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Toilet Training Individuals with Developmental Delays,
International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137.
doi: 10.20489/intjecse.728240
120
Saral, D. & Ulke-Kurkcuoglu, B. (2020). Toilet training individuals with developmental delays: A comprehensive review. In-
ternational Journal of Early Childhood Special Education, 12(1), 120-137. doi: 10.20489/intjecse.728240
Review Article-Received: 27.12.2019 Accepted: 31.03.2020
Dincer Saral1
ORCID: 0000-0003-0795-255X
Burcu Ulke-Kurkcuoglu2
ORCID: 0000-0003-0187-9742
Toilet Training Individuals
with Developmental Delays:
A Comprehensive Review*
Abstract
Acquisition of toileting skills is of vital significance for children with developmental disabili-
ties (DD) because individuals with DD are often delayed in or fail acquiring these skills.
The purpose of the study is to comprehensively review the studies demonstrating the ef-
fectiveness of toilet training for children with DD between 2009 and 2019. In this literature
search, four databases (ScienceDirect, EBSCOhost, Wiley Online Library and Spring-
erLink) were searched by using eight keywords and a total of 1360 studies were identified.
The studies were evaluated in terms of eligibility criteria and 23 studies were included in
the review. Authors examined the studies by the demographic, methodological and out-
come characteristics. The review highlighted that toilet training programs, packages or pro-
tocols are developed according to researchers’ preferences and participant characteristics,
as such, there is still no agreement on a common toileting program in literature. Directions
for future research are also discussed.
Keywords: Toilet Training Individuals with Developmental Delays
1
MA, Hacettepe University, Department of Special Education, Faculty of Education, Ankara, TURKEY.
e-mail: dincersaral@hacettepe.edu.tr
2
Ph.D., Anadolu University, Research Institute for Individuals with Disabilities, Eskisehir, TURKEY.
e-mail: bulkekurkcuoglu@anadolu.edu.tr
*Corresponding author.
*This article was presented as an oral presentation at 2nd International Congress on Early Childhood Intervention (ICECI 2018).
Introduction
Toileting refers to successful and un-
prompted accomplishment of recognizing
the need of visiting the toilet, waiting be-
fore elimination, going to toilet, in-toilet
elimination, having less or no toileting ac-
cidents and consistent dryness (Kur-
niawan, Purnamasari, Rakhmawati, &
Jalaputra 2018). In addition to the chain of
these steps, toileting contains such skills
as pulling pants up/down, sitting on the
toilet, appropriate use of toilet paper,
flushing and washing hands (Suppo &
Mayton 2012). In the population with typi-
cal development, these skills are com-
monly acquired between the ages of 3
and 5 (Dalrymple & Ruble 1992). How-
ever, many children with developmental
disabilities (DD) such as autism spectrum
disorder (ASD) and intellectual disability
(ID) are often delayed in or fail acquiring
these skills (Keen, Brannigan, & Cuskelly
2007; Levato et al., 2016). In a study by
Szyndler (1996), 82% of parents of chil-
dren with DD indicated their children were
affected by toileting difficulties. In addi-
tion, Matson, Horovitz and Sipes (2011)
found that more than a half of 153 partici-
pants with DD had frequent toileting prob-
lems. It is also notable that prevalence
rate of encopresis is 1.6% for typically de-
veloping individuals between 10-13 (Van
Der Wal, Benniga, & Hirasing 2005), while
it is 11.1% for the same age group with
DD (Simonoff et al., 2008). These studies
suggest that children with DD are more
likely to have toileting problems more so
than their peers with typical development
Toilet Training Individuals with Developmental Delays,
International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137.
doi: 10.20489/intjecse.728240
121
due to emotional factors, cognitive and
communication problems (Leader,
Mannion & Chen 2018).
Acquisition of toileting skills is a mile-
stone for the population with DD (Cicero &
Pfadt 2002). Problematic toileting skills
place barrier for this population in sociali-
zation or vocational and residential place-
ments (Kroeger & Sorensen-Burnworth
2009). Furthermore, toileting accidents
mainly cause hygiene, stigmatism, sleep
problems and derision, thus decreasing
the life quality of individuals with DD (Lott
& Kroeger 2004). Children having frequent
toileting accidents not only show anxiety
disorder and depression symptoms, but
have difficulties in gathering and maintain-
ing attention and have poorer academic
performance than their normally develop-
ing peers (Cox, Morris, Borowitz & Sut-
phen 2002). All these difficulties and prob-
lems diminish their self-confidence, reduce
access to daily life activities and social ac-
ceptance and impede with their emotional,
behavioral and academic skill develop-
ment (Joinson et al., 2006). Therefore,
competent toileting is the main self-care
skill that should be taught to the individuals
with DD (Call, Mevers, McElhanon, &
Scheithauer 2017; Kircaali-Iftar, Ulke-
Kurkcuoglu, Cetin, & Unlu 2009).
The most comprehensive toilet training
program, Rapid Toilet Training (RTT)
method, was developed and published in
1971 by Azrin and Foxx in order to toilet
train individuals with learning disabilities
rapidly. RTT method that heavily draws on
operant conditioning technique includes
such components as positive reinforce-
ment, positive punishment, hydration, and
scheduled sittings. The method has
demonstrated effectiveness in toilet train-
ing individuals with DD in wide variety of
studies (Foxx & Azrin, 1973). Despite its
success, the procedure is often broken
down into its components, which are used
as toilet training protocols in or/and of
themselves (e.g., Cicero & Pfadt, 2002).
Moreover, a lot of studies which modified
and shortened RTT have been used ever
since and have also shown to be effective
in teaching these skills (e.g., Rinald &
Mirenda, 2012).
