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ORIGINAL ARTICLE
The Effects of a Decision-Protocol Informed Toilet
Training Intervention for Preschoolers
with Disabilities
Madeline R. Frank
1
&Ji Young Kim
1
&Daniel M. Fienup
1
#Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
We describe a decision protocol for choosing among potentially efficacious toilet
training interventions and tested its effects with 3 preschool participants with
disabilities. We utilized a decision protocol (Keohane and Greer 2005)todeter-
mine whether to initially implement interval or rapid training interventions as well
as to determine whether adequate progress was being made with a particular toilet
training intervention. We utilized the decision protocol to individualize toilet
training procedure and evaluated its effects in a delayed multiple baseline design.
Results indicated that the toileting skills of all participants improved with in-
creased numbers of target voids on the toilet and decreased numbers of accidents
as a result of individualized training procedures.
Keywords Preschoolerswithdisabilities.Decision protocol.Intervaltoilettraining.Rapid
toilet training .Toilet training
Toileting competence is an important skill that affects socialization and school
placement (Kroeger and Sorensen-Burnworth 2009). In response, researchers
developed rapid and interval toilet training procedures for individuals with
developmental disabilities. In their seminal study, Azrin and Foxx (1971)evalu-
ated a rapid toileting intervention for adult participants with intellectual disabil-
ities. The researchers placed toilet training on a regular interval, reinforced
successful voiding on the toilet, and implemented over-correction and time-out
procedures contingent upon accidents. Early work in this area also included wet-
alarms to monitor accidents. Subsequently, researchers have evaluated modified
toilet training procedures that eliminated the usage of specialized equipment
https://doi.org/10.1007/s10882-019-09703-2
*Daniel M. Fienup
Fienup@tc.columbia.edu
1
Department of Health and Behavior Studies, Teachers College Columbia University, 525 W. 120th
Street, Box 223, New York, NY 10027, USA
Published online: 14 September 2019
Journal of Developmental and Physical Disabilities (2020) 32:477–488
(LeBlanc et al. 2005; Post and Kirkpatrick 2004) and these interventions have
resulted in increased appropriate toileting behaviors, maintenance of skills, and
generalization of skills to non-experimental settings.
Although there are many studies on toilet training in the field of applied behavior
analysis, few studies have been conducted in naturalistic educational school setting.
Cocchiola et al. (2012) filled this gap by developing a school-based toilet training
program for preschoolers and demonstrated the effectiveness of interval toilet training
for children with autism and developmental delays. The researchers showed that a
systematic procedure effectively increased correct voids on the toilet with
paraprofessional school personnel implementers. Greer et al. (2016) conducted a
component analysis of toilet training in a naturalistic setting with typically developing
preschoolers. The researchers examined the effects of a toilet training package as well
as individual components such as wearing underwear, frequent sitting on the toilet, and
differential reinforcement of appropriate toileting. The researchers found that the
toileting skills of some children improved as a function of wearing underwear; how-
ever, those effects tended to be delayed and the most immediate changes in toileting
behavior occurred with a treatment package.
Given the breadth of available toilet training interventions and components of
training, research is needed on how to determine which interventions to use with
which children, especially for children with disabilities who may require more
intensive interventions. A decision protocol may aid an interventionist in selecting
treatments and components. Decision protocols have been developed to assist
interventionists in deciding when to continue effective and discontinue ineffective
treatments (Kipfmiller et al. 2019), selecting measurement of problem behavior
(LeBlanc et al. 2016), and selecting among potentially-efficacious treatments for
children with escape-maintained behavior (Geiger et al. 2010, and to assist
teachers in deciding when to terminate ineffective instruction and how to change
teaching procedures (Keohane and Greer 2005). In the cases of decision protocols
for selecting interventions (Geiger et al. 2010; Keohane and Greer 2005), the
behavior of interest has a number of associated interventions with considerable
empirical support, but no silver bullet that is effective for every potential inter-
vention recipient. So is the case with toilet training interventions, where several
interventions have sound empirical backing, but no one intervention is appropriate
for all contexts (e.g., Halliday et al. 1987; Vermandel et al. 2008).
