Week 11 Special Topics PDF

Special Topics I WEEK #11 Bev Graham, PhD, MPA, BCBA- D, LBA  Habit Disorders AUSTIN & CARR CH. 6 ASSESSMENT AND TREATMENT OF HABIT DISORDERS Habit Disorders  Habit behaviors are repetitive or stereotypical responses that serve no apparent social function but are...

Special Topics I WEEK #11 Bev Graham, PhD, MPA, BCBA- D, LBA  Habit Disorders AUSTIN & CARR CH. 6 ASSESSMENT AND TREATMENT OF HABIT DISORDERS Habit Disorders  Habit behaviors are repetitive or stereotypical responses that serve no apparent social function but are maintained by operant contingencies.  Examples include physical damage and poor social acceptability.  Habit disorders can be maintained by automatic reinforcement in the form of self- stimulation or arousal reduction.  The four most frequent habit disorders are: tic disorders, trichotillomania, thumb sucking, and nail biting. Tic Disorders  Tic disorders are rapid, repetitive, and often jerking muscle movements (motor tics) or sudden, rapid, recurrent, nonrhythmic vocalizations (vocal tics).  Prevalence rates for motor tics are approximately 1% of the population, vocal tics are unclear but 6.5% of college students engage in throat clearing at least 5 times per day, and for Tourette's syndrome is approximately.04-.05%.  Individuals with tic disorders sometimes have concurrent problems such as obsessive-compulsive behaviors, attention deficit/hyperactivity disorder, aggression management problems, and sleep problems.  Tics may also cause physical damage such as cuts, burns, and bruises. Development and Current Etiological Theories of Habit Disorders  Genetic research shows a 77% concordance rate for tic disorders among monozygotic twins.  The biological perspective suggests that an excess of the neurotransmitter dopamine may be responsible for tics.  The behavioral perspective suggests that individuals experience heightened tension in specific muscle groups and tics may be maintained by tension reduction in those muscles; the tension may also be reduced by the presence of an anxiety-provoking person. Trichotillomania  Individuals with trichotillomania experience chronic hair pulling which results in noticeable hair loss.  They often experience a feeling of tension or anxiety that is relieved after pulling their hair.  Prevalence is approximately 1-4% of the population with adult females being 3 times more likely to receive the diagnosis than males.  Consequences of trichotillomania include chronic hair follicles damage or severe gastrointestinal difficulties if the hair is ingested. Development and Current Etiological Theories of Habit Disorders  Biological theories have not established a causal link between neurological activity and trichotillomania.  Some studies suggest that trichotillomania may be related to a serotonin deficiency.  Hair pulling may be maintained through social consequences.  The behavioral theory suggests that hair pulling produces automatic reinforcing consequences such as tactile stimulation and tension or anxiety reduction. Thumb Sucking  Thumb sucking occurs in up to 46% of children under the age of 4 and continues in 19% of children over the age of 5.  Thumb or finger mouthing occurs in approximately 2.8% of college-age adults.  Females are more likely to engage in thumb sucking than males.  Consequences of chronic thumb sucking include dental malocclusion, atypical root resorption, and increased risk of accidental poisoning.  The behavioral theory suggests that the behavior is learned early in infancy to modulate arousal. Nail Biting  Nail biting includes placing any digit into the mouth and biting either the nails or the skin around the nails.  Chronic nail biting can result in damage or inflammation of the tissue around the nail, possible infection, and shortening of the roots of the teeth. Development and Current Etiological Theories of Habit Disorders  Nail biting may be maintained by biological processes affected by clomipramine. Clomipramine is affective for treating OCD.  Nail biting is thought to be maintained by tension/anxiety or increased arousal in under- stimulating situations. Assessment of Habit Behaviors  It may be best to use a duration measure when assessing longer duration behaviors (such as thumb sucking, nail biting, and hair pulling).  Physical trace measures might not always correspond highly with the occurrence of the behavior (e.g., a small amount of the behavior might produce a substantial amount of damage). Measuring Habit Behaviors  Direct observation (live or videotaped) is preferable for the measurement of any habit behavior.  Nail biting may be measured using physical trace procedures, most often by measuring the length of the fingernails.  