Helping Children with Moderate-Profound Cognitive


Disability Achieve Continence:
Classroom Based Behavioral Protocol

Developed by Cindy Myers

Comprehensive Behavior Specialist
cindy.myers@slc.k12.ut.us
 
Students with Cognitive Disability
 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

 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
 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.

 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

 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
 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

 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

 Present your 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.

 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

 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
Materials List
 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

 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

 Promote independence

 Least to most prompt hierarchy

 Graduated guidance when physical prompting is

required

 Consider time delay prompting strategies for

dressing skills
 Training (30 minute Intervals)
8:00-8:05
Encourage fluid intake
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:

 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:

 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 area (with neutral affect!)

 Begin new training interval on the ½ hour

 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.
 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
 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

 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

 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

Students with Multiple and Profound 
Disabilities
 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 childs 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 SD 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 SD 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: ______________________________________
Other: ______________________________________
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 signature date

_______________________________________ _________________
teacher signature date

_______________________________________ __________________
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, trunck 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