Toilet training children with autism and developmental delays: an effective program for school settings.
ABSTRACT Current research literature on toilet training for children with autism or developmental delays focuses on smaller case studies, typically with concentrated clinical support. Limited research exists to support an effective school-based program to teach toileting skills implemented by public school staff. We describe an intervention program to toilet train 5 children with autism or developmental delays who demonstrated no prior success in the home or school setting. Intervention focused on (a) removal of diapers during school hours, (b) scheduled time intervals for bathroom visits, (c) a maximum of 3 min sitting on the toilet, (d) reinforcers delivered immediately contingent on urination in the toilet, and (e) gradually increased time intervals between bathroom visits as each participant met mastery during the preceding, shorter time interval. The program was effective across all 5 cases in a community-based elementary school. Paraprofessional staff implemented the program with minimal clinical oversight.
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ABSTRACT: Recent studies suggest that children are completing toilet training much later than the preceding generation. Our objective was to identify factors associated with later toilet training. Children between 17 and 19 months of age (n=406) were enrolled in the study. At enrollment, parents completed the Parenting Stress Index and the Receptive-Expressive Emergent Language Scale. Follow-up parent interviews were conducted every 2 to 3 months until children completed daytime toilet training. Information obtained at follow-up interviews included steps parents were taking to toilet train their child, child toilet training behaviors, presence and frequency of constipation, birth of a sibling, and child care arrangements. In a stepwise linear regression model predicting age at completion of toilet training, 3 factors were consistently associated with later training: initiation of toilet training at an older age, presence of stool toileting refusal, and presence of frequent constipation. Models including these variables explained 25% to 39% of the variance in age at completion of toilet training. In conclusion, a later age at initiation of toilet training, stool toileting refusal, and constipation may explain some of the trend toward completion of toilet training at later ages.Journal of Pediatrics 08/2004; 145(1):107-11. · 4.04 Impact Factor
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ABSTRACT: Our understanding and treatment of children with autism have changed dramatically since Leo Kanner first formally documented the disorder in 1943. With reference to the historical context, this paper reviews recent research addressing 4 major issues: early detection, intervention, education, and psychopharmacological management of children with autism and related (autistic) spectrum disorders (hereafter, "autism"). We conclude from our review of the evidence that, in the absence of additional, more compelling data, the clinical usefulness of existing screening instruments remains questionable. However, the potential importance of such research is underscored by the clear benefits of early behavioural intervention: despite differences in orientation, outcomes for children with autism can be significantly enhanced with early intensive intervention. Although many questions remain (notably, What are the critical therapeutic components? For whom? For what domains of development? For what level of intensity and duration?), interventions shown to be effective are all carefully planned, engineered, monitored, and designed to target specific skill domains. Including children with autism in regular classes within the public school system poses several challenges, the most pressing of which is the large number of school personnel who need to be trained in evidence-based teaching and behavioural management practices. Finally, psychotropic drugs may help to reduce some symptoms, but they are neither curative nor a substitute for other forms of support and intervention.Canadian journal of psychiatry. Revue canadienne de psychiatrie 10/2003; 48(8):506-16. · 2.48 Impact Factor
