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A Systematic Review of Rapid Toilet Training Intervention Intensity for

Individuals with Intellectual and Developmental Disabilities
Article in Education and Training in Autism and Developmental Disabilitites · June 2021
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J_ID: ETADD ART NO: 1ETDD210005ETADD Date: 9-May-21 4/C Figure: Page: 1 Total Pages: 19 ARTTYPE="ResearchArticle"
Education and Training in Autism and Developmental Disabilities, 2021, 56(2), 000–000
© Division on Autism and Developmental Disabilities
A Systematic Review of Rapid Toilet Training Intervention

Intensity for Individuals with Intellectual and Developmental
Disabilities
AQ:au
Jenee Vickers Johnson Jason C. Travers
University of Kansas Temple University
Heather J. Forbes and Kathleen Zimmerman

University of Kansas
Abstract : Approximately 50 years of research on rapid toilet training (RTT) first used by Azrin and Foxx
(1971) indicates RTT is effective for teaching individuals with intellectual and developmental disabilities
(IDD) independent toileting routines. Professionals focused on toilet training may be familiar with RTT proce-
dures but be less informed about the frequency and duration of RTT application. We systematically reviewed
the intervention research focused on rapid toileting training to better understand the intensity of RTT in the
intervention research literature. Results indicated intensity varied considerably by study but suggest RTT will
require approximately 30-min inter-sit intervals for six days per week, for a total of 373 hours to produce the
effect. Implications for research and practice are discussed.
Traditional parent-implemented interventions reinforcement for successful elimination, pun-

usually are sufficient to toilet train children ishment for accidents, and reinforcement for
without disabilities, but individuals with intellec- remaining dry between eliminations (i.e., dry
tual and developmental disabilities (IDD) often checks). Results showed rapid reduction of acci-
require time and resource-intensive interven- dents and increased eliminations in only four
tions to achieve continence (Ando, 1977; Blum intervention sessions with maintained conti-
et al., 2004; Cocchiola & Redpath, 2017; Dal- nence five months later. RTT subsequently was
rymple & Ruble, 1992). Accordingly, many replicated across settings, populations, and
researchers have investigated methods to im- intervention agents (e.g., Didden et al., 2001;
prove toilet training outcomes for individuals Foxx & Azrin, 1973a; Kroeger & Sorensen,
with IDD. Although some early researchers 2010; Luiselli, 1997). Most subsequent research
described toilet training according to operant used procedures from Azrin and Foxx (1971)
principles (Baumeister & Klosowski, 1965; Ellis, and found RTT to be generally effective and ef-
1963), incontinence among individuals with ficient for toilet training individuals with IDD
IDD often was considered inevitable until Azrin (Cicero & Pfadt, 2002; Kiddoo et al., 2006).
and Foxx (1971). Azrin and Foxx’s rapid A variety of procedural modifications are
method of toilet training (RTT) used a compre- evident in the RTT research. Original RTT
hensive toilet training protocol that required procedures used by Azrin & Foxx (1971) as
participants to sit on the toilet for 20 min every well as Foxx and Azrin (1973a, 1973b) were
30-min interval for eight hours per day. Other designed to expedite toilet training acquisi-
procedures involved increased fluid intake, a tion with frequent trips to the toilet and
urine alarm to detect incontinence, positive rewards for in-toilet voids. Individuals were
prompted to drink additional fluids to in-
Correspondence concerning this article should
crease toileting opportunities and subjected
be addressed to Jenee Vickers Johnson, University to positive practice, restitutional overcorrec-
of Kansas Department of Special Education, 1122 tion, or time-out following accidents to de-
W. Campus Road, Lawrence, KS 66045. E-mail: crease (i.e., punish) accidents. Urine alarms
jvicker3@ku.edu were used for immediate detection of toileting
Intervention Intensity in Toilet Training / 1
ID: diasv Time: 12:15 I Path: //mumnasprod/home$/diasv$/ET-ETDD210005

accidents, but undergarments were checked even when procedural fidelity to any interven-
between eliminations, and individuals were tion is adequate (Fuchs et al., 2017; Ledford et
rewarded for remaining dry. Graduated guid- al., 2016). Several researchers have highlighted
ance and differential reinforcement strategies the importance of examining intervention in-
were used to teach self-initiated and independ- tensity as a unique variable (Baker, 2012; Cod-
ent toileting. Subsequent researchers adapted ding & Lane, 2015; Neil & Jones, 2015; Polanin
that protocol to exclude punishing contingen- & Espelage, 2015; Warren et al., 2007; Yoder &
cies for accidents (e.g., Ardiç & Cavkaytar, 2014;
Connolly & Woynaroski, 2015).
Wilder et al., 1997). Other researchers also Intervention intensity refers to a dose-
McGoldrick, response relationship of an intervention, or
adapted the original protocol by removing
1976 urine alarms (Brown & Peace, 2010; Williams & the number of teaching episodes necessary
Sloop, 1978) and modifying systematic fluid for a desired outcome. Warren et al. (2007)
increase (Post & Kirpatrick, 2004). Similarly, conceptualized cumulative intervention intensity
researchers added novel components such as as the product of dose, dose frequency, and total
video-modeling (Keen et al., 2007; Lee et al., treatment duration. Dose is the number of
2013), request (i.e., mand) training (LeBlanc et teaching episodes delivered within a teaching
al., 2005; Post & Kirpatrick, 2004), and diaper- session (i.e., opportunities to respond; War-
fading procedures (Luiselli, 1996a,1996b). ren et al., 2007). Warren et al. (2017) identi-
Generally, these adapted RTT components are fied three key characteristics of dose: Rate of
associated with increased intervention time teaching episodes, intervention session
(Kroeger & Sorensen-Burnworth, 2009). length, and distribution of teaching episodes.
More complex and intense protocols make These characteristics are not necessary to
it difficult to ascertain the impact of specific determine the cumulative intensity necessary
to produce an effect, but still have practical
procedures or procedural combinations. For
significance. For example, when comparing
example, a component analysis of toilet train-
dose of two toileting programs, teaching epi-
ing procedures by Greer et al. (2016) found
sodes may defined as trips to the toilet. One
dense sitting schedule alone did not improve
program might take a child to the toilet six
toilet training. However, Hanney et al.’s
times in a 3-hr session; another might take the
(2013) archival analysis of toileting proce-
child to toilet six times in a 6-hr session. This
dures indicated a 9-min initial interval sched-
means programs may have the same overall
ule was effective for 23 children over an
dose, but observe different effects depending
average of 14 treatment days. Other RTT
on intervention duration. Similarly, two 8-hr
adaptations have reduced length of interven-
programs may each use eight teaching epi-
tion sessions (Ardiç & Cavkaytar, 2014; sodes per session but intersperse episodes dif-
Chung, 2007) and amount of time per sched- ferently. A toileting intervention protocol
uled sitting (McLay et al., 2015) with varied may require interventionists to escort the
effects on continence and overall increased child to the toilet four times per hour for the
intervention sessions. Despite these efforts to first hour and loosely distribute the remaining
clarify how intensity affects toilet training, var- four teaching episodes, whereas other proto-
ious aspects of intensity remain unclear. cols might evenly distribute episodes through-
out the session.
Intervention Intensity Dose frequency refers to the rate of inter-
vention sessions per day or week. A protocol
Protocols that include the essential procedures requiring two 3-hr toileting sessions per day
for any intervention are fundamental to an evi- for two weeks would have a dose frequency of
dence-based special education, but this knowl- 14 sessions per week. Some researchers have
edge is insufficient for informing intervention suggested learner characteristics and inter-
selection. Professionals also need information vention components influence the effects of
about how much of an intervention will be dose frequency (Fey et al., 2013; Yoder &
needed to produce the expected benefit (i.e., Woynaroski, 2015; Yoder et al., 2014). For
intensity intervention). Indeed, varied interven- example, Fey et al. (2013) found that higher
tion intensities can result in different outcomes dose frequency of an early communication
2 / Education and Training in Autism and Developmental Disabilities-December 2021

