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A method for home training an incontinent child
3". Behav. Ther. & Exp. Psychiat. Vol. 5, pp. 77-80. Pergamon Press, 1974. Printed in Great Britain.
A METHOD FOR HOME T R A I N I N G AN I N C O N T I N E N T CHILD ALAN J. LITROWNIK* San Diego State University Summary--A home training method for incontinent children utilizing a signal apparatus is described. Traditional toilet training techniques having failed to train a profoundly retarded 7-yr-old male, effective training was accomplished through simple procedures using an auditory signal apparatus. These procedures involved pairings of first the buzzer and running to the bathroom, and then bladder distension and the buzzer. After a number of such pairings the child began to indicate when his bladder was distended. This served as a cue for the parents to prompt the appropriate toileting response. Independent toileting behavior was effected within a 7-week period and maintained over a 5-month follow-up with generalization to new situations. IN GENERAL, effective toilet training involves three steps. During the first, habit training, the child is placed on the toilet (Sd) and any eliminative response is followed by parent attention or other rewards. A number of prompts, such as verbal instructions or demonstrations, may be employed in an attempt .to initiate the desired response on the part of the child. After a number of trials the child learns to respond appropriately when the parents place him or her on the toilet, but "accidents" may still occur. In the second stage the child begins to "inform" the parents either verbally or nonverbally when elimination is anticipated. The parents respond to this cue by either taking the child to the bathroom or instructing the child to "go 'to the bathroom". The final step usually involves a gradual unsystematic fading of parent interventions resulting in independent toileting behavior on the part of 'the child. In the majority of children, these three steps are evidenced for varying lengths of time with little or no problem. But, in approximately 10 per cent of the population, especially with lower I Q children, extreme difficulty due to inadequate training methods is experienced (Werry, 1973).
Difficulties experienced in trying to acquire stimulus control of eliminations are in part a function of the response itself. Thus, a number of signal devices have been developed which serve to alert the trainer when the child is eliminating (Azrin, Bugle and O'Brien, 1971; Van Wagenen and Murdock, 1966). Though many therapists argue that home or parent training is most efficient and effective (e.g. Wahler, 1972), reports of attempts to train enuretic retardates using lhe signal apparatus have all taken place in institutional 'settings where the staff or investigators affected the training (Azrin, Bugle and O'Brien, 1971; Azrin and Foxx, 1971; Mahoney, Van Wagenen and Meyerson, 1971). In addition, these reported programs have failed to provide for adequate generalization and follow-up. For example, Mahoney et al., (1971) effectively toilet trained four out of five retardates in an outpatient setting, but their restricted (single case) followup data indicated a failure in the maintenance and generalization of the training to the home environment. These programs also required intensive supervision and training, sometimes up to 8 hr a day over a 1--7 week period. In attempting ~o
*Requests for reprints should be sent to A. J. Litrownik, Department of Psychology, San Diego State University, San Diego, California 92115. 77
78
ALAN J. LITROWNIK
utilize this apparatus in the home, a number of modifications in the institutional techniques are necessary. Such modifications were made and an attempt to apply them in toilet training a profoundly retarded incontinent 7-yr-old male is described BACKGROUND At the time of the initial therapeutic contact, Steven, a profoundly retarded 7-yr-old, was nonverbal, unresponsive to simple commands, and totally incontinent. The parents had been told by Steven's pediatrician that he was, at 2 yr of age, severely retarded and that nothing could be done for him. As a result of this information the parents had not expected nor demanded anything of Steven for over 5 yr. After the parents were initially familiarized with basic reinforcement principles and utilized them in teaching Steven to obey simple commands they identified Steven's toileting behavior as being most bothersome and in need of modification. M E T H O D S AND O U T C O M E An initial baseline of accidents, including their frequency and time of day, was obtained between the hours of 3.30 and 9.00 p.m. over a 1-week period. The parents' records indicated a fairly stable rate of 4-6 accidents per day occurring at predictable times, such as after snacks, after dinner, and before bed.