The purpose of this study was to further extend the toilet training literature by
developing a decision protocol to inform individualized modifications to poten-
tially efficacious toilet training interventions (rapid and interval interventions).
This study was conducted in a naturalistic educational setting and followed the
general protocol articulated by Cocchiola et al. (2012). The decision protocol
(Keohane and Greer 2005) guided intervention selection and procedural modifi-
cations. For choosing toileting interventions, we considered a number of context
variables (e.g., Geiger et al. 2010; Keohane and Greer 2005) including parent
support, classroom resources, and progress to that point. Parental support was a
critical variable as the goal of the intervention was to produce outcomes that could
be supported in school and home settings. We also used the decision protocol to
pinpoint when instructional decisions were needed and what modifications would
help ameliorate challenges at that point.
Journal of Developmental and Physical Disabilities (2020) 32:477–488
478
Method
Participants, Setting, and Materials
We selected three preschool participants who did not use a toilet and had several
accidents each day. Ken, Dan, and Matt were all 4-years-old (4.1, 4.1, and 4.3,
respectively) and were educationally classified as preschoolers with disabilities. Toilet
training was age appropriate for these participants (American Academy of Pediatrics;
Shelov 2009) and none of the participants had histories of receiving toilet training at
school or home. Each participant was physically capable of sitting on a toilet and
controlling his urinary bladder movement without medical support. None of the
participants had medical diagnoses. The parents of each participant expressed interest
in toilet training and agreed to follow the same procedures at home to maintain
consistency.
Each participant attended an integrated preschool (ages 2 to 5) that followed the
Comprehensive Application of Behavior Analysis to Schooling (CABAS®) model
(Greer 2002). All participants were in the same classroom and the nearest bathroom
was located 32 m away from the classroom and included two child-sized toilets.
Additionally, the researchers utilized a portable toilet that was placed inside the
classroom. The researchers also utilized a variety of preferred stimuli as consequences
for appropriate behavior (edibles, videos, toys, and vocal praise). We identified pre-
ferred stimuli through conversations with participants’parents as well as through
observation of stimuli the child played with during school and stimuli that were found
to reinforce academic responding.
Interventionists
Two paraprofessionals (i.e., teaching assistants with Bachelor’s degrees) and one
special education teacher implemented all procedures. The special education
teacher was a Board Certified Behavior Analyst (BCBA) and was enrolled in a
doctoral program in Applied Behavior Analysis (first author). The teacher trained
the two paraprofessionals and provided oversight throughout the study using
Teacher Performance Rate Accuracy (TPRA) (Ingham and Greer (1992). One of
the paraprofessionals was enrolled in a Master’s program in Applied Behavior
Analysis (second author).
Data Collection
We collected data on: (1) the number of target urinary voids, (2) the number of urinary
accidents, and (3) the daily percentage of target voids on the toilet. A target urinary void
was defined as a participant sitting on a toilet and urinating in the toilet. Any amount of
urine constituted a target urinary void at the start of the study and after substantial
improvements in urinary voids were made, clinical judgment was used to gradually
increase the amount of urinary output required for participants to contact reinforcement
(e.g., see Cocchiola et al. 2012). A urinary accident was defined as a void in any place
other than the toilet. We also calculated the percentage of target voids (target voids/total
number of voids × 100).
Journal of Developmental and Physical Disabilities (2020) 32:477–488 479
Procedure
Baseline Prior to intervention, researchers measured target and accident urinary voids
using a dry/wet check baseline period every 15 min while the participants remained in
diapers. Per check, the researcher asked the participant, “Are you wet or dry?”and
visually checked whether the participant’s diaper was wet or dry. If the student was dry,
the researcher required the participant to respond (“I’mdry”) and praised him for
staying dry. No preferred stimuli were provided. If the student was wet, the researcher
required the participant to respond (“I’mwet”) and assisted the student with cleaning
himself and changing his diaper. When time for the participant to indicate his state (wet/
dry), if the participant made no response within 3 s, researchers prompted with an
echoic model.
Interventions Researchers chose among empirically supported interventions and de-
cided among them based on the toilet training decision protocol (described below). The
two primary interventions under consideration were the interval toilet training and rapid
toilet training interventions (for a comparison of interventions, see Table 1).
