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Toilet Training for Children with Autism: The Effects of Video Modeling

  • University of Tasmania, Launceston, Australia


This study assessed the effectiveness of an animated toilet training video for teaching daytime urinary control to five young boys with autism across several settings. A between and across groups multiple baseline design was used following a 2-week baseline-monitoring period. Children in the treatment condition received video modeling plus operant conditioning strategies, whereas children in the control condition received only operant conditioning strategies. Frequency of in-toilet urinations was found to be greater for children who watched the toileting video than for children who did not. Gains were maintained for three participants at a 6-week follow-up with generalization to a new setting for two participants. Results indicate that, for young children with autism who are resistant to toilet training, acquisition of urinary control may be facilitated by use of an animated toileting video in conjunction with operant conditioning strategies.
Running header: Toilet Training for Children with Autism
Toilet Training for Children with Autism: The Effects of Video Modeling
Deb Keen
Karen L. Brannigan
Monica Cuskelly
School of Education, University of Queensland
Address correspondence to Associate Professor Deb Keen, School of Education and
Professional Studies, Griffith University, Brisbane, Queensland 4111, Australia.
Toilet Training for Children with Autism 2
This study assessed the effectiveness of an animated toilet training video for teaching
daytime urinary control to five young boys with autism across several settings. A between
groups multiple baseline across groups design was used following a 2-week baseline-
monitoring period. Children in the treatment condition received video modeling plus operant
conditioning strategies, whereas children in the control condition received only operant
conditioning strategies. The frequency of in-toilet urinations was found to be greater for
children who watched the toileting video than for children who did not. Gains were
maintained for 3 participants at a 6-week follow-up with generalization to a new setting for
2 participants. The results indicate that, for young children with autism who are resistant to
toilet training, the acquisition of urinary control may be facilitated by the use of an animated
toileting video in conjunction with operant conditioning strategies.
Key words: autism, toilet training, video modeling
Toilet Training for Children with Autism 3
Toilet Training for Children with Autism: The Effects of Video Modeling
For typically developing children, daytime toileting skills are generally achieved
by 3-4 years of age (Blum, Taubman, & Nemeth, 2003; Butler, 1997; Schum, Kolb,
McAuliffe, Simms, Underhill, & Lewis, 2002). From the limited research available,
toileting skills acquisition appears to be delayed, and in some cases never achieved, by
individuals with autism (Ando, 1977; Dalrymple & Ruble, 1992; Tsai, Stewart, &
August, 1981; Whiteley, 2004; Williams, Oliver, Allard, & Sears, 2003). For example,
Tsai and colleagues collected data on 102 individuals with autism and reported that over
59% had not achieved bladder or bowel control by 3.5 years of age. This is a pressing
problem, as it can impact negatively on an individuals personal hygiene, self-confidence,
physical comfort, stigma (Cicero & Pfadt, 2002), independence, social acceptance (Sells-
Love, Rinaldi, & McLaughlin, 2002), and caregiver burden of care.
Appropriate toileting refers to the accomplishment of various unprompted
behaviours including recognizing the need for toileting and waiting before eliminating.
Other behaviours such as undressing, sitting on the toilet, using toilet paper appropriately,
dressing, flushing the toilet, washing hands (Baker & Brightman, 1997), and not
eliminating in places other than the toilet/potty (Mahoney, Van Wagenen, & Meyerson,
1971) are also important toileting behaviours. The achievement of toileting skills is an
important developmental milestone for people with disabilities as it allows individuals
to fully participate in community activities as well as to develop a sense of personal
responsibility and self confidence (Cicero & Pfadt, 2002, p. 319). Given the current
philosophies and policies regarding the importance of inclusion of children with special
Toilet Training for Children with Autism 4
needs in regular schools (Dempsey, 2005), the achievement of appropriate toileting is
often a goal in educational settings.
Current approaches to toilet training for individuals with disabilities have drawn
heavily on operant conditioning principles, originally outlined by Ellis (1963). Ellis
developed procedures based on a stimulus-response, reinforcement framework that
included a baseline-monitoring period for establishing the time and frequency of a
persons eliminations, and toilet visits based on that pattern of toileting. Modifications
and refinements to the original techniques used by Ellis followed. Certain techniques,
however, have remained fundamental to the majority of toilet training procedures
described in the literature. These techniques involve: baseline monitoring to identify
patterns of urination; toilet visits based on that pattern or a predetermined schedule;
increased fluid intake to increase frequency of urination and practice; use of prompts to
request toileting using pictures, language or signs; fading of prompts over time; and
reinforcement for appropriate toileting behaviors.
While these approaches have been successful for some individuals with
disabilities (Azrin, Bugle, & OBrien, 1971; Lancioni & Markus, 1999; Richmond, 1983;
Sells-Love et al., 2002; Wilder et al., 1997), toilet training for some individuals with
autism and intellectual disability has been particularly difficult in terms of both effort and
length of time required. For example, Dalrymple and Ruble (1992) reported that
individuals with both autism and severe to profound intellectual disability required about
3 years of training to achieve daytime bladder control compared to 1.2 years for
individuals with autism but without intellectual disability. Lower cognitive levels
predicted higher rates of regression in toileting after training for individuals with autism,
Toilet Training for Children with Autism 5
and individuals who lacked verbal skills took about 2.7 years to achieve bladder control
compared to 1 year for children with verbal skills.
Given the extent of the toileting difficulties for individuals diagnosed with autism,
there has been surprisingly little research with this population. Some early success was
reported by Ando (1977) using an approach based on the procedures of Azrin and Foxx
(1971) with five boys aged 6-9 years with autism and profound intellectual disability.
Appropriate urinations were reinforced and punishment such as verbal reprimands and
spanking was applied for inappropriate eliminations. Although training lead to a general
increase in self-initiated toileting skills, none of the boys were completely toilet trained at
post treatment. Furthermore, the use of punishment has, for some time now, been
considered inappropriate for ethical reasons.
