Clinical Practice in Pediatric Psychology © 2016 American Psychological Association

2016, Vol. 4, No. 1, 1–10 2169-4826/16/$12.00 http://dx.doi.org/10.1037/cpp0000131

Co-Occurring Autism and Intellectual Disability:

A Treatment for Encopresis Using a Behavioral Intervention
Plus Laxative Across Settings

Michael I. Axelrod Mary Tornehl

University of Wisconsin-Eau Claire Eau Claire, Wisconsin

Angela Fontanini-Axelrod
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Eau Claire Area School District, Eau Claire, Wisconsin

This document is copyrighted by the American Psychological Association or one of its allied publishers.

The current study investigated the effects of a behavioral intervention plus laxative
therapy for 2 adolescents with Autism Spectrum Disorder (ASD), Intellectual Disability
(ID), and chronic histories of constipation and frequent fecal accidents. The treatment
consisted of regularly scheduled toilet sits, an incentive system for bowel movements
in the toilet, and a cleanup procedure for fecal accidents, plus a laxative. The behavioral
intervention was implemented at home by each participant’s parents and at school by
educational staff. A multiple baseline design across participants was used to evaluate
the effects of the treatment on participants’ frequency of soiling, frequency of success-
ful bowel movements in the toilet, and successful self-initiated bowel movement in the
toilet. The treatment resulted in improvements in both participants’ fecal incontinence.
Specifically, both participants achieved full fecal continence after 9 and 10 weeks
respectively. Moreover, treatment gains were maintained following the withdrawal of
the behavioral intervention and laxative. Results indicate that a behavioral intervention
implemented across settings and laxative therapy can have a profound effect on the
encopresis of adolescents with co-occurring ASD and ID.

Keywords: across settings, autism, behavioral intervention, encopresis, intellectual

disability

Encopresis affects between 1.5 and 7.5% of all
children and adolescents (Axelrod et al., 2015).
Encopresis and constipation make up between 3%
and 5% of primary care referrals, 3% to 6% of
pediatric psychiatry referrals, and 30% of pediat-
ric gastroenterology referrals (Culbert & Banez,
2007; Hardy, 2009; Loening-Baucke, 1993).
However, there is some variability in the reported
prevalence of encopresis and Autism Spectrum
Disorder (ASD). Joshi and colleagues (2010)
found that 22% of children with ASD also had
This article was published Online First February 11, 2016.
Michael I. Axelrod, Human Development Center, University
of Wisconsin-Eau Claire; Mary Tornehl, Eau Claire, Wisconsin;
Angela Fontanini-Axelrod, School Psychology and Social Work,
Eau Claire Area School District, Eau Claire, Wisconsin.
Correspondence concerning this article should be addressed
to Michael I. Axelrod, Human Development Center, Univer-
sity of Wisconsin-Eau Claire, 105 Garfield Avenue, HSS 160,
Eau Claire, WI 54702-4004. E-mail: axelromi@uwec.edu
1
encopresis when sampling a psychiatrically re-
ferred group from the United States. However,
Mattila and colleagues (2010), using a community
sample from Finland, and Simonoff and col-
leagues (2008), using a community sample from
the United Kingdom, found that approximately
7% of children with ASD also had encopresis.
Finally, Radford and Anderson (2003) reported in
their clinical experience that between 10 and 20%
of preschool children with Autism had concomi-
tant encopresis. Unlike encopresis and ASD, re-
search on the prevalence of encopresis and Intel-
lectual Disability (ID) is sparse (Grey & McClean,
2007). von Wendt, Similä, Niskanen, and Järvelin
(1990), using a small sample of children with ID
from Finland, reported that approximately 30%
had encopresis at age 7. Other research has found
that low IQ (e.g., below 70) might be associated
with co-occurring encopresis underscoring the im-
portance of identifying effective treatment options
(see Matson & LoVullo, 2009).