Although literature suggests that teach-
ing toileting skills should be one of the pri-
mary research topics, only a handful of
studies has been conducted on these skills
(Francis, Mannion, & Leader 2017;
Mannion & Leader 2013). In fact, more toi-
let training interventions are reported from
diverse global settings such as the USA
(e.g., Kroeger & Sorensen, 2010), the
Netherlands (e.g., Van Oorsouw, Duker, &
Averink 2009), and Taiwan (e.g., Chang,
Lee, Chou, Chen, & Chen, 201) as com-
pared to developing countries such as Tur-
key, where only a limited number of stud-
ies have been published (e.g., Unlu,
2019). On the other hand, only two studies
reviewed the literature on toilet training
(Francis et al., 2017; Kroeger & Sorensen-
Burnworth 2009). Kroeger & Sorensen-
Burnworth (2009) reviewed data-based
studies published in peer-reviewed jour-
nals until 2008 and included a total of 28
studies. The studies were reviewed for
participant characteristics, training pro-
gram components, setting, length of time
and results. Francis et al. (2017) synthe-
sized the literature on toilet training inter-
ventions and reviewed 15 data-based and
peer-reviewed journal submissions be-
tween 2009 and July-2016 for the same
variables with the previous literature re-
view study. To our knowledge, there is not
a recent comprehensive review in litera-
ture on the topic since then. Additionally,
these two review studies mainly focused
on description of toilet training programs.
Therefore, a comprehensive review of the
literature on toilet training for individuals
with DD is further necessary to highlight
demographic, methodological and out-
comes characteristics of the studies in-
cluded. Furthermore, this review study
may assist teachers in identifying compo-
nents of the procedures as they are used
as toilet training programs in and of them-
selves. This study also serves as an
agenda for future research, which guides
researchers and the academia as by iden-
tifying research voids in extant studies. As
a result, the purpose of this study is to con-
duct a comprehensive review of the litera-
ture on toilet training to the individuals with
DD and to extend the previous descriptive
analysis studies by evaluating demo-
graphic, methodological and outcomes
characteristics of the studies published in
the last 10 years (2009-2019). Specifically,
the following research questions guided
the study: (a) What are the demographic
characteristics (age, gender and diagno-
sis) of the individuals profiled in the stud-
ies?; (b) What are the primary training
Toilet Training Individuals with Developmental Delays,
International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137.
doi: 10.20489/intjecse.728240
122
settings for toilet training programs?; (c)
What are the materials utilized in the stud-
ies?; (d) Which toilet training program
components are included in the toilet train-
ing packages?; (e) What are the character-
istics of the implementers of toilet training
programs?; (f) What is the total length of
training in the studies?; (g) What are the
experimental designs used in the studies?;
(h) Do the studies include information on
maintenance, generalization, interob-
server agreement and procedural fidelity
data? What are the results of them?; (i) Do
the studies include information on social
validity?, Which method are they collected
by?, Which dimensions of social validity
are evaluated?, and What are the results?;
and (j)What are the effectiveness results of
toilet training programs?
Method
Literature Search
This study conducted a descriptive analy-
sis of the papers on investigating the effec-
tiveness of toilet training programs for indi-
viduals with DD published among 2009-
2019. For this purpose, the studies were
identified through systematic databases
search. The search entailed two steps.
First, ScienceDirect, EBSCOhost, Wiley
Online Library and SpringerLink electronic
databases were searched using the key-
words autism, intellectual disability, mental
retardation, developmental disability, toilet
(training), and (in)continence. These key-
words were searched in abstracts, meth-
ods, and results sections of the articles.
The literature search produced 497, 162,
137 and 564 publications from the data-
bases respectively, which resulted in a to-
tal of 1360 studies. Second, studies were
selected if they met eligibility criteria.
Eligibility Criteria
The following inclusion criteria were deter-
mined to include relevant studies in the re-
view: (a) publication between the years of
2009-2019, (b) reporting of results for at
least one participant diagnosed with DD,
(c) designed with a single-subject research
model, (d) publication in Turkish or English
peer-reviewed journal. On the other hand,
the studies were excluded if they (a)
included participants all of whom were with
no diagnosis, (b) did not use a single-sub-
ject experimental design, (c) published in
a non-peer-reviewed journals (d) did not
investigate the effectiveness of a toilet
training component, package or program.
On the basis of the eligibility criteria, 23 ar-
ticles of 1360 were identified and included
in the study. Common reasons for exclud-
ing articles were article duplications, focus
on intervention not investigating the effects
of a toilet training program and using a
non-single-subject design. The process of
identifying eligible studies are depicted in
Fig. 1.
Intercoder Agreement
An independent coder who was a Ph.D.
candidate and a research assistant in Spe-
cial Education department analyzed and
coded %30,43 (n=7) of the included arti-
cles. All of the demographic, methodologi-
cal and outcome characteristics were
coded for the randomly selected articles.
The formula of [(Total number of inter-
coder agreements/ Total number of inter-
coder agreements and disagreements)
X100] was used to calculate the intercoder
agreement. The first author and the inde-
pendent coder came together and exam-
ined the content in case of any disagree-
ments. However, there were no observed
discrepancies between the observers and
the intercoder agreement was calculated
as 100%.
Results
Descriptive analysis of demographic,
methodological and outcome characteris-
tics of the reviewed studies on toilet train-
ing to the individuals with DD are listed and
summarized in Table 1. The following sec-
tions include
Demographic Characteristics
Participants
The reviewed studies included a total of
117 individuals. Demographic characteris-
tics of the participants in the studies were
evaluated by (a) identified disability, (b)
gender and (c) age.
Toilet Training Individuals with Developmental Delays,
International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137.
doi: 10.20489/intjecse.728240
123
Figure 1.
Study Selection Flowchart
Age. The majority of the studies provided
data on the age of a total of 49 participants
(n=21; e.g., Ozcan & Cavkaytar 2009).
However, two studies only reported the
mean and range years of the participants’
age that were 14.4 (range: 7.6-14.4) and
2.1 (range: 1.5-3.25) (Greer, Neidert, &
Dozier 2016; Van Oorsouw et al., 2009).
Therefore, they could not be included in
classification of age groups. Of the studies
that reported age, 21 were between 1-4
years, 21 were 5-10, and 7 were 11 and
over.
Gender. Where gender was reported, 86
participants were male and 29 were fe-
male. In one study (Greer et al., 2016), the
gender of 18 participants were derived
from pseudo names given to them. Since
two names were gender-neutral, they
could not be included in gender classifica-
tion.