A small number of studies have reported some success in toilet training for
children with an autistic spectrum disorder, however, these studies have generally lacked
information about important participant characteristics such as cognitive and receptive
language skills, have had small participant numbers, or lacked detail about training
procedures and outcome measures. For example, Luiselli (1997) taught daytime urinary
control at school to an 8-year-old boy with a diagnosis of Pervasive Developmental
Disorder. Scheduled in-toilet urination was achieved and maintained at 6 month follow
up, however self-initiated toileting was not reported. Other researchers have reported
encouraging results but have had small participant numbers and have not always reported
the cognitive or language abilities of the participants (Cicero & Pfadt, 2002; Post &
Kirkpatrick, 2004).
It has been argued that teaching procedures may need to be modified for children
with autism in order to address their particular needs (Shipley-Benamou, Lutzker, &
Toilet Training for Children with Autism 6
Taubman, 2002). Current toilet training procedures may not be optimal for this group of
individuals. Children with autism tend to have a relative strength in the visuospatial area
(Quill, 1997) and video modeling has been considered an effective treatment approach
because it minimizes attentional and language demands and requires the child only to
look at a small spatial area (Sherer et al., 2001). This approach has been used effectively
to teach a range of skills to individuals with autism (Charlop-Christy & Daneshvar, 2003;
Charlop-Christy, Le, & Freeman, 2000; DAteno, Mangiapanello, & Taylor, 2003;
Schreibman, Whalen, & Stahmer, 2000; Shipley-Benamou et al., 2002). Only one study
was found that used video modeling to teach toileting to a child with autism. In this
study, a 3-year-old boy with autism learned to walk to the toilet but did not learn to
urinate in the toilet (Bainbridge & Myles, 1999). The behaviour of walking to the toilet
increased when the boy was prompted after he watched the video and decreased when the
video was omitted.
The aim of this study was to assess the effectiveness of visual materials (i.e., a
toilet training video) in conjunction with operant conditioning strategies for developing
toileting skills in young children with autism across several settings. The study used a
between groups multiple baseline across groups design. It was hypothesized that video
modeling + operant conditioning strategies would be a more effective method than
operant conditioning strategies alone.
The participants were five boys aged from 4 years 5 months to 6 years 9 months
(mean age of 5 years 2 months) and a diagnosis of autism from a paediatrician. All
participants wet their underwear or urinated in inappropriate places on two or more
Toilet Training for Children with Autism 7
occasions per day, despite past attempts at toilet training. None of the boys had ever gone
to the toilet alone and without prompting. For descriptive purposes, all participants were
assessed using a number of measures. The childrens educational program consisted of
attendance at a kindergarten, special education unit, preschool, or a combination of these.
Two of the children (John and Allen) were on medication for anxiety.
The Scales of Independent Behavior (SIB-R; Bruininks, Woodcock, Weatherman,
& Hill, 1996) is an individually administered, norm referenced test with good
psychometric properties, which assesses adaptive functioning, and the frequency and
severity of problem behaviours. Age equivalents are provided for each subtest, and
subtests are combined into adaptive behaviour clusters. Available scores included
standard scores, percentile ranks and adaptive behaviour skill levels.
The Gilliam Autism Rating Scale (GARS; Gilliam, 1995) is a norm-referenced
checklist, which is used for screening autism and is based on the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-1V; American Psychiatric
Association, 1994). The test is completed by caregivers and subtest standard scores are
converted into an Autism Quotient, which has a mean of 100 and a standard deviation of
15. Percentiles are also able to be established. The Autism Quotient provides a measure
of the probability and severity of autism, which is rated from very low to very high.
The test has good psychometric properties.
The Differential Abilities Scale (DAS; Elliott, 1990) is an individually
administered, norm-referenced battery of 17 cognitive and 3 achievement tests for
children and adolescents aged 2.5 - 17 years. The test has good psychometric properties
(Sattler, 2001). Raw scores are converted to an ability score, a percentile rank and a T
Toilet Training for Children with Autism 8
score with a mean of 50 and a standard deviation of 10. Abilities are rated from very
low to very high.Several attempts were made to assess the children using the
nonverbal subtests without success, with the exception of the Picture Similarities Subtest.
The results from the standardized assessments showed that all 5 children scored
well below their same age peers in most adaptive behaviors, particularly in personal
living, social interaction, communication, and toileting (see Table 1). They were also
significantly delayed in cognitive development, scoring at or below the 16th percentile on
the Picture Similarities subtest of the DAS. Their autism severity rating was average for
all the boys except Allen (a pseudonym), who scored in the low range.All children
were non-verbal.
Participants were recruited from multiple sources that included participants from a
previous university research study, 14 special education units, a special school for
children with autism, and by posting information about the study on the University of
Queenslands website. Written information was provided and the details about the project
explained to parents and teachers, and written consent was obtained.
A between groups multiple baseline across groups design was used to evaluate the
effectiveness of the toilet training video in multiple settings after a 2-week baseline-
monitoring period. Although multiple baseline research designs often include three or
more clients/systems in order to demonstrate treatment effectiveness, two clients/systems
are considered appropriate (Kazdin, 1982; Richards, Taylor, Ramasamy, & Richards,
1999; Thyer, Artelt & Shek, 2003). This study proceeded with two groups as described
Toilet Training for Children with Autism 9
Children within groups were matched according to age, gender, and toileting
skills using their scores on the SIB-R, and they were randomly assigned to either a
treatment or control condition. Children in the treatment condition received video
modeling plus operant conditioning strategies, whereas children in the control condition
initially received only operant conditioning strategies. Children in the control condition
were introduced to the video once in-toilet urinations commenced for the child in the
treatment condition. Allen (treatment condition) and John (control condition) began
training while the remaining children continued with baseline monitoring. Once the
toileting status of Allen improved, a second pair comprising David (treatment condition)
and Tim (control condition) began training. Edward was allocated to a treatment
condition and began toilet training at the same time as David and Tim, as there was no
available matched control. For ethical reasons, participants in the control condition were
given the toileting video to watch once the toileting status of the child in the treatment
condition made some improvement, even if the new behavior had not stabilized.