intervention produced superior effects for positive effects is essential for advancing
children with symbolic play skills when com- research and practice related to toilet train-
pared to lower dose frequency, but found no ing. A large body of research suggests RTT
differences between high and low frequency and various adaptions are effective for toilet
conditions for children who did not have sym- training individuals with IDD, but how spe-
bolic play skills. Knowledge about whether cific procedures and interventions were
specific learner profiles, requisite skills, and applied is unclear. Reviews of toilet training
intervention components affect dose fre- research have focused primarily on proce-
quency for RTT could better inform profes- dures used, but no systematic reviews have
sional decisions about intervention selection examined the intensity of toilet training inter-
and application. ventions. Analysis of both procedural and in-
Intervention duration is the total days, tensity variations may stimulate additional
months, or years an intervention must be research to guide professionals toward more
implemented to produce an effect (e.g., an informed decisions. Two questions guided
intervention delivered from August to May our research:
would indicate a duration of nine months). Research Question One: What was the
Intervention duration may vary as a product dose, dose frequency, treatment duration,
of dose and dose frequency. For example, an and cumulative intensity in toilet training lit-
intervention with four sessions per day (e.g., erature for participants with IDD?
dose frequency) and 2-hr session length (e.g., Research Question Two: What are the proce-
dose) may have a shorter treatment duration dures and procedural variations reported in toi-
than a treatment with three sessions per day let training literature for participants with IDD?
and 1-hr session length. Precise reporting of
dose duration has significant practical impli-
Method
cations. Premature termination of a poten-
tially effective intervention may contribute to
reliance on unestablished or disproven prac- Search Procedures
tices, teacher burnout, and poor student out-
comes. Conversely, prolonged application of an An electronic search of Education Resources
ineffective intervention may preclude selection Information Center (ERIC), PsycINFO, and
of a more effective practice, impede student Academic Search Complete was used to iden-
progress, and waste already limited resources. tify literature on toilet training for individuals
As mentioned previously, cumulative inter- with disabilities. Only peer-reviewed articles
vention intensity is the product of dose, dose published in English were included in the
frequency, and dose duration and represents search. Abstracts and titles were searched with
the amount of an intervention necessary to terms representing toilet training and terms
produce a particular outcome (Warren et al., representing disability. The following terms
2007). Cumulative intensity is particularly represented toilet training: toileting, toilet
convenient because it may offer information train*, toilet-train*, potty train*, and potty-
about the total amount of time an interven- train*. The terms were paired with the terms
tion will require, regardless of the overall autis*, disabil*, delay, special need, retard*,
treatment duration. However, this metric special education. Articles were not restricted
alone is inadequate for informing how an by publication date. ERIC search resulted in
intervention should be administered. For 55 articles, PsycINFO resulted in 295, and
example, a toileting intervention with a 4-hr Academic Search Complete resulted in 187
dose, twice weekly dose frequency, and six- studies, for a total of 537 articles. Duplicates
week total duration would have a cumulative were removed and left 418 studies to be sub-
intensity of 48 hours (426 = 48). However, jected to screening and inclusion criteria.
a 6-hr dose, four-times weekly frequency, and
two-week duration also has 48-hr cumulative Screening and Inclusion Procedures
intensity, but may produce different effects.
Identification of key procedures and inten- Titles and abstracts were screened, and stud-
sity necessary for an intervention to yield ies were eliminated according to several