Traditional habit training techniques Steven's parents were instructed to sit Steven on the toilet three times per day at times when he usually urinated, as determined from the baseline observations. Since Steven had never before sat on a toilet seat, the parents had to physically prompt him to first take off his pants and then to sit on the toilet. After 1 week of training, Steven was taking off his own pants and sitting on the toilet for at least 2 rain at a time. The parents continued tn have Steven sit on the toilet approximately three times a day
for a 9-week period. During this time a number of prompts were administered in an attempt to initiate an eliminative response from Steven which could then be reinforced and strengthened. For example, while sitting on 'the toilet Steven's hand was placed in lukewarm water, water was run from a faucet, and the parents instructed Steven to "do this" and then grimaced and grunted. In addition, Steven was given excessive amount~ of liquid prior to sitting on the toilet in an attempt to increase the frequency of urinations and the probability that they would occur when he was on the toilet. But on only two occasions during the seventh week did Steven uninate while sitting on the toilet. Though immediately followed by food and social praise no appropriate urinations occurred during the next 2 weeks. Thus, attempts to habit train Steven by prompting the appropriate response and following it with reinforcing consequences were not successful.
Parent cue-trabffng The signal package apparatus (Van Wagenen and Murdock, 1966) was employed in an attempt to aid in the place training of the urinating response. Since the response was more readily perceived by the parents in the form of an auditory signal (buzzer), the occurrence of the response could be paired, though in the reverse order, with the appropriate situation and reinforcing consequences could follow. During the first 2 days, the parents responded to the buzzer by saying "p.otty", immediately running Steven to the bathroom, unhooking the buzzer, and finally reinforcing him with food and praise. It was assumed that the urinary response would be inhibited during the running and would thus immediately occur again when Steven was in the bathroom allowing for forward conditioning or place learning to occur. Thereafter, the parents were instructed to engage in the same initial chain of responses when the buzzer sounded but to follow unhooking of the buzzer with the instruction to "sit on the toilet" before reinforcing Steven.
A METHOD FOR HOME TRAINING AN INCONTINENT CHILD No appropriate responses occurred during the next 2 days, but on the fifth day Steven began to urinate in the toilet. During the next 18 days the parents only reinforced Steven after he eliminated in the toilet. They reported that over this period Stevcn's pants were getting less wet while he was urinating more and more in the toi'let. The parents also reported that during the third week they had noticed that Steven was pulling at the buzzer apparatus or beginning to fuss prior to his eliminations and the buzzer sounding. They were instructed to respond to these anticipatory responses by telling Steven "potty" and taking him to the bathroom if necessary. These procedures were begun on the 22rid day and over the next 14 days the buzzer sounded only three times. Thus the training had progressed to the second step where Steven was indicating (nonverbally) when he was going to urinate and the parents responded by instructing him to go "potty".
Independent training On ~he 36th day the parents began to walk Steven by the bathroom at times when he usually urinated. If he walked in he was instructed to go "potty". By the 50th day of training Steven was going to the bathroom on his own. During the next 14 days the parents reported that no accidents occurred. The buzzer was unhooked on the 65th day and was completely removed on the 72nd day. During this period no accidents (urinations or defecations) during the day were reported, nor were there any reports of nocturnal accidents. In addition, staff at Steven's special school reported that he had remained continent during the past 2-week period. Further evidence of generalization was obtained during a 2-week family vacation. No accidents were reported during this period when the family visited relatives. A 2-month personal follow-up and 5-month phone follow-up revealed that Steven had remained continent and that no problems were experienced.
79
DISCUSSION A number of traditional toilet training techniques were unsuccessful in habit training a profoundly retarded 7-yr-old male. The techniques were assumed to be inadequate rather than postulating an internal or retardate deficit explanation. The success of toilet training of retardates in institutional settings utilizing a signal apparatus and detailed instructional procedures support this assumption. An attempt was made to modify these institutional procedures so that home training could be effected with reasonable time demands being placed on the parent trainers. Steven's parents reported that they did not spend any more time during training than they had been devoting to incontinence prior to training. The parent time required was significantly decreased after 21 days when Steven began indicating when he had to urinate and was completely eliminated by the 50th day. Initially the buzzer functioned as a cue for the parents, indicating when they were to run Steven to the bathroom. Through contiguous association of the buzzer and the inhibiting response of running to the bathroom, the buzzer acquired aversive or inhibitory properties for Steven. This is supported, in part, by the fact that Steven urinated completely in his pants when training first began. Thus initially the buzzer did not inhibit urination and only after a number of buzzer-running pairings was 1he response inhibited when the buzzer sounded. As training progressed Steven began to pull at the buzzer apparatus, sometimes removing it wh!le fussing prior to elimination and the sounding of the buzzer. This also appears to support the contention that the buzzer acquired aversive or inhibitory properties which were now being associated with bladder distension. Discrimination, or place learning could then take place by physically or verbally prompting Steven to go to the bathroom and sit on the toilet when his anticipatory responses indicated that he had to urinate. These prompts were faded over a period of time eventually leading to the
80
ALAN J. LITROWNIK
acquisition of independent toileting behavior. Successful generalization of this 'training was evidenced d u r i n g other times of the day (and at night), in other situations (such as school, restaurants, other homes), and for other re-
sponses (such as defecation). In addition, effective home parent training resul~ted in m a i n t e n a n c e of this training over an o b s e r v ~ 5 - m o n t h period.
