In the field of Applied Behavior Analysis, analysts and clinicians do not attempt to change a person's behavior without understanding the behavior and why a person does what they do. That means a face-to-face meeting and observation of behaviors. But then what? How do we go about building a program to change a behavior?
After discovering what a child's preferences are, understanding their communication level, and knowing the goals, we have to do our research. Research can include journal articles from the field of behavior analysis and related fields to determine what has been tried in the past and what has worked.
As an example, a literature review of a rapid toilet training program with multiple components was completed for a young man who was reliant on diapers and wanted to decrease the use of diapers.
A literature review typically takes a few hours to read and write but it provide a foundation to begin building a solid plan for behavior change.
Literature Review
Independent toileting is a developmental milestone that is achieved for most typically developing children by the age of four (Schum et al., 2002). For children with a developmental disability, this can pose a challenge. Yet, the more self-care skills a child can develop, the more independence they and their parents achieve (Ardiç & Cavkaytar, 2014).
This paper is a review of the relevant literature to determine what methods might be employed to give a 16-year-old male with comorbid diagnoses of Lennox-Gastaut syndrome (LGS) and autism spectrum disorder (ASD), the best chance at toileting independence.
Interventions that have proven effective in previous research to reduce toileting accidents include the rapid toilet training (RTT) treatment package as devised by Azin and Foxx in 1971. Some of the components of the RTT treatment package such as: positive reinforcement, differential reinforcement, negative reinforcement, positive punishment, toileting schedules, scheduled sittings, increased fluids, enuresis alarm, graduated guidance, and modeling will be discussed as well as additional behavior analytic technologies that have shown success.
Theoretical Underpinnings
Analysis of the relevant literature reveals toilet training for individuals who have a developmental disability were beginning to make progress in the 1960s using operant learning procedures (Osarchuck, 1973). Azrin and Foxx (1971) developed the RTT method which seems to have become the most cited toilet training protocol. RTT has since been modified with some success while some treatment packages have included newer technologies.
Rapid Toilet Training
RTT, as a treatment package, consists of multiple behavior analytic tactics to teach correct toileting behavior, reduce toileting accidents, and connect toileting behaviors such as dressing, undressing, and handwashing into a complete behavior chain (Ardic & Cavkaytar, 2014; Azrin & Foxx, 1971; Averink, Melein, & Duker, 2004; Brown & Peace, 2011; Chung, 2007; LeBlanc, Carr, Crossett, Bennet, & Detweiler, 2005; Lomas Mevers, Muething, Call, Scheithauer, & Hewett, 2018; Post & Kirkpatrick, 2004; Sells-Love, Rinaldi, & McLaughlin, 2002).
RTT was developed by researchers Azrin and Foxx (1971) for a group of 9 adult males, labeled as retardates, living in a facility. The strength of the RTT treatment package, according to Azrin and Foxx, lies in the length of time required to achieve incontinence reduction, the acquisition and addition of independent toileting skills to the participant’s repertoire, and the generalization without regression of the trained behaviors. Researchers Azrin and Foxx used a multiple-baseline across subjects to ensure internal validity. External validity of their study was established through replication and the general utility of the treatment was firmly established.
The components of the RTT treatment package, according to Azrin and Foxx include: positive reinforcement in the form of praise and edible things; differential reinforcement by providing praise and an edible reinforcer every 5 minutes for dry pants; negative reinforcement by way of escape from the toilet after voiding or scheduled sitting time, positive punishment through the use of restitutional overcorrection by having participants clean their own soiled clothing; a toileting schedule, scheduled sitting times, increased fluids, modeling correct behavior, enuresis alarm, shaping behavior, and utilizing behavior chains.
Sells-Love et al. (2002) utilized a rigorous single-subject reversal design with high reliability establishing a causal relationship between the treatment and the behavior. The modified RTT replaced the toileting and sitting schedules with a prompting schedule and did not use overcorrection. Their modifications were shown to be effective in a special education classroom setting.
Researchers Averink et al. (2005) also excluded the overcorrection component and determined their modified RTT was successful without it. They did, however, add a response restriction component by limiting the physical space an individual could be in. They achieved a 72.9% success rate similar to but lower than Azrin & Foxx’s reported 80%. The work achieved a reliability score over 99%. Of note are their finding regarding the correlations between the number of accidents during training and the number of treatment hours needed.