Interval Toilet Training Researchers implemented interval toilet training in a similar
manner to that described by Cocchiola et al. (2012) with modifications to criterion and
time elapsed sitting on the toilet. Immediately upon arriving to school, the researcher
sat a participant down on the toilet until one of two conditions was met: (1) the child
had a target urinary void, or (2) 5 min elapsed. The researcher provided vocal
instructions (e.g., “go to the bathroom,”“sit on the toilet,”“pants up”)toassistthe
participant in the toileting routine. After the initial toileting opportunity, the researcher
placed the participant in regular underwear, prompted the child through washing his
hands, and immediately offered him water or a preferred beverage. At this point, the
researcher began the first interval (e.g., 30 min) and made increased fluids available to
the participant for the rest of the school day.
Researchers implemented differential consequences for no void, target voids, and
accidents. If a participant did not void within 5 min of being placed on the toilet, the
researcher brought the participant back to the classroom and started a new interval.
Table 1 Strengths and potential limitations of toilet training treatments
Intervention Description Strength Potential Limitations
Interval Toilet
Training
Child sits on toilet on
fixed-time schedule
(e.g., every 30 min)
and remains on toilet
for 5-min or until a
successful void
•Easier to generalize
•Relatively brief
interruptions of
instruction time
•Requires less time
at the toilet
•May require more
sessions to mastery
•May have to clean/change the
students more often
Rapid Toilet
Training
Child sits on toilet until
target void and short break
from sitting on
toilet contingent on a
successful void
•Immediate and regular
consequences
•May result in quicker
acquisition of toileting
competencies
•Requires a clinician or
teacher to be present at all
times
•Difficult to generalize
•Significant loss of instruction
time
Journal of Developmental and Physical Disabilities (2020) 32:477–488
480
Contingent on a target void, a researcher praised the participant, started a new interval
timer, and provided access to a preferred stimulus during a 5 min break in the free-play
area of the classroom. Contingent on an accident, the researcher told the participant
(using a neutral tone) that he was wet and instructed the participant to change and clean
himself. Because participants now wore clothing instead of diapers, the researcher
instructed the participant to take off shoes, socks, pants, and underwear, gave him
wipes to clean himself, and provided assistance with dressing in new clothes. The
participant was directed to put the wet clothes into a plastic bag and to put the bag to his
backpack. Afterwards, the researcher told the participant, “We pee on the potty, we stay
dry.”The researcher instructed the participant to sit on the toilet for an additional 5 min,
after which the researcher reset the interval toilet training timer.
Researchers began with an interval of 30 min and increased intervals by 15 min.
Criterion for increasing the interval was 100% target voids for two consecutive days.
Rapid Toilet Training Researchers implemented the rapid toilet training intervention in
a similar manner to the interval toilet training protocol. The primary difference between
interventions was that the rapid toilet training intervention did not limit the amount of
time the participants sat on the toilet; rather, a participant remained seated on the toilet
until he achieved a target urinary void (Azrin and Foxx 1971). Due to the fact that this
procedure could result in extended time away from regular instruction, the goal was to
move away from this intervention to the interval intervention. When the rapid inter-
vention was implemented, researchers implemented two phases of rapid and moved to
the interval procedure. The two phases were 15 min and 30 min reinforcer consumption
time contingent on a target void followed by sitting back on the toilet.
Decision Protocol The goal of the decision protocol was to assist clinicians and parents
in selecting toilet training interventions, assessing whether adequate progress was being
made, and assist in making modifications to interventions. Figure 1displays the
decision protocol and variables considered to select specific toileting interventions
and modify interventions that were producing inadequate progress. That is, the decision
protocol included both selection of interventions and rules to stop and continue
treatments based on a participant’s performance. The two primary interventions under
consideration were interval training and rapid toilet training. Both interventions have
strengths and weaknesses (see Table 1). For example, interval training allows a teacher
to continue regular instruction with only brief interruptions, but the intervention may
take some time to work effectively. With rapid toilet training, there is evidence of
immediate effects and frequent reinforcement for appropriate voiding, but given that
children remain on the toilet until a void and only briefly leave the toilet, this
intervention essentially put all regular instruction on hold.