 2 AXELROD, TORNEHL, AND FONTANINI-AXELROD
Interventions consisting of medical and be-
havioral components are most effective for the
treatment of retentive encopresis (RE). In their
exhaustive review of the RE treatment litera-
ture, McGrath, Mellon, and Murphy (2000),
using Chambless criteria standards, concluded
that a treatment combination of behavioral and
medical intervention (e.g., scheduled toilet sits,
rewards for successful bowel movements in the
toilet, initial disimpaction of the colon, laxative)
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was probably efficacious (i.e., a treatment dem-
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onstrating efficacy through having two studies
show significant differences between the treat-
ment and a waitlist control group; Chambless et
al., 1997). According to McGrath et al. (2000),
comprehensive medical interventions that failed
to include behavioral components did not meet
Chambless criteria for an efficacy category (i.e.,
well-established, probably efficacious, promis-
ing). More recently, Brazzelli, Griffiths, Cody,
and Tappin (2011) concluded in their review of
the literature that behavioral interventions plus
laxative therapy are more effective at improving
fecal incontinence associated with RE than lax-
ative therapy alone. As an example, Borowitz,
Cox, Sutphen, and Kovatchev (2002) randomly
assigned children to one of three groups: inten-
sive medical intervention, biofeedback, or en-
hanced toilet training involving scheduled toilet
sits and individualized incentive programs plus
medical intervention. All three groups signifi-
cantly decreased fecal accidents, and increased
bowel movements in the toilet and self-initiated
toileting over the course of 3, 6, and 12 months
of treatment. However, improvement rates were
higher for the enhanced toilet training plus med-
ical intervention group. Furthermore, children
in the enhanced toilet training plus medical in-
tervention group obtained these results in less
time using fewer laxatives. This last point is
perhaps most important, as children presenting
with chronic constipation and RE are often on
laxatives for months to years especially when
the laxative is used for maintenance (Pashankar,
2005).
Research on treating encopresis for children
with ID is also positive. In their review of the
literature, Lancioni, O’Reilly, and Basili (2001)
found that treatments incorporating scheduled
toilet sits, rewards for bowel movements in the
toilet, and consequences for fecal accidents
(e.g., clean up, delayed time-out) coupled, in
most instances, with medical intervention, were
highly effective but cautioned against general-
izing the results. Problems such as the use of
AB designs (i.e., baseline—treatment) and
treatment implementation in a single setting
(e.g., home, residential facility) plague the lit-
erature. Furthermore, the treatment length of the
reviewed studies tended to be exceptionally
long (e.g., 128 weeks).
Unfortunately, controlled research investigat-
ing interventions for children with ASD who
have RE is nonexistent. Neither randomized
controlled trials nor examples of single case
experimental design studies are found in the
literature. Matson (1977), in a case report, de-
scribed using a simple correction procedure in-
volving cleaning up fecal accidents to decrease
the frequency of fecal accidents of an adoles-
cent male with ASD. In another case report,
Dalrymple and Angrist (1988) employed a com-
prehensive toilet training intervention (e.g.,
scheduled toilet sits, shaping appropriate toilet-
ing behavior with reinforcement, positive prac-
tice, and an incentive system for the absence of
fecal accidents) plus mineral oil to increase
bowel movements in the toilet and decrease
fecal accidents of an adolescent female with
ASD, ID, and RE. There is an obvious need to
evaluate RE treatment protocols for individuals
with ASD.
Fortunately, research on toileting training in-
dividuals with ASD or ID, coupled with evi-
dence for the effectiveness of behavioral plus
medical interventions for RE, provides some
guidance when considering treatment options.
Procedures relying on positive reinforcement
(e.g., incentives for bowel movements in the
toilet) and prompting are common to toilet
training protocols for children with ASD or ID
(Kroeger & Sorensen-Burnworth, 2009; Matson
& LoVullo, 2009). For example, Azrin and
Foxx (1971) and, more recently, Cicero and
Pfadt (2002) showed that rewarding successful
elimination during the toilet training process
could lead to rapid success for individuals with
ASD or ID. These findings should not come as
a surprise, as interventions that rely on princi-
ples of applied behavior analysis (e.g., positive
reinforcement) have been successfully used to
improve the general behavior and enhance skills
of children with ASD or ID, as well as nonde-
velopmentally disabled children (see Alberto &
Troutman, 2013). Consequently, behavioral ap-
proaches applied to the treatment of RE for
 AUTISM, INTELLECTUAL DISABILITY, AND ENCOPRESIS
children with ASD or ID has both empirical and
theoretical support.