Post and Kirkpatrick (2004) used a modified RTT by replacing overcorrection with positive practice but did not use a research method that could identify a causal relationship between the intervention and the behavior. They did however demonstrate that modifications to RTT could be used effectively in a home environment.
LeBlanc et al. (2005) added a communication training component in their modified RTT treatment package. LeBlanc et al. used a nonconcurrent multiple-baseline across participants design with an IOA above 87% for 3 children diagnosed with ASD. Like Azrin and Foxx’s (1971) participants, the children had previous exposure to a less intensive toilet training program that did not result in correct toileting behavior there by concluding that some individuals need a more comprehensive treatment package when less intensive training has failed to produce the desired outcomes.
Chung’s (2007) research utilizing an ABC single-subject design achieved an IOA score of 100% but lacked treatment integrity data. Chung did not systematically define reinforcers which may have compromised the strength of the treatment method. Chung’s modified RTT treatment package did not include an alarm, overcorrection which resulted in a 79% success rate during the maintenance phase. Some generalization of the toileting behavior was noted in the home environment as well as school suggesting that a less rigorous procedure can have the desired outcome.
Researchers Brown and Peace (2011) were not able to determine which component of a modified RTT treatment package was successful and the internal validity of their work was weak due to the single-subject reversal design. They did, however, show their collection was valid. Brown and Peace’s modified RTT treatment package replaced overcorrection with positive practice, included communication training, but did not include a DRA.
Lomas Mevers et al. (2018) performed a consecutive case-series analysis over two years. Their work was not a controlled consecutive analysis as each individual’s data did not include full experimental controls. Of note in their their study was the finding that modifying RTT to meet the needs of each individual is successful.
Positive Reinforcement.
Positive reinforcement is a method of increasing correct toileting behavior that is used universally throughout the relevant literature and is included in all toileting treatment packages (Ardic & Cavkaytar, 2014; Azrin & Foxx, 1971; Averink, et al., 2005; Brown & Peace, 2011; Chung, 2007; LeBlanc, et al., 2005; Lomas Mevers, et al., 2018; Post & Kirkpatrick, 2004; Sells-Love, et al., 2002; Simon & Thompson, 2006; Tarbox et al. 2004)
Positive reinforcement takes on different forms such as social praise, engaging in reinforcing activities, consumption of edible things and getting preferred tangible items
All interventions saw a reduction in the incidence of toileting accidents by utilizing positive reinforcement immediately following correct behavior but positive reinforcement was not used exclusively in any of the research.
Of note is the study by Chung (2007) using a modified version of RTT that did not include positive punishment but relied on reinforcement. Chung’s research with a 12-year-old male diagnosed with a developmental disorder including seizures showed a decrease in urination accidents to 11% while attending school during the maintenance phase. While the findings suggest RTT can be utilized without the punishment component, Chung’s findings are not definitive as the individual did not reach 100% success in eliminating toileting accidents but there may have been confounding variables due to the individual’s seizures.
Differential Reinforcement
Differential reinforcement is a strategy included in the RTT protocol that provides positive reinforcement for the desired behavior and withholds reinforcement for undesirable behavior (Cooper, Heron & Heward, 2020). This strategy can be used to withhold reinforcement for incontinence or voiding in a diaper while reinforcement is provided for correct toileting (Ardic & Cavkaytar, 2014; Azrin & Foxx, 1971; Lomas Mevers et al., 2018; Post & Kirkpatrick, 2004; Sells-Love et al., 2002). Specifically, the use of differential reinforcement of alternative behavior (DRA), to reinforce continued dry pants on a dense or frequent schedule may be correlated with a successful reduction in toileting accidents and an increase in longer and longer intervals of dry pants (Lomas Mevers et al.; Post & Kirkpatrick).
Negative Reinforcement
Negative Reinforcement as a method to decrease the frequency of toileting accidents and/or diaper use may be a contributing factor to the success of RTT protocols (Azrin & Foxx, 1971; Averink et al., 2005). As part of a toilet training package, negative reinforcement can be used purposefully as seen in the work of Averink et al. with 40 individuals of varying ages in the form of lifting physical space restrictions for successful toileting procedures. The results were not completely successful for all as only 29 of the 40 individuals were able to reduce the use of diapers completely. This is lower the Azrin and Foxx who achieved an 80% reduction in toileting accidents though the sample was smaller including only 9 individuals instead of 40. The difference may be due in part to researchers Averink et al. excluding defecation data.