Self-report, self-monitoring, and parental report procedures have been criticized for methodological problems such as proneness to bias and distortion, lack of specificity, and relatively poor correspondence with more objective assessment strategies. A Functional Approach to the Assessment of Habit Disorders  Functional assessment may provide two key pieces of information: o Data needed to modify etiological theories of the various habit disorders. o Information to alter treatment plans to maximize their effectiveness.  Functional analysis attempts to identify the function(s) that maintain the behavior through antecedent and consequence manipulations. Treatment of Habit Disorders Tic Disorders Medical Treatments  The three most common medications used to treat tic disorders are haloperidol, clonidine, and pimozide.  Drugs used to treat tics have side effects such as dry mouth, constipation, sedation, and possible risk of developing permanent movement disorders such as tardive dyskinesia. Behavioral Treatments  Massed (negative) practice (MP): The participant intentionally engages in the target behavior rapidly and with great effort for a specified frequency or length of time.  Habit reversal (HR): A multi-component procedure originally developed to treat nervous habit and motor tics.  Awareness training: Utilizes four techniques to increase awareness of the habit behavior: o Response description o Response detection o Early warning o Situation awareness training Behavioral Treatments Cont.  Competing response (CR) training: The client engages in a behavior incompatible with the target habit behavior.  Motivation training: Increases motivation through three techniques: o Habit inconvenience review o Public display o Social support procedure o Symbolic rehearsal  Relaxation training: Effective as a sole treatment for tics, as it functions as a dissimilar CR. Trichotillomania Medical Treatments  Medications used to treat trichotillomania include fluoxetine, clomipramine, imipramine, haloperidol, and lithium.  Trichotillomania Behavioral Treatment  Habit reversal is the most extensively evaluated and is effective in 60% of the cases when presented in a group format.  Simplified HR package: Consists of awareness training and CR training with parental social support.  Self-monitoring has also produced effective results.  Other treatments: o Aversive conditioning o The elimination of covarying habit behaviors (e.g., thumb sucking). o Various reinforcement and punishment procedures. Thumb Sucking Medical Treatments  No medications have been used to treat chronic thumb sucking. Behavioral Treatments  Bitter substance application is one of the most popular and effective treatments.  Habit reversal is another popular and effective treatment. Nail Biting Medical Treatments  Clomiprimine is the only medical intervention attempted with nail biting. Behavioral Treatments  Self-monitoring has been demonstrated to be effective.  Habit reversal has also been evaluated in several studies.  Other treatments: o Electric shock o A portable self-administered shock device o Bitter substances o Contingency contracting o Covert sensitization  Feeding Disorders PIAZZA ET AL. (2021); CHAPTER 25 FROM FISHER ET AL. (2021) Feeding Disorders  Feeding disorders occur in over 60% of children, indicating a significant public health concern that necessitates awareness and intervention strategies.  Causes can be neurological (62%), structural (53%), behavioral (43%), cardiorespiratory (34%), and metabolic (12%), highlighting the multifaceted origins of these disorders.  Most children with feeding disorders have causes in two or more categories, which complicates the diagnosis and treatment processes and emphasizes the need for comprehensive evaluations.  Feeding disorders are prevalent among children with autism spectrum disorder, cerebral palsy, and Down syndrome, emphasizing the need for tailored interventions for these vulnerable groups. Causes of Feeding Disorders  Children with chronic medical problems directly affecting the digestive system may develop feeding disorders, which can be exacerbated by these conditions.  Examples of these medical problems include gastroesophageal reflux disease, where stomach acid frequently backs up into the esophagus, delayed gastric emptying that hampers efficient digestion, food allergies or food intolerances that can provoke painful or uncomfortable reactions, malabsorption syndromes that prevent the body from adequately absorbing nutrients, and metabolic disorders that impact how the body processes food.  Children with gastroesophageal reflux disease may associate eating with pain caused by acid reflux, leading to anxiety around meals and a reluctance to eat. Causes Continued  Nausea plays an important role in developing food aversions, significantly affecting a child's willingness to try new or previously enjoyed foods.  A single or few experiences of nausea paired with eating can lead to taste aversions, which are strong and can result in lifelong negative associations with certain flavors and foods.  