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Melmark New England, Andover,
Massachusetts, USA
Correspondence
James K. Luiselli, Melmark New England, 461
River Road, Andover, MA, 01810, USA.
Email: jluiselli@melmarkne.org
Abstract
Many children with autism spectrum disorder (ASD) have
gastrointestinal (GI) problems and associated fecal inconti-
nence, constipation, and diarrhea. We describe the design
and operation of a computer-assisted health monitoring
system for tracking and recording bowel movements at a
residential school. Implementation integrity of the system by
care providers was 100% for six targeted students with ASD
and GI difficulties. The utility, objectives, and effectiveness
of the system were rated positively by supervisory profes-
sionals, parents, and GI physicians. Our discussion focuses
on the advantages of computer-assisted data recording and
instrumentation technology for documenting health meas-
ures such as bowel movement frequency and quality in chil-
dren with ASD.
KEYWORDS
autism spectrum disorder, bowel movements, computer-assisted
data recording, health monitoring
RESEARCH ARTICLE
Health monitoring of students with autism
spectrum disorder: Implementation integrity and
social validation of a computer-assisted bowel
movement tracking system
Frank Bird | Andrew Shlesinger | Haritha Gopinathan |
Kimberly Duhanyan | Jessica Buckley | James K. Luiselli
DOI: 10.1002/bin.1874
Received: 14 December 2021 Revised: 12 February 2022 Accepted: 14 February 2022
1 | INTRODUCTION
Many children with autism spectrum disorder (ASD) have gastrointestinal (GI) abnormalities and associated bowel
elimination problems such as fecal incontinence, constipation, and diarrhea (Gubbiotti et al., 2019; Lefter et al., 2020).
These problems may be the result of impaired parasympathetic activity, increased endocrine stress response, gut
dysbiosis, food allergies, fiber-restrictive diets, and certain medications (Ibrahim et al., 2009; Kang et al., 2014). As
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Behavioral Interventions. 2022;1–11. © 2022 John Wiley & Sons Ltd.wileyonlinelibrary.com/journal/bin
well, children with ASD frequently do not defecate or eliminate consistently (e.g., frequency, stool size and composi-
tion) due to ineffective toilet training, bathroom avoidance, and unusual sensory perceptions (Matson, 2017). Regard-
less of etiology, bowel elimination problems pose health concerns, commonly co-occur with challenging behavior
(Ferguson et al., 2019; Parracho et al., 2005; Valicenti-McDermott et al., 2008) and may be socially stigmatizing
(Cicero & Pfadt, 2002).
Practitioners in many service settings for children with ASD and related disabilities may be required to implement
bowel elimination training programs (Call et al., 2017; Perez et al., 2021). Recording the occurrence-nonoccurrence,
context, and quality of bowel movements is necessary to evaluate the effectiveness of care provider training and also
dietary, pharmacological, and behavioral interventions. For example, Call et al. (2017) recorded the daily frequency
of continent and incontinent bowel movements of three children with ASD, intellectual disability, and developmen-
tal delay at an outpatient encopresis-treatment clinic. Specifically, “Data were recorded using paper data sheets by
making tally marks in one of two columns (‘incontinent’ and ‘continent’) to denote the type of bowel movement”
(p. 336). In Perez et al. (2021), bowel movements of 13 children with ASD at a treatment center were recorded
as a percentage measure from the ratio of appropriate (in-toilet) bowel movements divided by the total number
of appropriate bowel movements plus bowel accidents each day. In other programs, bowel movement frequency
and percentage data are supplemented with qualitative ratings from scales such as the Bristol Stool Chart (Lewis &
Heaton, 1997).
Warzak et al. (2017) advised that measurement reliability and integrity are critical to data recording of appro-
priate and inappropriate elimination (both urine and feces) in children with ASD. Further, measurement should be
practical, easily implemented, and generalizable among multiple care providers within service settings. Both Call
et al. (2017) and Perez et al. (2021) reported exemplary interobserver agreement (interobserver agreement (IOA))
but did not assess implementation integrity of bowel movement data recording. And although neither study indi-
cated operational difficulties acquiring data, conventional paper-and-pencil forms are easily lost or misplaced and the
recorded data must be summarized, centrally located, and displayed for visual inspection (graphs) as separate steps.