Identified disability. Almost half of the par-
ticipants (n=55) had a diagnosis of ID. Ad-
ditional participant diagnoses consisted of
ASD (n=24; e.g., Henriksen & Peterson
2013), multiple disability (n=7; e.g., Ozcan
& Cavkaytar 2009), developmental delay
(n=5; e.g., Brown & Peace 2011), Down
syndrome (n=4; e.g., Unlu, 2019), perva-
sive developmental disorder (n=2; e.g., Ar-
dic & Cavkaytar 2014) and psychomotor
developmental disability (n=1; Ardic &
Cavkaytar 2014). Furthermore, a total of
19 participants with typical development
participated in the studies (e.g., Greer et
al., 2016).
Toilet Training Individuals with Developmental Delays,
International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137. doi: 10.20489/intjecse.728240
124
Table 1.
Methodological Characteristics
Authors
Age-Gender
Diag.
Set-
ting
Ma-
teri-
als
Ind.
Vari-
able
De-
sign
Ma.
Gen.
IOA
and
PF
S.V.
Outcomes
(Positive Ef-
fect/Total
Ps)
Imple-
menter
Length
of
Train.
Ozcan & Cavkaytar (2009)
5-M
4-M
5-M
MD
MD
ID
Home
-
FTP
MPD
4 w
-
IOA:
%100
PF:
%94
-
Acq.: + (3/3)
Ma.: + (3/3)
Parent
120 d
Van Oorsouw et al. (2009)
Mean: 14.4
(7.6-14.4)
F(n=15)
M(n=33)
ID
Home
Dia-
pers
H,
PR,
RoP,
SS,
GG,
P
MBD
4 w
24
w
-
-
-
Acq.:+(48/48)
Ma.:+(48/48)
Care-
giver
-
Kroeger & Sorensen (2010)
4-M
6-M
ASD
ASD
Home
Bev-
er-
age,
Toys,
Edi-
bles,
Chair
H,
SS,
PR,
SCS,
GG
ABA
2 w
24
w
3 y
Home
IOA:
%100
+
Par-
ent-
Scale-
Ac-
cepta-
bility
and
Effec-
tive-
ness
Acq.: +(2/2)
Ma.: + (2/2)
Gen.: + (2/2)
S.V.: + (2/2)
Parent
4-5 d
Brown & Peace (2011)
13-M
DD
School
Dia-
pers
SS,
H,
PR,
RoP,
GG,
P,
CT
ABCA
4 w
24
w
2 y
Home
IOA:
%92
-
Acq.: + (1/1)
Ma.: + (1/1)
Gen.: + (1/1)
Parent
50 d
Chang et al. (2011)
9-M
MD
School
Com-
puter,
Dia-
pers
PR,
EA
ABAB
-
-
-
-
Acq. + (1/1)
Re-
searcher
30 d
Sonmez & Aykut (2011)
5-M
Down
Home
Potty,
Edi-
bles
FTP,
SP,
PR,
PNA
AB
5 d
Bath-
room
(home)
-
-
Acq. + (1/1)
Ma. + (1/1)
Gen.: - (1/1)
Parent
7 d
Toilet Training Individuals with Developmental Delays,
International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137. doi: 10.20489/intjecse.728240
125
Authors
Age-Gen-
der
Diag.
Setting
Materials
Ind.
Varia-
ble
De-
sign
M
a.
Gen.
IOA
and
PF
S.V.
Outcomes
(Positive
Effect/To-
tal Ps)
Implementer
Lengt
h of
Train.
Cocchiola
et al. (2012)
5,1-M
3,9-M
4,2-M
4,2-M
4,1-M
ASD
ASD
DD
DD
DD
School
Diapers,
Edibles,
Bever-
ages
SS, PR,
H, GG,
RoP
MBD
5
d
-
IOA
:
%1
00
-
Acq .:+(5/5)
Ma.: + (5/5)
Paraprofes-
sional
32-88
d
Rinald &
Mirenda
(2012)
3,3-F
3,11-F
3,5-M
3,7-M
3,9-M
5,11-M
ASD
ASD
ID
ASD
Dow
n
ASD
Home
Edibles,
Toys,
Book,
Bever-
ages,
Timer,
Stepstool
FTP, H,
PR, SS,
SCS, P
MBD
2
w
4
w
+
-
+
Parent-Scale-Sig-
nificance, Pro-
cess, Effective-
ness
Acq .:+(6/6)
Ma.: +(5/6)
S.V.: (5/6)
Parent
5-8 d
Henriksen
& Peterson
(2013)
12-F
ASD
Home
Edibles
PR,
PNA,
EA
AB
3
6
w
An-
other
house
-
-
Acq .:+(1/1)
Ma.:+(1/1)
Gen.:+(1/1)
Parent
35 d
Ozkubat &
Toret (2014)
7,5-M
7-M
7,1-M
ID
ID
ID
School
Timer
SCT,
ES
MBD
2
w
4
w
6
w
Home
IOA
:
%9
3
PF:
%1
00
+
Parent-Interview-
Acceptability and
Effectiveness
Acq .:+(3/3)
Ma.:+ (3/3)
Gen.:+ (3/3)
S.V.: (3/3)
Parent
-
Ardiç &
Cavkaytar
(2014)
3,10-M
4,8-M
3,4-F
PDD
PMD
PDD
Clinical
Setting
Potty
PR, H,
DC, ES,
GG
MPD
-
-
IOA
:
%1
00
PF:
%9
8
+
Parent-Interview-
Process and Ef-
fectiveness
Acq..:+ (3/3)
S.V.: + (2/3)
Researcher
6 d
Lee et al.
(2014)
4-M
ASD
Home
Picture
cards,
Toys, Dia-
pers
ES, VM,
SS,
GG,
EA, H,
PR, CT
CCD
5
d
Schoo
l
IOA
:
%1
00
PF:
%1
00
+
Parent, Teacher-
Scale,Interview-
Acceptability, Un-
derstandability
Acq.:+ (1/1)
Ma.: + (1/1)
Gen.: +
(1/1)
S.V.: + (2/2)
Researcher
-
Toilet Training Individuals with Developmental Delays,
International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137. doi: 10.20489/intjecse.728240
126
Authors
Age-Gen-
der
Diag.