criteria. Reports and reviews, studies with exposure, toilet training readiness skills (Bra-
medical interventions, and studies with de- zelton et al., 1999; Snell & Farlow, 1993),
pendent variables involving teacher or parent communication method, and problem behav-
attitude were excluded. Studies with no partic- ior were coded for participants. Studies also
ipants with disabilities, that did not use toilet were coded for the presence or absence of 14
training as part of the independent variable, or toilet training procedures. When authors
only evaluated bowel-training or bed-wetting noted adherence to previously published pro-
also were eliminated. A total of 105 studies tocol (e.g., Azrin & Foxx, 1971; Foxx & Azrin,
remained after initial screening. The full text of 1973a, 1973b; Leblanc et al., 2005), unreported
all 105 articles was evaluated for evidence that information was derived from the original proto-
inclusion criteria were met. Studies were col. To support replication and research trans-
included if authors (a) utilized an experimental parency, all search, screening, inclusion, and
or quasi-experimental design, (b) included at coding procedures as well as all results are avail-
least one participant with IDD (c) intervention able at our project page on the Open Science
procedures included at least one scheduled visit Framework (https://osf.io/n56rq/?view_only=
to the toilet per teaching session with reinforce- a5a5544ddfb744388c037f1274c28177).
ment for voiding in the toilet (d) scheduled Punishment procedures were coded “pres-
sitting and reinforcement were sustained ent” or “absent” when any aversive stimulus
throughout at least the first phase or treatment was applied after an accident with the intent
condition (e) dependent measures focused on to reduce future accidents. We coded for res-
voiding in toilet, accidents, or appropriate elim- titution, restitutional overcorrection, verbal
inations. A total of 45 studies met our inclusion reprimands, positive practice, time-out, cor- negative
criteria. poral punishment, and non-categorical proce- punishme
We then examined reference sections for dures. Restitution was coded “present” when nt
three recent reviews (Kiddoo et al., 2006; procedures required participants to change
soiled or wet clothing with minimal assistance
Kroeger & Sorensen-Burnworth, 2009; Richard-
after accidents. For example, restitution was
son, 2016). This resulted in two additional stud-
coded present when a participant whose urine
ies that met inclusion criteria. We also
was on their chair due to accident was
conducted a forward-reference search of Azrin
required to assist with clean up (Ando, 1977;
and Foxx (1971) on Google Scholar. This pro-
Bettison et al., 1976.). Restitutional overcor-
cess entailed the same screening procedures
rection was coded present when participants
described above for articles that cited Azrin and
were required to clean their own feces or
Foxx (1971). This resulted in three additional
urine and clean parts of the environment
studies that met inclusion criteria. An ancestral
unaffected by the accident (e.g., cleaning the
search of the references sections for all included
entire bathroom). Restitutional overcorrec-
studies was then conducted and resulted in four tion was also coded present if procedures in
additional studies that met inclusion criteria. which participants were required to clean
Finally, we conducted a hand search of the three themselves or clothing beyond what is ex-
journals with the most frequent number of RTT pected or necessary (e.g., showering after uri-
publications (Journal of Applied Behavior Analysis, nating in pants, washing their soiled clothing
Journal of Behavior Therapy and Experimental Psychi- in sink) were applied. Verbal reprimands
atry, and Journal of Child and Family Behavior were considered present anytime admonish-
Therapy). The hand search produced no addi- ing verbal feedback followed an accident (e.
tional studies that met inclusion criteria. This g., “No!” or “You’re wet!”) except when
resulted in a total of 55 studies for data extrac- authors specifically noted corrective feedback
F1 tion (see Figure 1). was delivered unemotionally or neutrally. Pos-
itive practice was coded as present when par-
Coding Procedures and Reliability ticipants were required to repeat the targeted
toileting behavior chain two or more times
Relevant data from each study was extracted following an accident. Negative punishment
and entered in a database for analysis. Demo- was coded as present when authors removed
graphic information, previous toilet training access to reinforcing stimuli contingent on

Figure 1. Prisma Chart Illustrating Identification, Screening, Eligibility, and Inclusion Procedures.

accidents. Punishment procedures that did (e.g., Ando, 1977). Total number of sessions
not fit into any established category were was recorded when treatment duration was
coded as “other” and described (e.g., waiting not provided. Cumulative intensity was re-
in soiled clothing; Song et al., 1976). ported in three variables: (a) total session
Parent training was considered present when hours, (b) total number of trips to the toilet,
interventions explicitly included a parent train- and (c) total time on the toilet throughout
ing and/or required parents to serve as inter- the intervention. Dose variables were multi-
vention agent. Studies were coded based on the plied by number of sessions to calculate cu-
presence of baseline elimination schedules. mulative intensity.
Elimination-based schedules relied on sittings The first author developed a coding manual
that coincided with times when eliminations and trained the second author to apply the
were more likely (e.g., if child frequently uri- manualized procedures. Five practice articles
nated at 9:30 a.m., then sits took place at that typifying various experimental designs and
time of day). Progressive sitting schedules relied schedule changes were selected. The second
on increasing the inter-sit interval after success- coder practiced until 80% fidelity on example
ful elimination(s). Finally, “diaper removed” was articles. Eleven articles [20%] were randomly
considered present anytime authors described selected for calculating interobserver agree-
removing a diaper or requiring participants to ment [IOA], not including the five practice
wear underwear, training pants, or urine alarms articles. Total count IOA [number of individual
during the intervention. constructs agreed/total constructs 100] was
Intervention intensity variables were coded calculated, and initial IOA was 97.3%. Disagree-
or calculated based on available data. Dose ments were resolved by reviewing the coding
was coded in four ways: (a) session length, (b) manual and article texts. Consensus was
number of scheduled trips to the toilet per reached, and final IOA was 100%.
session, (c) time on toilet per sitting, and (d)
inter-sit interval. A formula was used to derive
from original sources any unreported details Results
about dose. The formula was (number of
scheduled trips)(time per sitting + inter-sit Participant Characteristics
interval) = session length. Separate calcula-
tions were made for changes in session Two-hundred nineteen participants were in-
length, sitting schedule, or sitting duration. cluded in the 55 studies. Gender was reported
If session length was not explicitly provided, for 126 of the 219 participants; 24% were
but authors reported specific toileting female, and 76% were male. Age ranged from
schedule times (e.g., 8 a.m., 10 a.m., 2 p. 2.5 to 50 years old. The median age was 11.5
m.), then the difference between last sitting years old (mean = 12.9 yr). Only 38% of par-
and first sitting plus the duration of individ- ticipants were reported as having previous
ual sitting was used to estimate session toilet training. Only one participant had pre-
length (e.g., 2 p.m. – 8 a.m. + 30 min = 6.5 viously been continent prior to the study.
hr). Studies that occurred at school(s) but Ability to follow directions was noted for 27%
did not explicitly describe session length of participants (n = 57). Of those, 79% could
were coded as a 7-hr session duration. follow simple directives. Authors infrequently
Dose frequency was the number of teaching reported communication skills of partici-
sessions per week. Differences between overall pants. When reported (n = 123), 27% were
treatment duration and number of sessions described as nonverbal communicators, some
were used to estimate dose frequency when of whom used alternative and augmentative
unreported. Many interventions had fewer communication (AAC) such as picture-based
than seven treatment days, and weekly fre- systems (e.g., Kroeger & Sorenson, 2010; Lan-
quency was unnecessary. Dose duration was cioni et al., 2005; Leblanc et al., 2005), speech-
calculated for all sessions with scheduled toi- generating devices (e.g., Cicero & Pfadt, 2002;
leting and specific reinforcement for voiding. Doan & Toussaint; 2016) and sign language (e.
Dose duration was recorded in days, and a fac- g., Luiselli, 1987). Other authors reported the
tor of 30 converted monthly durations to days absence of vocal communication skills without