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ABSTRACT: To study the relationship between age at initiation of toilet training, age at completion of toilet training, and the duration of toilet training. A total of 406 children seen at a suburban private pediatric practice were enrolled in a study of toilet training between 17 and 19 months of age, and 378 (93%) were followed by telephone interviews with the parents every 2 to 3 months until the child completed daytime toilet training. Information obtained at follow-up interviews included how often parents were asking their child to sit on the toilet or potty and where the child urinated and defecated. Parents were considered to have initiated toilet training when they first took out a potty chair and discussed some aspect of training with the child. Intensive toilet training was defined as asking the child to use the toilet or potty >3 times per day. Age of initiation of toilet training correlated with age of completion of training (r = 0.275). The correlation between age at initiation of intensive training and age at completion was even stronger (r = 0.459). Younger age at initiation of intensive toilet training was not associated with constipation, stool withholding, or stool toileting refusal. However, age at initiation of intensive toilet training was negatively correlated with duration of toilet training (r = -0.481), indicating that initiation of training at younger ages was associated with a longer duration of training. In addition, the correlation between age at initiation of intensive toilet training and age at completion of training was not significant for those who began intensive training before 27 months of age (r = 0.107). Early initiation of intensive toilet training correlates with an earlier age at completion of toilet training but also a longer duration of toilet training. Although earlier toilet training is not associated with constipation, stool withholding, or stool toileting refusal, initiation of intensive training before 27 months does not correlate with earlier completion of toilet training, suggesting little benefit in beginning intensive training before 27 months of age in most children.PEDIATRICS 04/2003; 111(4 Pt 1):810-4. · 4.47 Impact Factor
60 TOILET TRAINING CHILDREN WITH AUTISM
kill deficits in the areas of self-help
may be a significant hurdle for
people diagnosed with autism and
other developmental disabilities. Indeed,
toilet training for children with devel-
opmental disabilities was (Konarski &
Diorio, 1985) and continues to be one of
the most frequently researched self-help
skills. Blum, Taubman, and Nemeth
(2004) defined effective daytime toilet
training as when a child has less than four
wetting accidents per week. For the vast
majority of typically developing children
in the United States, 98%, meet this
criterion by their third birthday (Blum,
Taubman, & Nemeth, 2003).
The field of applied behavior
analysis provides an ample body of
literature that spans over four decades
and describes effective toilet training
programs in applied settings. Early
models (e.g., Azrin & Foxx, 1974; Van
Wagenen, Meyerson, Kerr, & Mahoney,
1969) relied on intense yet short periods
of intervention coupled with direct
clinical support to maximize learning.
A seminal article written by Azrin and
Foxx remains a staple in current practice
for toilet training; more recent literature
follows the underpinnings of their find-
ings though points toward less focus on
the concept of rapid training and instead
concentrates on a durable life skill read-
ily implemented in nonclinical settings
(Cicero & Pfadt, 2002; Kroeger &
Sorensen-Burnworth, 2009; Kroeger &
Sorensen, 2010; LeBlanc, Carr, Crossett,
Bennett, & Detweiler, 2005; Stadtler,
Gorsky, & Brazelton, 1999).
Since the inception
Individuals with Disabilities Education
Act, 2004 (IDEA; U.S. Department of
Education, 2004), school districts are
required to teach skills that are beyond
the scope of straightforward academic
goals; a focus on and accountability for
functional life skills is a requirement as
well. Education of children who require
specialized services needs to address
broad issues of learning including adap-
tive skills that support inclusion (Bryson,
Rogers, & Fambonne, 2003).
Even with the vast body of informa-
tion available regarding toilet training,
there are few studies that deal directly
with the issue of toilet training in school
settings (see Luiselli, 1997) and even
fewer that remove direct, ongoing
clinical support during training. This
study evaluated a public school-based
toilet training procedure implemented
by paraprofessional staff with minimal
clinical support. The goal of the study
was to explore the effectiveness of a
formal toileting procedure to increase
continent voids as well as bladder
control for expanded periods of time in
a public school program with minimal
clinical oversight. The procedure in-
cluded multiple components, including
the following: removal of diapers during
school hours, a scheduled time interval
for bathroom visits, a maximum of 3
min sitting on the toilet at each visit,
positive reinforcement of urination in
the toilet, and gradually increasing time
intervals for bathroom visits as each
student progressed through training.