Setting
Materials
Ind. Vari-
able
Design
Ma.
Gen.
IOA
and
PF
S.V.
Outcomes
(Positive Ef-
fect/Total Ps)
Implementer
Length of
Train.
Drysdale et
al. (2015)
4,1-M
5-M
ASD
ASD
Home
Tablet PC, Pic-
ture Cards, Di-
apers
VM, CT,
SS, ES,
PR, GG,
RoP
MBD
4 h
School
IOA: %99
PF: >%95
+
Parent-Scale-Ac-
ceptability, Under-
standability
Acq.: + (2/2)
Ma.: + (2/2)
Gen.: + (2/2)
S.V.: + (2/2)
Parent and
Researcher
-
McLay et al.
(2015)
8,1-M
7,2-M
ASD
ASD
Home
Edibles, Tablet
PC
CT, VM,
PR, ES,
GG, DC,
RoP
MBD
12 w
16 w
School
IOA: %96,3
PF: %99,5
+
Parent-Scale-Ac-
ceptability, Under-
standability
Acq.: + (2/2)
Ma.: + (2/2)
Gen.: + (2/2)
S.V.: + (2/2)
Parent
12-29 d
Ohtake et
al. (2015)
12-M
ASD
Home
DVD Player
VM, PR,
GG, EA
MBD
8 w
-
IOA: %93
+
Teacher-Inter-
view-Process
Acq.:+ (1/1)
S.V.: + (1/1)
Teacher
21-28 d
Axelrod et
al. (2016)
13-M
14-M
MD
MD
Home and
School
Medications
Timer, Toys,
Stepstool
SS, PR, P
MBD
2 w
3 w
-
IOA: %100
PF: %94(home),
%87 (school)
-
Acq.:+ (2/2)
Ma.: + (2/2)
Parent and
school staff
63-70 d
Doan &
Toussaint
(2016)
2,6-M
5,10-M
4,9-M
ASD
ASD
ASD
Home and
Clinical
Setting
Toys, Edibles,
Diapers
PR, SS,
H, P
MBD
1 w
3 w
16 w
-
IOA: %100
PF: %100
+
Parent-Scale-Ac-
ceptability, Pro-
cess, Effective-
ness
Acq.:+ (3/3)
Ma.: + (3/3)
S.V.: +(3/3)
Parent
13-29 d
Greer et al.
(2016)
Mean: 2.1
(1.5-3,25)
ASD
TD(n=1
9)
Clinical
Setting
Underwear,
Potty
PNA,
PR, SS
MBD
-
-
IOA: %93
PF: %95
-
Acq.:+ (20/20)
Teacher
-
Toilet Training Individuals with Developmental Delays,
International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137. doi: 10.20489/intjecse.728240
127
Authors
Age-
Gender
Diag.
Setting
Materials
Ind. Varia-
ble
Design
Ma
.
Gen.
IOA
and
PF
S.V.
Outcomes
(Positive
Effect/Total
Ps)
Implementer
Leng
th of
Train
.
Mruzek et
al. (2016)
15,8-M
11,6-F
7,6-M
ID
ID
Dow
n
School
Edibles,
Beverages
H, PR, SS,
SCT, EA
MBD
-
-
PF:
%93
+
Teacher and
Paraprofes-
sional-Scale-
Understand
ability and Ac-
ceptability
Acq.:2/3
S.V.: 7/7
Teacher and
paraprofes-
sional
37-
38 d
Call et al.
(2017)
8-M
8-M
8-M
MD
MD
DD
Clinical
Setting
Potty, Medi-
cations, Edi-
bles
PR, SS
MBD
4
w
-
IOA:
%100
-
Acq.: 3/3
Ma.: 3/3
Therapist and
Parent
13-
21 d
Sutherland
et al. (2017)
8-M
ASD
Home
Timer, Tab-
let PC, Edi-
bles
SS, PR, P
ABC
8
w
-
IOA:
%99
TF:
%96
-
Acq.: 1/1
Ma. 1/1
Researcher
and Parent
39 d
Byra et al.
(2018)
5,9-M
6,11-M
ASD
ASD
Clinical
Setting
Table,
Chair, Pic-
ture Card,
Potty, Doll,
Edibles
VA, SLP, PR
AB
24
w
Hom
e
IOA:
%100
-
Acq.: 2/2
Ma.: 2/2
Gen.: 2/2
Researcher
-
Unlu (2019)
2,5-F
3,5-M
3-M
Dow
n
ASD
ASD
Home
Edibles, Di-
apers
DC, SS, PR,
H, FTP,
AB
1
w
2
w
-
-
-
Acq. 3/3
Ma.: 3/3
Mother
20 d
Toilet Training Individuals with Developmental Delays,
International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137.
doi: 10.20489/intjecse.728240
128
Methodological Characteristics
Methodological characteristics of the re-
viewed studies were evaluated by (a) train-
ing setting; (b) materials; (c) independent
variable; (d) experimental design; (e) im-
plementer; (f) length of training; (g) mainte-
nance; (h) generalization; (i) reliability, and
(j) social validity.
Training setting
The most common setting where the toilet
training occurred was participants’ own
homes (n=12; e.g., Kroeger & Sorensen
2010) followed by schools where the par-
ticipants were getting education (n=5;
Brown & Peace 2011), clinical setting such
as rehabilitation center (n=4; e.g., Doan &
Toussaint 2016), both home and school
(n=1; Axelrod, Tornehl, & Fontanini-Axel-
rod 2016).