TABLE 1
Characteristics of participants in rapid toilet training intervention studies.
Participant Characteristics Number of Participants (N = 219) % of Participants
Age
≤ 5 years 35 17%
5–10 years 57 28%
11–20 years 79 39%
>20 years 30 15%
Gender
male 94 75%
female 32 25%
Toilet Training Readiness Skills
Follow Directions 48 22%
Sit for five minutes 7 4%
Pull Pants up & Down 23 11%
Retain Urine 9 4%
Previous Toilet Training Exposure 84 38%
Problem behavior 19 12%
Vocal Communicator 33 15%
Disabilities
MR/ID 120 55%
ASD/PDD/PDD-NOS 44 20%
Multiple Disabilities/Unspecified 31 16%
DD 6 3%
Syndrome/Diagnosis 13 5%
Sensory Impairment 2 1%
Traumatic Brain Injury 3 1%
Note. ASD = Autism spectrum disorder; PDD = Pervasive developmental disorder; PDD-NOS= Pervasive de-
velopmental disorder not otherwise specified
indicating an alternative communication Session duration averaged 7.3 hr and was

T1 method (Ando, 1977; Edgar et al., 1975). Table reported in 40 studies. William and Sloop
1 includes these and additional relevant partici- (1978) reported the shortest session duration
pant characteristics. at 3 hr. The longest reported duration was 15
hr (Tierney, 1973). Notably, several studies
reported session duration as “all waking
Intervention Intensity hours,” and precise durations were unavail-
able. Authors of 93% (n = 50) of articles
T2 Table 2 also shows the nine variables for dose,
described inter-sit interval. Also, 65% (n = 36)
dose frequency, treatment duration, and cu-
of all studies reported time on toilet per sched-
mulative intensity. Authors of 24% of studies
uled sit. Sitting intervals ranged from 5 min to 4
(n = 13) reported enough information to hr as intervention progressed. Average interval
determine each indicator of intensity; on aver- across sessions was 56.3 min. Among 23 studies
age, authors reported sufficient information that varied inter-sit interval throughout the
to calculate six of the nine variables. At least intervention, the average initial inter-sit interval
one variable relating to dose was included in was 39.2 min. Average time per sitting was 10.8
98% of articles (n = 54). The number of sit- min, but participants were never required to sit
tings per session was reported or derived from for more than 35 min (Kroeger & Sorensen,
data in 61% of studies (n = 33). Sittings per 2010). Dose frequency was coded in 67% of
session ranged from 3-18 and averaged 6.7 sit- studies (n = 37) and reported per week; fre-
tings per session. quency averaged 5.8 sessions per week. All but

TABLE 2
Study-Level Intensity Data
Dose Cumulative Intensity
Sittings per Session Minimum Mean Maximum Time per Sessions per Total Total Total Time on Total
Session Duration ISI ISI ISI Sitting Week Sessions Hours Toilet Sittings
(hrs) (min) (min) (min) (min) (hrs)
Ando (1977) 120.0 7.0 183.6

Ardiç & Cavkaytar (2014) 8.0 5.7 30.0 10.0 6.7 37.8 8.9 53.3
Azrin & Foxx (1971) 9.0 8.0 30.0 20.0 7.0 6.0 48.0 18.0 54.0
Azrin et al. (1971) 9.3 6.0 5.0 10.0 20.0 8.8 14.5 60.0 9.1 43.5
Bettlson et al. (1976) 9.0 7.5 30.0 20.0 7.0 15.6 116.8 46.7 140.1
Brown & Peace (2011) 4.0 7.3 60.0 75.0 7.5 5.0 50.0 362.5 16.7 200.0
J_ID: ETADD ART NO: 1ETDD210005ETADD Date: 9-May-21
Chung (2007) 4.8 6.0 30.0 75.0 120.0 20.0 5.0 49.0 306.0 26.9 206.0
Cicero & Pfadt (2002) 10.0 5.5 30.0 1.5 5.7 31.2 1.4 56.7
Cocchiola et al. (2012) 5.5 6.0 30.0 73.5 120.0 3.0 5.0 56.4 369.9 13.6 319.3
Connolly & McGoldrick (1976) 4.3 4.5 30.0 45.0 60.0 10.0 5.0 30.0 135.0 21.7 130.0
Didden et al (2001) 7.3 30.0 30.0 15.0 38.5 65.6 280.7
4/C Figure:
Dixon & Smith (1975)

Doan & Toussaint (2016) 5.0 82.1 240.0 5.6 7.0 23.0
Dunlap et al. (1984) 30.0 45.0 60.0 6.6 415.3
Edgar et al. (1975) 8.0 4.0
Greer et al. (2016) 8.0 7.0 30.0 60.0 90.0 3.0 23.0 161.0 12.2 228.0
Page: 8
Hagopian et al. (1993) 30.0 7.5 7.0 110.0

Hundziak et al. (1965) 7.0 120.0 5.0 27.0 189.0
Keen et al. (2007) 6.5 11.0 98.5 3.0 5.5 74.4 818.4 24.2 483.6
Kroeger & Sorensen (2010) 5.0 10.0 15.0 25.0 7.0 4.5
Lancioni & Ceccarani (1981) 5.0 7.3 55.0 84.0 113.0 3.0 21.6 156.6 6.0 119.20