The current study was an attempt to extend
the literature on the treatment of RE to individ-
uals with co-occurring ASD and ID. Specifi-
cally, this study investigated the effects of a
standard RE treatment protocol for two adoles-
cents with co-occurring ASD and ID, and his-
tories of chronic constipation and frequent fecal
accidents. Treatment consisted of a behavioral
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
toilet training protocol involving regularly
This document is copyrighted by the American Psychological Association or one of its allied publishers.
scheduled toilet sits, an incentive system for
bowel movements in the toilet, a cleanup pro-
cedure for fecal accidents, and a commonly
used laxative. The study attempted to establish
empirical evidence for the treatment of RE for
children with co-occurring ASD and ID. Unfor-
tunately, investigations of interventions for chil-
dren with co-occurring ASD and ID who have
RE are nonexistent. The population of children
with ASD or ID clearly differs from their peers
without ASD regarding toileting and toilet
training. As Radford and Anderson (2003) point
out, children with ASD are more likely to ex-
perience problems associated with recognizing
the physiological signs related to feeling the
urge to defecate, the motor and communication
skills necessary for successful toilet training,
and social awareness (e.g., understanding when
and where it is appropriate to have a bowel
movement). Compounding the problem, enco-
presis can be a very difficult problem to treat.
For example, Arndorfer, Allen, and Aljazireh
(1999) found that pediatricians reported enco-
presis to be one of the most challenging referral
concerns seen in practice behind only disruptive
behavior and attention-deficit/hyperactivity dis-
order. Taken altogether, identifying effective
treatments for children with co-occurring ASD
and ID who are experiencing RE is important.
The study also addressed the implementation
of the toilet training components of the treat-
ment across settings and outcome data (i.e.,
frequency of soiling accidents, frequency of
successful bowel movements in the toilet, per-
centage of successful self-initiated bowel move-
ments in the toilet) were collected both at home
and school. In our review of the literature, few
studies reported implementing the treatment
and data collection procedures across settings.
For example, Boles, Roberts, and Vernberg
(2008) successfully treated the nonretentive en-
copresis of a 10-year-old boy by rewarding
3
scheduled toilet sits. The intervention and data
collection were implemented at home by the
boy’s grandmother and by staff at school. How-
ever, most studies either indicated the proce-
dures occurred at home or failed to report a
specific location for the intervention and data
collection. Given RE is likely to present in both
settings (see Christopherson & Friman, 2004),
research investigating treatment procedures
across those settings is important.
Method
Participants and Setting
Participants included two adolescent boys re-
ferred to an outpatient psychology clinic be-
cause of histories of encopresis with constipa-
tion and incontinence overflow. A primary care
physician referred both participants following a
physical examination that ruled out any under-
lying diseases or medical conditions that might
have been responsible for the fecal accidents
(e.g., spinal cord abnormalities, motility disor-
ders such as Hirsprung’s Disease). Interviews
and physical examinations indicated positive
histories of chronic constipation. Both partici-
pants had been previously treated with laxa-
tives, enemas, and a toilet training protocol that
included self-initiated toileting attempts and re-
wards for successful bowel movements in the
toilet, but these treatments failed to produce
positive effects. Consequently, the referring
physician recommended the families seek ser-
vices at the psychology clinic.
Dale was 13 years old at the time of the
study. His biological parents reported Dale had
never successfully had a bowel movement in the
toilet. According to his father, Dale had be-
tween one and three fecal accidents at home or
school per day. Rodney was 14 years old at the
time of the study. His biological parents re-
ported that Rodney was successfully toilet
trained at approximately 42 months of age but
currently experiencing frequent (i.e., 1–3 per
day) fecal accidents primarily at school and at
home on weekends. Dale and Rodney qualified
for a diagnosis of Autism based on state De-
partment of Education eligibility criteria. Ac-
cording to school records, Dale and Rodney’s
cognitive functioning, measured by a standard-
ized intelligence test, were significantly below
average (i.e., IQ below 65) when compared with
 4 AXELROD, TORNEHL, AND FONTANINI-AXELROD
same-aged peers and both participants met eli-
gibility criteria for ID.