Positive Punishment
Punishment procedures in the form of restitutional overcorrection, verbal reprimands, and positive practice have been included in RTT and modified RTT protocols at varying levels and have been a component of many toileting treatment packages. (Azrin & Foxx, 1971; Averink, et al., 2005; Brown & Peace, 2011; LeBlanc, et al., 2005; Lomas Mevers, et al., 2018; Post & Kirkpatrick, 2004). The drawback of positive punishment, according to Cooper et al. (2020), is the unintended consequences that may develop. Positive punishment has been discussed within the toileting treatment literature and in some cases, overcorrection has been replaced with positive practice as it is was found it be effective and is believed to be a milder form of punishment (Averink, et al.; Brown & Peace; LeBlanc, et al.; Lomas Mevers; Post & Kirkpatrick).
Toileting Schedules
Toileting schedules are shown to be an important component of toileting treatment packages correlated with successful toileting behavior skills acquisition (Ardic & Cavkaytar, 2014; Azrin & Foxx, 1971; Averink, et al., 2005; Brown & Peace, 2011; Chung, 2007; LeBlanc, et al., 2005; Lomas Mevers, et al., 2018; Post & Kirkpatrick, 2004). Toileting schedules outline when to take an individual to the toilet. This can be based on even increments of time or based on typical voiding times already known or established during baseline. The idea here is to increase opportunities for the correct behavior of voiding on the toilet so that individuals will be reinforced for the correct behavior.
Scheduled Sitting
Scheduled sittings are a protocol defining how long an individual is directed to sit on the toilet in the hope that voiding will take place during the interval. Scheduled sitting times as part of a toileting treatment package is effective. (Ardic & Cavkaytar, 2014; Azrin & Foxx, 1971; Averink, et al., 2005; Brown & Peace, 2011; Chung, 2007; LeBlanc, et al., 2005; Lomas Mevers, et al., 2018; Post & Kirkpatrick, 2004). Of note with regards to sitting intervals, Lomas Mever et al. determined that a sitting time of 60 minutes may be correlated with a lack of self-initiation.
Increased Fluids
An increase in fluid intake is a method of increasing the occurrence of urinating and thereby increasing the opportunities for correct behavior followed by reinforcement. Increased fluids appear to be a critical component of successful toileting treatment packages (Ardic & Cavkaytar, 2014; Azrin & Foxx, 1971; Averink, et al., 2005; Brown & Peace, 2011; Chung, 2007; LeBlanc, et al., 2005; Lomas Mevers, et al., 2018; Post & Kirkpatrick, 2004; Sells-Love, et al., 2002)
Modeling
Modeling is a strategy for acquiring new skills by watching a demonstration of the target behavior (Cooper et al., 2020). This strategy was used in RTT by having the study participants stay in the bathroom for 8 hours per day, in part, so they could watch each other going to the toilet (Azrin & Foxx, 1971) . While this aspect of toilet training may be present in some of the research in this review, it is not specifically identified as a component of the modified RTT protocols. The advancement of technology has created opportunities for video modeling to be included in toilet training packages and as such was studied by Lee et al. (2014). Their study was a changing-criterion design with a high IOA, high treatment fidelity, and acceptable social validity. The in-vivo video modeling was a success for all behaviors clearly shown in the video. The portions that were not shown, actual urination in the toilet, did not increase. In a multiple-baseline across behaviors design study by researchers Drysdale, Lee, Anderson, and Moore (2014) animation was used to create a video portraying urination in the toilet that was then incorporated into an in-vivo video modeling sequence. Drysdale et al. showed a 98% IOA, treatment fidelity using a checklist, and social validity was established using a questionnaire for the parents. The toileting outcomes were successful for both of the participants who were diagnosed with ASD.
Enuresis Alarm
A device that can detect and indicate the presence of moisture is part of the RTT protocol (Azrin & Foxx, 1971). Some modified RTT protocols made use of a wetness alarm as part of successful toilet training packages. (LeBlanc, et al., 2005; Lomas Mevers, et al., 2018).
