19: 45–50 (2004)

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/bin.149

TOILET TRAINING FOR A YOUNG BOY

WITH PERVASIVE DEVELOPMENTAL DISORDER
A. Randi Post and Michael A. Kirkpatrick*
Lynchburg College, Virginia, USA

We employed a variation of the Azrin–Foxx (1971) procedure with a 3.5-year-old boy diagnosed with
Pervasive Developmental Disability (PDD). Unique features of our design included tailoring to the in-
home environment, training without systematically increasing fluid intake, introduction under
circumstances that facilitated generalization and transfer without special procedures, the elimination
of some specialized equipment, and use of social and activity reinforcers. Training was successful and
was reported to have generalized to the inclusive school environment. Copyright # 2004 John Wiley &
Sons, Ltd.

INTRODUCTION

The behavioral approach to toilet training pioneered by Azrin and Foxx (1971) was
remarkably effective. Variations on some components of the program have also been
demonstrated to be efficacious (Taylor, Cipani, & Clardy, 1994). Still, these methods
are largely unavailable to families (Houts, Whelan, & Peterson, 1987), and there
appears to be little current research in this area (Luiselli, 1997). Increasing the
availability of effective toilet training methods might be facilitated by research
demonstrating how program components may be modified to individual cases
without compromising efficacy.
Effective toilet training programs share some combination of several features,
including the establishment of stimulus control, shaping or cuing toilet approach and
clothing removal, reinforcement of on-toilet elimination, and extinction or mild
punishment of incontinence (Azrin, Bugle, & O’Brien, 1971; Azrin & Foxx, 1971;
Hagopian, Fisher, Piazza, & Wierzbicki, 1993; Mahoney, Van Wagenen, &
Meyerson, 1971; Taylor et al., 1994). Sometimes special equipment, such as a pants
alarm, has been required (e.g., Azrin & Foxx, 1971; Mahoney et al., 1971). Stimulus
control is often facilitated by increasing fluid intake (Azrin & Foxx, 1971; Wilder,

*Correspondence to: Michael A. Kirkpatrick, Ph.D., Wesley College, 120 N. State Street, Dover, DE 19901, USA.
E-mail: Kirkpami@wesley.edu

Copyright # 2004 John Wiley & Sons, Ltd.

46 A. R. Post and M. A. Kirkpatrick

Higbee, Williams, & Nachtwey, 1997), and edible reinforcers are ubiquitous in the
literature. We made novel adaptations to this model to meet an individual child’s
needs and to make the procedures accessible to his family. Cued toileting in the
child’s preschool naturally occasioned generalization without necessitating special
procedures.

METHOD

Participant and Setting

The participant was a 3.5-year-old boy diagnosed with PDD. Prior to the
intervention, the procedure was discussed in detail with the child’s mother who
provided written, informed consent. The first author, who worked part-time as an in-
home aide and had established a history of implementing contingencies for
instruction, provided all training. Praise, attention, Blues Clues1 videos, promises of
opportunities to watch Blues Clues1 videos (i.e. periodic restatements of the
contingency), and opportunities to imitate peers (in school) had been used effectively
for several weeks during implementation of daily living and educational program
activities. The apparent effectiveness of these reinforcers established them as good
candidates for use in implementing the toilet training intervention. This history
allowed us to eliminate food and drink as reinforcers, and to proceed without
investing additional time and effort in a formal reinforcer preference assessment.
Toilet training was undertaken at this time because the mother expressed interest in
it as well as willingness to participate. Additionally, the child had begun attending an
inclusive preschool in which prompted independent urination could occur during
group lavatory trips. Diaper changes excluded the boy from this normal classroom
routine. We hypothesized that since the child spontaneously imitated peers in the
school setting, the opportunity to join the class in toileting might occasion transfer
from the home to the school environment.
All training sessions took place in the home setting using a small potty seat placed
over the toilet. The participant wore training pants during the intervention, but no
other specialized clothing or equipment was used. The child’s normal routine
permitted unrestricted access to preferred drinks to maintain adequate hydration, but
no systematic attempt was made to increase fluid intake.