Parent interviews and review of records indi-
cated that neither participant experienced night-
time fecal, or diurinal or nocturnal urinary in-
continence. Parent interviews suggested both
participants were able to comprehend and fol-
low multistep instructions related to toileting
(e.g., “go to the bathroom, close the door, try to
poop, wash your hands when done”). Further-
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more, both participants could manage toileting
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tasks (e.g., buttoning and unbuttoning pants,
wiping self, adequately washing hands) inde-
pendently. Finally, both participants were Cau-
casian and spoke standard English as their pri-
mary language.
The intervention took place at the partici-
pants’ home and school. Participants had a pri-
mary bathroom in their respective homes used
for most toileting events. Bathrooms were ar-
ranged to include resources should a fecal acci-
dent occur (e.g., washcloth, soap, plastic bag for
soiled clothing) and moist flushable wipes. Dale
and Rodney attended two different middle
schools in a medium-sized metropolitan area in
the upper Midwest. They were each placed in a
special education class for students with disabil-
ities and spent approximately 75% of their day
in the same classroom and with the same teach-
er. A certified special education teacher and
para-educator staffed each classroom. There
was a private bathroom within 15 feet of each
classroom. The private bathrooms each had a
standard toilet and sink. Because of Dale’s short
stature, small stepstools were placed in his
home and school bathrooms.
Measures
The dependent variables for analysis were
frequency of soiling accidents, frequency of
successful bowel movements in the toilet, and
percentage of successful self-initiated bowel
movements in the toilet. A soiling accident was
recorded when fecal matter was noted in the
child’s underwear or pants, or anywhere other
than the toilet (e.g., bed, floor). A successful
bowel movement in the toilet was recorded
when fecal matter was eliminated into the toilet.
A successful self-initiated bowel movement in
the toilet was recorded when the participant
eliminated fecal matter into the toilet without an
adult prompt or not during a scheduled toilet sit.
The percentage of successful self-initiated
bowel movements in the toilet was calculated
by dividing the number of successful self-
initiated bowel movements in the toilet by the
total number of successful bowel movements in
the toilet and multiplying by 100. Parents,
teachers, and para-educators served as data col-
lectors. Each received a 15-min training on data
collection procedures by the first author includ-
ing definitions and use of data collection forms.
Vignettes of various scenarios were used to
ensure data collectors understood the proce-
dures and used the data collection forms cor-
rectly. After reviewing the vignettes, data col-
lectors were required to obtain a 100% correct
on the data collection forms before the interven-
tion could begin.
Procedures
Participants were referred to the outpatient
psychology clinic following a consultation with
their primary care physician. The first author
began by obtaining signed informed consent
from both participants’ parents and signed per-
mission to consult with both participants’
schools. The first author then conducted a clin-
ical interview with parents that included general
background information (e.g., primary referral
concerns, previous attempts at intervention),
complete histories (e.g., medical, developmen-
tal, educational, psychiatric), and current toilet-
ing routines. Parents were told of the interven-
tion protocol and then provided the option to
forgo the collection of baseline data to imme-
diately begin treatment. Both participants’ par-
ents agreed to collect baseline data. Participants
were brought to the clinic for the second ap-
pointment. The first author described the inter-
vention protocol to participants and discussed
data collection procedures with parents. In be-
tween participants’ first and second clinic visits,
the first author met with relevant school staff
(e.g., classroom teachers, para-educators,
school administrators) to discuss the interven-
tion protocol and data collection procedures.
Parents and school staff were provided with an
intervention protocol checklist that described, in
detail, all elements of the intervention’s proce-
dures. The first author assessed understanding
by asking questions about the intervention pro-
tocol.
 AUTISM, INTELLECTUAL DISABILITY, AND ENCOPRESIS
Baseline. The referring primary care physi-
cian recommended both participants take mag-
nesium hydroxide (i.e., Milk of Magnesia) daily
at bedtime in an attempt to disimpact the colon
and establish regularity of bowel movements.
