Autism Spectrum Disorder is a developmental disorder effecting 1 in 59 children in the United States and the current ratio is approximately 4.5 male:1 female (Center for Disease Control and Prevention, 2018). According to the National Institute of Mental Health (2018), children, adolescents, and adults on the spectrum exhibit various characteristics of autism. Many children with autism show poor social skills, lack communication skills, as well as exhibit inappropriate or maladaptive behaviors. Children with autism also demonstrate recurring patterns in behaviors. With that said, understanding, recognizing, and improving socially significant behaviors is imperative.
Appropriate toileting is socially significant and a part of typical developmental stages. Appropriate toileting can be defined as independently going to the restroom, pulling undergarments down, sitting on the toilet facing forward, voiding in the toilet, pulling undergarments back up, and washing hands (Mahoney, Van Wagenen, & Meyerson, 1971). According to Ardic and Cavkaytar (2014), “basic self-care abilities and independence with toilet skills are among the most important skills that children with autism should attain” (p. 263). As children gain toileting independence, parents are able to step aside and trust their children will perform these new skills and in turn improve both the child and the parents’ quality of life. It is essential that children with autism are toilet trained efficiently and effectively.
While toilet training, like other new skills and tasks, can be difficult for typically developing children, it can be equally or more difficult for children on the spectrum due cognitive interruptions, sensory needs and maladaptive behaviors. For example, if a child has autism and lacks communication skills, toilet training is of low priority in the early stages of intervention, as the child is not developmentally ready for toilet training. Limited communication and/or access to communication makes toilet training nearly impossible. Although self-help skills are imperative for a child with autism to learn, they can be challenging to learn (Cocchiola, Martino, Dwyer, & Demezzo, 2012). Children with autism often exhibit repetitive behaviors that have been reinforced. For instance, a child voiding in his/her undergarments at 8 years of age shows a repetitive behavior that will be extremely difficult to “unlearn” due to a history of reinforcement.
Past research indicates that children were being toilet trained at the mean age of 28.5 months (Blum, Taubman, and Nemeth, 2004). There were several barriers associated with this late toilet training. Blum and colleagues discussed the transformation of infections, stress in families, as well as more diaper changes as some hardships associated with late toilet training. Currently, a typically developing child often begins training as early as 18 months (Greer, Neidert, and Dozier, 2016). Determining if a child is ready to be toilet trained is important because without the prerequisites of toilet training, there is a lower chance of successfully training the child. Greer and colleagues also state that, “most children between the ages of 18 and 30 months have the prerequisite skills to begin toilet training” (p. 69). Greer and colleagues continue by describing behaviors of readiness as: remaining dry for more than 2 hours, showing an interest in the toilet, being able to sit on the toilet for at least 3 minutes, and following rules and procedures for the toilet. After readiness is determined, understanding what is reinforcing as well as determining a reinforcement schedule for the child is critical. Completing a preference assessment to identify highly preferred reinforcers is a key component when using reinforcement schedules (Verriden & Roscoe, 2016).
In order to use reinforcement appropriately, a criterion must be set. While there are many schedules of reinforcement to consider, Differential Reinforcement of Other behaviors (DRO) delivers reinforcement when the target behavior does not occur (Cooper, Heron, & Heward, 2007). When toilet training, it is important to deliver reinforcement when the child does not void in his/her undergarments. A Continuous Reinforcement schedule (CRF) should also be used when teaching a new skill. a CRF schedule involves the delivery of reinforcement for every targeted response. In a toilet training intervention, reinforcement should be delivered for each successful void in the toilet rather than in his or her undergarments. Access to edible items and praise for voiding in the toilet, as well as liquids and preferred items for remaining dry/clean, shows an increase in appropriate toileting (Greer, Neidert, & Dozier, 2016). The study by Greer and colleagues (2016) also shows improvements in overall performance when differential reinforcement was used. DRO can be delivered using a partial interval or whole interval recording method. The value of the DRO schedule should increase as the client comes under control of the schedule (Repp, Barton, & Brulle, 1983). Reinforcement can be delivered under several contingencies. When toilet training, it is recommended that DRO should be delivered contingent on the absence of the response (i.e voiding in the undergarment) because it “weakens responding because the probability of the reinforcer is greater given the absence of responding” (Jessel, Borrero, & Becraft, 2015, p. 402). In other words, when there is no void in the undergarments, reinforcement should be delivered. The idea behind the differential reinforcement schedule is that temporal patterns will be developed and maintained (Hawkes & Shimp, 1975). Another key component when toilet training is manipulating the antecedent by transferring stimulus control. First, determining the child’s trends for voiding will identify what has stimulus control (Kroeger and Sorensen-Burnworth, 2009). Transferring stimulus control can be completed through the process of shaping.
