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A rapid method of toilet training the institutionalized retarded

Authors:
  • Penn State University Harrisburg

Abstract and Figures

Incontinence is a major unsolved problem in the institutional care of the profoundly retarded. A reinforcement and social analysis of incontinence was used to develop a procedure that would rapidly toilet train retardates and motivate them to remain continent during the day in their ward setting. Nine profoundly retarded adults were given intensive training (median of four days per patient), the distinctive features of which were artificially increasing the frequency of urinations, positive reinforcement of correct toileting but a delay for "accidents", use of new automatic apparatus for signalling elimination, shaping of independent toileting, cleanliness training, and staff reinforcement procedures. Incontinence was reduced immediately by about 90% and eventually decreased to near-zero. These results indicate the present procedure is an effective, rapid, enduring, and administratively feasible solution to the problem of incontinence of the institutionalized retarded.
Content may be subject to copyright.
JOURNAL
OF
APPLIED
BEHAVIOR
ANALYSIS
A
RAPID
METHOD
OF
TOILET
TRAINING
THE
INSTITUTIONALIZED
RETARDED'
N.
H.
AZRIN
AND
R.
M.
Foxx
ANNA
STATE
HOSPITAL
AND
SOUTHERN
ILLINOIS
UNIVERSITY
Incontinence
is
a
major
unsolved
problem
in
the
institutional
care
of
the
profoundly
retarded.
A
reinforcement
and
social
analysis
of
incontinence
was
used
to
develop
a
procedure
that
would
rapidly
toilet
train
retardates
and
motivate
them
to
remain
con-
tinent
during
the
day
in
their
ward
setting.
Nine
profoundly
retarded
adults
were
given
intensive
training
(median
of
four
days
per
patient),
the
distinctive
features
of
which
were
artificially
increasing
the
frequency
of
urinations,
positive
reinforcement
of
correct
toileting
but
a
delay
for
"accidents",
use
of
new
automatic
apparatus
for
signalling
elim-
ination,
shaping
of
independent
toileting,
cleanliness
training,
and
staff
reinforcement
procedures.
Incontinence
was
reduced
immediately
by
about
90%
and
eventually
decreased
to
near-zero.
These
results
indicate
the
present
procedure
is
an
effective,
rapid,
enduring,
and
administratively
feasible
solution
to
the
problem
of
incontinence
of
the
institu-
tionalized
retarded.
Institutionalized
patients,
especially
the
pro-
foundly
retarded,
often
urinate
and
defecate
in
their
clothing
during
the
day.
Several
stud-
ies
(Azrin,
Bugle,
and
O'Brien,
in
press;
Baumeister
and
Klosowski,
1965;
Bensberg,
Colwell,
and
Cassell,
1965;
Dayan,
1964;
Giles
and
Wolf,
1966;
Hundziak,
Maurer,
and
Wat-
son,
1965;
Kimbrell,
Luckey,
Barbuto,
and
Love,
1967;
Van
Wagenen,
Meyerson,
Kerr,
and
Mahoney,
1969)
have
reported
some
de-
gree
of
success
in
reducing
this
daytime
incon-
tinence
with
institutionalized
retardates
or
mental
patients
(Wagner
and
Paul,
1970)
by
using
reinforcement
principles.
Several
of
these
efforts
have
been
primarily
concerned
with
"habit
training",
i.e.,
successful
elimi-
nation
in
the
toilet
bowl
when
the
retardate
is
placed
there
at
regularly
and
frequently
scheduled
intervals
(Dayan,
1964;
Baumeister
1This
investigation
was
supported
by
the
Illinois
De-
partment
of
Mental
Health
and
Grant
17981
from
the
National
Institute
of
Mental
Health.
Grateful
acknowl-
edgment
of
assistance
is
given
to
C.
Bugle,
J.
Crider,
F.
Gould,
D.
Haworth,
Helen
Hook,
W.
Isaacs,
G.
Lingle,
Alice
Meyer,
F.
O'Brien,
R.
Patterson,
and
Carol
Shep-
ard.
The
apparatuses
were
constructed
by
D.
Sauer-
brunn.