Parents and school staff were instructed to
change nothing with regard to the treatment of
both participants’ RE. Data collection proce-
dures (i.e., weekly charts indicating fecal acci-
dents, successful bowel movements in the toi-
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let) were introduced during baseline. Parents
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and school staff were directed to conduct pants-
checks at predetermined 30-min intervals across
the day to assess for fecal accidents.
Toilet training plus laxative. The toilet
training protocol used in this study consisted of
four components: regularly scheduled toilet sits,
a reward system for successful bowel move-
ments in the toilet, a cleanup procedure for fecal
accidents, and a laxative. Brief toilet sits of 2
minutes were scheduled for every 15 minutes
the participant was awake beginning approxi-
mately 10 minutes after waking in the morning
and ending approximately 10 minutes before
turning the bedroom light off for bedtime. Par-
ents and school staff were instructed to indicate
to participants that it was time to use the bath-
room, guide them to the bathroom door at home
or school, and provide brief praise statements
for compliance (e.g., “thank you for listening,”
“good job going to the bathroom”). Parents set
a timer for 2 minutes, and knocked on the
bathroom and stated that the toilet sit ended
when the timer sounded. School staff also set a
timer for 2 minutes and knocked on the bath-
room door when the timer sounded. Participants
were instructed to sit on the toilet until either the
timer sounded at home or the teacher indicated
that the toilet sit was over when at school, pull
up their underwear and pants, state to their
parent or teacher whether they had successfully
had a bowel movement in the toilet, wash
hands, and open the bathroom door at which
time the parent or teacher would confirm a
bowel movement occurred in the toilet and re-
cord the stool’s size and consistency.
For the condition’s reward component, the
first author, in collaboration with parents and
school staff, developed individualized reward
systems for successful bowel movements in the
toilet. Specifically, Dale and Rodney earned
affordable “prizes” for every successful bowel
movement in the toilet. Participants, parents,
5
and school staff were asked to identify small
toys (e.g., metal cars, action figures) and activ-
ities (e.g., 10 minutes playing games on a tablet,
10 minutes shooting baskets in the gym) that
participants found enjoyable. Each item or ac-
tivity was given a corresponding number. Num-
bers were written on small slips of paper and
placed in a jar. Participants picked a slip of
paper out of the jar immediately following a
successful bowel movement in the toilet. If a
fecal accident occurred at home, the participant
was required to go to the bathroom, take off the
soiled clothing and clean soiled skin with dis-
posable wipe, put clean clothing on, wash the
soiled clothing by hand in the sink for 5 min-
utes, and ask a parent to help finish cleaning the
clothes in the washer and drier. If a fecal acci-
dent occurred at school, the participant was
required to get a change of clothing, go to the
bathroom, take off the soiled clothing and clean
soiled skin with disposable wipe, put clean
clothing on, and bring the soiled clothing home
in a plastic bag to wash in the sink for 5 minutes
and then put in the washer and report to a
parent. Parents and school staff were instructed
to repeat instructions to participants should be-
havior problems (e.g., noncompliance) occur
during toilet sits and cleanup procedures, and
then use disciplinary procedures consistent with
each setting (e.g., time-out from reinforcement,
loss of privileges) if problems persisted. Parents
and school staff reported participants were gen-
erally compliant with all requests and disciplin-
ary procedures were not needed during the
study.
Following consultation with the participants’
primary care physician, a recommendation was
made for participants to take 17 g of polyethyl-
ene glycol 3350 (i.e., MiraLAX) every morning
as maintenance therapy and discontinued use of
the magnesium hydroxide. Parents were in-
structed to mix the polyethylene glycol 3350
powder with a large glassful of water. Parents
and participants were instructed to be sure the
polyethylene glycol 3350 was taken following
breakfast. Parents and school staff continued
conducting pants-checks at predetermined 30-
min intervals across the day.
Follow-up. All components of the inter-
vention including daily doses of polyethylene
glycol and scheduled toilet sits were removed
following the last day of the treatment condi-
tion. Parents and school staff were directed to
 6 AXELROD, TORNEHL, AND FONTANINI-AXELROD
continue collecting data including conducting
pant-checks at predetermined 30-min intervals
across the day.
