- Email: [email protected]
Assessment of toileting difficulties in adults with intellectual disabilities: An examination using the profile of toileting issues (POTI)
Research in Developmental Disabilities 32 (2011) 176–179
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Assessment of toileting difficulties in adults with intellectual disabilities: An examination using the profile of toileting issues (POTI) Johnny L. Matson *, Daniene Neal, Julie A. Hess, Alison M. Kozlowski Louisiana State University, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 August 2010 Accepted 9 September 2010
A lack of toileting skills is one of many impairments that individuals with intellectual and developmental disabilities experience. Unfortunately, little research has focused on problems in this area including assessment, function, and treatment. A newly developed checklist, the Profile of Toileting Issues (POTI), is being considered for use to screen for toileting issues in this population, and to identify potential functions to target in treatment. The purpose of the current study was to examine the reliability of the POTI. Internal consistency was sound (a = .83) and interrater reliability was significant. The implications of these findings are included. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Enuresis Encopresis Toileting problems Assessment
1. Introduction Individuals with intellectual disabilities (ID) are susceptible to a number of impairments including those in social and daily living skills (Chen, Tseng, Hu, & Cermak, 2009; Iacono, Tracy, Keating, & Brown, 2009; La Malfa, Lassi, Bertelli, Albertini, & Dosen, 2009). While many researchers have examined issues of challenging behaviors and psychopathology within this population, little has focused on daily living skills such as toileting (Matson & Lovullo, 2009). The lack of these essential skills can be just as detrimental to an individual’s social and occupational functioning as many of the other well-studied conditions (e.g., comorbid psychopathology; Ashworth, Hirdes, & Martin, 2009; Bamburg, Cherry, Matson, & Penn, 2001; Kroeger & Sorensen-Burnworth, 2009; Rose, Bramham, Young, Paliokostas, & Xenitidis, 2009; Tenneij, Didden, Stolker, & Koot, 2009; van den Hazel, Didden, & Korzilius, 2009). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), a diagnosis of enuresis may be warranted if the individual at least 5 years of age, repeatedly voids in inappropriate places at least twice a week for a period of at least 3 consecutive months, or there is a significant impairment in daily functioning, and medical/physiological factors have been ruled out. The diagnostic criteria for encopresis are similar except that the individual must be only 4 years of age or older and experiences repeated passage of feces in inappropriate places at least once a month for 3 consecutive months (APA, 2000). ID, by definition, results in delayed motor and cognitive skills (Munde, Vlaskamp, Ruijssenaars, & Nakken, 2009; Soenen, Van Berckelaer-Onnes, & Scholte, 2009). However, very little research has examined the extent to which toileting problems are present in an ID population (Matson & Lovullo, 2009). Studies that have looked into differences in meeting this particular developmental milestone (i.e., toilet trained) have had very mixed results (Joinson et al., 2007; Von Wendt, Similia, Niskanen, & Jarvelin, 1990).
* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States. E-mail address: [email protected] (J.L. Matson). 0891-4222/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2010.09.014
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The assessment of toileting problems varies widely and usually consists of informal measures or use of individual items from larger measures of adaptive behavior (e.g., Vineland Adaptive Behavior Scales; Matson & Lovullo, 2009). In addition, assessment of these problems is rarely used to drive treatment. As many individuals with toileting problems see a pediatrician or primary care physician first, interventions are largely psychopharmacological (Bohmer, Taminiau, Klinkenberg-Knol, & Meuwissen, 2001; Borowitz et al., 2005). However, researchers have found that behavioral intervention is the empirically supported treatment of choice (Matson & Lovullo, 2009). As such, the field is in need of more research in this area and the development of standardized assessments that can better guide diagnosis and treatment. The purpose of the current study was to examine the reliability of a new measure for assessing toileting issues: The Profile of Toileting Issues (POTI; Matson, Dempsey, & Fodstad, 2010). The POTI is a new informant-based measure that screens persons with a current diagnosis of ID for problems with toileting that are more commonly found to occur with ID. The POTI is an individually administered checklist using informants to report on item endorsement. Items for the POTI were derived theoretically through a thorough literature review, looking at other instruments with items that assess toileting issues (e.g., Vineland Adaptive Behavior Scales, Second Edition; Sparrow, Cicchetti, & Balla, 2005), and reviewing medical assessments for toileting problems as well. Internal consistency as well as interrater reliability of the POTI were examined in this study. 