Treatment 1

Total Pages: 19
Lancioni & Ceccarani (1981) 5.0 7.3 55.0 84.0 113.0 3.0 23.3 168.6 6.4 127.00
Treatment 2
Lancioni et al. (1994) 3.3 4.5 28.3 52.5 77.1 3.5 4.5
Lancioni et al. (2000) 4.2 7.8 73.0 82.0 109.0 763.0 520.0
Leblanc et al. (2005) 5.0 81.3 240.0 7.5 7.0 19.7
(continued on next page)
ARTTYPE="ResearchArticle"
TABLE 2 (Continued)
Dose Cumulative Intensity
Sittings per Session Minimum Mean Maximum Time per Sessions per Total Total Total Time on Total
Session Duration ISI ISI ISI Sitting Week Sessions Hours Toilet Sittings
(hrs) (min) (min) (min) (min) (hrs)
Lee et al. (2014) 8.0 10.1 86.3 7.5 114.0 1140.0 228.0 912.0
Luiselli (1977) 6.0 84.0
Luiselli (1987) 4.5 11.0 165.0 183.3 220.0 7.0 168.0 1848.0 742.0
Luiselli (1994) 60.0 75.0 90.0 3.0 6.3 89.0
Luiselli (1996) 4.0 6.0 85.0 3.0 5.0 75 450.0 15.0 300.0
Luiselli (1997) 1.5 6.0 180.0 3.0 5.0 45.0 270.0 3.5 70.0
Luiselli (2007) 30.0 90.0 54.0 390.7 20.9 326.0
Luiselli et al. (1979) 4.0 6.5 30.0 70.8 95.0 10.6 4.0 55.0 357.5 47.8 357.5
J_ID: ETADD ART NO: 1ETDD210005ETADD Date: 9-May-21
McLay et al. (2015) 6.0 10.0 88.0 82.8 497.0

McManus et al. (2003) 7.0 30.0 5.0 65.0 455.0
Moskowitz et al. (2011) 30.0 5.6 143.0
Nand Singh (1976) 7.5 5.3 30.0 7.5 5.0 11.0 57.8 10.3 82.5
Post & Kirpatrick (2004) 7.3 9.0 30.0 90.0 150.0 8.8 24.0 216.0 26.8 140.0
4/C Figure:
Ricciardi & Luiselli (2003) 10.0 60.0 75.0 90.0 5.0 60.0 600.0 270.0
Richmond (1983) 4.5 15.0 56.3 120.0 5.0 20.0 90.0
Rinald & Mirenda (2012) 13.0 8.0 5.0 10.0 15.0 25.0 5.0 5.8 46.4 75.4
Sadler & Merkert (1977) 30.0 20.0
Sells-love et al. (2002) 7.0 30.0 5.0 23.0 161.0
Page: 9
Smith (1979) Group RTT 9.0 45.0 7.0 87.5 787.5

Smith (1979) Individual RTT 10.0 9.0 30.0 20.0 7.0
Smith (1979) Timed Intensive 9.0 30.0 7.0 85.4 756.0
Smith & Bainbridge (1991) 10.0 7.0 30.0 10.0 5.0 45.0 315.0 75.0 450.0
Smith & Smith (1977) 10.0 9.0 30.0 20.0
Smith et al. (1975) 9.0 8.0 30.0 20.0 7.0

Total Pages: 19
Smith et al. (2000) 5.0 5.8 51.0 293.3 255.0

Song et al. (1976) 3.7 4.0 30.0 68.0 87.0 3.3 5.0 23.0 92.0 5.9 81.0
Taylor et al. (1994) 12.0 8.0 30.0 10.0 6.0 60.0 15.0 90.0
Tierney (1973) 5.0 15.0 90.0 180.0 450.0 7.0 90.0 1350.0 450.0
Trott (1977) 7.5 7.0 20.0 20.0 5.0 4.0 17.5 15.8 25.0
Intervention Intensity in Toilet Training /

(continued on next page)
9
ARTTYPE="ResearchArticle"
one study (Taylor et al., 1994) had a daily fre-
Sittings
Total
quency of one-session per day. Authors of 46
245.8
27.0
studies reported total treatment duration. Num-
Cumulative Intensity
Total Time on ber of treatment sessions was reported in 85%

of studies (n = 47) and averaged 60.1 sessions
(SD = 67.1).
Toilet
(hrs)
Authors of 57% (n = 31) of studies included
30.5
21.2 at least one of the three cumulative intensity
9.0
variables. Total session hours was the primary
indicator of cumulative intensity and reported
Hours
Total
373.3
682.5
in 35 studies. Total session hours ranged from

27.0
17.5 hr (Trott, 1977) to 1,848 hr (Luiselli,

2007); average cumulative intensity was 373.3
Sessions
Total
hr (SD = 405.2). Total time on toilet and total

60.1
91.0
84.0
number of trips to toilet were calculable for

9.0
27 and 30 studies, respectively. On average,

Sessions per
participants spent 30.5 hours on the toilet

Week
and went to the bathroom 245.8 times (SD =

213.1) throughout the course of the interven-
5.8
7.0
7.0
tion. Percent of total intervention time on the

toilet ranged from 1% (Luiselli, 1996a) to
Time per
Sitting
(min)
90% (Trott, 1977). On average, 16% of total

Note: Squares indicate variable was not reported by authors or was unclear. ISI = inter-sit interval.
10.8
20.0
intervention time was spent on the toilet and

participants sat on the toilet one to two times
Maximum
an hour throughout the course of the inter-

(min)
ISI
vention (see Table 2).

121.6
Intervention Procedures
Mean
(min)
ISI
70.7
Figure 2 displays per study data for proce- F2

Dose
dural frequency. Replacing diapers with

Session Minimum
(min)
underwear was the most prevalent procedure

ISI
(n = 38).41
44.0
30.0
30.0
The second most common proce-

5.0
dure was punishment and was reported in

60% 33
Duration
62% of studies (n = 34). Procedures intended

(hrs)
to function as punishment included verbal

7.3
8.0
3.0
reprimands (n = 16), restitution (n = 13), neg-

ative punishment (n = 11), positive practice
Sittings per
Session
(n = 10), restitutional overcorrection (n = 7),

other (n = 7), and spanking (n = 2). Restitu-
6.7
3.0
tional overcorrection included showering and

mopping the bathroom after accidents (e.g.,
Azrin & Foxx, 1971; Taylor et al., 1994).
Spanking was the least prevalent punishment
TABLE 2 (Continued)
procedure and used in just two early studies

William & Sloop (1978)
Waye & Melynr (1973)
(Ando, 1977; Azrin et al., 1971). Thirty-one

Wilder et al. (1997)
percent of studies included verbal reprimands

(n = 17). Verbal reprimands preceded positive
practice in five studies (Doan & Toussaint,
2016; Dunlap et al., 1984; Leblanc et al., 2005;
Average
Smith & Smith, 1977; Trott, 1977). Positive