Taste aversions generalize to different foods and are difficult to treat, making early intervention and treatment strategies crucial for preventing long-term feeding issues. Maintaining Factors in Feeding Disorders  Inappropriate feeding behavior can be maintained by access to adult attention or tangible items as positive reinforcement, often leading to a cycle where negative behaviors are inadvertently encouraged.  Escape from food presentation and mealtime demands can also function as reinforcement, where a child may learn that refusing to eat or engaging in disruptive behavior results in the cessation of pressure to eat.  Environmental events may reinforce inappropriate mealtime behavior, even if the underlying cause of the feeding disorder is complex; this suggests that mealtime settings and parental expectations should be evaluated as part of a treatment program. Treatment of Feeding Disorders  Even if the underlying cause of a feeding disorder is unknown, treatment is possible by changing responses to the child's inappropriate mealtime behavior, thus promoting a healthier eating environment.  Stimulus fading can be used to increase acceptance and decrease inappropriate mealtime behavior, gradually introducing changes that help children adapt to more appropriate eating habits.  Examples of stimulus fading include changing the texture of food from liquid to baby food, spoon to cup, syringe to spoon, and syringe to cup, which helps children adjust to new methods and textures of eating. Treatment Continued  Antecedent interventions such as utensil manipulation can be used to increase mouth cleanliness and decrease packing, which refers to the tendency of a child to hold food in their mouth rather than swallowing it properly.  Examples of utensil manipulation include presenting food on an upright spoon, a flipped spoon, or a Nuk device, which encourages proper mouth movement and improves feeding efficacy. Applied Behavior Analysis (ABA) feeding therapy is a treatment that can help children with autism who have trouble eating. ABA feeding therapy can help with a variety of issues, such as: Increasing the number of foods a child eats Learning how to use utensils Eating at restaurants Learning how to eat certain textures or purees Improving swallowing Reducing mealtime tantrums Chewing  Chewing emerges in typically developing children around 12 months of age as caregivers introduce foods with increasing texture; this developmental milestone is vital for transitioning to solid foods.  Children with feeding disorders often do not begin chewing at 12 months of age, which may lead to difficulties in establishing healthy eating patterns and habits.  Caregivers often base the texture of food on the child's age rather than their chewing skills, leading to potential mismatches that can hinder the child's feeding development.  A mismatch between food texture and chewing skills increases the risk of aspiration, a serious concern that can lead to respiratory issues or choking if not addressed properly.  Children with poor chewing skills may develop inappropriate compensatory behavior, such as using their tongue to push food against the roof of their mouth, which can create further feeding complications and impede the natural progression of chewing abilities. Behavioral Pediatrics FRIMAN (2021); CHAPTER 24 FROM FISHER ET AL. (2021) Behavioral Pediatrics  Behavioral pediatrics encompasses the exploration of how children's behaviors are interconnected with their health care needs during pediatric consultations. This subfield of pediatrics emphasizes the importance of psychological and emotional well- being alongside physical health, recognizing that behavior can significantly impact a child's overall health and development.  Behavioral pediatricians are typically the primary professionals that caregivers reach out to when observing or experiencing concerns regarding a child's behavior issues. This early intervention is crucial, as it allows for timely support and assessment, helping to prevent further complications or the exacerbation of behavioral problems.  Rates of Behavioral  Disorders It has been estimated that about 25% of children who attend primary care services exhibit symptoms that fulfill the criteria for various behavioral or emotional disorders.  These may include conditions such as anxiety, depression, or attention-deficit/hyperactivity disorder (ADHD), indicating a significant prevalence of such issues in the pediatric population.  In addition to those meeting diagnostic criteria, a further 40% or more of children display subclinical behaviors or emotional responses that raise concerns among caregivers. These subclinical concerns, while not diagnostic, can still lead to considerable anxiety for both parents and children, potentially impacting their functioning and quality of life. Key Principles of Behavioral Pediatrics  Behavior is shaped by a constellation of current circumstances and historical contexts, emphasizing that understanding a child’s behavior requires considering both their immediate environment and their past experiences. This historical perspective allows for a more comprehensive view of the influences on behavior and can guide interventions.  