Materials
The training materials across studies var-
ied greatly. Nearly half of the studies in-
cluded edibles (n=13; e.g., Cocchiola,
Martino, Dwyer, & Demezzo 2012) and
eight used diapers (e.g., Lee, Anderson &
Moore 2014). Toys were employed in six
studies (e.g., Byra, White, Temple, & Cam-
eron 2018), potty in five (e.g., Sonmez &
Aykut 2011), timer and beverages in four
studies (e.g., Axelrod et al., 2016; Ozkubat
& Toret 2014). Additionally, picture cards
(e.g., Byra et al., 2018), technological de-
vices such as DVD player and computer
(e.g., Chang et al., 2011) were utilized in
three studies, medications (Axelrod et al.,
2016; Call, Mevers, McElhanon, &
Scheithauer 2017), stepstools (e.g., Rinald
& Mirenda 2012) and chairs (e.g., Kroeger
& Sorensen 2010) in two studies. One
study included book as a training material
(Rinald & Mirenda 2012). However, one
study provided no information about the
training materials (Ozcan & Cavkaytar
2009).
Independent variable
It is notable that all studies used toilet train-
ing programs and packages that mainly in-
cluded applied behavior analysis strate-
gies and techniques. Across 23 studies re-
viewed, the large majority (n=21) included
positive reinforcement (PR) (e.g., Byra et
al., 2018) followed by scheduled sitting
(SS) (n=10; Cocchiola et al., 2012). Hydra-
tion (H) and graduated guidance (GG)
from errorless teaching methods were
used in 10 studies (e.g., Van Oorsouw et
al., 2009), punishment procedures in six
(e.g., Brown & Peace 2011) and dia-
per/pad removal (DPR) (i.e., Drysdale,
Lee, Anderson & Moore 2015) and urine
alarm (i.e., Ohtake, Takahashi, &
Watanabe 2015) in five studies. Toilet
training protocols in four studies included
elimination schedule (e.g., Drysdale et al.,
2015), communication training (e.g.,
Brown & Peace 2011) and video modeling
(VM) (e.g., Drysdale et al., 2015). Both
studies used decreasing the intensity of in-
teraction with the participant in case of an
accident (e.g., Greer et al., 2016), dry
checks (DC) (e.g., Ardic & Cavkaytar
2014), scheduled chair sittings (SCS)
(e.g., Kroeger & Sorensen 2010) and
transfer of stimulus control (e.g., Mruzek,
McAleavey, Engel, & Smith 2016), simul-
taneous prompting (Sonmez & Aykut
2011) and system of least prompts (SLP)
and visual aids (Byra et al., 2018) were in-
cluded in one study. One study investi-
gated the effectiveness of parent training
program on the target skill, yet did not re-
port which toilet training components were
used (Ozcan & Cavkaytar 2009).
Research designs
In order to provide the methodological ri-
gor of the studies, the experimental design
of each study was recorded. It is notable
that all studies utilized effectiveness de-
signs to assess intervention effects (e.g.,
Kroeger & Sorensen 2010). In this regard,
more than a half of the studies (n=12) em-
ployed multiple baseline studies (e.g.,
Cocchiola et al., 2012). Four of the studies
targeting toileting skills evaluated the re-
sults with AB design (e.g., Unlu, 2019)
while multiple probe design was used in
two studies (Ardic & Cavkaytar 2014; Oz-
can & Cavkaytar 2009). Kroeger &
Sorensen (2010) employed ABA design,
while Chang et al. (2011) and Lee et al.
(2014) and Sutherland et al. (2017) used
ABAB, ABCA and ABC design respec-
tively.
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129
Implementers
With respect to the implementers, the par-
ents represented the majority of the imple-
menters (n=10; e.g., Rinald & Mirenda
2012) followed by experimenters in four
studies (e.g., Ardic & Cavkaytar 2014). In
three studies, both parent and experi-
menter were implemented the procedure
(e.g., Call et al., 2017). Teachers imple-
mented toilet training programs in two
studies (e.g., Greer et al., 2016), a care-
giver in one (Van Oorsouw et al., 2009)
and both a teacher and paraprofessional
aides in one (Mruzek et al., 2016). Lastly,
one study reported the procedure was im-
plemented by the child’s grandmother and
staff at school (Axelrod et al., 2016).
Length of training
This study also measured the total length
of training time in order to determine par-
ticipants’ mastery on the implementation of
toilet training protocols as it is a significant
measure for efficiency (Halcombe, Wolery,
& Gast, 1994). In 16 of the studies, re-
searchers reported the length of training.
These studies are grouped by months. In
fact, total training time took less than a
month in half of the studies (n=9; e.g.,
Kroeger & Sorensen 2010), between 1-2
months in five (e.g., Brown & Peace 2011)
and more than 2 months in two (e.g., Axel-
rod et al., 2016). Cocchiola et al. (2012) re-
ported total training time varied between
32 and 88 days.
Maintenance
Across the 23 studies reviewed, mainte-
nance measures were evaluated in large
majority (n=19; e.g., Ozcan & Cavkaytar
2009) while the remaining did not provide
information regarding this (e.g., Ardic &
Cavkaytar 2014). In those studies, mainte-
nance was evaluated between one and
three probes. Almost half of the studies
(n=11) evaluated maintenance with one
probe between five days and six months
after the intervention (e.g., Ozcan & Cav-
kaytar 2009); five studies with two probes
between two weeks and six months (e.g.,
Van Oorsouw et al., 2009) and four studies
with three probes between one week and
up to three years (e.g., Brown & Peace
2011).
Generalization
Only generalization across settings was
evaluated due to the nature of the skill. The
generalization was coded if the target skill
was measured in a context different from
training setting. In this regard, only 10
studies presented data measuring gener-
alization (e.g., Kroeger & Sorensen 2010).
Six of those conducted generalization
training in home setting (e.g., Brown &
Peace 2011), three in participants’ school
(e.g., Drysdale et al., 2015). In one study
of Rinald & Mirenda (2012), a systematic
generalization was not programmed; how-
ever, it was reported participants general-
ized the target skills according to parent re-
port.
Reliability
Reliability was coded in the studies by two
aspects: (a) IOA and (b) PF. 17 studies
collected and analyzed interobserver
agreement data on occurrence of target
behaviors (e.g., Byra et al., 2018), which
ranged from 92% to 100%. In Rinald &
Mirenda (2012), authors calculated IOA by
asking questions to participant’s parent im-
plementer, yet did not report the results.