2. Method 2.1. Participants The participants for this study were individuals residing in two large developmental centers in central and south Louisiana. Participants included 108 individuals (67 males, 41 females) ages 16–89 years (M = 48.89; SD = 12.23) who did not currently wear attends. Although individuals wearing attends certainly display toileting difficulties, the current assessment scale requires information that would not be readily available to caregivers of those individuals who rely on attends. Diagnoses of intellectual disability included mild (n = 12), moderate (n = 18), severe (n = 15), profound (n = 62), and unspecified (n = 1) levels of impairment. Ethnic classifications were Caucasian (n = 69), African American (n = 27), and Other (n = 12). A subset of participants was utilized for the interrater reliability analysis. Twenty-nine individuals (8 males, 21 females) ages 21–65 (M = 48.89; SD = 12.23) were randomly selected for interrater reliability. Diagnoses of intellectual disability included mild (n = 2), moderate (n = 6), severe (n = 5), and profound (n = 16) levels of impairment. Ethnic classifications were Caucasian (n = 22) and African American (n = 7). 2.2. Measures Profile of Toileting Issues (POTI; Matson, Dempsey and Fodstad, 2010). The POTI is a paper-based checklist scale that is completed by clinicians with the individual’s primary caregiver serving as the informant. The POTI contains 56 items that sample content reflecting diagnostic criteria for enuresis and encopresis and potential functions including pain, avoidance, internal cues, noncompliance, shame/deception, aversive parenting, peer rejection, and medical problems. Respondents are asked to rate each question as either ‘‘no problem present’’ (0), ‘‘problem present’’ (1), or ‘‘does not apply’’ (X). Scoring is completed by summing the responses (i.e., 0 or 1) for each POTI item. A higher total score is more indicative of a significant toileting problem. Interpretation of the results should only be made by a trained professional. The target population for the POTI is individuals with ID between the ages of 4 years through adulthood who are suspected of having a diagnosis of enuresis or encopresis based on chronological age criteria. 2.3. Procedure Doctoral students in clinical psychology with a master’s degree or at least one year post-bachelor’s degree experience administered the POTI with direct care staff serving as informants. The assessor read each item aloud to direct care staff members who were familiar with the individual for at least 6 months. Reviews of medical records were used to confirm answers to some of the POTI items. For a subset of the individuals, an additional POTI was administered to a different direct care staff member in order to examine interrater reliability. 2.4. Data analysis To determine internal consistency, Cronbach’s alpha was calculated for the POTI using SPSS 16. Any items with a coefficient below .30 were removed if alpha was increased by its removal (Leech, Barrett, & Morgan, 2008). To determine interrater reliability, Pearson-product moment correlation was calculated for the total POTI score between raters 1 and 2. 3. Results Cronbach’s alpha was used to assess internal consistency. Clark and Watson (1995) recommend using alpha levels of .8 for adequate internal consistency of a new scale. The internal consistency of all 56 items of the POTI was .79. Coefficients for
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items 23, 28, and 39 were unable to be calculated as there was zero variance for those items. Therefore, those items were removed from the measure. Next, each item with a coefficient value less than .30 was removed if data analysis indicated that the total scale alpha increased by its deletion. This resulted in the removal of an additional 21 items. Cronbach’s alpha was then calculated for the remaining 32 items and yielded an alpha of .83. Refer to Table 1 for those items that were retained in the POTI after the analysis. Nest, Pearson-product moment correlations were calculated between the total POTI scores for two independent raters. A significant correlation was found between the total POTI score for rater 1 and the total POTI score for rater 2, r (29) = .44, p < .05.
