TOILET TRAINING PACKPOSITIVE BEHAVIOUR SUPPORT SERVICES

TRASNA TRAINING SERVICES

POSITIVE BEHAVIOUR SUPPORT SERVICES

TRASNA TRAINING SERVICE

Chapel Gate, Time Square, Ballincollig, Co. Cork, Ireland

trasnatraining@bocss.org 021 4871292

Toileting Pack

Page Number

● Aim and Overview of content 2● Section 1: Medical Problems Checklist 3● Section 2: Bristol Stool Chart 5● Section 3: Assessment of Readiness Checklist 7● Section 4: Blank Daily Data Sheet 9● Section 5: Toilet Training Protocol 11● Section 6: Resources 13● Section 7: References 15

This Toilet Training pack has been produced by Trasna Training Services – a collective of individuals working with PBS in Ireland. The Toilet Training Pack is licensed under a Creative Commons Attribution-ShareAlike 4.0 International Licence.

All organisations and individuals are welcome and encouraged to use this Toilet Training Pack and have permission to tweak and build upon the content as necessary, as long as they credit Trasna Training Services and licence their new work under the identical terms.

Credit to Rachel Brownlow, MSc ABA, on the production of these materials. 1

Aim and Overview of Content

This pack contains all the necessary information to implement a toileting programme. It aims to set realistic aims for children by putting emphasis on small and achievable goals. It will outline the many different steps to toileting. It will also highlight our approach that the toilet training process is to be started when the child is ready (Brazelton, 1962, Gorzki, 1999). The question is not what age a child should be toileted at but whether or not the child is ready to be toileted. This enables this toileting pack to be of use to anyone who is either ready to currently start a toileting intervention or is thinking of doing one in the future.

This pack will include:

1. A readiness checklists which will help determine the readiness of the child to begin toileting

2. A medical checklist which will determine if the child needs any medical needs met before starting to toilet.

3. The steps which can be completed before a child is ready to begin the toileting process.

4. Resources to help with the toileting process5. A week length blank data sheet

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Section 1: Medical Problems Checklist

It is necessary that a medical problems checklist be completed before a toileting programme is started. This is to ensure that there are no issues which could prevent the toilet programme from working and may cause distress to the child. To complete this checklist parents should bring their child to their General Practitioner (GP) for a check-up. When the GP has stated that their child does not have any of these medical issues, or when they have dealt with the issues that were present by appropriate medical input, the parent may then move on to the readiness checklist. Children with ASD have a higher chance of having gastrointestinal problems and Autism spectrum disorders are more common in most constipation clinics than in the general population. Due to the prevalence of these issues it is extremely important that this checklist is completed in conjunction with a healthcare professional such as a local GP. The Bristol Stool Chart, in the next section, can be referred to to help with issues such as identifying constipation and diarrhoea though this diagnosis should always be formally made by a GP.

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Checklist 1: Common medical problems associated with toileting difficulties

Before you start toilet training, it is a good idea to speak with your child’s paediatrician or GP. They can rule out any medical problems that might get in the way of toilet training and say whether your child might be ready to start.

Urinary tract infections

Bowel infections

Coeliac disease

Diarrhoea

Constipation

Epilepsy

Any of these conditions may impact toilet training but with medical support and preparation they may not prevent your child from toilet training.

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Section 2: Bristol Stool Chart

The Bristol stool chart is a diagnostic medical tool designed to classify the form of bowel movement into seven categories. It was developed at the Bristol Royal Infirmary as a clinical assessment tool in 1997. There are seven types of stools according to the Bristol Stool Chart. It is an easy tool to use and parents can identify the appropriate stool that matches their child’s, making it easy for clinicians to diagnose any issues. Tracking a child's bowel movements using the Bristol Stool Chart will help with the medical checklist in the previous section. As Children with autism are more than 3.5 times more likely to suffer chronic diarrhoea or constipation (Centre for Disease Control and Prevention, 2006) then this is an important resource to use.

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The Bristol Stool

This chart was developed by K. W. Heaton and S. J. Lewis at the University of Bristol and

first published in the Scandinavian Journal of Gastroenterology in 1997.

What should my stools look like?

The type of stool or faeces depends on the time it spends in the colon. After you pass faeces,

what you see in the toilet bowl is the result of your diet, fluids, medications and lifestyle. You

can use the Bristol Stool Chart to check what your stools are telling you.