Another consideration is distributing data to and among professionals who are responsible for analysis and making
program decisions. In summary, there are multiple operations involved with data recording such that consolidation in
a single system would be pragmatically advantageous.
Advances in recording software and instrumentation may be one strategy that assists care providers with data
acquisition, summary, storage, display, and communication (Kazemi & Ramirez, 2018; Luiselli & Fischer, 2016; Yanag-
ita et al., 2016). Various systems exist for monitoring health indicators such as sleep (Shlesinger et al., 2020) and
seizures (diary.epilepsy.com) but to our knowledge, none that focus exclusively on bowel movement tracking and
reporting. Presented herein, we describe a computer-assisted system of bowel movement (health monitoring) in
children with ASD, evaluation of implementation integrity by care providers, and assessment of social validity from
clinicians, supervisors, nurses, parents, and GI physicians. The study did not compare the computer-assisted system
to other data recording procedures, rather quantified the procedural fidelity and stakeholder approval of an alterna-
tive to conventional methods.
2 | METHOD
2.1 | Participants and setting
The participants were 79 care providers at a residential school for children with ASD and intellectual disability.
Among the participants, 54.4% identified as female and 45.5% identified as male, 22–57 years old, with employment
tenure at the school ranging from 1 month to 21 years when the study began. All of the participants functioned as
direct service providers at two community-based group homes operated by the school. They formed a convenience
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sample and there were no inclusion and exclusion criteria other than the participants being residential care providers
for the students described below.
We identified six students that were targeted for the implementation integrity evaluation and social validity
assessment of the bowel tracking system. These students were selected because they presented with GI problems
that their parents highlighted, were followed closely by GI physicians, and required daily bowel movement documen-
tation for health monitoring. One student was female, five students were male, with diagnoses of ASD (N = 5) and
Rett syndrome (N = 1). Their average age was 18 years (range = 14–20 years) and they had been residential students
at the school between 4 and 14 years (M = 7.5 years). The parents of each student provided informed consent for all
of the procedures implemented with their daughter and sons.
Within the residential school, the students attended classrooms for 6.5 h on weekdays and lived in the two previ-
ously referenced community-based group homes. Three of the six students resided in one group home and the other
three students resided in the second group home with five co-living peers. A senior director of residential services,
assistant director of residential services, and program manager supervised the group homes. The participants worked
assigned daily shifts in the group homes, carried out instructional activities with students, and were responsible for
implementing the bowel movement tracking system. Common activities conducted by the participants were teaching
the students self-care, daily living, communication, and leisure skills, following behavior support plans, recording
program data, and managing the physical environment.
2.2 | Measurement
The study was conducted over a one month period (N = 30 days) in which the participants recorded bowel movement
measures each day the six identified students were present in the group homes. They recorded the measures during
bathroom visits that the students either self-initiated (e.g., requested to “Go to the bathroom.”) or were cued by the
participants according to a daily toilet schedule (e.g., “Time to use the bathroom.”). Participants provided individ-
ual supervision of student bathroom visits, maintaining privacy during the process, and recording bowel movement
measures upon completion.
The bowel movement tracking system recorded, reported, and analyzed the measurement data in a proprietary
software created at the residential school. To complete data recording, participants accessed an application on an
iPad™ tablet linked to a database using standard Windows authentication and password protocols. Once logged in,
participants chose the “health trackers” followed by bowel movement (BM) options. An electronic form then appeared
containing fields for recording bowel movement measures with accompanying “date,” “time”, and “comments” boxes.
According to residential school guidelines, participants were required to record one of three bowel movement meas-
ures into the system per student each day: (a) the student did not have a bowel movement during bathroom visit,
(b) the student flushed the toilet before bowel movement detection could occur during bathroom visit, and (c) the
student had a bowel movement of size and consistency specified on the Bristol Stool Chart during bathroom visit
(Figure 1). A fourth measure, leave of absence, was recorded on days a student was away from the group home. Upon
completion of data entry, participants clicked a “save” button.