Shaping occurs when the behavior is differentially reinforced to target an operant response class (Cooper, Heron, & Heward, 2007). Shaping consists of an approximation of the target behavior being exhibited and reinforcement delivered upon that approximation. When implementing a toilet training regimen, it is important to shape approximations of the wanted behavior (i.e. voids in the toilet). Because toilet training can be a difficult task, shaping the desired behavior through multiple phases is often used. Shaping the behavior requires positive and negative consequences in order to maintain the shaping process (Azrin & Foxx, 1971). For example, if a child voids in his/her pull-up during a phase when that is appropriate, reinforcement will be delivered however if the child voids in his/her undergarments during a different phase, where only voiding in the toilet is targeted, reinforcement should be withheld.
Parent training has been described as a “wide range of interventions designed to address maladaptive behaviors” (Bearss, Burrell, Stewart, & Scahill, 2015). Parent training is essential to the success of behavioral interventions because it promotes generalization and maintenance of skill acquisition. Most children with autism live with their parents well into adulthood and struggle with generalizing skills across people and settings (Kroeger & Sorensen, 2010). The literature also states that parent training should rely primarily on positive reinforcement and avoid punishment, such as reprimands. Training parents is also beneficial in that when children leave their home, they are most likely to be with their parents (Kroeger & Sorensen, 2010). The likelihood of generalization increases as the child is brought to new or different environments. In order for the following study to show success, parental compliance and appropriate implementation is vital.
According to Cocchiola, Martino, Dwyer, and Demezzo (2012), effective toilet training in children with autism is covered over four decades in applied settings. Different methods of toilet training should be replicated. A variety of toilet training methods with different reinforcement schedules, punishment procedures, as well as intensive parent training should be implemented within a wider age range of children with autism or other developmental disabilities to show validity in the interventions. The purpose of this study is to investigate the efficacy of a toilet training procedure that includes differential reinforcement and fading out pull-ups to increase defecating in the toilet.
Method
Participants
The participant in this study is an eight-year-old female named MB. MB was diagnosed with Autism Spectrum Disorder at 18 months old. MB exhibits the appropriate prerequisite skills for toileting and was chosen for this study due to her chronical age and developmental stage. Increasing and improving MB’s independence for toileting will not only improve her quality of life, it will improve her parents’ quality of life as well.
She is currently enrolled in a public-school classroom for children with autism or other behavioral needs. Her classroom consists of six students total, one teacher, and two paraprofessionals. MB is currently toilet trained when using the toilet to urinate however, she uses a pull-up for defecating. MB’s bowel movements are consistent in that they occur between 4:30 pm and 7:30 pm most days of the week. Due to this temporal consistency, implementation of the toileting procedures will be run during the evening hours in the home setting.
Setting
The intervention will be conducted in MB’s home. MB’s home consists of four bedrooms, two full bathrooms, one half bathroom, a kitchen, a laundry room, a dining room, and two living room spaces. MB spends her time in the two living room spaces, the kitchen, and uses the half bathroom that is located off the kitchen for toileting. Currently, pull-ups are accessible to MB and are located in a pantry in the kitchen. MB is able to access the pull-ups at her control. During the experiment, MB’s mom will have to comply with withholding access to pull-ups to maintain control of this variable.
Materials
Prior to the intervention, a preference assessment will be completed to identify meaningful reinforcers. The highest preferred item (iPad) will be used solely for toilet training. During the first phase of the intervention, in addition to the identified preferred item(s), a data collection sheet, timer, pen, and pull-ups will be available for the person running the intervention. During the second phase of the intervention, preferred items, reinforcers, a data collection sheet, timer, and pen will be used. Pull-ups will no longer be available.
