 Helping Children with Moderate-Profound Cognitive Disability Achieve Continence: Classroom Based Behavioral Protocol Developed by Cindy Myers Comprehensive Behavior Specialist

 Students with Cognitive Disability

Who can be toilet trained using this protocol?  Mild to profound cognitive disability  Ambulatory  Verbal or non-verbal  Physical and/or orthopedic disabilities including CP, TBI  Students with autism  Once toilet trained, but regressed

Exclusions & Cautions  Fears and phobias (treat fears first)  Children with medical conditions which proscribe excess fluids or toilet training  Children on neurogenic bowel and bladder programs  Children under the age of 4 years

Determining Readiness  Shows discomfort or recognition of wet/soiled diaper  ½ hour or more of dryness while in diaper  Age (over 4 ½ years old)  Shows interest in the toileting activities of others  Displays no fears of being in, on, or around the bathroom or toilet (if fears exist, deal with them first with behavioral desensitization program

Determining Readiness cont.  Physician ’ s exam to rule out medical/physical causes  Parental interest or request  Positioning, adaptive equipment addressed and in place before beginning program

Prioritizing in a Classroom  Students who show multiple signs of readiness  Student who stays dry for prolonged periods of time  Older students who show any signs of readiness  Students with good gross motor and adequate fine motor skills  Encouragement from home

General Philosophy  Increased fluid intake to maximize opportunities for practice  Pre-determined, time based toileting schedule  Use of positive reinforcement  No punishment component  Modified version of Foxx & Azrin ’ s toileting procedure  Training occurs in the classroom and is then later generalized to home  Minimizes stress to families and caregivers for training responsibilities

Getting Started  Review and understand each procedure in the training protocol  Train assistants and others who will be sharing toilet training duties  When ready, schedule a conference with parents or guardians

Parent Conference  Present your proposal to toilet train the student  Provide a copy of the protocol to parent to keep  Explain the procedures  Do you need to modify the student ’ s IEP to include a toileting goal?

Parent Conference cont.  Obtain written permission  Agree on a starting date and review date  Discuss and agree on terminology that will be used  Provide parents with a materials list of items you want them to supply

Materials List  6 pairs of conventional underwear. NO PULL UPS!!!!  3 changes of elastic waisted, loose, easy to manipulate pants  2 to 4 changes of socks  Washable, easy on/off footwear  Variety of preferred liquids (approximately 30 ounces)  Variety of preferred thirst promoting treats & snacks  Highly prized reinforcer to be used only for toilet training  Activities or items for entertainment while toilet sitting  Two washable chairs  Cleaning supplies  Disposable diaper wipes, disposable gloves  Plastic bags timer  Data sheets, clipboard, pencil

Data Sheet  Review protocol and data sheet  Mark data sheet as you go  Use data to make programming decisions  Latency between being placed on toilet & production  Ability to remain dry until taken to the toilet; how long?  Times that accidents/successes occur; patterns

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

Training (30 minute Intervals) 8:00-8:05 Encourage fluid intake 8:00 – 8:15 Sitting on the toilet  May be looking at books or singing songs  15 minutes 8:15 – 8:30 Dry pants checks  Sitting in chair face to face with trainer  May be looking at books or playing with toys  Check every 5 minutes until 8:30

If Success Occurs:  Praise and reward with highly prized reinforcer while still on the toilet  With least amount of prompting necessary, direct student to stand up from toilet, pull up pants, walk to chair  Begin dry pants checks at 5 minute intervals until the next ½ hour training interval begins  Start new training interval on the ½ hour

If an accident occurs:  Calm or neutral voice for informational feedback, “ Your pants are wet. You need to use the toilet. ”  Direct student to the toilet using the least amount of prompting necessary  Student pulls down & takes off wet clothing  Sits on the toilet for the remainder of the 30 minute interval (or 15 minutes, whichever is less)  Student picks up wet clothing & puts it in bag  Adult cleans area (with neutral affect!)  Begin new training interval on the ½ hour

Dry Pants Check  Student and trainer sit in chairs in bathroom or just outside bathroom door  Trainer sets timer for 5 minutes  When timer rings, trainer prompts student to lightly touch underwear in crotch area (optional) and verbally reinforces dry pants  Caution: touching crotch area may not be appropriate for many students!