Reprints
may
be
obtained
from
either
author,
Behavior
Research
Laboratory,
Anna
State
Hospital,
Anna,
Illinois
62906.
and
Klosowski,
1965;
Hundziak
et
al.,
1965;
Kimbrell
et
al.,
1967).
Attempts
have
been
made
to
train
normal
independent
toileting
(Bensgerg
et
al.,
1965;
Giles
and
Wolf,
1966;
Van
Wagenen
et
al.,
1969)
but
quantitative
data
regarding
the
enduring
success
of
these
attempts
have
not
been
given.
In
all
of
these
studies,
the
post-training
data
were
either
ab-
sent
or
too
incomplete
to
determine
the
de-
gree
of
the
continence
that
endured
after
the
training,
as
was
also
concluded
by
Rentfrow
and
Rentfrow
(1969)
in
a
recent
review.
At
present,
no
procedure
of
established
effective-
ness
is
available
for
producing
and
maintain-
ing
normal
independent
toileting
by
institu-
tionalized
retardates.
The
overall
rationale
used
in
the
present
effort
was
that
normal
toileting
is
not
simply
a
matter
of
learning
to
respond
to
bladder
and
bowel
pressures
by
relaxing
the
spincter
but
rather
is
a
complex
operant
and
social
learning
process
that
has
been
hindered
by
a
reduced
learning
capacity
and
by
institution-
alization.
In
line
with
this
rationale,
a
general
procedure
was
developed
in
which
positive
reinforcement
was
given
for
appropriate
elimi-
nation
and
inhibitory
training
for
untidiness
(see
also
Van
Wagenen
et
al.,
1969;
Giles
and
Wolf,
1966).
Urine-sensing
apparatuses
were
89
1971,
49
89-99
NUMBER
2
(SUMMER
1971)
N.
H.
AZRIN
and
R.
M.
FOXX
used
to
provide
feedback
to
the
trainer
such
that
he
could
then
deliver
the
reinforcers
or
inhibitors
immediately
after
the
eliminatory
response
(see
also
Mowrer
and
Mowrer,
1938;
Van
Wagenen
and
Murdock,
1966;
Watson,
1968;
Van
Wagenen
et
al.,
1969;
Azrin
et
al.,
in
press).
The
operant
level
of
urination
(Van
Wegenen
et
al.,
1969)
or
defecation
(see
Giles
and
Wolf,
1966)
was
increased
to
provide
more
responses
that
could
be
reinforced,
rather
than
dealing
with
the
low
frequency
of
elimination.
Generalization
of
the
effect
of
training
was
enhanced
by
conducting
the
training
on
the
patient's
own
ward
(see
Giles
and
Wolf,
1966).
Dressing
and
undressing
skills
and
un-
prompted
approach
to
the
toilet
were
taught
as
part
of
training
(see
Giles
and
Wolf,
1966;
Van
Wegenen
et
al,
1969).
These
procedures
were
modified
and
developed
in
this
study
for
the
intended
effect
of
rapidity
and
complete-
ness
of
continence.
In
addition,
administrative
procedures
were
arranged
for
assuring
the
con-
tinued
social
concern
of
the
ward
staff
so
that
the
effects
of
the
training
would
endure.
METHOD
Subjects
Nine
male
incontinent
and
profoundly
re-
tarded
residents
were
selected
from
a
hospital
ward;
the
other
residents
of
that
ward
were
either
continent,
totally
blind,
or
non-ambula-
tory.
The
nine
had
a
mean
age
of
43
yr
and
a
range
of
20
to
62
yr.
Their
mean
number
of
years
of
hospitalization
was
21
and
ranged
from
6
to
45
yr.
All
but
one
had
an
IQ
less
than
30;
the
median
was
14
with
a
range
of
7
to
45.
Several
had
major
physical
and
medi-
cal
problems,
e.g.,
two
had
paralysis
of
one
arm
and
one
was
partially
blind.
Speech
was
minimal
for
three
residents
and
absent
for
five;
one
was
echolalaic.
All
had
limited
re-
ceptive
speech
but
could
follow
simple
di-
rections.
Virtually
no
interaction
was
observed
between
residents
on
the
ward
of
either
a
pos-
itive
or
negative
nature.