Maintenance and generalization to a new setting were assessed at 6 weeks post training.
Setting and Materials
Baseline monitoring, intervention, and post treatment evaluations were
undertaken in home and educational settings for each child. All training took place during
the day between 7 am and 6 pm, 7 days per week, by the childs parents and teachers. All
carers had access to a 30-min timer, a video player and television, recording sheets, and a
6 min animated toilet training video. The toilet training video was developed by the
Intellectual Disability Services Council in South Australia in association with Minda
Incorporated (2001). It shows the sequence of toileting steps required by both males and
females in a simple and logical order, and animated characters provide simple verbal
Toilet Training for Children with Autism 10
instructions. The video makes use of colour, sound, music and interesting and friendly
characters such as a green frog, and praise is given for appropriate toileting. A set of A4
picture cue cards accompanies the video.
Baseline monitoring. Data were collected on the childs frequency of prompted or
unprompted daily in-toilet urinations between 7am and 6pm in home and educational
setting(s) over two weeks by caregivers. During this time, children remained in nappies
and were given free access to fluids in order to match the training condition. They were not
prompted to use the toilet during this period and no toilet training occurred. Carers checked
the childs nappy every 30 min and recorded the required information on monitoring
sheets. A regular yet individualized schedule of toilet visits was established for each child
after assessing his pattern of toileting during baseline.
Selection of rewards (reinforcement). Parents completed a reinforcement schedule
and, in order to determine the relative motivating strength of individual reinforcers,
procedures established by Frost and Bondy (2002) were followed. For example, parents
presented a choice of items to their child and then observed their childs reaction. They
took note of which items were chosen first, how their child reacted when items were
presented and taken away, and what happened when items were presented again. Carers
were also given instructions about the selection and delivery of rewards. For example,
rewards were restricted to toilet training times and needed to be given immediately after a
toileting success.
The toilet training procedures were explained to caregivers (i.e., parents and
teachers) just prior to the commencement of toilet training, and all caregivers received
written toilet training procedures and instructions. Caregivers were asked to select the
minimum level of prompting required for the completion of the toileting steps. The
Toilet Training for Children with Autism 11
second author contacted all caregivers at least once per week to check on progress and to
monitor treatment compliance.
Intervention. During intervention, children were given free access to a range of
fluids in order to increase the frequency of urination and practice. On average, toilet
training occurred six to seven times per day for each child, according to the schedule
established during baseline. Children in the treatment condition were required to watch a
6 min animated video of toileting on each occasion prior to toilet use. Children in both
conditions were prompted to request toileting using pictures, language or signs.
Reinforcement was given initially for any and all of the following: walking to the toilet,
undressing, sitting on the toilet, eliminating in the toilet, redressing, flushing the toilet,
and hand washing. Promises of rewards for appropriate eliminations in the toilet were
also given. Children were required to sit on the toilet for 3 min. If the child did nothing
on the toilet after this time, carers were advised to tell the child that they did not have to
wee or poo, and to provide no other attention. If the child was unable to sit for 3 min,
carers were advised to encourage the child to sit back on the toilet. For accidents that had
already occurred, carers were advised to say Youre wet in a flat tone, and to prompt
the child to change his pants. Carers were advised to check the childs pants every 30 min
and to record the required information on monitoring sheets. This was done in order to
assess the childs pattern of toileting and whether his toileting schedule needed
adjustment. An asterisk was used to indicate whether the eliminations occurred without
prompting. If the children indicated that they needed to use the toilet or if they began to
urinate away from the toilet, carers were advised to say no, no, hurry, wee in the toilet
and to take the child quickly to the toilet. Once at the toilet, carers were required to
prompt urination.
Toilet Training for Children with Autism 12
The frequency of in-toilet urinations per day during baseline, intervention and
follow-up for all five children is presented in Figure 1. There were zero in-toilet
urinations for all participants during baseline. The three children in the treatment group
(Allen, David, and Edward) had 4, 11 and 14 in-toilet urinations respectively during the
treatment/control period and for two of the children (David and Edward) some of these
urinations were unprompted (see Figure 2). The two children in the control condition
(John and Tim) had zero and two in-toilet urinations respectively during the
treatment/control period. Given the unique responses of the children to the training
approaches, a more detailed description of the results for each child is presented below.
Allen (treatment condition). Allen had four in-toilet urinations during the
treatment/control period, the first occurring 25 days after toilet training commenced. By
day 50 he displayed a lack of interest in watching the video and his mother and one
teacher withdrew from the study. Data were then only received from one school setting
on two consecutive days per week. Although he had from one to two in-toilet urinations
per day in that setting until day 124, the results for Allen were not maintained at follow-
up. Some changes occurred in Allens life from day 124 onwards. For example, he had a
new carer at school and, during the follow-up period, he became ill and ceased taking
anxiety medication.
John (control condition). John had zero in-toilet urinations during the
treatment/control period. The video was introduced on day 51 and Johnsfirst in-toilet
urination occurred 28 days after this. By day 101 he displayed a lack of interest in
watching the video and began to protest about toilet training. It was hypothesized that
Toilet Training for Children with Autism 13
privacy at the toilet may have been an issue for John as he often hid under the bed to
urinate, he used particular gestures to indicate that he wanted to be left alone at the toilet,
and he had urinated in the toilet alone and without prompting on days 78 and 82. In order
to provide greater privacy, his mother remained out of sight when he sat on the toilet.
Picture cue cards from the video were also placed in conspicuous places at home, in order
to redirect the child from places where inappropriate urinations occurred. Correct in-toilet
urinations began on day102 and he urinated in the toilet in a new setting on day 110.
However, his pattern of correct in-toilet urinations was inconsistent during intervention.