Dry Pants Check cont.  Trainer gives desirable, thirst promoting treat along with verbal/social R+  Trainer sets timer for next 5 minute dry pants check

Expanding the Environment at School  After 2 days of no accident while training in the bathroom, bring the student back into the classroom and continue ½ hour training intervals  Accidents will happen. Be prepared to clean up  Student participates in pleasant table tasks within the classroom  Present easy, familiar work tasks  No new learning  Toilet training is still the main focus

Increase the Time Between Toileting Trips  When data are stabilized for dry pants at ½ hour intervals, discontinue offering fluids  Take student to the toilet at ½ hour intervals  Decrease dry pants checks  Decrease reinforcement as indicated by data  After >3 days of no accidents, begin increasing toileting schedule as appropriate  After 2 weeks of success at 1 ½ hour intervals, toilet on “ class schedule ”

Generalizing to Home  Meet with parents & review progress at school  Ask parents to toilet student at 1 ½ hour intervals at home  Use social praise or small edible treat  Continue to use diapers at night  Use diapers in social situations or outings

 Students with Multiple and Profound Disabilities

Who Can Be Trained?  Students with a variety of physical disabilities including cerebral palsy  Students who use wheelchairs for mobility  Students who are verbal or non-verbal

Cautions & Exclusions  Students on Neurogenic bowel & bladder programs  Check with doctor before considering students with spinal cord injuries  Paraplegia, quadriplegia, spina bifida

Determining Readiness Maintains dry diaper for ½ hour or more Age over 4 ½ Displays no fear of being in, on, or around the bathroom or toilet Communication system in place

Determining Readiness cont.  Consultation with physical therapist:  Positioning  Transition to the toilet  Weight bearing  Adaptive equipment issues  Issues specific to the student  Address issues before beginning!

General Philosophy  Track the childs natural schedule of elimination “ Predict ” the time episodes of elimination are likely and toilet the child around those times  Use of positive reinforcement  No punishment component  Training occurs in the classroom and is then generalized or trained in the home  Minimizes stress to families & caregivers for training responsibility

General Philosophy cont.  Uses consistent “ signals ” or communication mands to develop relationships between action & consequences  Uses routines and environmental S D to elicit appropriate toileting response

Making “ toileting ” a Routine  Task analyze the steps involved for that student to “ toilet ”  Develop a routine or procedures to be followed in a consistent manner each time the student is toileted  Standardize presentation of environmental or artificial stimuli that will be used as S D for steps in the toileting chain.

Communication System  Evaluate the communication needs of the student  Consult with a SLP if appropriate  Make a list of vocabulary, mands, or signals that are associated with all tasks around toileting  Moving from work area to toilet  Lifting, carrying  Undressing/dressing  Urination, defecation  “ finished ”  Hygiene

Getting Started  Review and understand each procedure in the training protocol  Schedule a meeting to present your plan to the student ’ s parents  Provide a copy of the protocol for parents to keep  Ask parents to contact the student ’ s physician regarding medical feasibility of toilet training  Modifying the student ’ s IEP to include a toilet training goal

Getting Started cont.  Obtain written permission  Agree on a starting and review date  Discuss terminology that will be used  Agree on signals & communication mands that will be used (if applicable)  Provide parents with a materials list of items you want them to supply

Vocabulary List for Toileting Urination: __________________________________ Defecation: _________________________________ Toilet: _____________________________________ Body Parts: _________________________________ Other: _____________________________________ Communication Mands/Cues Lifting: _____________________________________ Up/down: ___________________________________ Toilet: ______________________________________ Other: ______________________________________

Permission for Toilet Training I give permission for my child, ______________________ to participate in the schedule based toilet training procedures described in this document. I know of no medical or physical reason that would preclude toilet training for my child. I have discussed toilet training with my physician. _____________________________________________________ parent signaturedate ________________________________________________________ teacher signaturedate _________________________________________________________ principal/administrator signature date ________________________________________ __________________ physician signature (if applicable) date

Meet With Physical Therapist Discuss Equipment Needs  Consider  Potty chair, commode, adaptations to regular toilet  Seat/safety belts  Positioning  Head, trunck support  Wall bars  Transition to/from toilet  Issues specific to the student  Seizures, spasticity, etc.