On the other hand, a number of studies
measured PF (n=12; e.g., Drysdale et al.,
2015). When PF was reported, it ranged
from 93% to 100%. In Drysdale et al.
(2015), despite vaguely reported, PF cal-
culation was stated as over 95%.
Social validity
Across 23 studies included in this review,
studies rarely contained measurement of
social validity. With respect to this, only 10
studies collected social validity data, and
all used subjective evaluation strategy to
analyze specific aspects of the interven-
tion process (e.g., Rinald & Mirenda 2012).
Seven of them collected social validity in-
formation from participants’ parents (e.g.,
Ozcan & Cavkaytar 2009), one from teach-
ers (Ohtake et al., 2015), one from both
parents and teachers (Lee et al., 2014)
and one from teachers and paraprofes-
sionals (Mruzek et al., 2016). The remain-
ing of the studies did not provide infor-
mation regarding social validity assess-
ment (e.g., Brown & Peace 2011). With re-
spect to data collection techniques, six
studies collected social validity information
through scale (e.g., Rinald & Mirenda
2012), three by interview (e.g., Ozkubat &
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130
Toret 2014) and one by both (Lee et al.,
2014) to evaluate the experimental effects
of the independent variable(s). Those that
used scale to collect this information ana-
lyzed specific aspects of the intervention
process as acceptability, understandability
of the intervention, training process, effec-
tiveness of training program, behavior
change and importance of the study. On
the other hand, studies using interview
asked individuals questions to analyze the
aspects of training process, effectiveness
of training program and its acceptability.
Outcome Characteristics
The studies were analyzed and reported
by acquisition, maintenance, generaliza-
tion and social validity.
Acquisition
Across 23 studies, toilet training programs
were mostly effective on teaching target
skill(s). Mruzek et al. (2016) reported two
out of three children substantially pro-
gressed in acquisition but one child kept on
toilet accidents despite some adaptations.
Secondly, a study of Greer et al. (2016) re-
ported eight children initially did not im-
prove in toileting skills who then acquired
the skills following implementation of addi-
tional components. In short, %99,14 of the
participants in all studies included in the re-
view acquired the target skills. However, it
should be noted that Lee et al. (2014)
stated the intervention was effective on
dressing, sitting on toilet and flushing but
not on acquisition of in-toilet voiding.
Maintenance
Across the studies reviewed, the skills ac-
quired maintain for all participants after the
termination of intervention process (e.g.,
Henriksen & Peterson 2013). However,
Rinald and Mirenda (2012) reported they
could not measure maintenance for one
participant as he withdrew from the study
after acquisition of target skills.
Generalization
Where generalization measured, eight
studies reported the skills could generalize
across a different setting. However, in a
study of Sonmez and Aykut (2011), one
out of three participants could not general-
ize the acquired skill.
Social Validity
The studies measuring social validity re-
ported positive social validity outcomes
(e.g., Kroeger & Sorensen 2010). How-
ever, Ardic and Cavkaytar (2014) reported
one family stated their satisfaction with the
study was not in a great scale as the inter-
vention process did not include bowel con-
trol training. Furthermore, in a study of
Rinald and Mirenda (2012) the authors
could not measure social validity for one
participant as he withdrew from the study.
Discussion
The current review evaluated studies
on teaching toilet training skills to the indi-
viduals with DD. 23 studies that met inclu-
sion criteria were included in the review.
The overall results showed that almost all
individuals with DD were trained on the im-
plementation of toilet training programs,
generalized the target skill(s) across other
settings and maintained them after termi-
nation of the intervention. Furthermore, the
current literature review indicated that
most toilet training programs include com-
ponents used in the earliest method, Rapid
Toilet Training, developed by Azrin and
Foxx (1971) and that there does not exist
a standardized toilet training program, thus
researchers compose toilet training inter-
vention packages by components accord-
ing to their preferences. In this regard, a
number of prominent results that emerged
in the current study may guide future re-
search and practice for individuals with
DD.
First of all, the majority of participants
in the studies had a diagnosis of ASD and
ID (n=81; e.g., Henriksen & Peterson
2013), which weaken generalizability of ef-
fectiveness results of the toilet training in-
tervention packages across other disability
groups. One possible reason for this could
be that population with these diagnoses
have more difficulties in acquisition of toi-
leting skills than those with other disability
types (Kircaali-Iftar, Ulke-Kurkcuoglu, &
Kurt 2014; Leader et al., 2018). Moreover,
difficulty in learning toilet training skills for
individuals with DD and in teaching due to
length of time and effort can be deterrent
and disincentive factors for educators and
researchers in teaching toileting skills
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131
(Cicero & Pfadt 2002). However, a result
of this review that even individuals with
multiple disabilities can acquire toileting
skills (e.g., Chang et al., 2011) may en-
courage researchers to develop various
toilet training programs. On the other
hand, as similarly noted by a previous re-
view on toileting skills (Kroeger &
Sorensen-Burnworth 2009), a small num-
ber of participants in reviewed studies
were in or after adolescence period (n=7;
e.g., Ohtake et al., 2015) while majority
were in early childhood and preschool pe-
riod (n=28; e.g., Rinald & Mirenda 2012).
Therefore, it can be suggested the popula-
tion in focus in terms of age group was
similar to the population with typical devel-
opment (2-4). This finding is consistent
with the previous research findings that
suggest individuals with DD should be toi-
let trained during preschool period (Fran-
cis et al., 2017). In literature, despite some
hypotheses and assumptions in terms of
relationship between toileting problems in
this population and individual’s quality of
life, there is only a handful of empirical
studies investigating the subject (Leader et
al., 2018), as such, future research is war-
ranted to further evaluate short- and long-
term effects of toilet training during early
periods on individual’s quality of life.