The
residents
were
regularly
toileted
as
part
of
the
ward
routine
after
each
meal.
Despite
these
regularly
sched-
uled
periods,
incontinence
remained
the
ma-
jor
ward
problem.
Habit
training
procedures
had
been
used
previously
with
these
residents
but
had
not
produced
bladder
and
bowel
con-
trol
or
independent
toileting.
Experimental
Design
A
three-day
baseline
measure
of
inconti-
nence
was
obtained
for
each
resident,
after
which
the
nine
residents
were
randomly
as-
signed
to
a
treatment
or
control
group,
the
two
groups
being
matched
on
the
basis
of
the
average
number
of
accidents
for
the
group.
The
experimental
group
of
four
residents
was
trained
as
a
group.
When
the
last
experi-
mental
resident
completed
training,
after
12
days,
training
began
for
the
control
group
(N
=
5).
Four
of
the
five
residents
in
the
con-
trol
group
began
training
as
a
group,
the
fifth
being
added
as
soon
as
one
of
the
four
com-
pleted
training.
As
each
of
the
nine
residents
completed
training,
they
were
placed
on
the
post-training
maintenance
program.
The
matching
of
groups
permitted
a
standard
between-groups
statistical
evaluation
of
the
effects
of
toilet
training.
The
later
training
of
the
control
group
permitted
a
within-subject
evaluation
for
all
residents
by
comparing
the
pre-
and
post-training
accidents
for
each
of
the
nine.
Recording
All
previous
reports
of
incontinence
have
based
the
accident
data
on
the
retrospective
verbal
reports
or
uncorroborated
written
re-
ports
of
parents
or
attendants
who
presumably
recorded
accidents
on
an
unknown
basis
of
selective
attention
at
different
times.
In
the
present
study,
the
resident
was
observed
every
hour
for
8
hr
each
day
and
a
written
record
taken
at
that
moment
by
an
assigned
observer
as
to
whether
the
pants
were
wet
or
soiled.
The
recording
procedure
was
kept
constant
for
the
three-day
period
preceding
training
and
the
first
12
days
after
training
for
each
resident.
Any
accidents
observed
between
the
hourly
checks
were
also
recorded.
When
pants
were
wet
or
soiled,
they
were
changed
immed-
iately
so
that
successive
observations
of
wet
pants
did
reflect
repeated
wettings.
Twelve
days
after
the
last
resident
was
trained,
the
recording
procedure
was
changed
to
be
more
compatible
with
the
continence
maintenance
procedures
described
below.
The
residents
were
individually
observed
six
times
per
day
at
roughly
2.5-hr
intervals
by
an
assigned
ob-
server.
Corroboration
of
the
records
was
con-
ducted
through
several
methods.
Reliability
was
assessed
on
the
third
day
of
the
baseline
90
TOILET
TRAINING
OF
THE
ADULT
RETARDED
period
and
twice
during
the
12-day
post-train-
ing
period
by
having
the
trainer
and
a
ward
staff
member
concurrently
observe
the
resi-
dents
with
each
observer
unaware
of
the
other's
records;
perfect
agreement
was
ob-
tained.
The
ward
supervisors
regularly
ob-
served
the
residents
during
the
maintenance
period,
especially
at
the
designated
observa-
tion
hours
and
indicated
in
writing
their
con-
firmation
or
disagreement
with
the
data
re-
corded.
Virtually
all
such
reports
were
in
agreement.
Intermittent
observations
by
the
trainer
on
the
ward
corroborated
the
occur-
rence
of
the
supervisory
as
well
as
the
regular
observations.
The
record
sheets
were
located
in
the
supervisor's
office
and
changed
each
day
to
discourage
retrospective
or
unsupervised
recording.
Table
1
is
a
listing
of
the
various
steps
of
the
toilet
training
procedure.
Table
1
Outline
of
the
Toilet
Training
Procedure
I.
When
No
Accidents
Occur
1)
Resident
seated
in
chair
when
not
seated
on
toilet
bowl
2)
Resident
drinks
fluids
every
half-hour
3)
Scheduled
toileting
of
resident
every
half-hour
4)
Resident