At the start of each morning shift in the group homes, the application tabulated student bowel movement data
from the previous day and sent an email notification to nursing and administrative staff detailing students who had
gone three consecutive days without a bowel movement or there was missed data recording during this period. A
second criterion that prompted an email notification was three consecutive days in which a student had bowel move-
ments categorized as Type 1, 2, 6, and 7 from the Bristol Stool Chart (Lewis & Heaton, 1997). The nursing department
at the residential school had determined that this pattern, uninterrupted by bowel movement Type 3, 4, and 5, could
be caused by severe constipation or intestinal blockage, necessitating immediate resolution. An example of such
correspondence would be: “John Doe: unhealthy BM types recorded for last 3 days, staff note he has experienced
Type 1 bowel movement only.” In addition, the application provided a color-coded chronological bar chart on the
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FIGURE 1 Bowel movement electronic data-entry form including bristol stool chart legend
data-entry screen and a reporting module. Figure 2 illustrates the appearance of a student bowel movement chart
created within the system.
Supervisors, nurses, and allied health professionals at the residential school reviewed the bowel movement
data by logging into the system as described, then selected “all reports” to produce student charts and narrative
comments. Reports are reviewed when email alerts are sent to these individuals, during scheduled appointments
with physicians, and at the discretion of school administrators. Copies of reports are also sent either electronically via
email or on paper to parent-guardians each month and upon request.
2.3 | Training and performance management
Upon being hired as new employees at the residential school, the participants received orientation training at which
time they learned to implement the bowel movement tracking system among many other job-related skills. Training
consisted of written guidelines, demonstration of data recording, practice, and review from a lead trainer. The simu-
lated behavioral skills training (BST: Vladescu & Marano, 2021) was followed with observations from group home
supervisors to support implementation integrity in vivo (DiGennaro Reed et al., 2013; Luiselli, 2021a). Supervisors
continued to be present in the group homed throughout the month-long study to check in with participants, deliver
performance feedback, and confirm the status of data recording per student.
2.4 | Interobserver agreement
We assessed interobserver agreement (IOA) by having a second participant record bowel movement data simulta-
neously and independently with the participant who was supervising a student bathroom visit. The second partic-
ipant entered data on a hardcopy form that was later compared to the electronic data entry of the supervising
participant. An agreement was scored when both participants recorded the same bowel movement measure during
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FIGURE 2 Example bowel movement chart
the same bathroom visit and if a bowel movement occurred, the same type from the Bristol Stool Chart (Lewis &
Heaton, 1997), as well. For duration of the study, IOA was assessed on average 42.4% of the time among the six
students (M = 23.8%–75%). Average IOA (agreements/agreements + disagreements × 100) was 100%.
2.5 | Implementation integrity evaluation
As described previously, the measurement criteria were that participants monitor students during daily self-initiated
and scheduled bathroom visits and record bowel movement measures per visit in the computer-assisted tracking
system. We evaluated implementation integrity from the electronic data entries on days the students were present
in the group homes during the one-month period. An integrity metric was compiled from the ratio of days with a
recorded bowel movement measure over the total days in residence. In illustration, if a student spent two weekend
visits with family during the month, she/he would have been present in the group home for 26 days. If the bowel
movement tracking system registered 24 days with data recordings, implementation integrity for the student would
be 92.2% (24/26 × 100).
2.6 | Social validity assessment
Social validity assessment was conducted with 18 clinicians, supervisors, and nurses who were responsible for coor-
dinating and reviewing data from the bowel movement tracking system. They completed an online questionnaire
independently and anonymously that included six statements concerning the utility, objectives, operation, and effec-
tiveness of the system: (1) the bowel movement tracking system is useful for health monitoring of students with GI
concerns, (2) through training and supervision, care providers are capable of recording bowel movement data reliably,
(3) the Bristol Stool Chart clearly classifies types of bowel movements, (4) the bowel movement tracking system
provides useful data when parents meet with their GI physician, (5) the bowel movement tracking system provides
useful data for nurses making decisions about prescribed over-the-counter medications, and (6) the bowel move-
ment tracking system provides extended evaluation of interventions to treat GI problems. For each statement, the
respondents endorsed one of five numerical ratings on a Likert-type scale (1: strongly disagree, 2: disagree, 3: neither
disagree nor agree, 4: agree, 5: strongly agree).
