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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

Cindy Myers

Comprehensive Behavior Specialist

[email protected]


Add scan spectrum
Add/scan spectrum Achieve Continence: A Classroom Based Behavioral Protocol


Who can be toilet trained using this protocol
Who can be toilet trained using this protocol? Achieve Continence: A Classroom Based Behavioral 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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. Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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. Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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: Achieve Continence: A Classroom Based Behavioral Protocol

  • 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: Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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. Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocolat 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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 Achieve Continence: A Classroom Based Behavioral Protocol

  • 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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