The Bristol Stool Chart shows seven categories of stool. Each person will have different

bowel habits, but the important thing is that your stools are soft and easy to pass – like types

3 and 4 below.

● Type 1–2 may indicate constipation

● Type 3–4 are ideal stools as they are easier to pass, and

● Type 5–7 may indicate diarrhoea and urgency

Frequency of bowel movement vary from child to child. Some children will have a bowel

movement every two-three days, while others move their bowels two to three times daily.

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Section 3: Assessment of readiness checklist

It is important that a toileting intervention is not started until the child is ready. Readiness for toileting includes ability to follow some simple instructions, to complete motor activities such as pull up and down pants and to stay dry for at least an hour. If a child is not ready then this will make toilet training take much longer and this may become aversive to the child i.e. the child may wish to avoid the process, leading to problems further down the line. To ensure that a child is ready, the following readiness checklist should be completed. The readiness checklist is comprised of a list of questions for parents to answer about their child. If most of the answers are no, then it is likely that this is not the time to start the toileting intervention and instead the focus should be on the pre toileting skills that can be learned and making the bathroom a positive place. Another thing to be considered is whether the parent is ready for a toileting intervention. Toilet training is a considerable time commitment and requires patience and persistence. If the parent does not feel like they can commit the time at this moment then it may be better to delay toilet training until a better time which suits such as a holiday or a time when they are less busy or pressured.

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Checklist 2: Readiness checklist

Questions to ask yourself about your child

Does your child show awareness of toileting? e.g. Pulls at nappy or pants when going, goes to a particular place, such as behind the couch, to pass a motion?

Are they able to tell you (or show you with a sign or gesture) that they have wet or soiled her nappy or clothes?

Are they able to follow a simple instruction like ‘Sit on the toilet’?

Can they pull their pants up or down?

Do they have regular formed bowel movements of type 3 or 4?

Do they have enough bladder control to stay dry for at least one hour at a time during the day?

Are they taking any medications which may affect the toilet training process?

Are there possible rewards you could use for toilet training? (e.g. a favourite tv show or a preferred food or activity)

List here if so:

Does your child have a particular word they associate with toileting e.g. toilet/pee/poo?

We recommend you use a word which can be used throughout adult life e.g. toilet.

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Should many of these answers be, “No” then you may need to reconsider the timing of toilet training. You can still work on toilet awareness with your child, e.g. modelling toileting, social stories and apps on toileting until further toilet readiness is shown. You can work on building interest in play, toys, music and activity schedules that could be used as reward systems. Another readiness activity could be getting your child to practice skills such as responding to requests to sit on the toilet and pulling pants up and down.

Section 4: Blank Daily Data Sheets

It is necessary to figure out if the child can stay dry for up to an hour before starting toilet training. It is also helpful to find out how often the child voids i.e. passes pee or poo at during the day and the time between the child consuming liquids or food and then voiding. When an approximate schedule can be found then these are the optimum times to take the child to the toilet as they have the highest likelihood for success. The daily data sheets can be used to find out when and follow a schedule. The data sheets should be filled in for a full week, where every hour the child’s nappy pr pants is checked to see is it dry/ clean. In the relevant space it is then recorded if nappy is dry, wet or has a bowel movement. When a bowel movement occurs, the type of bowel movement can be recorded by using the type shown in the Bristol Stool Chart e.g. Type 3. When the child eats or drinks this is also to be recorded and the amount of time between this and the wet or soiled nappy can be tracked. The data sheets should be filled in each day during the child's waking hours.

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Daily Baseline Toilet Recording Sheets

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This recording sheet is to establish can your child hold for more than an hour and if there is a pattern to their toileting which can support the times to take your child to the toilet.

Section 5: Toilet Training Protocol

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This section describes the elements which should be included in a toilet training programme. It gives recommendations of things to consider when starting, such as beginning on holiday, when there is more time to dedicate to the toilet training. It also outlines realistic aims such as reinforcing the behaviour of a child for pulling down their pants or sitting on the toilet. The role of reinforcement in toilet training is outlined with some examples appropriate to children given. This protocol aims to make toileting a positive experience for the child, emphasising the need for the bathroom to be made a fun and positive place which could be done by singing and other suitable activities that the child enjoys. The child should not be kept sitting on the toilet for a long period of time as the bathroom may become aversive.