By follow-up he had achieved two in-toilet urinations in one day and his mother stated
that she was able to redirect him to the toilet once an inappropriate elimination
David (treatment condition). David had 11 in-toilet urinations during the
treatment/control period. Although he protested initially when taken to the toilet, his first
in-toilet urination occurred 3 days after toilet training commenced. As it had been for
John, privacy at the toilet may have been an issue for David as he often urinated in
outdoor settings or in his bedroom when others were not present. Subsequently, from day
83, the changes made to Johns training were introduced for David. In-toilet urinations
began on day 84. Shortly after this, he self-initiated toileting, and urinary control
generalized to an unfamiliar setting (e.g., a community bathroom). As he had lost interest
in watching the video at this time, the video was discontinued. However, his toileting
skills regressed at the commencement of the school holidays on day 107. The toilet
training procedures plus the changes described above were reintroduced on day 118 with
subsequent gains that were maintained at follow-up.
Toilet Training for Children with Autism 14
Tim (control condition).Tim had two in-toilet urinations during the
treatment/control period. Although the video was introduced on day 89, he had not
achieved another in-toilet urination by follow-up. His mother withdrew from the study on
day 105 and all data points from that time onwards refer to one school setting only.
Edward (treatment condition). Edward had 14 in-toilet urinations during the
treatment/control period and his first in-toilet urination occurred one day after the
commencement of toilet training. Even though he protested when taken to the toilet, he
achieved from 0-2 in-toilet urinations per day at home up to day 76. As with John and
David, privacy at the toilet may have inhibited Edwards use of the toilet as he often
urinated in outdoor settings when others were not present and the same changes that were
made for John and David were implemented for Edward on day 106. The frequency of
in-toilet urinations increased from that point onwards and the results were maintained at
follow-up. At school, Edward often protested about going to the toilet, and he often
urinated before reaching the toilet. In an attempt to address this issue, he watched the
video while sitting on the toilet from day 73 onwards. However, no in-toilet urinations
occurred in that setting by follow-up.
The results from this study suggest that video modeling in conjunction with
operant conditioning techniques may enhance the achievement of daytime urinary skills
among young children with autism when compared to operant conditioning techniques
alone. During the treatment/control condition, the frequency of in-toilet urinations was
greater for children who watched a toileting video than for children who did not.
Furthermore, participants in the treatment condition achieved a more consistent pattern of
Toilet Training for Children with Autism 15
in-toilet urinations than participants in the control condition. At follow-up, gains were
maintained for the three children that had received training across several settings (John,
David and Edward) and for two of these children, toileting behavior generalized to a new
setting. For the other two children (Allen and Tim), training ceased at home after the
treatment/control condition although they continued to receive toilet training at school.
Reduced opportunities for practice may have impacted on the acquisition of toileting
skills by follow-up for these children and may have helped to account for the
disappointing results for Tim.
The results are consistent with the view that children with autism may be assisted
in their learning when information is presented visually (Biederman et al., 1999; Charlop-
Christy et al., 2000; DAteno et al., 2003; Houlihan et al., 1995; Shipley-Benamou et al.,
2002). The application of video modeling for teaching toileting skills to this population
has not been previously tested, and the results from the current study suggest that, for
young children with autism, the development of toileting skills may be facilitated by the
use of an animated toileting video in conjunction with operant conditioning principles.
The use of video modeling plus the use of picture cue cards may have been
effective in the current study because they minimized the need for oral instructions
among a group of children who were non-verbal. However, video modeling was not
necessary for the achievement of some toileting skills. For example, one participant in the
control condition learned to pull up his pants, flush the toilet, and wash his hands
independently during the treatment/control period. This is consistent with previous
studies that demonstrated the effectiveness of operant conditioning principles for toilet
training children with disabilities (Cicero & Pfadt, 2002; Post & Kirkpatrick, 2004).
Toilet Training for Children with Autism 16
Although the operant conditioning principles used in this study were similar to
those used in other studies for toilet training individuals with autism, the outcomes for
children in this study were more modest. For example, in the Cicero and Pfadt (2002)
study three children with autism requested the use of the toilet, urinated appropriately in
the toilet, and had zero urinary accidents after 18-20 days of toilet training. However,
children in the current study had not reached zero urinary accidents by follow-up. Several
factors may account for differences. Cicero and Pfadt conducted their study in the school
bathroom for the entire day where inappropriate eliminations could be prevented by
rushing participants to a nearby toilet. Toilet training in bathrooms was not undertaken in
the present study for ethical and practical reasons. For example, it was felt that other
important learning tasks would need to be put on hold for an unspecified amount of time
while training occurred in the bathroom, and extra staff time would be needed. However,
this created access problems, as toilets were generally located at some distance from the
childs main daily activities. Also, it is not known if the participants in the Cicero and
Pfadt (2002) study and the present study had similar cognitive and verbal profiles. This is
an important consideration as cognitive and verbal skills are associated with the
achievement of toileting skills among individuals with autism (Dalrymple & Ruble,
1992). Participants in the current study achieved low scores on tests of cognitive
functioning and language comprehension, and they were also highly resistant to toilet
Responses of individual children to the toilet training procedures used in this
study emphasize the complexities of toilet training for children with autism. For some of
the children, the intervention period prior to achieving the first in-toilet urination was
greater than previously reported (e.g., 25 days for Allen, 28 days for John after
Toilet Training for Children with Autism 17
introduction of the video). In contrast, David achieved his first in-toilet urination after 3
days and Edward after only 1 day. Given the small number of participants it is difficult to
draw conclusions about the specific factors or child characteristics that may have led to
these different outcomes.
One interesting finding from this study was the impact of picture cue cards and
privacy on toileting behavior. For 3 participants (John, David and Edward), the frequency
of in-toilet urinations increased when the child was afforded greater privacy when sitting
on the toilet, and when picture cue cards were used to redirect the child away from areas
where inappropriate urinations were occurring. While these intervention techniques were
not the focus of this research, they suggest a promising avenue for further investigation.