Toilet Training Children With Autism and Developmental Delays:
An Effective Program for School Settings
Michael A . Cocchiola, Jr ., Gayle M . Martino, Lisa J . Dwyer, and Kelly Demezzo
Capitol Region Education Council:
CREC River Street Autism Program
Current research literature on toilet training for children with autism or
developmental delays focuses on smaller case studies, typically with con-
centrated clinical support. Limited research exists to support an effective
school-based program to teach toileting skills implemented by public
school staff. We describe an intervention program to toilet train 5 children
with autism or developmental delays who demonstrated no prior success in
the home or school setting. Intervention focused on (a) removal of diapers
during school hours, (b) scheduled time intervals for bathroom visits, (c) a
maximum of 3 min sitting on the toilet, (d) reinforcers delivered immedi-
ately contingent on urination in the toilet, and (e) gradually increased time
intervals between bathroom visits as each participant met mastery during
the preceding, shorter time interval. The program was effective across all
5 cases in a community-based elementary school. Paraprofessional staff
implemented the program with minimal clinical oversight.
Keywords: autism, paraprofessional staff, school setting, toilet training
Behavior Analysis in Practice, 5(2), 60-64
61 TOILET TRAINING CHILDREN WITH AUTISM
Participants and Settings
Participants were 5 boys ranging in age from 3 to 5 years
old and were diagnosed with either autism or a developmental
delay (see Table). None of the participants demonstrated urinary
continence, even though parents reported at least one attempt
to teach toileting skills at home, and the school also attempted
to toilet train the participants. All 5 participants were assigned
to the same preschool classroom, intended to deliver services to
children identified with autism or developmental delays.
All participants were enrolled in a preschool setting in
Connecticut and had active individualized educational plans
(IEPs) in place. Their school day consisted of direct instruc-
tion as well as inclusionary time with peers, based on each
participant’s ability and individual needs. The classroom had
an assigned special education teacher, and each participant had
1:1 support throughout the day. The 1:1 staff held at least an
associate’s degree and received ongoing training and oversight
from a Board Certified Behavior Analyst (BCBA). The partici-
pants attended school 5 days per week, 6 hours per day.
The toilet training program occurred in the same preschool
classroom for each child. The classroom provided a small area
for discrete trial instruction, a play area, an area for morning
circle, and a snack area. A bathroom adjoining the classroom
had a small toilet designed for preschool-aged children, allowing
for a smooth transition from the classroom into the bathroom
throughout the day.
Response Definition and Measurement
The dependent variable (DV) was the percentage of cor-
rect urinations in the toilet. Correct urination for the purpose
of this study was defined as the release of urine while seated on
the toilet. The independent variable was the school-based toilet
training program. Assigned 1:1 staff were responsible for all
data collection. Data were generated by recording each child’s
urinary status throughout the day. A monthly scatter plot
was provided, which was separated into 30-min increments
each day (go to http://www.abainternational.org/Journals/
bap_supplements.asp for a copy of the data sheet). Staff
documented the occurrence of urination immediately in the
cell corresponding with the time of day. The coded format on
the scatter plot included C for correct, A for accident, and I for
incomplete. Correct was defined as the release of urine while
seated on the toilet. Accident was defined as release of urine at
any other location. Incomplete was defined as when the child
neither urinated in the toilet nor had an accident during a 30-
min interval. At the end of each day, the percentage correct was
determined by a simple C/A+C equation (number correct over
the number correct plus accidents). This allowed for a simple
conversion to a percentage correct per day.
The data collected also allowed for detection of reliable times
each participant was more likely to produce urine throughout
the day. These data were readily available by plotting the times
of the day over a more extended period of time (e.g., 1 week or
longer) and determining a pattern of urination.
Interobserver Agreement and Program Fidelity
A second observer collected data for the purpose of assess-
ing interobserver agreement (IOA) and participated in an aver-
age of 37% of all bathroom visits (range, 31% to 45%) across
all 5 participants during baseline and intervention phases. IOA
was 100% across all subjects during baseline, intervention, and
post-treatment data collection.
Training for paraprofessionals began with a 1-hr in-service
training before the start of the program. This training consisted
of a PowerPoint presentation to explain procedures, a review
of data collection systems, and role playing of the procedure.