Data Recording
On- and off-toilet urination (wetting) were recorded at scheduled intervals that
changed across phases. Phase I required off-toilet checks every five minutes. Phases

Copyright # 2004 John Wiley & Sons, Ltd. Behav. Intervent. 19: 45–50 (2004)
Toilet training 47

II and III required off-toilet checks every 30 and 60 minutes respectively. In Phase IV,
wetness was recorded whenever it was observed incidentally.
The participant’s mother and the first author recorded data separately on an
irregular rotation to insure data reliability. The observers had worked together for
several weeks prior to the intervention, during which time they arrived at agreement
over criteria for changing diapers. Reliability checks occurred on 18% of the baseline
intervals. Agreement was consistently 100%. Because of the high reliability observed
during baseline and in order to minimize demands on the mother, relatively
infrequent reliability checks (9%) were deemed adequate throughout the interven-
tion. Reliability remained at 100% throughout treatment, so no change in the
frequency of assessments or review of operational definitions was necessitated.

Procedure
Natural (untrained) urination times were recorded over a period of three days in
order to arrange training to occur when the child was most likely to urinate. A
baseline was then established over two days during which the participant wore
diapers and was checked for dryness every 15 minutes. He was taken to sit on the
toilet for exactly 5 minutes every half hour. On- and off-toilet urination were
recorded, and wet diapers were changed as necessary.

Phase I
The child was taken to the bathroom to sit on the toilet every 30 minutes on each
8–10 hour training day. Initially, training was to begin during intervals when
urination was likely, based on its occurrence during baseline. However, toilet sitting
was observed to function as an S-delta for urination. That is, the boy did not urinate
during toilet sitting, but wet his training pants as soon as they were back on.
Consequently, 30 minute time intervals were utilized in the first phase, centered on
times when wetting had occurred during baseline.
Physical assistance followed by prompt fading was used to shape pulling the
training pants down and up. Time on-toilet began at 20 minutes per thirty-minute
period. The first author provided frequent verbal praise and attention for compliant
toilet sitting, along with intermittent restatements of the Blue’s Clues1 contingency.
The boy was allowed to choose a Blue’s Clues1 video upon on-toilet urination. Off-
toilet, the boy was checked for dryness and praised for dry training pants every five
minutes. If he was wet, the trainer flatly stated ‘You’re wet’. He was then changed. If
he was dry, the trainer enthusiastically exclaimed ‘You’re dry’. By day three the boy
displayed occasional escape and aggressive behaviors, including moving around on
the toilet seat, pouting, hitting or pinching. These were verbally redirected while

Copyright # 2004 John Wiley & Sons, Ltd. Behav. Intervent. 19: 45–50 (2004)
48 A. R. Post and M. A. Kirkpatrick

toilet sitting continued. Subsequent sitting intervals were shortened to 10 minutes.

This antecedent control effectively reduced aggression.

Phases II, III, & IV

Once 80% of all urination occurred on-toilet for three consecutive days, the time
off-toilet was increased. Phase II required toilet sitting at hourly intervals, with
checks every 30 minutes. Phase III separated toilet sitting episodes every two hours,
with hourly checks. Phase IV increased the interval to 2.5 hours with checks every
75 minutes. Time on-toilet during phases II, III, and IV was reduced to 5 minutes or
until urination was completed, whichever occurred first. Each phase was discontinued
when 80% of urination occurred on the toilet for three consecutive days. When the
child requested the toilet, he was enthusiastically praised for self-initiation and taken
to the bathroom.

Follow Up
One week after Phase IV was completed, a follow-up period of 21 days was
instituted to record accidents during waking hours.

RESULTS

During baseline there were zero incidents of on-toilet urination. Over the two 24
hour baseline days, the child wet his diaper an average of 5.5 times per day (i.e., every
time he urinated). On the first day of Phase I, he wet his training pants four times,
each time within about five minutes of getting off the toilet. After the first 3.5 hours
he consistently urinated on the toilet for the remainder of the day. By day four
urination occurred reliably within ten minutes of his sitting on the toilet if it was
going to occur during that interval. Percentages of on-toilet urination, and the number
of treatment days required to achieve the criterion of 80% on-toilet urination in each
phase, are displayed in Figure 1.