Across the studies reviewed, toilet
training interventions took place in a vast
variety of setting including a single (e.g.,
home; Sutherland et al., 2017) and multi-
ple locations (e.g., both home and clinical
setting; Doan & Toussaint 2016). Previous
review study outlined that there was a shift
in settings of interest from institutional set-
ting to outpatient clinics (Kroeger &
Sorensen-Burnworth 2009). However, the
current study yielded in a notable finding
that half of the studies conducted in home
setting. Of the studies reviewed, another
prominent finding was SS, DPR and H
were commonly used. In this regard, prob-
lem situations (e.g., toileting accidents,
leaving the class, etc.) during toilet training
while using these components in institu-
tional settings may have changed that
shift, which is toward home setting.
Previous review studies on toileting
skills did not evaluate the materials used in
experiments (Francis et al., 2017; Kroeger
& Sorensen-Burnworth 2009). We found
out that the most common materials were
edibles (n=12) followed by diapers (n=8).
Considering the nature of the target skills
and high preference of reinforcement-
based strategies in the studies, inclusion
of edibles and diapers in toilet training pro-
grams is meaningful. Interestingly, two re-
cent studies have used medications for toi-
let training participants (Axelrod et al.,
2016; Call et al., 2017). One possible rea-
son for utilization of medications is be-
cause they might yield in faster acquisition
for the individuals with DD. Nevertheless,
future research of medication component
is recommended to entail a clinical setting
or involvement of medical staff for side ef-
fect analysis, approving administration of
medications or consultancy.
Technology-based methods or com-
ponents still appear to be rare but emerg-
ing in toilet training research. In fact, tech-
nology was utilized in 35% of the studies
reviewed (e.g., Chang et al., 2011), which
was 25% in the review study by Kroeger &
Sorensen-Burnworth (2009). Considering
the length of the interventions are over one
month in half of the studies reviewed (e.g.,
Cocchiola et al., 2012), toilet training is
quite burdensome interventions. Thus, in-
cluding wireless (i.e., enuresis alarms) and
digital technology (i.e., tablet computers)
systems in protocols may provide imple-
menters with easiness, thus streamlining
the intensity and the length of the interven-
tions. Moreover, advancements in technol-
ogy may improve “cost-benefit” of the toilet
training interventions in that such techno-
logical devices can be used alone in toilet
training individuals with DD, which is an
important topic for future investigations.
Within the current review, a prominent
result was that independent variable in all
studies was a training package composed
of more than one method or toilet training
components. Although toilet training pro-
grams are not alone evidence-based prac-
tices, they are comprised of such evi-
dence-based practices as errorless teach-
ing method (e.g., SLP and GG) and visual
aids (e.g., VM). In that regard, it can be
thought toilet training programs are not
standardized training packages, as such,
they are composed by researchers’ prefer-
ences, which means no precise agree-
ment on toilet training components for a
toilet training program still exists in litera-
ture. Even so, it is important to note that
one toilet training component, PR, was in-
cluded in the training packages in almost
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all studies reviewed (n=21). Previous liter-
ature review studies outlined that the com-
ponent had been commonly used in toilet
training intervention programs since the
development of the most cited and com-
prehensive toilet training protocol by Azrin
and Foxx in 1971 (Francis et al., 2017;
Kroeger & Sorensen-Burnworth 2009).
Therefore, it can be proposed that PR is a
standard component in a toilet training
package. Pertaining to VM, our evaluation
permitted the identification of interest in
the method although Kroeger & Sorensen-
Burnworth (2009) reported only two stud-
ies had utilized VM. In a study of Ohtake et
al. (2015), for instance, the participant
watched an animated hero in video with
which the student was pre-occupied and
improved his target behaviors. Consider-
ing that toileting is of private and personal,
researchers can avoid violating both par-
ticipants’ and families’ privacy and ethical
issues through animated video modeling.
Future studies can continue to further eval-
uate the effectiveness of videos in which
animated cartoon characters are incorpo-
rated on teaching in-toilet elimination in
addition to chains toileting skills such as
dressing, flushing and washing hands.
No previous reviewed studies evalu-
ated who implemented toilet training pro-
grams to participants with DD (Francis et
al., 2017; Kroeger & Sorensen-Burnworth,
2009). Kroeger & Sorensen-Burnworth
(2009) reported that the least used inter-
vention was family training programs on
teaching toileting skills. However, it should
be noted that the current review found at
least one implementer was participant’s
parent in more than half of the studies re-
viewed most of which was conducted in
the past five years (e.g., McLay et al.,
2015) and that three studies investigated
the effectiveness of family training pro-
grams on target skill(s) (Ozcan & Cavkay-
tar 2009; Rinald & Mirenda 2012; Sonmez
& Aykut 2011). The trend of focus in train-
ing toward family member implementers
should mean researchers are giving higher
level of importance to recognition of family
involvement. Considering family involve-
ment in education of individuals with DD
contributes to longer maintenance of ac-
quired skills and helps them and their fam-
ilies fulfil their needs (Ozcan & Cavkaytar
2009), future research are warranted to in-
vestigate the effectiveness of intervention
not only for participants’ performance, but
also in terms of parental self-efficacy, suc-
cess perceptions, and so on.
The majority of the studies reported
length of training duration (n=17) which
previous toilet training reviews also ana-
lyzed (Francis et al., 2017; Kroeger &
Sorensen-Burnworth 2009). Within the
current review, we found that the studies in
which length of training was short (1-30
days) utilized the components of rapid toi-
let training method (e.g., PR, H, SCS and
SS) developed by Azrin & Foxx (1971).
However, those using the components of
traditional toilet training method (e.g., DC
and P) associated with bladder/bowel dis-
tension, reinforcement- and punishment-
based strategies of behaviorist approach
took longer (over 60 days). Therefore, fu-
ture research should further evaluate
which combinations of the components are
more effective and efficient in order to help
researchers and families implement a pro-
cedure to individuals with DD in the most
effective and efficient manner possible.
No previous review studies on toilet
training evaluated information in terms of
experimental design (Francis et al. 2017;
Kroeger & Sorensen-Burnworth 2009).
