Toilet Training: AAP Guidelines

• The study evaluated the combined and sequential effects of 3 toilet-training procedures for young children:
  • Underwear
  • A dense sit schedule
  • Differential reinforcement
• 20 children participated in the study.
• Classroom teachers implemented all 3 procedures with 6 children.
  • 2 showed clear and immediate improvements
  • 3 showed delayed improvements
• Teachers sequentially implemented with 12 children
  • At least 2 of the 4 improved with the underwear component after baseline
• None of the 8 improved with the dense sit schedule or differential reinforcement.
• When initial training components were ineffective, teachers implemented additional components sequentially until toileting performance improved or all components were implemented.
• The report for the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services (2006) stated that most children between 18 and 30 months have the skills to begin toilet training. Brazelton et al. (1999) indicated most children complete toilet training by 36 months.
• The American Academy of Pediatrics (1999; Schmitt, 2004b) emphasizes the role of childcare centers in toilet training.
  • Childcare centers can identify when a child is ready
  • Childcare centers can assist the caregiver with strategy development and implementation, and relay information about the child's progress (American Academy of Pediatrics, 1999).
• Pediatricians often initially discuss toilet training (Christophersen, 1991).
  • The pediatric community recommends when and how to train children (Brazelton et al., 1999; Schmitt, 2004a, 2004b; Schum et al., 2002).
• Recommendations:
  • Replacing diapers or pull-on training pants with underwear (Schmitt, 2004a, 2004b)
  • Routinely prompting children to sit on the toilet for a few minutes ( Schmitt, 2004a)
  • Using incentives to encourage success (Schmitt, 2004a, 2004b).
• Behavior analysts have evaluated recommended training procedures with individuals with intellectual or developmental disabilities.
• Kroeger & Sorensen-Burnworth, 2009) offer a review of training procedures used with children with developmental disabilities.
• Tarbox, Williams, and Friman (2004) showed decreases in accidents and increases in appropriate eliminations when diapers were removed.
• Simon and Thompson (2006) showed improvements in toileting performance when typically developing children wore underwear instead of diapers.
  • Two of five children had fewer accidents and increased appropriate eliminations, and a third child improved when underwear came after increased fluids and longer time on the toilet.
• Researchers evaluated the effects of changing the undergarment type while all other training procedures remained constant determining the additive effects of the underwear procedure.
• The American Academy of Pediatrics (Schmitt, 2004a) recommends prompting children to sit on the toilet routinely.
• LeBlanc, Carr, Crossett, Bennett, and Detweiler (2005) used a multilevel schedule with three children with autism spectrum disorder who were unresponsive to less intensive training.
  • Training began with 10 min on the toilet with 5-min breaks (Level 1) eventually ending with 5-min sits and 4-hr breaks (Level 12) depending on progress.
  • Hanney, Jostad, LeBlanc, Carr, and Castile (2013) replicated LeBlanc et al.'s findings with a larger number of children with autism.
  • In the studies by LeBlanc and Hanney et al the introduction of scheduled sits occurred alongside prompts, consequences, fluid consumption, an alarm, and positive practice.
  • Modifying the sit schedule on toileting performance was confounded by the simultaneous introduction of other training procedures
• The American Academy of Pediatrics recommends incentives to encourage the acquisition of toileting skills (Schmitt, 2004a, 2004b).
• Azrin and Foxx (1971) provided access to edibles and praise for eliminating in the toilet, liquids, and a preferred chair for remaining dry resulting in fewer accidents.
• Differential reinforcement began simultaneously with the start of other training procedures, preventing firm conclusions regarding the effects of differential reinforcement.
• Some training components are more influential than others and may be ineffective, effective only when combined with other components, or even contraindicated.
• Other components may be too complicated to implement with sufficiently high levels of procedural integrity.
• It is important to identify the effects of components so those that contribute to improving performance are implemented, thereby improving the effectiveness and efficiency of toilet training.
• A component analysis of training procedures would allow for the identification of the necessary and sufficient procedures.
• Ward-Horner and Sturmey (2010) described two types of component analyses.
  • Drop-out method: all components are implemented and single components are withdrawn based on stable responding to determine the contribution of each component.
  • Add-in method: identifies necessary components to produce responding.
    • Individual components are introduced following stable baseline responding, and subsequent components are added successively to determine the additive value.
• The current study uses a methodology similar to that described by Tarbox et al. (2004) and Simon and Thompson (2006) evaluating the combined and sequential effects of placing children in underwear, arranging a dense schedule of sits, and programming differential reinforcement
• The study specifically targeted increases in urinary eliminations in the toilet, decreases in urinary accidents, and increases in independent requests.

Method

• Evaluated toilet-training procedures with children from three early education classrooms in which enrollment ranged from 5 to 20 children and teacher-child ratios ranged from 1:1 to 1:10.

  • Most training procedures implemented by teachers enrolled in an undergraduate practicum course.
  • Teachers used a least-to-most prompting strategy to compliance with toileting routines.
  • Bathrooms were located in each classroom and were equipped with child-sized fixtures.