Another goal of the decision protocol was to use interval training and gradually
increase the duration of intervals between sitting on the toilet. Once researchers selected
the appropriate initial toileting intervention, progression of phases was made in accor-
dance with each participant’s performance data. Researchers continued phases when a
participant’s data demonstrated ascending trends and increased the interval when
criterion was met. Researchers made a decision to stop a phase and change toileting
interventions (e.g., between interval and rapid interventions) when the data showed no
improvement or a decrease in target behaviors across three successive data paths or five
Journal of Developmental and Physical Disabilities (2020) 32:477–488 481
overall data paths (Keohane and Greer 2005). A single data path was a line connecting
two data points and we analyzed consecutive data paths. The rapid training intervention
was implemented if: 1) parents indicated support of the rapid intervention over the
interval intervention, or 2) if a participant made inadequate gains with the interval
intervention. When a decision point to change toileting interventions arose, researchers
assessed the available classroom resources, holidays and breaks in the schedule, and
parent input. Considering parental input and scheduled breaks was critical in making
instructional changes as one goal of toilet training was maintenance and generalization
across different times and settings.
Experimental Design
We utilized a delayed multiple baseline design to evaluate the effects of a decision-
protocol informed intervention on appropriate urinary voiding. Following 2 to 3 days of
baseline assessment, we began intervention. As one participant began intervention, we
began formal baseline data collection with the next participant. It is of note that while
we collected formal baseline data at specific times, the selected participants exhibited
multiple accidents per day prior to formal data collection (since birth). Decisions to
change toilet training intervals and/or implement a rapid toilet training intervention
were made based on the decision protocol (see Fig. 1).
Interobserver Agreement (IOA)
A second observer independently collected data for the purpose of assessing interob-
server agreement (IOA) and participated in 20% of all diaper checks (baseline) and
toileting opportunities (intervention). IOA was calculated by adding the number of
trials with agreement across both observers, dividing by the total number of trials, and
multiplying by 100%. Agreement was 100% for all baseline and intervention sessions.
The second observer was regularly involved in the participants’daily care and not an
outside observer. A separate sheet for data and the TPRA form (Ingham and Greer
1992) were used to collect IOA.
Results
Figure 2displays the number of accidents and target voids on the toilet. Figure 3
displays the percentage of daily target voids for each participant. During baseline,
Ken (top panels) displayed four to five accidents with no target voids on the toilet.
Due to his parent’s interest in the interval intervention, we began with a 30 min
interval toilet training phase along with continued 15 min wet/dry checks. Within
4 days Ken demonstrated two consecutive days of no accidents and multiple target
voids in the toilet. His behavior maintained this pattern of performance as the
15 min wet/dry checks were eliminated and the interval was increased to 45 and
60 min, respectively.
Dan’s data are displayed in the middle panels of Figs. 1and 2. During baseline, Dan
emitted three to five accidents and zero target voids on the toilet. Due to his parent’s
Journal of Developmental and Physical Disabilities (2020) 32:477–488
482
interestinthe interval intervention, we began with a 30minintervaltoilettrainingphase
along with continued 15 min wet/dry checks. Across five data paths (decision protocol
rule), Dan’s performance did not improve, with 0 to 1 target voids per day and 0 to 1
accidents per day. Thus, we implemented the 15-min reward rapid toilet training
intervention and Dan continued to have 0 to 1 target voids and accidents per day. After
3days,Dan’s parents expressed interest in returning to interval toilet training to mimic
theintervention the parents determined manageableat home.Toincreasetheprobability
ofsuccesswith interval training, giventhattheinterventionwasunsuccessfulat first, the
researchers began using the portable toilet in classroom, placed Dan on the toilet every
90 min, and had him stay on the toilet for 15 min or until he engaged in a target void.
Immediately,accidentsreducedtozeroandtargetvoids increased to two. This pattern of
responding continued as the amount of time sitting on the toilet was reduced to 5 min, a
transition was made back to the regular toilet, and even continued when researchers
simply asked Dan every 90 min if he needed to use the toilet.