A BCBA provided didactic training and oversight of the staff
for the first day of program implementation. Following this
initial training, the consulting BCBA or special education
teacher intermittently completed direct observation of pro-
gram implementation, at least weekly. Any steps performed
incorrectly were reviewed with the direct care staff and cor-
rected at the time of the observation. The density of clinical
Table. Age, Diagnosis, and Length of Treatment for Each Participant
Age at Onset of
Number of School
Days for Mastery
Number of Calendar
Days for Mastery
Cal 5 years, 1 month Developmental Delay65 110
Lou 3 years, 9 monthsAutism88135
Job 4 years, 2 monthsAutism46 72
Tom 4 years, 2 months Developmental Delay51 86
Cam 4 years, 1 monthDevelopmental Delay3279
62 TOILET TRAINING CHILDREN WITH AUTISM
support provided was based on the success of each participant.
If the child was successful, weekly review of data occurred and
the time between bathroom visits was increased. If the child
demonstrated limited success, clinical staff more carefully
monitored and assessed the effectiveness of reinforcer, accuracy
of the bathroom visit schedule, the clarity of staff prompts, and
suggested changes as warranted.
Before the start of intervention, clinical staff interviewed
each participant’s parents and direct care staff to identify highly
preferred items for use in the toilet training program. Once the
team compiled a list of high preference items for each partici-
pant, direct preference assessments were conducted (Paclawskyj
& Vollmer, 1995). The participants had no access to the nomi-
nated items outside of the toilet training program. Four of the
5 participants selected edible rewards (e.g., M&Ms, crackers,
etc.), and one participant selected a handheld, battery-operated
spin toy. Access to the toy was limited to 15 s directly following
A concurrent multiple baseline across participants design
was used to detect the effect of the training program on correct
urinations. The baseline consisted of keeping the child in their
regular diapers throughout the day, checking the diaper to de-
termine if it was wet or dry every 30 to 60 min, and scheduled
visits to the bathroom every 60 to 120 min. The teacher based
this schedule on typical bathroom reminders that occurred in
the inclusionary preschool program. Positive verbal and social
interaction were delivered contingent on the presence of a dry
diaper as well as for urination in the toilet.
A multicomponent toilet training procedure was then
implemented by paraprofessional staff.
A countdown timer, a soft child-sized potty seat, a foot-
stool for leg support, three clean sets of clothes, and individual-
ized reinforcers were used while implementing the following
Diaper removal. At the beginning of the school day, the
participant’s diaper was removed, and he wore regular under-
pants and sweatpants for the remainder of the day.
Fluid offering. At the beginning of the day, students were
given 8 oz of water or high preference beverage, preferably in-
gested within the first 90 min of the day. Additional fluids were
offered if limited urinary output occurred. After participants
successfully urinated in the toilet at least every 90–120 min,
fluid offering was discontinued and typical fluid intake (e.g.,
snack time, lunch time) remained in place for the remainder of
Bathroom visits. Upon entering the classroom, participants
were immediately taken to the bathroom. Participants sat on
the toilet for a maximum of 3 min. Staff reset the timer for
another 30 min interval, immediately after each trip to the
bathroom. At the end of every 30 min, the timer sounded, the
staff delivered the instruction “Time for Potty” and directed
the participant to the bathroom with graduated guidance and
social praise for cooperation.
Bathroom task analysis. Once in the bathroom, staff deliv-
ered verbal cues to move through the program procedures. The
cues included: Go to bathroom, lights on, close door, pants
down, sit on toilet, stay on toilet [as needed], all done [upon
sound of timer or upon urination], pants up, wash hands,
lights off. Cues were succinct, upbeat, and were posted on the
bathroom wall for staff to reference. Social praise followed all
attempts to comply with each step. Once seated on the toilet,
the staff set the timer for 3 min. At the start of the interval,
staff held the reinforcer in the participant’s field of vision. In an
upbeat manner, staff stated, “First pee, then X” (X = reward).
This statement occurred at least 2 to 3 times during the 3-min
interval. Positive social interaction occurred when the par-
ticipant remained seated. Staff gently redirected the participant
back onto the toilet if needed.