• Short barrier used in one classroom to prevent children from entering the bathroom unsupervised.

• Research assistants conducted weekly edible and leisure preference assessments with each child.

  • Teachers presented children with a choice of one of the two edible items and 30s of one of the two tangible items when the child meet the contingencies to access the preferred stimuli.
  • In the event that a child contacted the reinforcement contingencies more than once in a single bathroom visit, the teacher delivered one additional edible item with 30-s access to the tangible item.

• Teachers performed undergarment checks when the child arrived in the classroom and again every 30 min.

  • Teachers prompted the child to say "potty" or "bathroom" and to walk to the bathroom.
  • Teachers changed children with wet or soiled undergarments with minimal.
  • All children washed their hands before they left the bathroom.

• For scheduled sits on the toilet, teachers prompted the child to say “potty” or “bathroom” and walk to the bathroom.

• Teachers suspended data collection and toileting routines while children slept, except those with underwear remained in underwear during naptime.

  • Children returned to the nap area after cleaning the child's cot after accidents.

• Independent requests to sit (i.e., self-initiations) resulted in a 3-min sit plus teacher praise and reset future scheduled sits on the toilet.

• Twenty children ages 19 to 39 months old within AHRQ (2006) guidelines who showed little progress with low-intensity training at a university-based early childhood education center participated.

  • Children were recruited for participation if parents expressed interest, caregiver report indicated readiness skills, supervisor recommended, and the child's toileting performance did not improve with baseline procedures. One child was diagnosed with autism. Up to five children participated in each classroom at any given time.

• Teachers collected frequency data on each child's urinary accidents, appropriate urinary eliminations, and self-initiations throughout the day.

  • An accident was urinating anywhere other than in the toilet and was recorded each time a child's undergarments were wet.
  • An appropriate elimination was urinating in the toilet.
  • A self-initiation was independently requesting toilet access.
  • Children said or signed "potty" or "bathroom” and gestural mands

• Agreement consisted of both data collectors recording the same information for a children being dry Interobserver agreement:

  • Averaged 97% for accidents
  • 93% for appropriate eliminations
  • 95% for self-initiations

• The second observer also collected data on procedural integrity by assessing teachers' implementation of each child's training protocol as as well as undergarment check sit on 16% of opportunities:

  • Procedural integrity averaged 90% for teachers' undergarment checks and sits at the appropriate time.
  • Procedural integrity averaged 95% for teachers' correct undergarment check or sit.
  • teachers appropriately delivered preferred items for 12% of opportunities averaging 98% procedural integrity.

• Children participated in a set of baseline procedures designed to reflect a low-intensity toilet-training program.

  • Followed by a toilet-training package of three training components or to each component sequentially.
  • Components were counterbalanced across children
  • Teachers conducted occasional probes to assess toileting performance in the absence of all training procedures

Procedure Types

• Baseline: Children wore disposable diapers or pull-on training pants and were prompted them to sit on the toilet every 90 min.
• Underwear: This condition was identical to baseline(every 90 min) but wore cotton underwear and plastic pants over underwear and remained in underwear throughout the day including naps.
• Dense Sit Schedule: teachers prompted to sit on the toilet every 30 min instead of every 90 min
• Differential reinforcement: Four children participated with dry undergarments resulting in delivery of preferred items.
• Toilet-training package: the teacher implemented the underwear, dense sit schedule, and differential reinforcement components simultaneously.

Study Design

• Design and Data Analysis:
• Evaluated effects of each toilet-training component alone and combined
• Nonconcurrent multiple baseline design across subjects by staggering the first component across children following the point that had stabilized
• We evaluated added training components with children by returning to a condition or implementing a new condition
• The possibility of improved toileting performance was examined by calculating the mean difference for each measure from the mean of the immediately preceding phase.

Results

• The data are from the initial baselines and the initial training components implemented with each child.

  • Training package did not immediately improve Lizzy performance
  • Gayle's performance improved across so it was difficult to determine if training package improved with a higher percentage of appropriate eliminations
  • Ingrid also improved over time regardless of condition had a clear decrease in self-initiations

• Jim's training results were was similar to Gayle and Ingrid improved across making it diffcult to discern

• Bethany immediate improvement improvement had low training

• Two or six children showed benefits delayed increased low exposure across conditions improved by the low intensities or maturational variables

• Danny's first and second exposures to were correlated delayed improvements to baseline for Tammy decrease increase

• Leahs remained unchanged to facilitate for least two

• The dense to did improve Ernie increase remained participate extended that continue performance theOverall contribute and suggestion any

• Display performance was effect Nancy no levels however overall

• Prolonged improved limited baseline training Effect

• Analysis improvement correlated

• Effect indicate a standardized difference

• The training reduction improvements and one one the for.

Discussion

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This resource covers toilet training guidelines from the American Academy of Pediatrics as well as effective strategies and incentives used in childcare centers. It also references a study on toilet training and highlights the importance of waiting until a child is ready.