Interventions in the field of behavioral pediatrics are designed to address a broad array of concerns, focusing primarily on issues such as child discipline, incontinence, sleep disorders, habit disorders, and symptoms associated with attention-deficit/hyperactivity disorder (ADHD). Each area requires tailored strategies that take into account the individual needs and contexts of each child. Bedtime Problems  Sleep disorders are a significant concern, with research indicating that at least 30% of families experience sleep issues three or more nights each week. These problems can disrupt family dynamics and lead to broader issues affecting children's physical health and emotional stability.  Common difficulties faced by families regarding children's sleep include resistance at bedtime, which may manifest as tantrums or protests when it is time to sleep, as well as fussing and crying while settled in bed. Additionally, night waking, where children wake during the night and struggle to return to sleep, can significantly hinder both the child’s and caregivers’ sleep quality.  In attempts to manage these sleep issues, pediatricians may prescribe soporific drugs to aid with sleep; however, the use of such medications often comes with various side effects. Furthermore, the therapeutic benefits of these drugs frequently diminish once the medication is stopped, raising concerns about their long-term adequacy and safety as a solution.. Understanding and Treating Sleep Problems of Children with Autism Gregory P. Hanley. Ph.D., BCBA-D DATAFINCH NOVEMBER , 2014  Why is Good Sleep Important? Good sleep is restorative; without it, children are: more irritable more easily fatigued more likely to suffer from unintentional injury less likely to follow instructions less likely to learn academic concepts more likely to engage in problem behavior (meltdowns, self-injury, aggression, stereotypy) Hanley (2014)  How Prevalent are Sleep Problems? Sleep problems are prevalent: 35 - 50% of young children 63 - 73% of children diagnosed with autism Sleep problems are persistent -they do not typically remit with time Hanley (2014)  Treatment Options? 81% of children’s visits to pediatricians, psychiatrists, or family physicians for sleep problems result in a prescription for a medication despite no FDA approval, no medication labeled for pediatric insomnia, no (or inconsistent) efficacy signal in literature Hanley (2014) Common Sleep Problems Nighttime routine noncompliance Sleep-interfering behavior Delayed sleep onset Night awakenings Early awakenings Assumptions Regarding Sleep Behavioral quietude /Falling asleep are the behaviors of interest Can be influenced by past and present events in one’s sleeping environment ◦ can be motivated (or demotivated) ◦ can become reliant on environmental cues ◦ can be affected by other reinforcers for other behaviors available at night How do we assess and treat children’s sleep problem? Through a general understanding of the common factors that influence good sleep and sleep problems Using an open-ended indirect assessment to identify the personal factors influencing the sleep problem ◦SATT (Sleep Assessment and Treatment Tool) By encouraging parents to develop the intervention with us ◦ we support parents in their implementation of the assessment-based treatment via phone calls and weekly visits. Step 1: Develop Ideal Sleep Schedule Step 2: Routinize Nighttime Routine Step 3: Optimize Bedroom Conditions Step 4: Regularize Sleep Dependencies Step 5: Address Sleep Interfering Behavior  Age-Based Sleep Averages: Age Total Sleep Night Sleep # Naps 2 11 hrs 30 min 9.5 hours 1 (2 hrs) 3 11 hrs 15 min 10 hours 1 (1hr15min) 4 11 hrs 10 -11 hours 0-1 5 10 hrs 45 min 6 10 hrs 30 min 9 10 hrs 12 9 hrs 45 min 15 9 hrs 15 min 18 9 hrs Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006  Sleep Scheduling Cautions: Difficulty falling asleep, staying asleep, or complying with nighttime routines may occur if child is expected to be in bed too long Difficulty waking up or daytime tiredness may be related to child being in bed for too short of a time Implication: Select the right sleep total for child  Step 1: When should the bedtime be scheduled? At the beginning of sleep treatment: set the start of the sleep routine slightly later than when the child fell asleep the previous night Then gradually transition sleep phase earlier if child falls asleep within 15 min move bedtime 15 min earlier next night until desired bedtime is achieved (Piazza et al., 1991) Step 2: Routinize Nighttime Routine Develop a nighttime routine that occasions “behavioral quietude” Try to implement it consistently across nights With kids diagnosed with autism we often encourage parents to arrange choices on picture schedule We ensure that activities progress from active to passive That baths are earlier in routine, so we don’t alter the descent of core body temperature The release of endogenous melatonin is facilitated by decrease in ambient light, so we ask that ambient light gets progressively dimmer And we encourage light snacks without caffeine during the routine.  