Acknowledgements--The author is indebted to D. T. Shannon and R. F. Peterson for their consultation and L. R. Franzini for his critical reading of the paper. REFERENCES AZRIN N. H., BUGLE C. and O'BR1EN F. (1971) Behavioral engineering: Two apparatuses for toilet
training retarded children, J. appl. Behav. Anal. 4, 173-181. AZRIN N. H. and Foxx R. M. (1971) A rapid method of toilet training the institutionalized retarded, J. appI. Behav. Anal. 4, 89-99. MAHONEY K., VAN WAGENEN R. K. and MEYERSON L.
(1971) Toilet training of normal and retarded children, J. appl. Behav. Anal. 4, 173-181.
VAN WAGENENR. K. and MURDOCK E. E. (1966) A transistorized signal-package for toilet training of infants, 1. exp. Child Psychol. 3, 312-314. WAHLER R. G. (1972) Some ecological problems in child behavior modification, Behavior Modi[ication: Issues and Extensions (Edited by Bijou S. W. and RIBES-INESTA E.), pp. 7-18, Academic Press, New York. WERRY J. S. (1973) Psychosomatic disorders, Psychopathological Disorders o/ Childhood (Edited by QUAY H. C. and WE~RY J. S.), pp. 122-172, Wiley, New York.
A METHOD FOR HOME T R A I N I N G AN I N C O N T I N E N T CHILD ALAN J. LITROWNIK* San Diego State University Summary--A home training method for incontinent children utilizing a signal apparatus is described. Traditional toilet training techniques having failed to train a profoundly retarded 7-yr-old male, effective training was accomplished through simple procedures using an auditory signal apparatus. These procedures involved pairings of first the buzzer and running to the bathroom, and then bladder distension and the buzzer. After a number of such pairings the child began to indicate when his bladder was distended. This served as a cue for the parents to prompt the appropriate toileting response. Independent toileting behavior was effected within a 7-week period and maintained over a 5-month follow-up with generalization to new situations. IN GENERAL, effective toilet training involves three steps. During the first, habit training, the child is placed on the toilet (Sd) and any eliminative response is followed by parent attention or other rewards. A number of prompts, such as verbal instructions or demonstrations, may be employed in an attempt .to initiate the desired response on the part of the child. After a number of trials the child learns to respond appropriately when the parents place him or her on the toilet, but "accidents" may still occur. In the second stage the child begins to "inform" the parents either verbally or nonverbally when elimination is anticipated. The parents respond to this cue by either taking the child to the bathroom or instructing the child to "go 'to the bathroom". The final step usually involves a gradual unsystematic fading of parent interventions resulting in independent toileting behavior on the part of 'the child. In the majority of children, these three steps are evidenced for varying lengths of time with little or no problem. But, in approximately 10 per cent of the population, especially with lower I Q children, extreme difficulty due to inadequate training methods is experienced (Werry, 1973).
