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Toilet Training Non-ambulatory Students. Cindy Myers Comprehensive Behavior Specialist [email protected] 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.

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Toilet training non ambulatory students l.jpg

Toilet Training Non-ambulatory Students

Cindy Myers

Comprehensive Behavior Specialist

[email protected]


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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


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Cautions & Exclusions

  • Students on Neurogenic bowel & bladder programs

  • Check with doctor before considering students with spinal cord injuries

    • Paraplegia, quadriplegia, spina bifida


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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


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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!


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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


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General Philosophy cont.

  • Uses consistent “signals” or communication mands to develop relationships between action & consequences

  • Uses routines and environmental SD to elicit appropriate toileting response


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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 SD for steps in the toileting chain.


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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


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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


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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


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  • Vocabulary List for Toileting

  • Urination: __________________________________

  • Defecation: _________________________________

  • Toilet: _____________________________________

  • Body Parts: _________________________________

  • Other: _____________________________________

  • Communication Mands/Cues

  • Lifting: _____________________________________

  • Up/down: ___________________________________

  • Toilet: ______________________________________

    • Other: ______________________________________

    • Other: ______________________________________

    • Other: ______________________________________


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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 signature date

_______________________________________ _________________

teacher signature date

_______________________________________ __________________

principal/administrator signature date

________________________________________ __________________

physician signature (if applicable) date


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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.


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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)


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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


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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


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