Step 3: Optimize Bedroom Conditions Cooler temperature Indirect lighting only Non-undulating noise Best toys/preferred activities not visible  Nighttime Noncompliance Considerations Tendency to not follow instructions or resist guidance to, for example, put on PJs, brush teeth, or get in bed Solutions: Start routine just prior to natural sleep phase Promote instruction following during the day ◦ See steps on handout (e.g., name game, follow through, etc.) Compliance Considerations: Response to name: Stop what he is doing, look at me, and say yes. Follow through: Make sure your words matter. Arrange big discrepancy: compliance results in getting to stay up longer, reading a long book or more books, extra snack, stickers or tokens for things in the morning Noncompliance does not result in the withholding of an expected reinforcing event like reading a book (no extinction please) Step 4: Optimize Sleep Dependencies Transitioning from behavioral quietude to sleep depends on stimuli associated with falling asleep  Optimizing Sleep Dependencies Transitioning from behavioral quietude to sleep depends on stimuli associated with falling asleep Problems: Things that occasion sleep are not present when the child wakes up during the night = Night Awakenings Things that occasion sleep are suddenly removed or inconsistently available = Sleep Onset Delay and possibly sleep interfering Behavior Examples: TV, radio, books, bottles, “full belly,” presence of another person, being rocked or patted, lights, fallen stuffed animal or blanket  Optimizing Sleep Dependencies Occasion sleep with things that don’t require your presence, can be there in the middle of the night, and are transportable (e.g., for vacations or nights at Grandparent’s home)  Optimizing Sleep Dependencies Good dependencies: pillow, blanket, stuffed animal (with bed rails), pacifier, sound machine on continuous Eliminate or fade “bad” ones and replace with “good” dependencies  Step 5: Address Sleep Interfering Behavior SLIB = Behaviors that interfere with behavioral quietude necessary for falling asleep The big four are: leaving bed (curtain calls) crying / calling out playing in bed or in bedroom (this includes motor or vocal stereotypy) talking to oneself  Step 5: Address (SLIB) Be sure to first properly consider what the likely reinforcers are for the interfering behavior Attention / Interaction Food/drink Access to TV or toys Escape/avoidance of dark or of bedroom Automatic reinforcers (those directly produced by the behavior)  Addressing SLIB Part 1 Provide the presumed reinforcer prior to bidding the child good night  Addressing SLIB Part 2 After bid goodnight, eliminate access to presumed reinforcer following IB With socially mediated IB, options include: Extinction, Progressive Waiting, Time-Based Visiting, Quiet-Based Visiting, Quality Fading, or Bedtime Pass With automatically-reinforced SLIB, we use: Relocation of relevant materials Blocking Addressing SLIB Time-Based Visiting Visit your child at increasingly larger intervals after the bid good night and across nights (hopefully before IB occurs); during visit re-tuck them, bid good night, and leave. Day First Secon Third Fourth Fifth Sixth Seventh visit d visit visit visit visit visit visit 1 10 s 30 s 1 min 3 min 5 min 10 30 min min 2 30 s 1 min 3 min 5 min 10 min 30 min 3 30 s 3 min 5 min 10 30 min min 4 1 min 3 min 5 min 10 30 min min 5 1 min 5 min 10 30 min min 6 5 min 10 min 30  Addressing SLIB Bed Time Pass Give your child a bedtime pass to be used as needed after the bid good night to have one request granted. If # of IBs was high before you try this treatment, provide more than one bedtime pass initially and then fade out the number each night. If sleep is dependent on parent presence and IBs are intense, consider also Parent Fading 1. Lie next to child on bed for three nights 2. Lie on mattress next to bed for three nights 3. Move mattress closer to door every three nights 4. Sit on chair in bedroom at door with door open for three nights 5. Sit outside door whilst still visible to child for three nights 6. Sit outside door not visible to child for three nights 7. Sit outside room with door closed for three nights.  Addressing Night Awakenings Should be resolved with appropriate sleep schedule and healthy sleep dependencies If not, address issues related to temperature, food, light, noise, incontinence, nighttime reinforcers If not, we actively teach child to know when it is okay to get up for the day usually with moon/sun clocks  Freedom from sleep problems is possible and probable with: Individualized assessment Individualized and comprehensive treatment: Step 1: Develop Ideal Sleep Schedule Step 2: Routinize Nighttime Routine Step 3: Optimize Bedroom Conditions Step 4: Regularize Sleep Dependencies Step 5: Address Sleep Interfering Behavior Encopresis (eng-kuh-pree-suhs)  Encopresis, which is the involuntary passage of stool, is primarily driven by fecal retention. This condition is generally not attributed to characterological issues or psychopathological disturbances but rather stems from physical and behavioral factors that contribute to a child’s inability to manage bowel movements effectively.  