Baseline (Wet/Dry Check)
Steady St ate Responding
Increased accidents OR parent interest
Interval Intervention Rapid Int ervention
30 min (15 min check)
CRIT ERI ON MET
NOT
15 min reward
30 min
CRITERION MET
NOT
45 min
CRIT ERI ON MET NOT
CRITERION MET NOT
30 min reward
CRIT ERI ON MET NOT
60 min
CRIT ERI ON MET
NOT
Ma in t enanc e
Reassess c ont ext variables
Fig. 1 The flow-chart displays how one can select between toilet training interventions, move from phase to
phase when a child makes adequate progress (i.e., “criterion met”) and how to change interventions when
adequate progress is not being made (i.e., “not”)
Journal of Developmental and Physical Disabilities (2020) 32:477–488 483
Matt’s data are displayed in the bottom panels of Figs. 1and 2. During baseline,
Matt displayed an increasing number of accidents with five accidents and zero target
voids on the second day of baseline. Given that the number of accidents emitted by
Matt exceeded what could reasonably be maintained by researchers within the
-1
0
1
2
3
4
5
6
7
Accidents
Target Voids
-1
0
1
2
3
4
5
6
7
-1
0
1
2
3
4
5
6
7
1 3 5 7 9 1113151719212325272931333537394143454749
Days
sdioVforebmuN
Matt
Dan
Ken
BSL 1 2 3 4 5
1 2 3 4 5 6
1 2 3 4 5 6 7
1: 15min checks, Int-30
2: Int-30
3: Int-45
4: Int-60
1: 15min checks, Int-30
2: Rapid 15-reward
3: Int-90, 15-min P P
4: Int-90, 5-min P P
5: Int-90
6: Int-90 as k pa rticipant
1: Rapid 15-rew ard
2: Rapid 30-re ward
3: Int-30 P P
4: Int-30
5: Int-45
6: Int-60
7: Int-75
Fig. 2 The graph displays number of target voids and accidents across the three participants. PP = the use of a
portable potty in the classroom. Int =interval
Journal of Developmental and Physical Disabilities (2020) 32:477–488
484
classroom environment (considering that Ken and Dan were also undergoing interven-
tion) and Matt’s parent’s support of the rapid intervention, we first implemented
15 min- and 30 min-reward rapid toilet training procedures before attempting interval
training. Matt required two phases of rapid toilet training to demonstrate no accidents
-10
0
10
20
30
40
50
60
70
80
90
100
-10
0
10
20
30
40
50
60
70
80
90
100
-10
0
10
20
30
40
50
60
70
80
90
100
1 3 5 7 9 1113151719212325272931333537394143454749
Days
sdioVtegraTfoegatnecreP
1 2 3 4 5 6 7
Matt
Dan
Ken
1 2 3 4 5 6
BSL 1 2 3 4 5
1: 15min c hecks , Int-30
2: Int-30
3: Int-45
4: Int-60
1: 15min c hecks , Int-30
2: Rapid 15-re ward
3: Int-90, 15-min P P
4: Int-90, 5-min P P
5: Int-90
6: Int-90 ask participan
t
1: Rapid 15-re ward
2: Rapid 30-re ward
3: Int-30 PP
4: Int-30
5: Int-45
6: Int-60
7: Int-75
Fig. 3 The graph displays the percentage of voids that were target voids. PP = the use of a portable potty in the
classroom. Int= interval
Journal of Developmental and Physical Disabilities (2020) 32:477–488 485
and 100% target voids on the toilet. Starting with the second phase of intervention,
researchers increased the criterion for moving between phases (from two) to three
consecutive days with 100% target void because holidays and parent-teacher confer-
ences restricted Matt from continuous instruction at school. For phase four, the criterion
was four consecutive days with 100% target void because Thanksgiving break resulted
in longer no-school period. Parents and researchers wanted to ensure maintenance of
progress prior to moving forward too quickly. Then, we implemented the interval toilet
training procedure. Matt required four phases of interval training to demonstrate no
accidents and 100% target voids on the toilet.