Difficulties experienced in trying to acquire stimulus control of eliminations are in part a function of the response itself. Thus, a number of signal devices have been developed which serve to alert the trainer when the child is eliminating (Azrin, Bugle and O'Brien, 1971; Van Wagenen and Murdock, 1966). Though many therapists argue that home or parent training is most efficient and effective (e.g. Wahler, 1972), reports of attempts to train enuretic retardates using lhe signal apparatus have all taken place in institutional 'settings where the staff or investigators affected the training (Azrin, Bugle and O'Brien, 1971; Azrin and Foxx, 1971; Mahoney, Van Wagenen and Meyerson, 1971). In addition, these reported programs have failed to provide for adequate generalization and follow-up. For example, Mahoney et al., (1971) effectively toilet trained four out of five retardates in an outpatient setting, but their restricted (single case) followup data indicated a failure in the maintenance and generalization of the training to the home environment. These programs also required intensive supervision and training, sometimes up to 8 hr a day over a 1--7 week period. In attempting ~o
*Requests for reprints should be sent to A. J. Litrownik, Department of Psychology, San Diego State University, San Diego, California 92115. 77
78
ALAN J. LITROWNIK
utilize this apparatus in the home, a number of modifications in the institutional techniques are necessary. Such modifications were made and an attempt to apply them in toilet training a profoundly retarded incontinent 7-yr-old male is described BACKGROUND At the time of the initial therapeutic contact, Steven, a profoundly retarded 7-yr-old, was nonverbal, unresponsive to simple commands, and totally incontinent. The parents had been told by Steven's pediatrician that he was, at 2 yr of age, severely retarded and that nothing could be done for him. As a result of this information the parents had not expected nor demanded anything of Steven for over 5 yr. After the parents were initially familiarized with basic reinforcement principles and utilized them in teaching Steven to obey simple commands they identified Steven's toileting behavior as being most bothersome and in need of modification. M E T H O D S AND O U T C O M E An initial baseline of accidents, including their frequency and time of day, was obtained between the hours of 3.30 and 9.00 p.m. over a 1-week period. The parents' records indicated a fairly stable rate of 4-6 accidents per day occurring at predictable times, such as after snacks, after dinner, and before bed.
Traditional habit training techniques Steven's parents were instructed to sit Steven on the toilet three times per day at times when he usually urinated, as determined from the baseline observations. Since Steven had never before sat on a toilet seat, the parents had to physically prompt him to first take off his pants and then to sit on the toilet. After 1 week of training, Steven was taking off his own pants and sitting on the toilet for at least 2 rain at a time. The parents continued tn have Steven sit on the toilet approximately three times a day
for a 9-week period. During this time a number of prompts were administered in an attempt to initiate an eliminative response from Steven which could then be reinforced and strengthened. For example, while sitting on 'the toilet Steven's hand was placed in lukewarm water, water was run from a faucet, and the parents instructed Steven to "do this" and then grimaced and grunted. In addition, Steven was given excessive amount~ of liquid prior to sitting on the toilet in an attempt to increase the frequency of urinations and the probability that they would occur when he was on the toilet. But on only two occasions during the seventh week did Steven uninate while sitting on the toilet. Though immediately followed by food and social praise no appropriate urinations occurred during the next 2 weeks. Thus, attempts to habit train Steven by prompting the appropriate response and following it with reinforcing consequences were not successful.
Parent cue-trabffng The signal package apparatus (Van Wagenen and Murdock, 1966) was employed in an attempt to aid in the place training of the urinating response. Since the response was more readily perceived by the parents in the form of an auditory signal (buzzer), the occurrence of the response could be paired, though in the reverse order, with the appropriate situation and reinforcing consequences could follow. During the first 2 days, the parents responded to the buzzer by saying "p.otty", immediately running Steven to the bathroom, unhooking the buzzer, and finally reinforcing him with food and praise. It was assumed that the urinary response would be inhibited during the running and would thus immediately occur again when Steven was in the bathroom allowing for forward conditioning or place learning to occur. Thereafter, the parents were instructed to engage in the same initial chain of responses when the buzzer sounded but to follow unhooking of the buzzer with the instruction to "sit on the toilet" before reinforcing Steven.
A METHOD FOR HOME TRAINING AN INCONTINENT CHILD No appropriate responses occurred during the next 2 days, but on the fifth day Steven began to urinate in the toilet. During the next 18 days the parents only reinforced Steven after he eliminated in the toilet. They reported that over this period Stevcn's pants were getting less wet while he was urinating more and more in the toi'let. The parents also reported that during the third week they had noticed that Steven was pulling at the buzzer apparatus or beginning to fuss prior to his eliminations and the buzzer sounding. They were instructed to respond to these anticipatory responses by telling Steven "potty" and taking him to the bathroom if necessary. These procedures were begun on the 22rid day and over the next 14 days the buzzer sounded only three times. Thus the training had progressed to the second step where Steven was indicating (nonverbally) when he was going to urinate and the parents responded by instructing him to go "potty".