Fecal retention occurs due to a combination of various factors, including a constitutional predisposition that may cause slow gastrointestinal transit time, poor dietary choices that lack sufficient fiber, inadequate physical leverage for easier stool passage, painful experiences related to the passage of hard stools, as well as negative reinforcement associated with attempts to hold in stools. This complex interplay often sets the stage for encopresis to develop.  Though rare, there are instances where fecal retention can be associated with traumatic events such as sexual abuse, underscoring the need for comprehensive evaluations to rule out any underlying severe issues when assessing a child for encopresis. Encopresis - Medical Factors  In many instances, constipation plays a crucial role in the onset of encopresis. Chronic constipation can lead to fecal impaction, which may cause a phenomenon where the child cannot feel the urge to have a bowel movement, further complicating the issue.  In rare occurrences, neurological issues such as Hirschsprung’s disease, an abnormality affecting the large intestine leading to problems with passing stool, and anatomical defects that necessitate medical intervention can also contribute to the development of encopresis. In such cases, medical management is critical for resolution. Encopresis - Behavioral Assessment  A thorough behavioral assessment for encopresis involves conducting interviews that specifically inquire about factors related to constipation. Essential questions should encompass: o The length of intervals between bowel movements, which may indicate chronic issues. o The size of bowel movements, where unusually large instances may signal impaction. o The presence of foul odors in fecal matter, suggesting retained feces. o The texture of stools, inquiring whether they are hard and whether passage is difficult or painful. o Assessing the child's awareness of their bowel movements, including whether they can feel the urge and make it to the toilet in time. o Determining if the child hides soiled underwear, which might suggest avoidance behaviors linked to shame or embarrassment. Incentive Programs  Incentive programs are structured approaches that aim to improve compliance and desirable behaviors through rewards. These programs typically involve: o Dividing a comprehensive regimen into manageable, easy-to-follow steps, making them less overwhelming for the child. o Offering tokens or points contingent on completing these specified actions, creating a direct correlation between effort and reward. o Implementing a system where tokens are removed or withheld if the steps are not completed, reinforcing the importance of consistency. o Facilitating regular exchanges where children can trade their tokens for predetermined rewards, further incentivizing adherence to the regimen. Rapid Toilet Training (Azrin & Fox 1971) Participants: 9 male incontinent males with profound disabilities residing on a hospital ward Mean years of hospitalizations was 21 years Mean age was 43 years old Randomly assigned to treatment or control group following baseline Azrin & Fox (1971) Apparatus 1 A moisture-sensitive pair of shorts that sounded a signal when the resident urinated or defecated in the shorts. A wire connected the sensors in the shorts to a small circuit box worn on a belt under the resident's shirt. The circuit box sounded a bleep-tone whenever the residents urinated or defecated in the shorts as the moisture completed a low voltage circuit that was far below the threshold of feeling. Azrin & Fox (1971) Apparatus 2 Detected appropriate toileting by emitting a tone when urine or feces occurred. Enabled immediate reinforcement. The residents were required to sit on the toilet every half hour and to remain there for 20 min or until an appropriate elimination was signalled by the toilet alarm, whichever occurred first. Azrin & Fox (1971) Maintenance Procedures Azrin & Fox (1971)  Six weeks after training, five residents were discontinued from the Ward Maintenance Program since they had not had an accident for over four weeks. Nine weeks after training, two more residents were discontinued from the maintenance program. The Ward Maintenance Program was dropped in the middle of the fifth month after the two remaining residents were continent for four weeks. The ward attendant in charge of the clothing room reported that since completion of training the number of pants sent to the hospital laundry