Training
Parent training of the procedures will be required as the procedures will be implemented in the home setting, by MB’s mom. The intervention will be initially implemented by the plan developer before transitioning to the parent. Training will consist of a verbal review and modeling each phase of the intervention. Check listing will also be completed for each phase as it is reached by MB and feedback will be immediately delivered until the parent demonstrates 100% competency. The parent will be required to collect and review data daily. The researcher will discuss the procedures with the parent to determine if the parental needs are met, as well.
Dependent Variables
The dependent variables are defecating in a pull-up and defecating in the toilet. Defecating in a pull-up is the dependent variable during Phase one of the intervention. Defecating in the toilet is the dependent variable during Phase two of the intervention. Defecating in a pull-up will be defined as MB having a bowel movement in a pull-up, while sitting, facing forward, on the toilet. Defecating in a pull-up or undergarments, without sitting on the toilet will be considered an “accident”. Defecating in the toilet will be defined as MB having a bowel movement while sitting, facing forward on the toilet.
Independent Variables
The independent variables for this study will include two different schedules of reinforcement and the fading out of pull-ups. Differential reinforcement of other (DRO) behaviors will be used to reinforce when MB does not defecate in her undergarments during Phase one of the intervention. During Phase two, DRO will be used when MB does not defecate in a pull-up.
A continuous reinforcement (CRF) schedule will also be used during both phases of the intervention. During Phase one, CRF will also be used every time MB defecates in the pull-up, while sitting on the toilet facing forward. It is important to only reinforce defecating in the pull-up while sitting on the toilet to pair the pull-up with the toilet. CRF will also be used during Phase two when MB defecates in the toilet.
Pull-ups will be accessible to MB’s mom. MB will be allowed access once she sits on the toilet during the first phase of the intervention. Pull-ups will no longer be available during Phase two of the intervention. Pull-ups appear to have stimulus control over toileting behavior because she consistently voids in the pull-up and does not in anything else (e.g. underwear, toilet, etc.). Through this toileting procedure, stimulus control will be transferred from the pull-up to the toilet using differential reinforcement, shaping, and fading.
MB’s toileting behavior will be shaped across two phases. During Phase one, the dependent variable will be defecating in a pull-up while sitting on the toilet. The master criteria for moving to Phase two is as follows: When MB defecates for three consecutive days with 90% of trials successful (poop in the pull-up while sitting on the toilet), the parent or practitioner will move to Phase two. During Phase two, the pull-up will be systematically faded out so that the dependent variable will be defecating in the toilet.
Design
A multiple baseline across behaviors/multiple probe design will be used to determine the effects of a reinforcement schedule and fading out pull-ups on increasing defecating in the toilet and decreasing defecating in a pull-up. This design was chosen because there are two dependent variables that will be addressed, defecating in a pull-up while sitting on the toilet and defecating in the toilet, across two different phases. There will be no reversal during this intervention. Baseline data will consist of frequency of asking for a pull-up, duration of sitting, and voids in a pull-up. and will be collected before the first phase of the intervention. Prior to Phase two, baseline data will also be collected. MB must defecate in the pull-up while sitting on the toilet with a 90% success rate over three consecutive data collection days before moving to Phase two. Phase two will be terminated after MB defecates in the toilet with a 90% success rate over 30 consecutive data collection days.
Procedures
Prior to Phase one of the intervention, baseline data will be collected. A multiple-stimulus-without-replacement (MSWO) preference assessment will also be used to determine preferred items to be used for reinforcement. During Phase one, when MB requests a pull-up, parent or practitioner must tell MB she has to sit on the toilet. Prior to Phase one, pull-ups should no longer be readily available for MB to access. When MB asks for a pull-up, the phase will be presented in steps as follows:
Step 1: First, tell her to “pee pee in the potty”. (reinforce with verbal praise)
Step 2: Put the pull-up on her and have her sit on the toilet while wearing the pull-up. (reinforce sitting)
• Allow access to manipulatives like toys, books, or preferred items
Step 3: Set timer for data collection purposes (duration of sitting with pull- up)
Step 4: Tell MB, “Go poo poo!”