Experimental Design
A multiple baseline design across participants
was used to assess the effects of the treatment on
participants’ frequency of fecal accidents, fre-
quency of successful bowel movements in the
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toilet, and percentage of successful self-initiated
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bowel movements in the toilet. Following base-
line, the toilet training plus laxative intervention
was implemented with each participant. The
intervention was removed when a participant
had only one fecal accident across two weeks.
Follow-up data were collected two (i.e., Rod-
ney) to three (i.e., Dale) weeks after the inter-
vention was removed and then at 20, 24, and 30
weeks from the start of baseline. Results were
analyzed through visual and descriptive meth-
ods.
Interobserver Agreement and
Treatment Integrity
Reliability of the dependent variables was
assessed by having each participants’ mother
and father or classroom teacher and para-
educator separately record successful bowel
movements in the toilet, whether the bowel
movement occurred following a scheduled or
unscheduled (i.e., self-initiated) visit to the
bathroom, and soiling accidents. Interobserver
agreement was calculated by dividing the num-
ber of agreements (bowel movements in the
toilet and fecal accidents) by the number of
agreements plus the number of disagreements
multiplied by 100%. Because both parents and
school staff members were not always available
to conduct a reliability check, interobserver
agreement was evaluated for 52% of recorded
bowel movements in the toilet and 58.1% of
fecal accidents. Percentage of agreement was
100% for both bowel movements in the toilet
and fecal accidents.
Treatment integrity (i.e., the degree to which
the intervention was implemented as pre-
scribed) was assessed several ways. First, par-
ents and school staff separately completed treat-
ment protocol checklists provided by the first
author each day. Treatment protocol checklists
included intervention steps involving scheduled
toilet sits, immediate delivery of rewards, and
appropriate implementation of the cleanup proce-
dures. In addition, parental checklists for the home
included when and how much of the laxative was
taken. Treatment integrity for the protocols was
calculated by dividing the number of correctly
implemented intervention steps by the total num-
ber of intervention steps and multiplying by
100%. The average treatment integrity value at
home was 94%. The average treatment integrity
value at school was 87%. Second, parents and
school staff kept calendar records that recorded
the date and time of each scheduled and un-
scheduled toilet sit. Calendar records were com-
pared with treatment protocol checklists to de-
termine the degree to which the two integrity
measures matched. Agreement was calculated
by dividing the total number of agreements plus
disagreements by the total number of agree-
ments and multiplying by 100%. The average
agreement at home and school was 100%. Fi-
nally, the first author observed 1-hr time blocks
across 10 randomly selected intervention days
at school and used the treatment protocol check-
list to record treatment integrity. Across the 10
hours of observation, 100% of the interven-
tion’s steps were implemented as prescribed.
Results
Figure 1 displays the frequency of bowel
movements in the toilet and the number of fecal
accidents per week for Dale and Rodney. Con-
sistent with history, both participants failed to
have a bowel movement in the toilet during the
baseline phase while having, on average, at least
two fecal accidents per day. During the inter-
vention phase, the number of successful bowel
movements in the toilet increased and the
frequency of fecal accidents decreased for
both participants. Specifically, Dale achieved
zero fecal accidents by the intervention’s 9th
week and Rodney achieved zero fecal acci-
dents by the intervention’s 10th week. Both
participants maintained improvements imme-
diately following the withdrawal of the inter-
vention and during long-term follow-up at
weeks 20, 24, and 30.
Dale’s mean number of fecal accidents per
week was 15.67 during the baseline phase. He
failed to have a successful bowel movement in
the toilet during baseline. His mean number of
fecal accidents per week decreased to 8.3 and
 AUTISM, INTELLECTUAL DISABILITY, AND ENCOPRESIS 7
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Figure 1. Frequency of fecal accidents and successful bowel movements in the toilet for
each participant across conditions.

his mean number of successful bowel move-
ments in the toilet per week increased to 3.2
during the intervention phase suggesting the
toileting training plus a daily laxative was ef-
fective at improving Dale’s fecal incontinence.