Independent training On ~he 36th day the parents began to walk Steven by the bathroom at times when he usually urinated. If he walked in he was instructed to go "potty". By the 50th day of training Steven was going to the bathroom on his own. During the next 14 days the parents reported that no accidents occurred. The buzzer was unhooked on the 65th day and was completely removed on the 72nd day. During this period no accidents (urinations or defecations) during the day were reported, nor were there any reports of nocturnal accidents. In addition, staff at Steven's special school reported that he had remained continent during the past 2-week period. Further evidence of generalization was obtained during a 2-week family vacation. No accidents were reported during this period when the family visited relatives. A 2-month personal follow-up and 5-month phone follow-up revealed that Steven had remained continent and that no problems were experienced.
79
DISCUSSION A number of traditional toilet training techniques were unsuccessful in habit training a profoundly retarded 7-yr-old male. The techniques were assumed to be inadequate rather than postulating an internal or retardate deficit explanation. The success of toilet training of retardates in institutional settings utilizing a signal apparatus and detailed instructional procedures support this assumption. An attempt was made to modify these institutional procedures so that home training could be effected with reasonable time demands being placed on the parent trainers. Steven's parents reported that they did not spend any more time during training than they had been devoting to incontinence prior to training. The parent time required was significantly decreased after 21 days when Steven began indicating when he had to urinate and was completely eliminated by the 50th day. Initially the buzzer functioned as a cue for the parents, indicating when they were to run Steven to the bathroom. Through contiguous association of the buzzer and the inhibiting response of running to the bathroom, the buzzer acquired aversive or inhibitory properties for Steven. This is supported, in part, by the fact that Steven urinated completely in his pants when training first began. Thus initially the buzzer did not inhibit urination and only after a number of buzzer-running pairings was 1he response inhibited when the buzzer sounded. As training progressed Steven began to pull at the buzzer apparatus, sometimes removing it wh!le fussing prior to elimination and the sounding of the buzzer. This also appears to support the contention that the buzzer acquired aversive or inhibitory properties which were now being associated with bladder distension. Discrimination, or place learning could then take place by physically or verbally prompting Steven to go to the bathroom and sit on the toilet when his anticipatory responses indicated that he had to urinate. These prompts were faded over a period of time eventually leading to the
80
ALAN J. LITROWNIK
acquisition of independent toileting behavior. Successful generalization of this 'training was evidenced d u r i n g other times of the day (and at night), in other situations (such as school, restaurants, other homes), and for other re-
sponses (such as defecation). In addition, effective home parent training resul~ted in m a i n t e n a n c e of this training over an o b s e r v ~ 5 - m o n t h period.
Acknowledgements--The author is indebted to D. T. Shannon and R. F. Peterson for their consultation and L. R. Franzini for his critical reading of the paper. REFERENCES AZRIN N. H., BUGLE C. and O'BR1EN F. (1971) Behavioral engineering: Two apparatuses for toilet
training retarded children, J. appl. Behav. Anal. 4, 173-181. AZRIN N. H. and Foxx R. M. (1971) A rapid method of toilet training the institutionalized retarded, J. appI. Behav. Anal. 4, 89-99. MAHONEY K., VAN WAGENEN R. K. and MEYERSON L.
(1971) Toilet training of normal and retarded children, J. appl. Behav. Anal. 4, 173-181.
VAN WAGENENR. K. and MURDOCK E. E. (1966) A transistorized signal-package for toilet training of infants, 1. exp. Child Psychol. 3, 312-314. WAHLER R. G. (1972) Some ecological problems in child behavior modification, Behavior Modi[ication: Issues and Extensions (Edited by Bijou S. W. and RIBES-INESTA E.), pp. 7-18, Academic Press, New York. WERRY J. S. (1973) Psychosomatic disorders, Psychopathological Disorders o/ Childhood (Edited by QUAY H. C. and WE~RY J. S.), pp. 122-172, Wiley, New York.