Materials List (May change for individual student)  Diapers, wipes, disposable gloves  Highly desired reinforcer to be used only to R+ appropriate toileting  Items to entertain student as s/he sits on the toilet  Items recommended by the physical therapist unique to the student (neck brace, foam pads, etc.)  Data sheets, clipboard, pen or pencil  Timer

Data Sheets (There are two data sheets)  Baseline Data  Data Sheet 1  Collect baseline data and develop a high probability toileting schedule  Mark data at ½ hour intervals  Indicate if diaper is (D) Dry, (W) Wet, or (S) Soiled  Look for:  Trends or patterns of dry diapers  Trends or patterns in time or urination/defecation

Data Sheets (cont)  Program Data  Data Sheet 2  Determine schedule of high probability times that elimination is likely to occur  Indicate if diaper is (D) Dry, (W) Wet, or (S) Soiled when taken to the toilet  Indicate if student (U) Urinated, (BM) Bowel Movement, or (O) No Production while on the toilet  Review data to confirm accuracy of high probability schedule

The Training  Place student on toilet at times indicated by the high probability schedule  Use consistent routines and communication mands associated with toileting  Use techniques for transfer as identified by the physical therapist

If Success Occurs  Reinforce student with social praise paired with the highly desired reinforcer  Immediately remove student form toilet (using identified communication mands) and put in a clean diaper  Return student to regular programming  Mark data sheet  Place student on toilet at the next “ high probability ” time

If No Elimination Occurs:  Leave student on the toilet for 15 minutes  Remove student from the toilet after 15 minutes (using appropriate communication mands) and put in a clean diaper  Return student to regular class routine  Wait ½ hour and place student on the toilet again (using appropriate communication mands) for 15 minutes of toilet sitting  Repeat ½ hour intervals until elimination occurs (either on the toilet or in the diaper)  Return to the original “ high probability ” schedule

For Wet or Soiled Diapers:  Give informational feedback (use designated mands if appropriate) “ Your pants are wet, you need to use the toilet ”  Place student on the toilet for 15 minutes of toilet sitting  If elimination occurs on the toilet, treat as a toilet success and R+  Remove student from the toilet after elimination or 15 minutes, whichever happens first

Wetting & Soiling cont. Place in a clean diaper using communication mands and routines Return student to regular programming and mark data sheet Continue with original “ high probability ” toileting schedule

Generalizing to Home  When the student is successfully urinating on the toilet >75%, generalization to the home should occur  Meet with parents to discuss progress at school  Discuss what adaptations would be necessary for toileting to occur at home  Help parents locate resources, equipment for use at home

Generalizing to Home  Provide parents with a data sheet to track ½ hour intervals of wet/dry at home  Meet again and review baseline data and establish a “ high probability ” schedule  To assist parents in tracking wet/dry  May have to check at hourly intervals  May have to check at ½ hour intervals for a predetermined period of time (2 hours)

Toilet Training at Home  Parents toilet student based on the high probability schedule  Parents place student on toilet for 15 minutes of toilet sitting (using appropriate communication mands associated with the toileting routine)  Parents R+ successful elimination on the toilet with social R+ paired with highly desired R+  Place student in clean diaper and return to normal activities

Training at Home cont.  If accident occurs, give informational feedback. Clean student then place on toilet for 15 minutes of toilet sitting (using communication mands).  If elimination occurs while toilet sitting, treat as a success an R+  Place student in clean diaper, return to regular activity (using communication mands), and continue with high probability schedule  Use highly desired reinforcer for successful toileting only  Students should continue to wear diaper between toilet trips and at night until toilet use is well established