Williams practice was reported in 11 studies and

Toilet Training Procedures Intensity
Number of Treatment Sessions

Cumulative Intensity (hours)
Progressive sitting schedule
Elimination-based schedule
Stimulus fading procedure
DRO for remaining dry*

Systematic instruction*
Preference assessment
Initiation training*
Diaper removed*
Request training
Video modeling
Fluid increase*
Parent training
Urine alarm*
Punishment*
Ando (1977) 1 1 183.6
Ardiç & Cavkaytar (2014) 1 1 1 1 1 37.8 6.7
Azrin & Foxx (1971) 1 1 1 1 1 1 1 48.0 6.0
Azrin et al. (1971) 1 1 1 60.0 14.5
Bettison et al. (1976) 1 1 1 1 1 1 116.8 15.6
Brown & Peace (2011) 1 1 1 1 1 362.5 50.0
Chung (2007) 1 1 1 1 1 306.0 49.0
Cicero & Pfadt (2002) 1 1 1 1 1 1 31.2 5.7
Cocchiola et al. (2012) 1 1 1 1 1 369.9 56.4
Connolly & McGoldrick (1976) 1 1 135.0 30.0
Didden et al (2001) 1 1 1 1 1 1 38.5
Dixon & Smith (1976) 1 1 1 1 1 1 1
Doan & Toussaint (2016) 1 1 1 1 1 1 1 23.0
Dunlap et al. (1984) 1 1 1 1 1 1 1 415.3
Edgar et al. (1975) 1 1 1 1
Greer et al. (2016) 1 1 1 161.0 23.0
Hagopian et al. (1993) 1 1 1 110.0
Hundziak et al. (1965) 189.0 27.0
Keen et al. (2007) 1 1 1 1 1 1 1 1 1 818.4 74.4
Kroeger & Sorensen (2010) 1 1 1 1 1 1 1 4.5
Lancioni & Ceccaroni (1981) - 1 1 1 1 1 156.6 21.6
Lancioni & Ceccaroni (1981) - 2 168.6 23.3
Lancioni et al. (1994) 1 1 1 1 1
Lancioni et al. (2000) 1 1 1 763.0 109.0
Leblanc et al. (2005) 1 1 1 1 1 1 1 1 19.7
Lee et al. (2014) 1 1 1 1 1 1 1 1140.0 114.0
Luiselli (1977) 1 1 1 1 84.0
Luiselli (1987) 1 1 1848.0 168
Luiselli (1994) 1 1 89.0
Luiselli (1996) 1 1 450.0 75.0
Luiselli (1997) 270.0 45.0
Luiselli (2007) 390.7 54.0
Luiselli et al. (1979) 1 1 357.5 55.0
McLay et al. (2015) 1 1 1 1 1 1 1 1 1 88.0
McManus et al. (2003) 1 1 1 1 455.0 65.0
Moskowitz et al. (2011) 1 1 1 1 1 1 143.0
Nand Singh (1976) 1 1 1 57.8 11.0
Post & Kirpatrick (2004) 1 1 1 1 1 1 216.0 24.0
Ricciardi & Luiselli (2003) 1 1 1 600.0 60.0
Richmond (1983) 1 1 1 1 90.0 20.0
Rinald & Mirenda (2012) 1 1 1 1 1 46.4 5.8
Sadler & Merkert (1977) 1 1 1 1 1 1 1
Sells-love et al. (2002) 1 1 1 161.0 23.0
Smith & Bainbridge (1991) 1 1 1 1 1 1 1 787.5 87.5
Smith & Smith (1977) 1 1 1 1 1
Smith (1979)- Individual RTT 1 1 1 1 1 1 1
Smith (1979)- Group ITT 756.0 87.5
Smith (1979)- Timed Training 315.0 84.0
Smith et al. (1975) 1 1 1 1 1
Smith et al. (2000) 1 1 293.3 51.0
Song et al. (1976) 1 1 1 1 1 1 1 92.0 23.0
Taylor et al. (1994) 1 1 1 1 1 1 1 1 1 60.0 6.0
Tierney (1973) 1 1 1350.0 90.0
Trott (1977) 1 1 1 1 1 1 17.5 4.0
Waye & Melynr (1973) 1 1 1 682.5 91.0
Wilder et al. (1997) 1 1 1 84.0
Wiliams & Sloop (1978) 1 1 1 1 1 1 27.0
373.3 9.0
60.9
Total/Mean 3 5 5 11 13 14 14 16 16 22 26 31 33 41 373.3 60.9
averaged 4-5 positive practice trials following and discontinuing prompted sitting after the
an accident. Negative punishment was first initiation, but other authors used tactile
reported in 11 studies and included hour- cues and timers to replace adult prompts
long deprivation periods (Azrin & Foxx, 1971; (Lancioni et. al.,1994; 2000). Stimulus fading
Didden et al., 2001, Taylor et al., 1994), 10- procedures (n = 5) and video modeling (n =
min periods of withheld attention (Ando, 3) were the least prevalent procedures. Stimu-
1977; Smith & Bainbridge, 1991), and denied lus fading involved transferring stimulus con-
access to preferred activities contingent on trol for elimination from faulty stimuli to the
accidents (Luiselli, 1997; Moskowitz et al., toilet. Faulty stimuli included water (Hago-
2011). Time-out averaged 24.5 minutes. Idio- pian et al., 1993), clothing (Taylor et al.
syncratic punishment procedures were used 1994), and diapers (Luiselli, 1996a; Riccardi
in six studies (Ando, 1977; Lancioni & Ceccar- & Luiselli, 2003; Smith et al., 2000).
oni, 1981; Song et al., 1976; Smith, 1979;
Smith & Bainbridge, 1991; Waye & Melynr,
1993). 56% Discussion
31
Participants in 51% of studies (n = 28) were The purpose of this review was to examine
given extra fluids to increase toileting oppor- intervention intensity and procedural compo-
tunities. Authors of 14 studies described the nents included in research on toilet training
fluid amount per participant per session; for individuals with IDD. Regarding the first
amount ranged from .24 L (McManus et al.,
research question, we found toileting studies
2003) to 8.28L (Bettison et al., 1976) with a
varied considerably in treatment duration
mean of 2.28L per participant per session.
and cumulative intensity. This finding might
Rate of liquids provided ranged from .03L to
be expected given differences in intervention
1.1L per hour, but liquids were most often
procedures and sitting schedule across the
provided at rate of .33L (8 ounces) per hour,
included studies. Dose frequency was less vari-
consistent with medical recommendations
able, which may be attributed to treatment
(Verbalis et al., 2007). Dry checks were reported
settings and agents. That is, parent-directed
in 47% of studies (n = 26). Dry check intervals
interventions and interventions in residential
ranged from 5-60 min (mean = 12.5 min). Tan-
settings often occurred seven times per week
gible and edible reinforcers were the most com-
mon reinforcers for dry checks, but Luiselli (i.e., every day), but school-based interven-
(1977) used a token reinforcement system for tions often occurred five times (days) per
remaining dry. Systematic instruction for toilet- week. Overall, however, two aspects of inter-
ing skills was reported in 13 studies and vention intensity frequently appeared in stud-
included most-to-least prompting strategies ies with the shortest intervention durations:
(Kroeger & Sorensen, 2010; Post & Kirkpatrick, (a) dose with progressive sitting schedule and
2004), least-to-most prompting (Didden et al., dense initial schedule (e.g., from every 5 to 30
2001; Lancioni & Ceccaroni, 1981; McLay et al., minutes) and (b) dose frequency that was at
2015; Moskowitz et al., 2011), graduated guid- least five days per week. Importantly, dose
ance (Azrin & Foxx, 1971; Smith, 1979; Smith and dose frequency are associated with faster
et al., 1975; Taylor et al., 1994), visual supports rates of skill acquisition in early intensive be-
(Keen et al., 2007; et al., 2013), and task analysis havioral intervention (Granpeesheh et al.,
(e.g., Cocchiola et al., 2012). Lee et al., 2014 2009) and augmentative and alternative com-
Authors of 49% of studies (n = 26) used munication instruction for learners with
29 severe disabilities, despite large discrepancies
procedures53% for teaching initiating/requesting
Thirteen
to use the bathroom. Twelve studies included in cumulative intensity (Simacek et al., 2018).
procedures for prompting participants to Regarding our second research question,
request the bathroom prior to the scheduled we found some procedures were common
sit. Initiation procedures involved fading across most studies. The most common proce-
prompts for toileting trips to naturally occur- dure was replacing diapers with underwear,
ring or unobtrusive stimuli (n = 15). Azrin followed by punishment procedures, differen-
and Foxx (1971) taught initiation by moving tial reinforcement for remaining dry, and
a chair farther and farther from the bathroom increased fluid intake. All of these procedural