We distributed a second social validity questionnaire consisting of five statements to the parents and GI physi-
cians of the six students: (1) the bowel movement tracking system at the residential school accurately monitors bowel
movements, (2) the bowel movement tracking system at the residential school provides valuable data during physi-
cian visits, (3) the Bristol Stool Chart clearly classifies types of bowel movements, (4) the bowel movement tracking
system provides useful data for making decisions about prescribed over-the-counter medications, and (5) the bowel
movement tracking system provides extended evaluation of interventions to treat GI problems. The parents and
physicians also completed the questionnaire anonymously using the same five-point Likert-type scale.
3 | RESULTS
Figure 3 shows that implementation integrity was 100% among the participants implementing the bowel movement
tracking system at the two group homes. These results were based on a total of 214 student data recordings during
the study. The social validity ratings by clinicians, supervisors, and nurses are presented in Table 1 and the ratings
by parents and GI physicians are presented in Table 2. All of the clinicians, supervisors, and nurses completed the
questionnaire (return rate = 100%) with average ratings between 4.2 and 4.7 per statement and a mean score of 4.3
(“agree”). The six parents returned the questionnaire (return rate = 100%) and the average rating was 5.0 (“strongly
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agree”) for each statement. Four of the six GI physicians completed the questionnaire (return rate = 66.6%) with an
average rating of 4.7 per statement (“agree”).
4 | DISCUSSION
We described a computer-assisted system of bowel movement tracking for health monitoring of students with ASD
including evaluation of implementation integrity and assessment of social validity. The system was associated with
maximum measurement reliability and implementation integrity was exemplary among a large group of residential
care providers. Persons responsible for system administration, parents of students, and GI physicians were uniformly
positive about the objectives, methods, and effectiveness of bowel movement tracking.
Participants were taught to use the bowel movement tracking system during their orientation training as new
care providers at the residential school followed by in vivo supervision “on the job.” This combination of simulated
training and post-training performance management is recognized as an evidence-based approach with human
services employees (DiGennaro Reed et al., 2013; Lerman et al., 2015; Reid, 2017). Further, training and performance
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FIGURE 3 Percent implementation integrity across two group homes
Questionnaire statement
Average
rating
The bristol stool chart clearly classifies types of bowel movements 4.7
Through training and supervision, care providers are capable of recording bowel movement data reliably 4.3
The bowel movement tracking system provides useful data when parents meet with their GI physician 4.3
The bowel movement tracking system provides useful data for nurses making decisions about over-the-
counter medications
4.3
The bowel movement tracking system provides extended evaluation of interventions to treat GI problems 4.3
The bowel movement tracking system is useful for health monitoring of students with GI concerns 4.2
Note: 1: strongly disagree, 2: disagree, 3: neither disagree nor agree, 4: agree, 5: strongly agree.
TABLE 1 Social validity ratings by clinicians, supervisors, and nurses
management were directed at highly conspicuous daily routines, namely bathroom visits that participants conducted
with students on a daily basis. These factors plus the user-side facility of the system may have contributed to imple-
mentation integrity, notwithstanding the need for more formal evaluation. For example, our study did not quantify
the time devoted to training and performance management or compare the effects of different methods of bowel
movement tracking on integrity. Of course, BST would be applicable to other methods of data recording, not solely
efficacious with a computer-assisted system.
Social validity is a valuable evaluative measure but underreported in human services research (Ferguson
et al., 2018; Gravina et al., 2019; Luiselli, 2021b). Wolf (1978) emphasized that direct and indirect consumers of
programs should provide feedback about service provision that reflects acceptance and approval. In the present
study, we targeted professionals who managed the bowel movement tracking system and made decisions from
reviewing the health monitoring data. For example, nurses at the residential school advised about diet, medication,
physical activity, and hydration status of students from these data. The GI physicians who completed the social valid-
ity questionnaire reported that the bowel movement tracking system aided their consultations and recommendations
with students. Parents also judged the system as beneficial on many levels. This broad-based appeal would appear to
support the objectives of bowel movement tracking and utility of recorded data.
