Helping Children with Moderate-Profound Cognitive Disability Achieve Continence: A Classroom Based B...
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Helping Children with Moderate-Profound Cognitive Disability Achieve Continence: A Classroom Based Behavioral Protocol. Cindy Myers Comprehensive Behavior Specialist [email protected] Add/scan spectrum. Who can be toilet trained using this protocol?.

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Helping Children with Moderate-Profound Cognitive Disability Achieve Continence: A Classroom Based Behavioral Protocol

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Helping children with moderate profound cognitive disability achieve continence a classroom based behavioral protocol

Helping Children with Moderate-Profound Cognitive Disability Achieve Continence: A Classroom Based Behavioral Protocol

Cindy Myers

Comprehensive Behavior Specialist

[email protected]


Add scan spectrum

Add/scan spectrum


Who can be toilet trained using this protocol

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

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

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

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

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

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

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

Parent Conference

  • Present you 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

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

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

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

Prompting Strategies

  • Promote independence

  • Least to most prompt hierarchy

  • Graduated guidance when physical prompting is required

  • Consider time delay prompting strategies for dressing skills


The training

The Training

  • 30 minute Training Intervals

  • 8:00 – 8:05 encourage fluid intake

  • 8:00 – 8:15 sitting on the toilet

  • 8:15 – 8:30 dry pants check


Training intervals

Training Intervals

  • 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

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

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 are (with neutral affect!)

  • Begin new training interval on the ½ hour


Dry pants check

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

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

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

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

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


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