Toilet Training Non-ambulatory Students Cindy Myers Comprehensive Behavior Specialist

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 child’s 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, truck 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