Consequences for voiding in the toilet. Staff carefully ob-
served for any urinary output. If the participant urinated even a
drop when on the toilet, staff delivered the reward, enthusiastic
social praise within 0.5 s (e.g., “You peed on the potty! Time
for X!”), and allowed the child to get off of the toilet. Clinical
judgment was used to gradually increase the amount of urinary
output required for reinforcement, after substantial improve-
ments in urination on the toilet were initially established. If
the participant excreted no urine at the end of 3 min, the timer
sounded and the staff member guided the participant to pull
his pants up, wash his hands, and exit the bathroom.
Consequence for urinary accidents. Staff responded to wet-
ting episodes with a neutral notification to the participant that
he was wet (e.g., “You wet your pants. You need to change”).
Staff immediately guided the child to the bathroom and as-
sisted him in changing his clothes in a neutral manner. Upon
exiting the bathroom, the staff reset the timer for 30 min.
Adjusting the schedule of bathroom visits. Once the participant
reached 100% correct urination for at least 3 consecutive days,
the duration of time between trips to the bathroom increased
by 15 min increments. In some instances, the child went well
beyond the 3 consecutive day criterion. This occurred for two
reasons. First, if criterion was met on a Friday, we preferred to
extend criterion to ensure that the skill remained intact after a
weekend recess from program. Second, staff were instructed to
maintain the bathroom visit schedule until data were reviewed
by the clinical team. At times, data reviews were limited to
several days beyond meeting criterion due to the availability
of the clinician on site. Schedule changes continued until the
participant was able to remain dry all day and urinate on the
toilet with 100% accuracy when visits to the bathroom were
scheduled every 120 min.
Thinning the reward schedule. Social praise continued to
occur for every checked instance of dry pants and for correct
urinations on the toilet; however, a gradual thinning of the
edible rewards with 4 participants and the tangible reward
with 1 participant occurred throughout the process. Once the
participant urinated appropriately in the toilet on a 60 min
63 TOILET TRAINING CHILDREN WITH AUTISM
schedule, the reward was provided for every second or third
The formal program ceased once the participant demon-
strated the ability to correctly urinate in the toilet with 100%
accuracy on a 120-min schedule of bathroom visits. At this
point, the participant was cued with a more natural schedule
(e.g., typical bathroom breaks with preschool-aged children).
Social praise for correct urinations remained in place in the
school setting. Daily data collection continued at least 5 days
after mastery and occurred at 2-hr intervals to assess mainte-
nance of the skill.
Results and Discussion
Figure 1 depicts data for Cal, Lou, Job, Tom, and Cam.
Baseline for Cal revealed 38% correct urination in the toilet
over 16 days in baseline. Cal required 65 days of training to
reach the mastery criterion (100% continent voids in the
toilet during bathroom visits scheduled at 120 min intervals).
Baseline for Lou revealed 8% correct over 24 days. Lou required
88 days of training to reach the mastery criterion. Baseline for
Job revealed 34% correct over 40 school days. Fluctuation in
the data appeared to be related to spring recess and a short
summer break (1-week each), causing short-term regression,
though Lou’s performance quickly recovered. Job rapidly moved
through the sequence of increased time intervals and had no ac-
cidents throughout the treatment, requiring a total of 46 days
to reach the mastery criterion. Baseline for Tom revealed 14%
correct in the toilet over 12 days of baseline. Like Job, Tom
moved quickly through the training requiring 51 days to meet
the mastery criterion. Baseline for Cam revealed 9% voiding
in the toilet over 15 school days. In the beginning of treat-
ment, Cam had multiple accidents from 11:30 am to 12:30
pm. Based on these data, Cam was brought to the bathroom
every 15 min from 11:15 am to 12:30 pm. The remainder of
the day continued with a 30 min schedule for bathroom visits.
Cam reached the mastery criterion after 32 school days. Table 1
summarizes the number of school days as well as calendar days
required for each student to move from diaper dependency to
100% mastery criterion with a 2-hr bathroom visit schedule
The purpose of this study was to investigate the efficacy
of a toilet training program for children with autism and de-
velopmental delays in a public school setting with minimal
clinical oversight and with the intervention implemented by
paraprofessional direct care staff. Results from this study dem-
onstrated that all 5 participants were able to retain urine in
their bladder for periods of 2 hrs or more and urinate in the
toilet after implementation of this program in school.