During the course of the study it was not possible to control for all variables, and
there were some confounding factors. Due to the length of the study, change was
inevitable, and it is important to note that children with autism often regress when
changes to routines are introduced (Dalrymple & Ruble, 1992). Factors such as illness,
changes in carers, and changes in medication are likely to have impacted on the
acquisition of toileting skills for the children concerned. From a clinical perspective,
however, it is important to recognize that these factors may arise for families, and to
consider how families can be supported during these periods of change or disruption.
At the conclusion of this study, none of the children were completely toilet
trained. However, parents who participated in the study until follow-up reported benefits
from their participation in addition to increased toilet use by their children. For example,
when compared to previous attempts at toilet training, they felt that their children had
progressed well. Redirection to the toilet at the commencement of an inappropriate
urination was occurring at follow-up, fewer nappies were being used, and some of the
Toilet Training for Children with Autism 18
skills learnt from the toileting program generalized to other activities for some children
(e.g., dressing and undressing for swimming).
All caregivers found the toileting procedures very resource intensive and stressful.
Access to toilets was difficult in most settings and carers stated that their motivation
wavered at times due to the length of time required to achieve the first in-toilet urination.
Carers felt that patience, persistence, consistency across settings, access to a support
person with whom they could problem solve, as well as privacy and relaxation for the
child were important factors in toilet training. They felt it would be helpful if carers were
made aware that childrens toileting skills may regressfollowing changes of routine and
that the training period may be extensive.
This study has identified a number of factors that may be important in the
acquisition and maintenance of toileting including video modeling, operant conditioning
techniques, settings in which the training occurs, privacy, and frequency of toilet visits.
For example, gains were noticed for one participant (David) when the frequency of
training at home was reduced to once a day, with the number of toilet visits increasing
when an in-toilet urination was achieved at this time. Further research into the variables
that may affect the acquisition of toileting skills and ways to provide more effective toilet
training to children with autism are needed.
Toilet Training for Children with Autism 19
Toilet Training for Children with Autism 20
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Toilet Training for Children with Autism 25
Table 1
Description of Participants
Allen John David Tim Edward
Age (Year:Month) 4:7 4:5 4:9 4:7 6:9
Percentile 5 16 Invalid 12 1DAS
T Score 34 40 Invalid 38 23
Language (Year:Month) 3:10 2:0 1:3 2:0 2:0
Toileting (Year:Month) 1:9 1:11 2:0 1:6 2:3
Dressing (Year:Month) 4:10 3:5 2:4 2:9 2:6
Motor (Percentile) 89 93 <1 6 <1
11 <1 <1 <1 <1
Personal Living
13 1 <1 <1 <1
GARS (Severity) Low Average Average Average Average
Toilet Training for Children with Autism 26
Figure Captions
Figure 1. Daily frequency of in-toilet urinations across pairs of participants at baseline,
intervention, and follow-up.
Figure 2. Frequency of prompted and unprompted in-toilet urination during the
treatment/control period.
Toilet Training for Children with Autism 27
Pair 1: Allen (Treatment) and John
Treatment Control
Frequency of In-Toilet
Pair 2: David (Treatment) and Tim
Treatment Control
Frequency of In-Toilet
Edward (Treatment)
Frequency of In-Toilet
Figure 2.
... Ho et al. (2019) examined the effects of using VM to develop joint attention and social engagement; according to their results, five out of six participants showed significant improvement in the targeted skill. VM has proven effective in improving conversation skills, such as extending and joining a conversation, responding to others (Stauch et al., 2018), greeting skills (Kouo, 2018), eye contact and turn-taking ( € Ozerk, 2015), facial expression (Axe and Evans, 2012;Mason et al., 2012), sharing an interest with others and making a request (Wilson, 2013), gesture skills (Cardon, 2013;So et al., 2016), and personal hygiene skills (Keen et al., 2007). ...
... Teachers stated that they maintained their personal hygiene: "The student maintains good personal hygiene (e.g., he washes his hands before going to the cafeteria to have lunch and brushes his teeth after he finishes eating)." A similar result was reported by prior studies, with VM proving effective in enhancing everyday life skills, such as handwashing (Meister et al., 2015), brushing teeth (Kellems et al., 2018), or toileting skills (Keen et al., 2007), for all participants with ASD. Karayazi et al. (2014) found SS to be effective in improving specific social behaviors (nose-wiping) for individuals with ASD. ...
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Social communication difficulties are one of the most common issues among individuals with autism spectrum disorder (ASD), as ASD affects their social and academic lives and isolates them from their environment. Several studies that utilized video modeling, video self-modeling, or social stories (or social stories combined with video modeling) have yielded promising outcomes in improving the social skills of individuals with ASD. However, to date, the effects of the combination of all three strategies have not been studied. The current study aimed to examine the effectiveness of an educational program based on multiple strategies, including social stories, animated video modeling, and video self-modeling, to improve the social communication skills of a sample of six high-functioning students with ASD at the Autism Academy of Jordan. A mixed method (quantitative and qualitative) approach was used to examine the impact of the program on the experimental group. The results of the Mann–Whitney test indicated that compared to the monitoring group, all participants in the experimental group achieved significant improvements in the post-test of the Autism Social Skills Profile in both the domains of social reciprocity and social participation skills. Furthermore, the data from teachers’ interviews, analyzed using WebQDA software, corroborated the results in terms of significant improvements in students’ social skills after the implementation of the educational program. The implications of the study for psychological and educational interventions are addressed, and research suggestions are made to promote the personal and social development of individuals with ASD.
... Studies have shown that bladder control is acquired around the age of 3-4 years (36.8 months ± 6 months [range = 22-54 months]) in children with typical development (Blum, Taubman, & Nemeth, 2003). However, it is usually delayed, or it could not be acquired for various reasons in children with developmental disabilities (Keen, Brannigan & Cuskelly 2007). This situation negatively affects the child's quality of life and leads to a decrease in the child's self-esteem and social acceptance (Call, Mevers, McElhanon, & Scheithauer, 2017). ...