Toilet training protocol

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● Set realistic goals!!● Preferably begin on a weekend or during holidays where you have more time to

support and be successful.● A social story, visual schedule or modelling can support prior to training.● Make toileting and the bathroom a fun place to be! ● Try to provide an environment that is pleasant but not so exciting that your child will

tense up their body which could interfere with the ‘letting go’ which needs to occur to allow voiding.

● Ensure your body language is as relaxed as possible.● Remove nappy.● Increase fluid intake. More fluids will be necessary the older the child as bladder

capacity increases with age. In infancy bladder capacity is very small, at age 1-2 years it doubles, at age 3 it increases and at age 4 it doubles again.

● It typically takes 30 minutes for a drink to go through the body; therefore chances of toileting are increased if you take your child to the toilet during this window.

● Only let your child sit on the toilet for a maximum of 3 minutes (sing songs together or look at picture books if liked).

● Toilet training should occur over at least a 4 hour period daily to be considered toilet training.

● There will be accidents, remember to change your child in the toilet.● Consider highly reinforcing items (access to I-pad, a few a chocolate buttons at the

end of a packet, bubbles) that can be given immediately on toileting.● There are many steps to learning to toilet which are displayed below, such as giving

your child a treat for entering the bathroom and pulling down their pants (1), or sitting on the toilet (3).

Section 6: Resources13

In this section there are some resources which might be of help for the toilet training process. These includes apps which the child can play on, songs which can be played in the bathroom to help make it a positive place and videos which may increase a child's understanding of the toileting process.

Resources

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● Toilet training appsFree to download from the app store

The Potty Book- The potty book is an animated story of girl Sara who is potty training. Most of the elements in the book are interactive and respond to touch with funny movements and sounds.

Potty Training- Learning with the animals: Your little one will start to learn the “gotta-go-to-the-potty” signs that the little animals have and begin to recognize them in themselves. Watching and encouraging all of the animals to go to the big kid potty sets a positive mood for potty training.

● Video LinksElmo Potty Time song

https://www.youtube.com/watch?v=t6D-ArgwMO4

Duration: 5.14 minutes

Tom & Emily going to the bathroom

https://www.youtube.com/watch?v=ri5RHQ58RcM

Emily #1

https://www.youtube.com/watch?v=A_DxlUD4vTE

Emily #2

https://www.youtube.com/watch?v=RZgCYeRXi0E

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Section 7: References

This section contains references to all the articles accessed and used to inform this toileting pack and presentation.

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ReferencesArdiç, A., & Cavkaytar, A. (2014). Effectiveness of the modified intensive toilet

training method on teaching toilet skills to children with autism. Education and Training in Autism and Developmental Disabilities, 263-276.

Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet training the institutionalized retarded. Journal of applied behavior analysis, 4(2), 89-99. DOI: 10.1901/jaba.1971.4-89

Bainbridge, N., & Smith Myles, B. (1999). The use of priming to introduce toilet training to a child with autism. Focus on Autism and Other Developmental Disabilities, 14(2), 106-109.DOI: 10.1177/108835769901400206

Bettison, S. (1978). Toilet training the retarded: analysis of the stages of development and procedures for designing programs. Australian Journal of Mental Retardation, 5(3), 95-100. DOI:10.3109/13668257809010176

Brazelton, T. B. (1962). A child-oriented approach to toilet training. Pediatrics, 29(1), 121-128.

Call, N. A., Mevers, J. L., McElhanon, B. O., & Scheithauer, M. C. (2017). A multidisciplinary treatment for encopresis in children with developmental disabilities. Journal of Applied Behavior Analysis, 50(2), 332-344. DOI: 10.1002/jaba.379

Centers for Disease Control and Prevention (2006). Centers for Disease Control and Prevention Parental report of diagnosed autism in children aged 4–17 years – United States, 2003–2004 MMWR, 55 (17) (2006), pp. 481-486

Chaidez, V., Hansen, R. L., & Hertz-Picciotto, I. (2014). Gastrointestinal problems in children with autism, developmental delays or typical development. Journal of autism and developmental disorders, 44(5), 1117-1127. DOI: 10.1007/s10803-013-1973-x

Cicero, F. R., & Pfadt, A. (2002). Investigation of a reinforcement-based toilet training procedure for children with autism. Research in Developmental Disabilities, 23(5), 319-331. DOI:10.1016/SO891-4222(02)00136-1