During the follow-up phase, Dale’s mean num-
ber of fecal accidents decreased to fewer than
one per week while the mean number of suc-
cessful bowel movements in the toilet increased
to 6.17 per week, suggesting he maintained
improvements after the removal of the interven-
tion.
Rodney’s mean number of fecal accidents per
week was 19.20 during the baseline phase. He
failed to have a successful bowel movement in
the toilet during baseline. His mean number of
fecal accidents decreased to 7.1 per week and
mean number of successful bowel movements
in the toilet increased to 4.9 per week during the
intervention phase suggesting the toilet training
plus laxative had a positive effect on Rodney’s
fecal incontinence. During the follow-up phase,
Rodney’s mean number of fecal accidents was
less than one per week and his mean number of
successful bowel movements in the toilet in-
creased to 6.4 suggesting he maintained im-
provements following the removal of the inter-
vention.
 8 AXELROD, TORNEHL, AND FONTANINI-AXELROD
Regarding self-initiation of bowel move-
ments in the toilet, both Dale and Rodney failed
to successfully self-initiate a bowel movement
in the toilet during baseline. During the inter-
vention phase, the percentage of successful self-
initiated bowel movements in the toilet per
week increased for both participants. The mean
for Dale was 34.38% (range: 0% to 62.5%) and
for Rodney was 28.57% (range: 0% to 66.7%),
with an increasing trend for both participants.
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Both participants successfully self-initiated all
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bowel movements in the toilet during the fol-
low-up phase when the scheduled toilet sits
were discontinued.
Discussion
The study’s primary purpose was to investi-
gate the effects of a standard RE protocol in-
volving a behavioral intervention plus laxative
therapy for two adolescents with co-occurring
ASD and ID, and histories of chronic constipa-
tion and frequent fecal accidents. Both partici-
pants exhibited a decrease in the frequency of
fecal accidents while, at the same time, in-
creased the frequency of bowel movements in
the toilet during intervention and follow-up
(i.e., no intervention) conditions. Rodney and
Dale each achieved full fecal continence after
nine and 10 weeks of intervention respectively.
Dale had only one fecal accident and Rodney
had three fecal accidents during the five weeks
of follow-up. Both participants had zero fecal
accidents 25 (for Rodney) and 27 (for Dale)
weeks after the intervention was initiated.
The results, on the surface, are not surprising.
Previous research has found that a combination
of behavioral and medical intervention is most
effective at reducing the frequency of fecal ac-
cidents while increasing the frequency of bowel
movements in the toilet (see Brazzelli et al.,
2011; McGrath et al., 2000). Moreover, evi-
dence-based toilet training approaches for chil-
dren with ASD or ID rely on behavioral inter-
ventions (see Azrin & Foxx, 1971; Cicero &
Pfadt, 2002). However, the current study ex-
tends the research on behavioral intervention
plus laxative therapy by demonstrating the
treatment’s effectiveness with two adolescents
with co-occurring ASD and ID, and represents
the first demonstration that an already estab-
lished treatment for RE can be applied to ado-
lescents with co-occurring ASD and ID. Fur-
thermore, the results were obtained with a
relatively short laxative duration. The current
study’s findings confirm previous research sug-
gesting behavioral interventions (e.g., toilet
training) have an effect on the duration children
are on laxatives because of their chronic consti-
pation (see Borowitz et al., 2002). In the current
study, participants were able to discontinue lax-
ative use after 10 weeks.
The study is noteworthy for two additional rea-
sons. First, both participants also exhibited in-
creased frequency of successful self-initiated
bowel movements in the toilet during both inter-
vention and follow-up conditions. That is, both
participants had more successful bowel move-
ments in the toilet following self-initiated versus
adult-prompted toilet sits during intervention and
follow-up than when compared with baseline.
Over the course of the intervention, both partici-
pants gradually increased the percentage of self-
initiated successful bowel movements in the toilet
per week from zero to more than 60%, suggesting
a gradual increase in independent toileting behav-
ior. Furthermore, both participants self-initiated all
successful bowel movements in the toilet during
the follow up condition, suggesting full skill ac-
quisition. These results are rather remarkable
given that Dale had no and Rodney had little
previous success self-initiating bowel movements
in the toilet. The behavioral intervention targeted
self-initiated toileting and independence through
prompting and the incentives aided in reinforcing
successful toileting. These results are important
given that a goal of many individuals with ASD or
ID is independence in daily living skills, including
toileting.