A wearable wetness alarm has shown promising results as the main component in toileting success (Chang, Lee, Chou, Chen, & Chen, 2011). In a school setting, researchers Chang et al. evaluated a wearable device that alerted a teacher and not the individual being trained. The participant was a 9-year-old boy with multiple disabilities including hearing impairment. The occurrences of wet diapers showed a significant decrease during the treatment phases while the number of urinations remained statistically unchanged during a single-subject ABAB reversal. The researchers concluded the device was helpful to the teacher and could be helpful to the child if it vibrated to alert him. LeBlanc et al, (2005) noted that the use of the wetness alarm decreased the amount of time a caregiver has to spend inspecting an individual’s pants visually or physically for toileting
Prompt Fading
Physical assistance is often the first method of prompting a new skill (Cooper et al., 2020). Prompts follow a hierarchy of fading from physical to gestural to verbal until prompts are no longer needed. In Azrin and Foxx’s research, they used graduated guidance, a method of closely following an individual’s movements and providing physical assistance when needed. Fading graduated guidance is done by rapid increases in distance between the individual and the guiding hands (Cooper et al.). Modified RTT protocols typically include graduated guidance and/or prompt hierarchies and fade the prompts as quickly as possible so individuals do not become prompt dependent (Ardic & Cavkaytar, 2014; Azrin & Foxx, 1971; Averink, et al., 2005; Brown & Peace, 2011; Chang et al., 2011; Chung, 2007; LeBlanc, et al., 2005; Lomas Mevers, et al., 2018; Post & Kirkpatrick, 2004; Sells-Love, et al., 2002). Of note, Chung (2007) found a child could be taught to successfully void on the toilet without learning the rest of the behaviors despite attempts at prompt fading.
Communication Training
Communication training prior to each occurrence of going to the toilet in the form of a picture exchange procedure or a verbal request to access the toilet using modeling and prompting has been shown to increase compliance with toileting (Brown & Peace, 2011; LeBlanc, et al., 2005; Lomas Mevers, et al., 2018).
Diapers
In the majority of articles included in this review, most specify the use of underwear instead of diapers (Ardic & Cavkaytar, 2014; Azrin & Foxx, 1971; Averink, et al., 2005; Brown & Peace, 2011; Chung, 2007; LeBlanc, et al., 2005; Lomas Mevers, et al., 2018; Sells-Love, et al., 2002). While diaper-wearing may provide convenience for parents, caregivers, and teachers, it has been found to contribute to incontinence (Simon & Thompson, 2006; Tarbox, Williams & Friman, 2004).
Tarbox, Williams, and Friman (2004) employed a single-subject reversal design to gain an understanding of the effect a diaper has on incontinence. The weakness of their study was a lack of data on the individual’s water intake. IOA was 100% for their study and the mean percentage of integrity was 92%. The participant, a 29-year-man diagnosed with developmental disabilities, showed a decrease in toileting accidents when he did not wear a diaper suggesting the diaper had gained discriminative control or was an establishing operation for the occurrence of incontinence. Similarly, Simon and Thompson’s (2006) study involving 5 typically developing children decreased toileting accidents when diapers were removed and exchanged for underwear in 4 of the 5 children in a child-care setting. Simon and Thompson’s study utilized a nonconcurrent multiple-baseline and reversal design. Their IOA for the study was above 99% and the procedural integrity was scored at 100% by the teacher. The weakness of the study was the researchers were unable to identify the extent to which the underwear wearing contributed to the toileting success.
Conclusion
As with all behavior analysis interventions, reinforcement must be what the program is built on. As increased fluids provide increased opportunities to void, this, in turn, creates more opportunities for reinforcement. Each intervention in the relevant literature if used in a toilet treatment package must be utilized in a way that Kaimi will have increased opportunities for the reinforcement he prefers.
Each of the studies in this review was an attempt to add critical research to the knowledgebase. Lomas Mevers et al., (2018) performed the most comprehensive study by way of individualizing each of the toileting intervention components to each individual. The common components did not work for all the individuals in the study, for example, the sitting schedule was discontinued for 5 of the participants because it did not seem to encourage self-initiation. This is the greatest strength identified in this literature review.
Individualizing a toileting treatment package for someone will take into account their age, strength, prior training, preferences, and maladaptive behaviors.
References
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