Teaching a child with challenging behaviour to use the toilet: a clinical case study

Abstract

Accessible summary• Using the toilet is important for people's independence, health and dignity.• It can be difficult to teach people to use the toilet when they are aggressive or oppositional. • This study describes how standard toilet training methods can be adapted to help a 13-year-old child with challenging behaviour learn to use the toilet independently. SummaryLearning to use the toilet is an important developmental step for a child's independence, health and dignity. It can be particularly difficult to teach continence skills to disabled children with aggressive or challenging behaviour. This study showed how Azrin & Foxx's (1971) basic toilet training procedure could be modified to teach a 13-year-old child with learning disabilities with aggressive behaviour to use the toilet in school. Urinary continence was achieved within 2 weeks and maintained at 6-week follow-up. Long-term data showed continence was maintained at 6-, 12-and 24-month follow-up. The programme was subsequently successfully transferred into the home. There is a strong evidence base for effective continence programmes, and the challenge now is how to disseminate their findings and ensure they are systematically used.

Toileting Problems in Children and Adolescents with Parent-Reported Diagnoses of Autism Spectrum Disorder

“…Kroeger and Sorensworth (2009) identified scheduled toilet sittings as a common component of many toilet training programs, which was taken from Azrin and Foxx's RTT method. Scheduled toilet sitting involves individuals sitting on or on front of the toilet (depending on sex and training protocol) at regular intervals (for example every 90 minutes) for a set period of time (for example 30 seconds), and is still employed in as part of multicomponent toileting programs today (Van Oorsouw, Duker, Melein, & Avernik 2010;Brown & Peace, 2011;Cocchiola, Martino, Dwyer, & Demezzo, 2012;Suppo & Mayton, 2012;Rinald & Mirenda, 2012;Kroeger & Sorensen-Burnworth, 2010;Lee et al, 2014;Drysdale et al, 2015;McLay et al, 2015;Axelrod et al, 2016). However, if an individual is demonstrating difficulty initiating trips to the toilet, that is, if the individual has not already started to approach the toilet independently for elimination, a new method, which involves scheduled chair sittings has been demonstrated to be successful to initiate this step which is vital to the maintenance of toileting success (Rinald & Mirenda, 2012;Kroeger & Sorensen-Burnworth, 2010).…”

“…Some studies have therefore employed the technique of removing the individual's pad or diaper as part of a multi-component toilet training program. (Cocchiola et al, 2011;Brown & Peace, 2011;Rinald & Mirenda;Drysdale et al, 2015;McLay et al, 2015;Van Oorsouw et al, 2009). Underlying this technique is the idea that removing pads or diapers may have negative reinforcing effects (Cocchiola et al, 2011;Brown & Peace, 2011).…”

“…In contrast, wearing a pad or diaper removes this wet feeling, and it's negative reinforcing properties. However, it should be noted that in order for wetness to have a motivating function, the individual must be observed to be particularly aware of, or become upset by being wet (Brown & Peace, 2011). There are also some ethical issues to be aware of and careful consideration of the short-term and long-term effects of such a strategy should be employed.…”

“…There are also some ethical issues to be aware of and careful consideration of the short-term and long-term effects of such a strategy should be employed. The short-term benefits associated with wearing a pad such as the reduced feeling of discomfort associated with wetness should be carefully weighed up against the long-term benefits of helping the individual to become continent (Brown & Peace, 2011). For example, in Van Oorouw et al's study, caretakers of participants who were wearing a diaper again post-intervention were requested to remove the diaper for one or more days to record the participants' number or accidents.…”

Toilet training for children with autism

“…Despite this and more recent research evidence about toilet training children with disabilities (Rogers 2002, Harris 2004, Brown and Peace 2011, and the availability of some useful information and tools to support toilet training, there is a lack of consensus about the right time to start toilet training (Kaerts et al 2012). This may be exacerbated by low expectations about children wth disabilities, or a tendency to delay toilet training while other problems are addressed.…”