Second, the study’s behavior intervention and
data collection procedures were implemented
across settings. Specifically, the scheduled toilet
sits, incentive system for successful bowel move-
ments in the toilet, cleanup procedures, and all
data collection occurred at both home and school.
Although it is unclear whether the intervention
implementation across settings enhanced partici-
pants’ response to treatment, addressing the prob-
lem both at home and school seems logical. Re-
search investigating interventions for encopresis
implemented across settings is sparse, as much of
the published research on encopresis treatment
targets the problems only in the home (e.g.,
Borowitz et al., 2002; Rockney, McQuade, Days,
Linn, & Alario, 1996), potentially ignoring an
important setting for treatment. According to
 AUTISM, INTELLECTUAL DISABILITY, AND ENCOPRESIS
Christopherson and Friman (2004), implementing
interventions for encopresis in school settings will
likely enhance the success of evidence-based
treatments.
Limitations and Direction for
Future Research
Despite the promising results, the study had
several limitations. First, external validity is
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
limited by the sample size, participant charac-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
teristics, and setting. Although this study adds
to the literature on RE treatment and individuals
with co-occurring ASD and ID, the small sam-
ple size makes it difficult to establish the effi-
cacy of the treatment procedures for this popu-
lation. Furthermore, study characteristics (e.g.,
participant age and level of intellectual ability)
limit the generalizability of the findings to ad-
olescents with co-occurring ASD and ID. Fu-
ture research should attempt to replicate this
study’s procedures to establish the effectiveness
of toilet training plus laxative therapy for chil-
dren with co-occurring ASD and ID, and histo-
ries of RE. Replication is important given the
paucity of research. Second, the treatment’s be-
havioral procedures were time intensive and
required a high level of commitment from par-
ents and school staff. The study failed to incor-
porate fading procedures that might have re-
duced the need for parent or school staff
involvement. Future research might consider
systematically fading the behavioral procedures
to make the treatment’s procedures less in-
volved. For example, the time between toilet
sits could be increased from 15 to 30 to 60 min
or the delivery of rewards could be moved from
a continuous to an intermittent schedule.
Third, interobserver agreement data were
limited to parent and school staff self-report.
Although percentage of agreement was calcu-
lated separately based on parent and school staff
self-report, the study failed to include additional
observations by independent observers to verify
these self-reports. Future research should use
observers other than those invested in the out-
comes to aid in establishing interobserver agree-
ment values. Fourth, there were no independent
treatment integrity checks conducted at home.
Although the current study relied on several
methods to assess treatment integrity within the
home, observational data were not collected.
Future research should consider using other
9
treatment integrity assessment methods when
investigating interventions that occur within
participants’ homes.
Finally, long-term follow-up data (e.g., at 1
year) were not collected. As a result, it is unknown
whether participants were able to remain continent
past four months and maintain colonic functioning
without either behavioral interventions or laxative
therapy. Including these data is important given
that many children with RE continue to have
problems with incontinence even after treatment
has been successful (see Rockney et al., 1996).
Future studies should collect follow-up data be-
yond 30 weeks to determine the long-term effec-
tiveness of the RE treatment.
Conclusion
Despite these limitations, empirical evidence
reported in this study suggests that a behavioral
intervention involving scheduled toilet sits, an
incentive system for successful bowel move-
ments in the toilet, and a cleanup procedure for
fecal accidents combined with laxative therapy
can have a profound impact on the incontinence
of adolescents with co-occurring ASD and ID
who also have RE. These findings are important
for researchers looking to establish the effec-
tiveness of RE treatment protocols with differ-
ent populations of children. For practitioners,
the results reported in the current study provide
guidance for those looking for an effective treat-
ment that can be implemented across settings.
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Received September 18, 2015
Revision received January 4, 2016
Accepted January 5, 2016 䡲