Discussion
In this study, we developed and tested a clinical decision making model for toilet
training interventions. We utilized the school-based toilet training procedure by
Cocchiola et al. (2012) and incorporated a decision protocol to choose between interval
and rapid toilet interventions and make modifications based on participant perfor-
mance, parent input, and available resources. Participant outcomes suggest the effec-
tiveness of the decision-based toilet training protocol on enhancing toileting compe-
tence for preschoolers with developmental disabilities in a school setting across 49
school days. Our study also extended the rapid toilet training model by Azrin and Foxx
(1971), demonstrating the effectiveness of a combined intervention where both interval
and rapid toilet training were used.
Clinical decision protocols have been developed to guide clinicians and behavior
analysts in the selection of interventions for target behaviors such as escape (Geiger
et al. 2010), visual analyses of graphs (Kipfmiller et al. 2019) and selection of
measurement procedures (LeBlanc et al. 2016). These protocols are especially useful
when a clinician has to make decisions about which intervention, among several
interventions with empirical support, to implement (e.g., Geiger et al. 2010)aswell
as when to make changes to the intervention based on a student’s performance data
(Kipfmiller et al. 2019;KeohaneandGreer2005). Decision protocols add structure to
making such decisions and provide variables to consider when choosing or altering an
intervention. In natural settings, an important consideration is the available resources
for implementing interventions and choosing empirically supported interventions that
can be supported by the educational environment.
In this study, we summarized the two most commonly used toilet training interven-
tions –rapid and interval (see Table 1)–and presented a clinical decision model for
selection of interventions and guidelines to stop, continue, and modify toilet training
interventions based on an individual’s performance and contextual variables (e.g., parent
support). Several studies determined effective toilet training treatments for children with
disabilities and found that components of one intervention can be more effective for
some individuals while less for others (Greer et al. 2016). The use of a decision protocol
acknowledges that there is no one-size-fits-all toilet training protocol and that clinicians
need to consider the constraints of the environment and child characteristics. In ran-
domized control trial studies of toilet training interventions, even the “best”interven-
tions –those shown to have better effects than another intervention - do not equally
affect all participants (e.g., Halliday et al. 1987; Vermandel et al. 2008). This suggests
Journal of Developmental and Physical Disabilities (2020) 32:477–488
486
the need for decision protocols, such as that described in this study, to assist clinicians in
applying and evaluating the effectiveness of interventions at the level of the individual.
Although our study successfully demonstrated the effectiveness of the decision-
based toilet training protocol, the study is not without limitations. One limitation was
the experimental design. Our design shows limited control for maturation and instruc-
tional history as Dan and Matt’s baseline data only overlap with the intervention portion
of the participant before them. However, anecdotally, all three participants displayed
multiple urinary accidents per day prior to the intervention, suggesting that the formal
baseline data reported in the graphs extended prior to formal measurement and the
design still shows changes in behavior at three different points in time (Horner et al.
2005). Another limitation was a lack of measurement of toileting competence at home.
Parents reported that the participants toileting improved at home, but empirical dem-
onstration would have provided insight into generality of the protocol. Further, this
particular toilet training decision protocol, even though based on empirical literature,
does not have evidence that it works more effectively compared to an alternative model.
However, the flow of the frameworks is logical for clinicians and parents who seek
guidance in deciding to continue a phase and selecting treatments. For future studies,
researchers should investigate the effects of the decision protocol in a home setting and
evaluate the effectiveness of the decision protocol by comparing the model to alterna-
tive models in terms of efficiency and maintenance. Despite room for improvement, the
toilet training decision protocol, similar to other articles on decision protocols (Geiger
et al. 2010;Kipfmilleretal.2019; LeBlanc et al. 2016), provides a systematic approach
for practitioners and parents to make clinically related decisions and functions as a
useful resource for treatment selection under environmental constraints and complex
situations with limited options.
Compliance with Ethical Standards
Ethical Approval The school’s Institutional Review Board deemed this research as exempt educational
research. All procedures performed in studies involving human participants were in accordance with the
ethical standards of the institutional and/or national research committee and 1964 Helsinki declaration and its
later amendments or comparable ethical standard.
Informed Consent Each participant’s parent consented to the dissemination of data collected during regular
educational activities.
Conflict of Interest All three authors claim no conflict of interest.
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