components were included in Azrin and Foxx but did not examine these outcomes due to
(1971). The frequent use of these procedural space concerns. It may be beneficial to exam-
components may reflect high practicality or ine whether positive effects (per original
social validity (Horner et al., 2005). Alterna- author reports) were maintained or general-
tively, less common procedures like stimulus- ized. If RTT with lower intensity resulted in
fading and request training may reflect novel/ toileting skills that were not maintained or
recent procedures or procedures more appro- did not generalize, then such a finding might
priate for specific settings and learners. Notably, reflect an association with intensity and main-
forms of punishment varied (e.g., verbal repri- tenance or generalization. It seems plausible
mands, negative punishment, positive practice, that intensity may affect maintenance and
restitution in the form of cleaning up after acci- generalization. Accordingly, future studies
dents), even though punishment procedures might examine this directly. To support this,
were relatively common. Earlier studies relied readers may access our raw data and coding
on punishment procedures, such as corporal manual for this project at our Open Science
punishment, that are unethical by contempo- page (https://osf.io/n56rq/?view_only=
rary standards and therefore very likely unac- a5a5544ddfb744388c037f1274c28177).
ceptable to current professionals and other
stakeholders.
Implications for Research
Limitations We suspect intervention intensity for toileting

training is impacted by the presence and ab-
Our findings and implications should be con- sence of specific procedures (Codding et al.,
sidered in light of several limitations. First, we 2011). Future research should evaluate
only included studies of RTT that included whether different intensities of toileting
scheduled sittings and reinforcement for void- schedules affect rate of acquisition, including
ing in the toilet. Relatedly, we excluded stud- interventions with more frequent sittings or
ies that only used negative-reinforcement longer sit durations. Researchers might also
contingencies for eliminations without a evaluate the impact of specific toilet training
schedule. We also did not include studies that procedures on intervention outcomes, partic-
were not peer-reviewed (e.g., dissertations ularly for procedures with lower social validity
and theses). A review that includes gray litera- (e.g., positive practice, urine alarms). Finally,
ture might obtain different results. Second, researchers might analyze the relationships
we did not evaluate methodological quality or between participant characteristics and toilet-
exclude studies based on methodological ing training acquisition as functions of inter-
rigor. A more exclusive analysis might result vention intensity and/or procedures. Such
in different depictions of intervention inten- findings likely would help professionals
sity for RTT. Third, we employed the con- address the toileting needs of their students
struct of intervention intensity introduced by in socially valid ways.
Warren et al. (2007). Although this source is Dose was the most frequently reported in-
well-cited and appears conceptually sound for tensity variable in the form of inter-sit inter-
evaluating toileting intensity, increased and val. Inter-sit intervals were highly variable and
more recent attention to intervention inten- ranged across interventions and intervention
sity may lead to different aspects of interven- conditions, but results suggest a progressive
tion intensity (e.g., Fuchs et al., 2017). sitting schedule with dense initial schedules
Fourth, IOA was calculated on only 20% of may reduce overall intervention time. Thus,
included articles. Although agreement was an initial sitting schedule where an individual
high, some coding errors for other articles is taken to the bathroom every 5 to 30
might have remained. However, we believe minutes may be necessary. Dose frequency
the initial reliability was sufficiently high to was not commonly reported, but our findings
allay such concerns. Finally, we extracted in- indicate at least five sessions a week is neces-
formation about generalization and mainte- sary for toilet training success. Differences in
nance of effects (per original author report), dose frequency were generally due to