This study differs from prior research as it describes a method
that can be implemented in a school setting by paraprofessional
staff. It implements toilet training in a nonclinical setting with
minimal clinical support, and good effects were observed
without the use of procedures like restitution or overcorrection
for incontinence. All 5 participants succeeded, though each
took varying time periods to meet criterion, ranging from 32
to 88 school days with an overall mean of 56 school days. The
number of calendar days (to include weekends, holidays, and
breaks) across all 5 participants ranged from 72 days to 135
days with an overall mean of 96 days, or just over 3 months.
Toilet training can be a developmental obstacle for par-
ticipants diagnosed with autism or developmental delays, yet
toileting skills are an important part of a person’s development
that allows for greater independence and enhances dignity in
the social domain (McManus, Derby, & McLaughlin, 2003).
Paraprofessional staff, who are often available in school districts
serving children with autism and developmental delays, were
45 6075 90 105120
45 6075 90 105120
4560 7590 105 120
% Correct Urination
4560 7590 105120
45 607590 105120
Figure 1. The percentage of correct urinations per school day is
represented for 5 participants. Breaks in the x-axis refer to seasonal
vacations and data labels denote time between bathroom visits.
64 TOILET TRAINING CHILDREN WITH AUTISM
capable in the current study to implement an effective out-
come with minimal support from supervising clinicians. These
results are encouraging because they suggest that this procedure
may be practical enough for educational staff to implement in
Nevertheless, the amount of time dedicated to the process
of toilet training does have an inherent cost in terms of time
lost to teaching other important skills. Before implementing
the program, the school-based team met with the parents and
clearly described the amount of time that toilet training would
take. In the beginning, an average of 5 to 10 min per ½ hr was
used to transition to the bathroom, sit on the toilet, and return
to work. As the interval between bathroom visits expanded, the
impact of other programming was less of a concern. Parents
were informed of this issue and understood and agreed to the
impact on academics before enrolling their child in this study.
Future research should attempt to determine the impact that
allocating time to toilet training has on academic learning
There are several limitations of this analysis that should be
considered. First, although the procedures were applied across
multiple children and paraprofessionals, additional applica-
tions of these procedures should be researched in other schools
to determine the generality of the program. In addition, the
generality of the program would also be better understood by
measuring the effects of the school-based program on in-home
continence. Once mastery was attained in the school setting
in the current study, the special education teacher met with
the parents to review procedural guidelines and encouraged
the parents to monitor program implementation in the school.
Parents of the participants reported successful toileting in the
home environment following the successful training at school.
Nevertheless, objective measurement of these sorts of outcomes
are necessary to predict the likely generality of school-based
toilet training programs.
A second limitation of this study was the omission explicit
procedures to train and detect self-initiations to use the bath-
room during the toilet training treatment program. The skill of
self-initiating toileting is important and future research should
replicate this toilet training program and add procedures for
teaching self-requesting of bathroom visits.
Despite the limitations presented here, the data across par-
ticipants provide strong evidence that paraprofessionals readily
available in an inclusionary school system can effectively imple-
ment a data-based toilet training program with lasting effects.
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Many thanks to the parents who willingly agreed to include
their children in this study. They remain anonymous to ensure
the confidentiality of the children, though their cooperation is
deeply appreciated. Also, we are indeed grateful to the special
education teachers, ABA therapists and the school district, all of
who worked as dedicated staff to meet the needs of the children
and provide empirical evidence to forward to the scientific and
educational community at large. Correspondence regarding this
paper should be addressed to Michael A. Cocchiola, Jr., Capitol
Region Education Council-River Street Autism Program, 601
River Street, Windsor, CT 06095. Email: mcocchiola@crec.
Action Editor Jonathan Tarbox