DISCUSSION

Training was effective despite the absence of procedures to systematically

increase fluid intake. It is unclear whether the scheduling of training to occur
at probable urination times aided in achieving success because initially the absence
of clothing or presence of the toilet appeared to inhibit urination. Regardless, the

Copyright # 2004 John Wiley & Sons, Ltd. Behav. Intervent. 19: 45–50 (2004)
Toilet training 49

Figure 1. On-toilet urination is plotted across baseline (B) and phases I, II, III, and IV. Four days
separated the end of Phase I and the start of Phase II. Thirteen days separated the end of Phase II and the
start of Phase III. Follow-up is not depicted.

procedure was effective without increasing urination. Additionally, we have shown

that established social and non-consumable reinforcers could replace edibles effec-
tively, and that functional reinforcers observed in other settings might effectively be
applied to toilet training without further assessment of reinforcer efficacy. Our
success shows that less formal procedures may not necessarily present obstacles to
training.
Families might easily replicate the in-home procedure since time requirements for
assessment were minimized, no specialized electronic devices were required (e.g.
pants alarm), and the intervention proceeded using informally established social and
activity reinforcers. This latter point warrants caution. While reinforcers were
selected informally, they had been observed to demonstrate functional reinforcing
properties when applied as consequences for daily living and educational activities.
Reinforcer efficacy was not presumed on the basis of structural properties or
subjective perceptions. Functional reinforcers should still be assumed to be important
for effective training.
Prompted toileting was reported to occur in the preschool classroom without any
additional training. Joining the ‘potty time’ trip to the bathroom with peers may have
functioned as an important social reinforcer, although data were not collected to test
this hypothesis. Regardless of its functional significance, the resulting inclusion is
consistent with mainstreaming practices and helps socially validate the intervention.
The boy’s reported enthusiasm upon joining the class for this activity provided
further social validation data, and produced accolades from his teacher.

Copyright # 2004 John Wiley & Sons, Ltd. Behav. Intervent. 19: 45–50 (2004)
50 A. R. Post and M. A. Kirkpatrick

While the present design lacked the necessary controls to permit causal inferences
regarding specific program components, we have nevertheless demonstrated
acquisition of an important adaptive living skill with a novel combination of
modifications to the Azrin–Foxx (1971) design. More data-based replications and
extensions are needed to guide practitioners in their efforts to address wide ranging
individual needs across varied settings. Among the components deserving of more
systematic investigation are the scheduling of training at ‘natural’ urination times,
introduction of training when the skill acquires increased social significance
(represented here as mainstreaming in the school), and the use of activities,
specifically preferred videos, as reinforcers. Each of these features offers the
potential for increasing the possible combinations of training components, thereby
offering more variations from which families can choose to accommodate individual
needs and circumstances.

REFERENCES

Azrin, N. H., Bugle, C., & O’Brien, F. (1971). Behavioral engineering: Two apparatuses for toilet
training retarded children. Journal of Applied Behavior Analysis, 4, 249–253.
Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet training the institutionalized retarded.
Journal of Applied Behavior Analysis, 4, 89–99.
Hagopian, L. P., Fisher, W., Piazza, C. C., & Wierzbicki, J. J. (1993). A water-prompting procedure for
the treatment of urinary incontinence. Journal of Applied Behavior Analysis, 26, 473–474.
Houts, A. C., Whelan, J. P., & Peterson, J. K. (1987). Filmed versus live delivery of full-spectrum home
training for primary enuresis: Presenting the information is not enough. Journal of Consulting and
Clinical Psychology, 55, 902–906.
Luiselli, J. K. (1997). Teaching toilet skills in a public school setting to a child with pervasive
developmental disorder. Journal of Behavior Therapy and Experimental Psychiatry, 28, 163–168.
Mahoney, K., Van Wagenen, R. K., & Meyerson, L. (1971). Toilet training of normal and retarded
children. Journal of Applied Behavior Analysis, 4, 173–181.
Taylor, S., Cipani, E., & Clardy, A. (1994). A stimulus control technique for improving the efficacy of an
established toilet training program. Journal of Behavior Therapy and Experimental Psychiatry, 25,
155–160.
Wilder, D. A., Higbee, T. S., Williams, W. L., & Nachtwey, A. (1997). A simplified method of toilet
training adults in residential settings. Journal of Behavior Therapy and Experimental Psychiatry, 28,
241–246.

Copyright # 2004 John Wiley & Sons, Ltd. Behav. Intervent. 19: 45–50 (2004)