• If MB tries to get up, allow her to get up, but remove the pull-up.
• Tell her “You have to sit on the potty to wear the pull-up”.
*When MB asks for the pull-up again, repeat step 2 and follow the procedure.
• If MB voids in her pull-up while standing or sitting anywhere other than the toilet, tell her “You have to poo poo while sitting if you want to earn (insert highly preferred reinforcer)”.
• If MB voids in her pull-up while sitting on the toilet, completing the targeted response, reinforcement should immediately be delivered in conjunction with verbal praise.
• When MB defecates in her pull-up, while sitting on the toilet for three consecutive days with 90% of trials successful, see Phase 2.
Prior to Phase two of the intervention, baseline data will be collected. Phase two will begin once MB defecates in a pull-up while sitting on the toilet with a 90% success rate for three consecutive days. During Phase two, pull-ups, again, should not be accessible to MB. If/when MB asks for the pull-up, tell her “Let’s go sit on the potty!”, and Phase two will be presented in steps as follows:
Step 1: First, tell her to “pee pee in the potty”. (reinforce with verbal praise)
Step 2: Set timer for data collection purposes (duration of sitting)
Step 3: While she is sitting on the toilet, tell her, “Go poo poo!”
• If MB tries to get up, allow her to get up and remind her that she needs to “poop in the potty”.
• Tell her “You have to poop on the potty to earn (insert highly preferred item)”.
• If MB poops in undergarments or anything other than the toilet, tell her “you have to poo poo in the potty to earn (insert highly preferred item)”.
• If MB defecates in the toilet, completing the targeted response, highest preferred item should be immediately delivered in conjunction with verbal praise.
The intervention will be terminated when MB defecates in the toilet with a 90% success rate for 30 consecutive days.
Treatment Fidelity
To determine if the intervention and procedures were run effectively and correctly, the researcher will follow-up weekly with the parent to review data collection. Data collection will be analyzed to ensure parents are accurately collecting and maintaining the data. Pull-ups will not be accessible to MB to ensure environmental control. Highly preferred reinforcers, including the iPad will be withheld unless being used for the intervention.
Data Analysis
Upon completion of each week, the data will be used to create a visual analysis to determine the efficacy of the procedures. The data collected will be graphed based on frequency, duration, and compliance. Graphs will be analyzed after six consecutive weeks to determine the efficacy. If data does not show an increase in toilet use and decrease in pull-up use, another intervention will be considered.
During Phase one, the researcher as well as MB’s mom will collect duration data for sitting on the toilet with the pull-up on, the reinforcer delivered for sitting, + or – for defecating in the pull-up while sitting, and the reinforcer delivered for defecating in the pull-up while sitting.
During Phase two, the researcher and MB’s mom will collect duration data for sitting on the toilet, the reinforcer delivered for sitting, + or – for defecating in the toilet, and the reinforcer delivered for defecating in the toilet. From the data collection, the researcher will be able to determine compliance, frequency of defecating, time of defecating, as well as reinforcement efficacy during both phases of the intervention plan. Data collection sheets for Phase one and Phase two can be found in Appendix A.
Reliability
The reliability of the intervention will be determined through interobserver agreement (IOA). Interobserver agreement “refers to the degree to which two or more independent observers report the same observed values after measuring the same events” (Cooper, Heron, & Heward, 2007, p. 113). IOA for data obtained by timing, unscored-interval IOA, and scored-interval IOA will be used during the intervention plan.
IOA for data obtained by timing will be used to determine the accuracy of the duration of sitting. Two or more observers will obtain duration data. Unscored-interval IOA data will collected for the non-occurrences of defecating. Lastly, scored-interval IOA data will be collected for occurrences of defecating. Example IOA data collection can be found in Appendix B.
Social Validity
MB’s parents will be given a pre-treatment preference survey to complete a prior to the intervention to determine parental procedural preferences as well as intervention needs. They will be given a post-treatment satisfaction survey at the completion of the intervention. The satisfaction survey will be based on the protocol in place and will include a scale of 1 to 3 (1= unsatisfied, 2= moderately satisfied, 3= satisfied). The pre-treatment preference survey and satisfaction survey can be found in Appendix C.n here…