However, the social validity assessment could have been improved by including open-ended responses on the
questionnaires, for example, asking informants to list perceived limitations of the computer-assisted system and
suggest system changes that might refine data recording further. Also, the positive reactions by the GI physicians
could have been explored in greater detail—did the bowel movement data presented to them affect their recommen-
dations to parents about medications and general health care of students? Finally, all parents endorsed the highest
rating for each item on the social validity questionnaire. These results may have reflected a response bias that could
be controlled by including items with reverse coding (Swain et al., 2008).
Relative to system design and operation, the bowel movement tracking and health monitoring system is fully
integrated into an existing enterprise-level database. No additional installation or configuration is required beyond
release of the software and creating an email address group to receive alerts. All of the demographic information
required by the software is pulled from an existing school population electronic record. The entire database system
is hosted internally on servers configured with standard fail-over technology—should one server fail, a second server
takes over seamlessly. Notably, the bowel movement tracking system was designed by an in-house software devel-
oper and did not require additional funding. The residential school provides the computer hardware at the group
homes installed in a network environment with data stored at a central and easily accessed location.
We highlight the notification component as a unique feature of the computer-assisted system. Indication that
students are not having regular bowel movements, the quality is undesirable, or elimination data are not being
recorded consistently is routed directly to nurses, clinicians, and supervisors. Rapid notification enables the treatment
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Questionnaire statement Average rating parents
Average rating
physicians
The bowel movement tracking system at the residential school accurately
monitors bowel movements
5.0 4.7
The bowel movement tracking system at the residential school provides
valuable data during physician visits
5.0 4.7
The bristol stool chart clearly classifies types of bowel movements 5.0 4.7
The bowel movement tracking system at the residential school provides
useful data for making decisions about over-the-counter medications
5.0 4.7
The bowel movement tracking system at the residential school provides
extended evaluation of interventions to treat GI problems
5.0 4.7
Note: 1: strongly disagree, 2: disagree, 3: neither disagree nor agree, 4: agree, 5: strongly agree.
TABLE 2 Social validity ratings by parents and gastrointestinal (GI) physicians
team to review student health plans, consult with physicians, and consider changes to diet, medication, nutrition, and
physical activity. It is advantageous, too, that timely alerts free providers from labor-intensive retrospective analysis
of paper and electronic charts to arrive at treatment decisions, possibly reducing hospital visits occasioned by severe
constipation, bowel obstruction, and diseases of the GI tract.
The study was limited to a single human services setting notwithstanding a relatively large participant sample.
Also, we conducted a descriptive evaluation without experimental control such as introducing bowel movement
tracking training with participants sequentially in a multiple baseline design across group homes (Kazdin, 2011).
Despite the aforementioned advantages of computer-assisted data recording and instrumentation technology (Whit-
ing & Dixon, 2014; Yanagita et al., 2016), some service settings may not be able to support or pay for large-scale
adoption. Finally, many system variations are possible and should be studied in future research. For example, how do
paper-and-pencil and digital methods of data recording compare relative to accuracy and implementation integrity?
Second, different approaches to training data recording competency with care providers should be evaluated. And
as presented in this study, research assessment of the opinions and recommendations from care providers and other
stakeholders can inform system changes that facilitate health monitoring among children with ASD.
ACKNOWLEDGMENT
The authors received no funding.
CONFLICT OF INTERESTS
The authors declare that they have no conflicts of interest.
ETHICS APPROVAL
All procedures were reviewed and approved by senior administrators at the residential school and were in accordance
with U.S. Federal Policy for the Protection of Human Subjects.
DATA AVAILABILITY STATEMENT
Research data are not shared.
ORCID
James K. Luiselli https://orcid.org/0000-0001-6989-9155
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How to cite this article: Bird, F., Shlesinger, A., Gopinathan, H., Duhanyan, K., Buckley, J., & Luiselli, J. K.
(2022). Health monitoring of students with autism spectrum disorder: Implementation integrity and social
validation of a computer-assisted bowel movement tracking system. Behavioral Interventions, 1–11. https://
doi.org/10.1002/bin.1874
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