intervention agent or setting variations; par- seven-days a week. This is consistent with Dun-
ent directed interventions and interventions lap et al. (1984) findings that voiding
in residential settings often occurred seven improved when procedures were applied
times (days) per week, but school-based inter- across settings. Moreover, RTT studies with
ventions occurred five times (days) per week. lower cumulative intensity often included par-
Regardless of frequency, toilet training ent training, whereas studies with higher cu-
interventions may require an approximate mulative intensity rarely included parent
treatment duration of 60 sessions over 77 days training. Although these differences do not
to produce the expected effect. Cumulative indicate parent training is a critical compo-
intensity was calculable as total session hours nent of RTT, parent training may contribute
in most studies. Interventionists can expect to to quicker toileting outcomes and skill
spend approximately 373 hours toilet train- generalization.
ing. In typical school settings, this means Replacing diapers with underwear was com-
teachers who devote 7 hours a day to toilet monly reported, and underwear use has
training would spend 45 to 46 school days unique empirical support beyond other com-
applying intervention procedures. Learners mon toileting procedures. Specifically, several
will need approximately 245 trips to the bath- component analyses indicate replacing dia-
room throughout the course of the interven- pers with underwear expedites toilet training
tion. Individuals in need of toilet training likely even when other variables are held constant
require supervision in the bathroom, and prac- (Greer et al., 2016; Simon & Thompson,
titioners implementing toilet training may 2006; Tarbox et al., 2004). Undergarment
spend 31 to 32 hours in the bathroom, or type may contribute to toilet training by
around 8% of their intervention time in the increasing salience of uncomfortable sensa-
bathroom. Professionals who are aware of these tions associated with being wet/soiled (i.e.,
practical issues may better prepare to allocate altering the aversive qualities of accidents).
Although other toileting procedures are ulti-
resources to toileting training, but also may
mately faded (e.g., scheduled toileting,
avoid premature termination of an apparently
increased fluids, reinforcement for voiding),
ineffective toileting intervention.
underwear persists when the intervention is
completely withdrawn. Unless an individual
Implications for Practice has a medical condition affecting bowel or
bladder control, the overwhelming evidence
Our findings suggest initial toileting sched- suggests professionals should require under-
ules that optimize opportunities to void in the wear during toilet training.
toilet and contact reinforcement affect overall Behavior analysts are required to use the
intervention duration. Thus, practitioners least intrusive protocols for intervening, with
should implement toileting at an initial inten- aversive procedures being applied only after
sity which maximizes opportunities to contact reinforcement-based tactics have been ex-
reinforcement. An initial schedule with fre- hausted with unsatisfactory results (BACB,
quent, brief trips to the toilet (e.g., 5 minutes 2014). However, some punishing consequen-
on toilet, 10 minutes off) may benefit individ- ces likely play an important role in toileting
uals in the initial stages of training, particu- acquisition, and reinforcement for appropri-
larly if the learner voids immediately upon ate eliminations alone may not effectively
sitting on the toilet. Conversely, a less dense reduce accidents. Importantly, there are natu-
toileting schedule with longer scheduled sits ral social and physical consequences for acci-
(e.g., 20 minutes on toilet, 30 minutes off) dents that likely function as punishers. For
may better serve individuals with a delayed example, authors of several studies used resti-
voiding response. If neither are feasible, tution in relatively benign ways (e.g., chang-
teachers might use brief periods of intensive ing clothing) that likely function as punishing
toileting with sittings timed with the child’s consequences to reduce future accidents.
elimination patterns (Cocchiola et al., 2012). Requiring a child to assist in or independently
Ideally, toileting interventions should be change their soiled clothing is a typical and
implemented across environments and occur socially valid consequence that may function

as a punishing contingency to decrease future there exists sufficient evidence to warrant

accidents for some individuals. Also, overcor- application of RTT procedures to improve
rection procedures that require repetition of continence in individuals with IDD.
a prosocial behavior (e.g., repeating the bath-
room routine, cleaning the bathroom rather References
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A Systematic Review of Rapid Toilet Training Intervention Intensity for

Article in Education and Training in Autism and Developmental Disabilitites · June 2021

Jenee Vickers Johnson Jason C. Travers

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Heather J. Forbes Kathleen Zimmerman

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Core concepts in special education research View project

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A Systematic Review of Rapid Toilet Training Intervention

Heather J. Forbes and Kathleen Zimmerman

Traditional parent-implemented interventions reinforcement for successful elimination, pun-

Intervention Intensity in Toilet Training / 1

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2 / Education and Training in Autism and Developmental Disabilities-December 2021

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Intervention Intensity in Toilet Training / 3

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4 / Education and Training in Autism and Developmental Disabilities-December 2021

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Intervention Intensity in Toilet Training / 5

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6 / Education and Training in Autism and Developmental Disabilities-December 2021

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Participant Characteristics Number of Participants (N = 219) % of Participants

indicating an alternative communication Session duration averaged 7.3 hr and was

Intervention Intensity in Toilet Training / 7

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Dose Cumulative Intensity

Ando (1977) 120.0 7.0 183.6

Dixon & Smith (1975)

Hagopian et al. (1993) 30.0 7.5 7.0 110.0

8 / Education and Training in Autism and Developmental Disabilities-December 2021

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McLay et al. (2015) 6.0 10.0 88.0 82.8 497.0

Smith (1979) Group RTT 9.0 45.0 7.0 87.5 787.5

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Smith et al. (2000) 5.0 5.8 51.0 293.3 255.0

Intervention Intensity in Toilet Training /

one study (Taylor et al., 1994) had a daily fre-

Total Time on ber of treatment sessions was reported in 85%

in 35 studies. Total session hours ranged from

17.5 hr (Trott, 1977) to 1,848 hr (Luiselli,

hr (SD = 405.2). Total time on toilet and total

number of trips to toilet were calculable for

27 and 30 studies, respectively. On average,

participants spent 30.5 hours on the toilet

and went to the bathroom 245.8 times (SD =

tion. Percent of total intervention time on the

90% (Trott, 1977). On average, 16% of total

intervention time was spent on the toilet and

an hour throughout the course of the inter-

vention (see Table 2).

Figure 2 displays per study data for proce- F2

dural frequency. Replacing diapers with

underwear was the most prevalent procedure

The second most common proce-

dure was punishment and was reported in

62% of studies (n = 34). Procedures intended

to function as punishment included verbal

reprimands (n = 16), restitution (n = 13), neg-

(n = 10), restitutional overcorrection (n = 7),