... This age range was appropriate to provide toilet training to both children with typical development and developmental disabilities (Blum et al., 2003). This finding also indicated that there was a delay for children with developmental disabilities (Keen et al., 2007). Toilet training was mostly carried out in educational settings (Cochiola et al., 2012;Perez et al., 2020), and the studies conducted at home is limited (Rinald & Mirenda, 2012). ...
... In the literature, there are a few VBI research where contents are prepared with animations. Keen et al. (2007) conducted a study aimed to teach toilet skills to five boys with autism spectrum disorder (ASD) aged 4-6. In the study in which video modeling (VM) and operant conditioning strategies were used, only the scene showing toileting and organs was animated due to ethical concerns. ...
... In the literature, it is seen that most of the studies on VP and other VBI used videos prepared with camera recordings, while in a few studies, only some skill steps were made up of animation. In this study, similar findings were obtained with VBI studies using animation (Drysdale et al., 2015;Keen et al., 2007;McLay et al., 2015). ...
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The primary purpose of this study is to examine the effectiveness of presenting animated video prompting (VP) in teaching car wash skills to individuals with mild intellectual disability (ID). In addition, it was aimed to investigate the permanence of the teaching, the generalizability of the acquired skill, and the opinions of the participants and their families in the research about animation VP. A multiple probe design with probe conditions across subjects, one of the single-subject research designs, was used in the study. The participants of the study were three males with mild ID, ages 18–24. The study's findings show that individuals with mild ID can learn the car wash skill using the VP method prepared with animations. The use of animation can facilitate the preparation of video-based content, and video-based instruction can become widespread. Further research can investigate whether there is a difference in effectiveness and efficiency between the animation VP methods and the VP methods prepared using camera records.
... Moreover, modern VBT may contain a variety of tools, such as interactive 3D objects, interactive maps, and embedded quizzes, to increase interactivity (Kolås, 2015). Avatars and animated characters can be easily adapted to different cultural contexts, thus accommodating learners of different cultural backgrounds, professions, literacy levels, and ages (Keen et al., 2007;Maredia et al., 2018;Patell et al., 2020). ...
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Emerging technologies coupled with the power of big data will transform organizations, requiring drastic changes to traditional approaches in training, communications, and team collaboration, to name only a few examples. Scholars and practitioners in the HRD field are tasked with empirically studying these new phenomena in order to assist both employees and organizations in effectively transitioning to future work. The advent of technological innovations has opened a new frontier of simulated training, including virtual reality-based simulations (VRBS). But are these innovations more effective than traditional approaches, such as video-based training (VBT)? Empirical investigations of these emerging technologies have been limited in the field of HRD. The current study addresses the gap in the HRD literature by conducting the first empirical research related to VR technology and its impact on training. The paper examines VRBS with a mixed methods research design within the interpersonal skills training context, experimentally comparing the effectiveness of this new medium to more traditional training platforms such as VBT. Results were mixed, with all hypotheses at least partially supported by data. Findings suggest that VR does engage trainees more fully and generate more transferable knowledge than video. The paper triangulates quantitative and qualitative data to draw conclusions and highlight issues that are emerging along with this new technology.
... In the research of Piccin S. et al. (2017) an effective tool for learning hygiene items in people with ASD is the presentation of the skill through video animation. For young children with ASD, the acquisition of urinary control can be facilitated by the use of animated toilet video in combination with operational editing strategies (Keen, Brannigan, & Cuskelly, 2007). In addition to personal hygiene skills, people with ASD have problems acquiring academic knowledge and skills. ...
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Introduction: Austism spectrum disorder (ASD) heterogeneity requires these individuals to have functional heterogeneity. Compared to the general population, numerous studies have shown that people with ASD have a lower functional status in performing daily activities and most of them require assistive technology. Methodology: We performed a comparative analysis of the collected data from 72 subjects with ASD and 75 neurotypical controls aged 3-24 years using the Rochester Health Status Survey IV (RHSS-IV) by conducting a structured individual interview to provide a comparative item for functional status and use of assistive technology in Macedonia. Results: Children with ASD have a lower functional status in performing daily activities required for eating, dressing, showering and using the toilet (p = 0.000), as well as acquiring academic knowledge and skills (p = 0.000). Children with ASD use more assistive technology (p = 0.032) as opposed to neurotypical children and the most commonly used are alternative and aumentative devices (p = 0.002). Conclusion: Most children with ASD have a lower functional status in performing the daily activities required for eating, dressing, showering and using the toilet, as well as acquiring academic knowledge and skills unlike their peers with neurotypical development. Also, children with ASD use alternative and augmentative devices, which is not the case with children in the control group. Accurate quantification is crucial for the progress and positive outcome of children with ASD.
... Keen et al. [15] investigate the effectiveness of an animated toilet training video for children with autism. The result of the study shows that visual support through toilet training has a positive effect on the children's behaviour, as the children in the treatment group urinate more in the toilet than the control group. ...
Care for people suffering from cognitive impairment is demanding and requires a high level of personnel attendance by nurses and driving costs as well as the need for additional human resources. Specifically, the toileting process is a neglected area and taboo topic that has not been tackled so far. People with cognitive impairments like dementia often cannot go to the toilet on their own. Instead, caregivers need to accompany them to provide assistance. We present a computer vision solution which detects the current pose of a person on the toilet based on privacy-preserving 3D depth data. Instructions of the next step the user needs to perform is provided on a screen. The proposed toileting guide is regarded to be useful in terms of increased autonomy, especially for persons with mild dementia. Additionally, time is expected to be relieved care givers which leads to improvement of work load and efficiency.