Cocchiola, M. A., Martino, G. M., Dwyer, L. J., & Demezzo, K. (2012). Toilet training children with autism and developmental delays: an effective program for school settings. Behavior analysis in practice, 5(2), 60-64. DOI: 10.1007/BF03391824

Doan, D., & Toussaint, K. A. (2017). A parent-oriented approach to rapid toilet training. International Electronic Journal of Elementary Education, 9(2), 473-486. DOI:10.1177/10883576050200020601

Friman, P. C. (1986). A preventive context for enuresis. Pediatric Clinics of North America, 33(4), 871-886. DOI:10.1016/S0031-3955(16)36078-3

Gorrindo, P., Williams, K. C., Lee, E. B., Walker, L. S., McGrew, S. G., & Levitt, P. (2012). Gastrointestinal dysfunction in autism: parental report, clinical evaluation, and associated factors. Autism Research, 5(2), 101-108. DOI: 10.1002/aur.237

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Gorzki, P.A. (1999). Toilet training guidelines: The role of the parent in toilet training. Pediatrics, 103(6, suppl.), 1362-1363.

Greer, B. D., Neidert, P. L., & Dozier, C. L. (2016). A component analysis of toilet‐training procedures recommended for young children. Journal of applied behavior analysis, 49(1), 69-84. DOI: 10.1002/jaba.275

Kroeger, K., & Sorensen, R. (2010). A parent training model for toilet training children with autism. Journal of Intellectual Disability Research, 54(6), 556-567. DOI: 10.1111/j.1365-2788.2010.01286.x

Levato, L. E., Aponte, C. A., Wilkins, J., Travis, R., Aiello, R., Zanibbi, K., ... & Mruzek, D. W. (2016). Use of urine alarms in toilet training children with intellectual and developmental disabilities: A review. Research in developmental disabilities, 53, 232-241. DOI:10.1016/j.ridd.2016.02.007

Mack, A. H. (2011). Association of Hospitalization for Infection in Childhood With Diagnosis of Autism Spectrum Disorders. Year Book of Psychiatry & Applied Mental Health, 2011(C), 58-59. DOI: 10.1016/j.ypsy.2010.09.005

Mahoney, K., Wagenen, R., & Meyerson, L. (1971). Toilet training of normal and retarded children. Journal of Applied Behavior Analysis, 4(3), 173-181. DOI:10.1901/jaba.1971.4-173

Mannion, A., & Leader, G. (2013). Comorbidity in autism spectrum disorder: A literature review. Research in Autism Spectrum Disorders, 7(12), 1595-1616. DOI: 10.1016/j.rasd.2013.09.006

McElhanon, B. O., McCracken, C., Karpen, S., & Sharp, W. G. (2014). Gastrointestinal symptoms in autism spectrum disorder: a meta-analysis. Pediatrics, 133(5), 872-883.

Nikolov, R. N., Bearss, K. E., Lettinga, J., Erickson, C., Rodowski, M., Aman, M. G. & Arnold, L. E. (2009). Gastrointestinal symptoms in a sample of children with pervasive developmental disorders. Journal of autism and developmental disorders, 39(3), 405-413. DOI: 10.1007/s10803-008-0637-8

Rinald, K., & Mirenda, P. (2012). Effectiveness of a modified rapid toilet training workshop for parents of children with developmental disabilities. Research in Developmental Disabilities, 33(3), 933-943. DOI: 10.1016/j.ridd.2012.01.003

Schieve, L. A., Gonzalez, V., Boulet, S. L., Visser, S. N., Rice, C. E., Braun, K. V. N., & Boyle, C. A. (2012). Concurrent medical conditions and health care use and needs among children with learning and behavioral developmental disabilities, National Health Interview Survey, 2006–2010. Research in developmental disabilities, 33(2), 467-476. DOI:10.1016/j.ridd.2011.10.008

Warzak, W. J., Forcino, S. S., Sanberg, S. A., & Gross, A. C. (2016). Advancing Continence in Typically Developing Children: Adapting the Procedures of Foxx and Azrin for Primary Care. Journal of Developmental & Behavioral Pediatrics, 37(1), 83-87. DOI:10.1097/DBP.0000000000000232

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POSITIVE BEHAVIOUR SUPPORT SERVICES

TRASNA TRAINING SERVICE

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