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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. Cindy Myers Comprehensive Behavior Specialist 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

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