... Alternative strategies that have received some empirical support are predominantly based on intervention packages. These include the use of video modeling and video self-modeling, which is commonly paired with prompting and reinforcement procedures and regularly scheduled practice opportunities (Bainbridge & Smith Myles, 1999;Drysdale et al., 2015;Keen, Brannigan, & Cuskelly, 2007;Lee et al., 2014;Sutherland, Carnett, van der Meer, Waddington, Bravo, & McLay, 2018;McLay et al., 2015). There are also a limited number of studies that have investigated the use of environmental or stimulus modification procedures such as the modification or removal of diapers. ...
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This chapter provides an overview of educational needs of students with intellectual and developmental disabilities (IDD) in academic subject areas and research-based instructional strategies to address their needs in educational settings. A review of recent academic intervention research is provided with a focus on variations in participant characteristics (e.g., age, diagnosis, functional ability) across academic subject domains (e.g., literacy, mathematics, science). Based on results of the synthesized literature, the chapter offers practical recommendations for educators to select appropriate academic goals and effective instructional strategies for students with IDD to support them to achieve meaningful academic outcomes in educational settings.
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Background Children and young people with neurodisability often need help to achieve socially acceptable bladder and bowel control. Approaches vary depending on whether or not the impairment results from spinal cord pathology that impairs motor control and sensation of the bladder and bowel. Currently, there is uncertainty about which interventions are effective. Objective The objective was to summarise the available evidence on and current practice for improving continence in children and young people with neurodisability. Design A systematic review of the effectiveness, cost-effectiveness and factors that modify intervention implementation, alongside a cross-sectional, online survey of current practice with health professionals, parent carers, school and care staff and young people with neurodisability. Results Twelve databases were searched in the review, resulting in 5756 references; 71 studies (72 papers) were included in the analyses. Most of the evidence was for children with spinal cord pathology, which involved evaluations of pharmacological approaches and surgical techniques, whereas the evidence pertaining to those with non-spinal-cord-related pathology tended to be for behavioural interventions. The methodological quality of studies was rated as being moderate to poor. There were three robust qualitative studies about the experience of continence among children with spinal cord pathology. We found substantial heterogeneity across the interventions that we evaluated in terms of quality, study design and outcomes measured. No economic studies were found. The results were synthesised narratively and reported in text and tables. We did not find any eligible studies evaluating interventions using toilet and clothing adaptations in the review, although the survey highlighted that these types of interventions are frequently used and considered. In total, 949 people responded to the survey: 202 health professionals, 605 parent carers, 122 school and social care staff, and 20 young people. The survey results illustrated the different roles that professionals have in improving continence, highlighting the importance of a multidisciplinary approach to supporting children and young people and their families. Clinicians employ a range of assessments and interventions to improve continence or independent toileting, depending on the needs of the child. Limitations Quantitative studies in the review were not methodologically robust. The survey had a risk of response bias. Conclusions Our research found a dearth of good-quality evidence for many of the interventions currently in use, and no evidence of experiences of implementing interventions for children with non-spinal-cord-related pathology. There was also no evidence of cost-effectiveness of any of the interventions. Future work There is a need to involve young people and families in the design of high-quality evaluative research for interventions that aim to improve continence. This is especially the case for children with autism and learning disability, who have been neglected in previous evaluative and qualitative research. We recommend better training for health, education and care professionals about toileting, informed by evidence and the lived experiences of children and their families. We recommend a joined-up multidisciplinary and holistic approach to improving continence to maximise independence, dignity and comfort. It is vital that children and young people with neurodisability have early access to regular, integrated assessment of their bladder and bowel health, and are fully supported with appropriate personalised treatment. Study registration This study is registered as PROSPERO CRD42018100572. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 25, No. 73. See the NIHR Journals Library website for further project information.
Children with autism spectrum disorder (ASD) with rigidities, anxiety or sensory preferences may establish a pattern of holding urine and stool, which places them at high risk of developing bladder bowel dysfunction (BBD). BBD, despite being common, is often unrecognised in children with ASD. With this case report of a 7-year-old girl with ASD presenting with acute retention of urine, we attempt to understand the underlying factors which may contribute to the association between BBD and ASD. Literature review indicates a complex interplay of factors such as brain connectivity changes, maturational delay of bladder function, cognitive rigidities and psychosocial stressors in children with ASD may possibly trigger events which predispose some of them to develop BBD. Simple strategies such as parental education, maintaining a bladder bowel diary and treatment of constipation may result in resolution of symptoms.
Personal hygiene and grooming involve a variety of behaviors that should be performed regularly to support physical health and social inclusion. Sufficient personal hygiene and grooming practices can be difficult for people with intellectual disabilities to attain due to deficits in motor, communication, and cognitive abilities. This chapter outlines evidence-based approaches to teaching a variety of grooming and hygiene practices, including dressing, oral hygiene, menstrual care, handwashing, bathing, grooming, and toileting. The chapter begins by describing general evidence-based approaches, commonly implemented in the teaching of personal hygiene tasks and concludes by summarizing the available evidence supporting their effectiveness for use across specific personal hygiene activities with people with intellectual disabilities.
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This study investigated the use of video priming, or exposure, as a means for reducing or eliminating the disruptive behavior of children with autism in transition situations. Specifically, it was hypothesized that such disruptive behavior would be reduced if the children received prior priming to upcoming transitions. Three children with autism who demonstrated severely disruptive behavior during transitions viewed short videos of specific transition situations in which parents reported behavioral difficulties. A multiple-baseline design across participants showed that the implementation of the video priming procedure led to a reduction or elimination of the disruptive behavior. Further, behavior reductions generalized to new transition situations. The results are discussed in terms of the possible mechanisms responsible for treatment effects and the potential advantages of using video interventions with this population.