each week had been reduced by over 40% Azrin & Fox (1971) Social Validity of Procedures During the training, the residents obtained an unusually higher density of positive reinforcement in the form of both food, drinks, verbal praise, hugs, and attention. Most residents would not leave the toilet at the end of the daily training sessions even when asked to leave. Two of the residents who had completed training and were in the ward maintenance program repeatedly attempted to reenter the training area even though the toilet area was partitioned off from the rest of the ward. At no time did any of the residents physically aggress toward the trainer. Only two residents attempted to leave the toilet, and then only during some of the timeout periods. Azrin & Fox (1971)  Toilet Training Current estimates are that 30%-50% of children with ASD have problems with toilet training Toilet training is a significant developmental milestone for children, usually starting between 18 to 30 months of age. Recognizing the right time to begin is crucial for successful training and can impact a child's confidence and comfort. Childcare centers play a vital role in supporting caregivers throughout the training process. By collaborating with families, these centers help ensure children are ready and prepared for this journey. Pediatricians are often the first point of guidance for families in their toilet training endeavors. Greer, Neidert & Dozier Purpose: Compare 3 Methods of Toilet Training Method 1: Underwear Approach The underwear method involves introducing children to underwear during training, fostering independence and ownership. Among the group of 20 children, those who started with this method showed clear improvements. This method encourages children to recognize their body's signals more effectively. Method 2: Dense Sit Schedule A structured dense sit schedule involves having children sit on the toilet at regular intervals, regardless of need. Method 3: Differential Reinforcement Differential reinforcement focuses on rewarding children for positive toilet behaviors without punishing failures. Rewards may include verbal praise, stickers, or special privileges, enhancing motivation to succeed. Greer, Neidert & Dozier  Participants 20 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 were implemented by classroom teachers who were students enrolled in an undergraduate practicum course on early childhood education and care. Teachers used a least-to-most (vocal, model, physical) prompting strategy to guide child compliance with toileting routines. Greer, Neidert & Dozier  Procedures Conducted weekly edible and leisure multiple-stimulus-without-replacement preference assessments with each child. The two most highly preferred edible and leisure items were selected for toilet training for the upcoming week. Teachers presented children with a choice of one of the two edible items and 30 s of one of the two tangible items when children met the contingencies to access the preferred stimuli. Teachers performed undergarment checks when the child arrived in the classroom and again every 30 min throughout the study. Greer, Neidert & Dozier  Baseline Children wore disposable diapers or pull-on training pants during baseline. Teachers prompted children to sit on the toilet every 90 min and delivered preferred items after appropriate eliminations. Bowel movements on the toilet also resulted in access to the preferred items; however, bowel control was not a focus of this study. Greer, Neidert & Dozier  Evaluated the combined and sequential effects of three recommended toilet-training procedures on levels of accidents, appropriate eliminations, and self- initiations. When these three training components were combined, we observed clear improvements in toileting performance for two of the six children Four children benefited from the underwear component following baseline Four of six children showed improvements when underwear was added as a second or third component. None of the eight children who experienced the dense sit schedule or differential reinforcement following baseline showed improvements in overall performance. Three of six children showed improved levels of appropriate eliminations when differential reinforcement was used in conjunction with underwear Placing children in underwear may improve their toileting performance when used with low intensity training (e.g., periodically prompting the child to sit Greer, Neidert & Dozier on the toilet and providing differential reinforcement). Conclusions Researchers should consider collecting data on negative vocalizations, noncompliance, and disruptive behavior (e.g., tantrums) during toilet training. Researchers should consider evaluating which prerequisite skills are predictive of successful toilet training. Researchers should continue to address the question of which components are necessary and sufficient to improve toileting performance Greer, Neidert & Dozier Questions?