However, we found that slightly more than
half of the studies reviewed used multiple
baseline design (n=12). This may be due
to multiple baseline designs require re-
peated measurements during baseline,
which increases credibility. Furthermore, a
prominent finding of the current study is
that only effectiveness of toilet training pro-
grams or components were investigated
across all reviewed studies. In another
words, there has been no comparative sin-
gle-subject studies on examining efficacy
of toilet training packages, programs or
components for individuals with DD. Deter-
mining which toilet training components
are efficient may be of significance to build
easily implementable toilet training proto-
cols that take a short time to complete,
which should be the focus of future re-
search endeavors.
The studies measuring data in
maintenance represented the greater
number (n=19), which previous toilet train-
ing reviews did not focus on. However, it
should be noted that half of the studies
measured maintenance with one probe
and that 15 studies collected the mainte-
nance data within one month following the
termination of intervention. On the other
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doi: 10.20489/intjecse.728240
133
hand, a few studies collected long-term
maintenance data which ranged from 2
and 3 years (Brown & Peace 2011;
Kroeger & Sorensen 2010). Although
these studies reported positive mainte-
nance effect to a large extent, Hyams,
McCoull, Smith and Tyrer (1992) reported
14 participants with ID could not maintain
toileting skills 10 years after they acquired
the skills. In this sense, future longitudinal
research of larger sample sizes is needed
to further measure long-term maintenance
data of toileting skills since they are of
great importance for participants’ with DD
life quality, hygiene and social acceptance.
Nine of the studies included data on
generalization of the target skill(s) and one
study reported that they did not collect
generalization data. However, participant’s
parent informed researcher of positive ef-
fects for generalization of the skills across
home setting (Rinald & Mirenda 2012). It is
notable that none of the studies conducted
in structured settings such as school or
clinical settings (n=8) included information
on generalization (e.g., Ardic & Cavkaytar
2014). If a person cannot apply a skill or
concept across other situations (e.g., new
people or settings), learning cannot be es-
tablished since generalization is one of the
stages of learning (Wolery, Ault, & Doyle
1992). Therefore, it is recommended fu-
ture research be conducted for evaluating
data in generalization whether the targeted
skills will generalize across other settings.
Reporting critical treatment steps in
studies may assist researchers develop a
standardized and effective toilet training
package. Slightly more than half of the
studies reviewed (n=12) included data with
respect to PF and IOA. Therefore, it is sug-
gested that more studies be conducted for
collecting both types of reliability data.
More than a half of the reviewed stud-
ies (n=13) did not appear to have as-
sessed social validity. However, such in-
formation is necessary to measure stake-
holder’s perceptions of social acceptability
of the toilet training programs consisting of
various components. Among the other
studies that included social validity infor-
mation, most of the studies (n=9) reported
ratings of teachers and parents were high
for training process, acceptability, effec-
tiveness and understandability of the inter-
vention (e.g., McLay et al., 2015). How-
ever, in a study by Ardic & Cavkaytar
(2014) one participant’s mother stated she
was not completely satisfied with the treat-
ment as it did not include bowel control
training. Among the studies that did meas-
ure social validity information, all collected
data from indirect consumers (participants’
teachers and parents). The aim of meas-
uring social validity is to identify the signif-
icance of behavior change and the accept-
ability of procedure which generates the
change (Carr, Austin, Britton, Kellum, &
Bailey 1999). In this sense, no studies spe-
cifically evaluated the consumers’ percep-
tions of toilet training components. On the
other hand, evaluating the opinions, per-
ceptions and suggestions of direct con-
sumers (e.g., the participants with DD) to-
ward treatment, intervention and toilet
training components, in particular, may not
only contribute to higher quality of scien-
tific experiments, but also guide research-
ers to develop a standardized toilet train-
ing program or protocol in the future. Addi-
tionally, considering the sensitive and pri-
vate nature of toileting skills, it is highly im-
portant for implementers to understand
and protect participant’s privacy. Even so,
of the ten studies from the current review
that did report on social validity, none in-
cluded questions or items pertaining to
ethical rules or issues. Thus, including
such questions in social validity measure-
ment may guide researchers plan inter-
vention procedure and help students pro-
tect their rights and privacy.
With respect to outcomes from the
studies, a review study on toilet training by
Kroeger and Sorensen-Burnworth (2009)
evaluated 28 studies and reported positive
outcomes for all children in 23 studies. Au-
thors stated one participant in four studies
could not improve the target toileting and
that only 19 out of 40 participants improved
the target skill in one study. Another review
study by Francis et al. (2017) reported par-
ticipants in one single-subject study could
not acquire toileting skills. Furthermore, it
should be noted that both review studies
showed the evaluation of maintenance
and generalization of the studies reviewed,
yet did not report performances of partici-
pants in detail. However, as mentioned
previously, the current study found the tar-
get skill(s) could effectively enhance,
maintain and generalize across various
settings in most of the studies included in
the review for the individuals with DD. In
fact, Mruzek et al. (2016) reported the
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International Journal of Early Childhood Special Education (INT-JECSE), 12(1) 2020, 120-137.
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134
training package did not facilitate positive
outcomes for one participant despite a
number of adaptations made including dif-
ferential reinforcement and increasing the
intensity of reinforcers. Furthermore, Lee
et al. (2014) indicated the intervention was
not effective in teaching in-toilet elimina-
tion but dressing, sitting on toilet and flush-
ing for the participant, although they made
adaptations by adding in-vivo modeling
component in intervention. In another
study by Greer et al. (2016) on evaluation
of toilet training components, it was re-
ported dense SS and differential reinforce-
ment components were not effective for
eight children. However, they improved the
target skills upon implementation of addi-
tional component, wearing underwear.
In conclusion, all of the toilet training
programs in the studies included in the cur-
rent study are derivatives and modified
versions of original Azrin and Foxx study
(1971). Furthermore, no standardized toi-
leting programs of fixed components for in-
dividuals with DD have existed ever since.
With respect to this issue, it can be con-
cluded that toilet training programs, pack-
ages or protocols are built according to re-
searchers’ preferences and participant
characteristics, as such, there is still no
agreement on a common toileting program
in literature. Therefore, further studies are
needed to teach toilet training skills to indi-
viduals with DD.
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