Conference Paper
Background: Many children with autism spectrum disorders present with behavioral difficulties that necessitate the use of an abbreviated measure of intelligence. The authors of the Stanford- Binet Intelligence Scales, Fifth Edition (SB5) (Roid, 2003) report a correlation of .81 between the Full Scale IQ (FSIQ) and Abbreviated IQ (ABIQ) for children ages 2 to 5 and a correlation of .87 for children ages 6 and above. Coolican, et. al, (2008) examined the performance of children with ASD on the SB5 and determined that ABIQ scores accounted for 89.9% of the variance in the FSIQ, and that ABIQ overestimated FSIQ in 15 out of 17 cases. Objectives: To determine the relationship between the SB5 ABIQ and FSIQ in a sample of children with ASD; to determine this relationship when the sample is stratified on level of cognitive functioning; and to determine the rate of false positives/negatives for children with scores above and below 70. Methods: This study utilizes the Autism Treatment Network (ATN) Registry data. 519 children (male = 441; ages 2-17 years) who had a SB5 FSIQ (thus, generating an ABIQ) were included in the study. Correlations between the FSIQ and ABIQ and a regression analysis were performed to determine the proportion of variance in the FSIQ accounted for by the ABIQ. Subjects were also split into High Functioning (IQ >70) vs. Low Functioning groups. Correlation coefficients were run between ABIQ and FSIQ for these two groups. FSIQ scores and ABIQ scores were analyzed to examine the rate of false positives (ABIQ <70 and FSIQ > 70) and false negatives (ABIQ > 70 and FSIQ < 70). Results: The correlation between the ABIQ and the FSIQ for the entire sample was r=.899 (p<.0001) and a regression using the FSIQ as the dependent variable showed a strong relationship (r=.910, p<.0001) for the entire group. There was a weaker (but significant) correlation between ABIQ and FSIQ for the 212 subjects with IQ scores < 70 (r=.672) while the relationship between ABIQ and FSIQ for subjects with cognitive levels > 70 was stronger (r=.806, p<.0001). There was 90% agreement for individuals (n=178) who were low functioning on the FSIQ and the ABIQ (10% rate of false positive) and 85% agreement rate for individuals (n=341) who were high functioning on the FSIQ and the ABIQ (15% false negatives). Conclusions: Results show a strong relationship between abbreviated and full cognitive measures of intelligence in a sample of children with ASD. Compared to Roid’s rate of false positives for the SB5 standardization sample (<1%), we see an increased rate of false positives and false negatives. This suggests that while the ABIQ may both over and underestimate overall cognitive abilities, it is a valid estimate of intelligence.
AN ABACD design was utilized to examine the effectiveness of a video-taped modeling program. The purpose of the program was to increase community involvement of a man with developmental disabilities who was refusing to go on outings following recent invasive medical procedures. The initial program consisted of a baseline phase, during which the subject most often refused to go out into the community, and an intervention phase involving the presentation of a brief video as a prompt lo go on an outing. The video portrayed two of the subject's peers going out to eat, shopping, or going to a bank. A return to baseline was followed by a phase involving therapist contact in which taping and program redevelopment occurred. Following this phase, intervention was again implemented. This intervention phase involved brief video presentations that portrayed the subject himself going on outings. The results suggest clinically significant improvement during both intervention phases. This study illustrates the utility of peer- and self-modeling programs in treating populations with severe disabilities and endorses the usefulness of video as a modeling tool.
The use of single-system research designs (SSRDs) has the potential to help social workers empirically evaluate the outcomes of practice. Descriptions of using SSRDs to evaluate social work practice are provided. SSRDs have the potential to help social workers in Chinese contexts to provide scientifically credible evidence to others that social services benefit the people.
Early elements in an operant chain of toilet behaviors were trained in three normal infants and five retarded children. Following that, eliminative behaviors were conditioned by operant procedures. Each child was equipped with an auditory signalling device that gave cues to the learner. Baseline behavior was recorded for a period of five days. The procedure for training consisted of two steps. First, a response was obtained through physical, verbal, and auditory prompts. Second, prompts were faded until the child responded in the presence of the auditory signal. When the device was removed the child performed without the auditory prompt. Parents were instructed in a similar procedure to enhance generalization in the home. Seven of the eight subjects reached a criterion and maintained that behavior during three criterion sessions.
Research on video modeling has typically utilized either competent peer models or self-models engaging in criterion performances. Although both methods have demonstrated utility in achieving skill acquisition, each has potential disadvantages. The current research utilized a multiple probe design across tasks and replicated across participants in order to demonstrate the efficacy of an instructional video modeling technique to teach functional living skills to three children with autism. Five tasks were selected. Prior to the development of each training video, task analyses were created. Videotapes were developed from the participant's viewing perspective, that is, as the participant would be viewing the task. Instructional video modeling was effective in promoting skill acquisition across all three children and maintained during the postvideo phase and a 1-month follow up.
The identification of efficient teaching procedures to address deficits in imaginative play skills, which are commonly seen in children with autism, is a challenge for professionals who are designing treatment programs. In the present study, video modeling was used to teach play skills to a preschool child with autism. Videotaped play sequences included both verbal and motor responses. A multiple-baseline procedure across three response categories (having a tea party, shopping, and baking) was implemented to demonstrate experimental control. No experimenter-implemented reinforcement or correction procedures were used during the intervention. Results indicated that the video modeling intervention led to the rapid acquisition of both verbal and motor responses for all play sequences. This procedure was shown to be an efficient technique for teaching relatively long sequences of responses in relatively few teaching sessions in the absence of chaining procedures. In addition, the complex sequences of verbal and motor responses were acquired without the use of error-correction procedures or explicit experimenter-implemented reinforcement contingencies.
Perspective taking refers to the ability to determine mental states of others in order to explain or predict behavior. In typically developing children, this skill appears around age 4 years (Baron-Cohen, Leslie, & Frith, 1985), but it is delayed or absent in children with autism. In the present study, video modeling was used to teach perspective taking to three children with autism. A multiple-baseline design across children and within child across tasks was used to assess learning. Generalization across untrained similar stimuli was also assessed. Video modeling was a fast and effective tool for teaching perspective-taking tasks to children with autism, resulting in both stimulus and response generalization. These results concurred with previous research that perspective taking can be taught. Unlike other studies, however, wider ranges of generalization were found.