Table 1 Descriptions, means and standard deviations (Std. Dev.) and item correlations for the POTI items. POTI item number and description 1. Does not urinate in toilet 2. Does not defecate in toilet 3. Has daytime toileting accidents 4. Has nighttime toileting accidents 5. Had wet underwear in past month 6. Had soiled underwear in past month 7. Does not experience bowel movement once every three days 8. Lost toileting skills 9. Notice smears in underwear 10. Others complain of odor 11. Has a gastrointestinal disease 12. Had constipation prior to age three months 13. Urinates/defecates when coughing/sneezing 14. Only urinates/defecates small amount 15. Has strong urge before toileting accident 16. Has difficulty starting to urinate 17. Has weak or ‘‘stop–go’’ stream 18. Has excessive post-urination dribbling 19. Requires use of laxatives 20. Complains of feeling full after toileting 21. Has food allergies 22. On medication with side effect of constipation 23. Purposely withholds stool 24. Expresses fear about toileting 25. Communicates ‘‘I do not have to go to the bathroom’’ 26. Refuses to use the restroom 27. Hides wet clothes 28. Gets yelled at for not using restroom 29. Complains of social problems 30. Does not stop activity to use restroom 31. Complains of stomach aches 32. Does not communicate need to use restroom 33. Hides soiled clothes 34. Gets teased about accidents/odor 35. Complains of pelvic aches 36. Does not let caregiver know about wet/soiled clothes 37. Has lack of appetite 38. Blames self for accidents 39. Rejected by peers 40. Motor problems interfere with toileting 41. Not independent in self care 42. Requires encouragement to toilet 43. Exhibits problem behaviors when asked to toilet 44. Complains of pain while toileting 45. Attempts to toilet even if they have not defecated in 24–48 h 46. Gets yelled at to use restroom 47. Does not become upset after accident 48. Attempts to defecate in toilet 49. Attempts to urinate in toilet 50. Has urinary tract diagnosis 51. Frequently wakes to toilet 52. Has cloudy urine 53. Has bloody stool 54. Has bloody urine 55. Has hard stool 56. Has soft or runny stool Bolded items indicate those items that were retained.
Mean .14 .06 .40 .29 .35 .23 .06 .05 .37 .07 .35 .31 .03 .12 .04 .05 .01 .02 .66 .01 .07 .63 – .02 .19 .10 .05 – .01 .12 .05 .18 .01 .01 .03 .18 .05 .02 – .09 .27 .10 .06 .03 .06 .01 .25 .02 .02 .14 .17 .02 .02 .01 .06 .13
Std. Dev.
Item-total correlation
.35 .25 .49 .45 .48 .42 .23 .21 .49 .26 .48 .47 .17 .33 .19 .21 .10 .14 .48 .10 .26 .49 – .14 .40 .30 .21 – .10 .33 .21 .38 .10 .10 .17 .38 .21 .14 – .29 .45 .30 .25 .17 .25 .10 .44 .14 .14 .35 .37 .14 .14 .10 .25 .34
.03 .08 .77 .57 .72 .48 .13 .18 .46 .28 .04 .37 .00 .16 .23 .18 .09 .25 .23 .09 .01 .15 – .02 .18 .30 .30 – .12 .53 .19 .40 .15 .15 .03 .55 .08 .17 – .17 .31 .32 .30 .07 .14 .18 .44 .04 .04 .12 .25 .16 .02 .13 .12 .04
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4. Discussion Deficits in social and adaptive skills are recognized as problematic for persons with ID (Bossaert et al., 2009; Lin et al., 2009; Matson, Rivet, Fodstad, Dempsey, & Boisjoli, 2009). However, despite the fact that toileting issues are common in this population, little research has been published which addresses these issues. The POTI introduces a new assessment measure for toileting problems in adults diagnosed with ID. Unfortunately, no other assessment measures have been developed to assess for these problems. This is the case despite the fact that such difficulties have the potential to significantly impede independent living. A strength of the POTI is that it attempts to fill this void, by providing clinicians with a screening tool to assist in detecting these problems and thus serve as a screener. Additionally, this data should prove useful in identifying possible functions to target in treatment. Other strengths include the ease of administration and scoring and the quick administration time. These data provide a preliminary indication that the POTI has promise as a tool for clinicians to utilize when screening for toileting issues in individuals diagnosed with intellectual disabilities. The scale has strong internal consistency, and interrater reliability was encouraging. Given these findings, it appears that additional research regarding the psychometric properties of the POTI and an examination of its factor structure is warranted. The scale fills an important niche and will hopefully prove useful for identifying and prioritizing this important set of self-help skills. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders-text revision (4th ed.). Washington, DC: American Psychiatric Association. (Author). Ashworth, M., Hirdes, J. P., & Martin, L. (2009). The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Research in Developmental Disabilities, 30, 512–520. Bamburg, J. W., Cherry, K. E., Matson, J. L., & Penn, D. (2001). Assessment of schizophrenia in persons with severe and profound mental retardation using the Diagnostic Assessment for the Severely Handicapped-II (DASH-II). Journal of Developmental and Physical Disabilities, 13, 319–331. Bohmer, C. J. M., Taminiau, J. A. J. M. , Klinkenberg-Knol, E. C., & Meuwissen, S. G. M. (2001). The prevalence of constipation in institutionalized people with intellectual disability. Journal of Intellectual Disability Research, 45, 212–218. Borowitz, S. M., Cox, D. J., Kovatchev, B., Ritterband, L. M., Sheen, J., & Sutphen, J. (2005). Treatment of childhood constipation by primary care physicians: Efficacy and predictors of outcome. Pediatrics, 115, 873–877. Bossaert, G., Kuppens, S., Buntinx, W., Molleman, C., Van den Abeele, A., & Maes, B. (2009). Usefulness of the Supports Intensity Scale (SIS) for persons with other than intellectual disabilities. Research in Developmental Disabilities, 30, 1306–1316. Chen, Y.-W., Tseng, M.-H., Hu, F.-C., & Cermak, S. A. (2009). Psychological adjustment and attention in children with developmental coordination disorder using different motor tests. Research in Developmental Disabilities, 30, 1367–1377. Clark, L. A., & Watson, D. (1995). Constructing validity: Basic issues in scale development. Psychological Assessment, 7, 309–319. Iacono, J., Tracy, J., Keating, J., & Brown, T. (2009). The interaction with disabled persons scale: Revisiting its internal consistency and factor structure, and examining item-level properties. Research in Developmental Disabilities, 30, 1490–1501. Joinson, C., Heron, J., Butler, R., Von Gontard, A., Butler, U., Emond, A., et al. (2007). A United Kingdom population-based study of intellectual capacities in children with and without soiling, daytime wetting, and bed-wetting. Pediatrics, 120, 308–316. Kroeger, K. A., & Sorensen-Burnworth, R. (2009). Toilet training individuals with autism and other developmental disabilities: A critical review. Research in Autism Spectrum Disorders doi:10.1016/j.rasd.2009.01.005. La Malfa, G., Lassi, S., Bertelli, M., Albertini, G., & Dosen, A. (2009). Emotional development and adaptive abilities in adults with intellectual disability: A correlation study between the Scheme of Appraisal of Emotional Development (SAED) and Vineland Adaptive Behavior Scale (VABS). Research in Developmental Disabilities, 30, 1406–1412. Leech, N. L., Barrett, K. C., & Morgan, G. A. (2008). SPSS for intermediate statistics: Use and interpretation (3rd ed.). New York: Taylor & Francis Group. Lin, J.-D., Hu, J., Yen, C.-F., Hsu, S.-W., Lin, L.-P., Loh, C.-H., et al. (2009). Quality of life in caregivers of children and adolescents with intellectual disabilities: Use of WHOQOL-BREF survey. Research in Developmental Disabilities, 30, 1448–1458. Matson, J. L., Dempsey, T., & Fodstad, J. C. (2010). The profile of toileting issues (POTI). Baton Rouge, LA: Disability Consultants, LLC. Matson, J. L., & Lovullo, T. V. (2009). Encopresis, soiling and constipation in children and adults with developmental disability. Research in Developmental Disabilities, 30, 799–807. Matson, J. L., Rivet, T. T., Fodstad, J. C., Dempsey, T., & Boisjoli, J. A. (2009). Examination of adaptive behavior differences in adults with autism spectrum disorders and intellectual disability. Research in Developmental Disabilities, 30, 1317–1325. Munde, V. S., Vlaskamp, C., Ruijssenaars, A. J. J. M. , & Nakken, H. (2009). Alertness in individuals with profound intellectual and multiple disabilities: A literature review. Research in Developmental Disabilities, 30, 462–480. Rose, E., Bramham, J., Young, S., Paliokostas, E., & Xenitidis, K. (2009). Neuropsychological characteristics of adults with comorbid ADHD and borderline/mild intellectual disability. Research in Developmental Disabilities, 30, 496–502. Soenen, S., Van Berckelaer-Onnes, I., & Scholte, E. (2009). Patterns of intellectual, adaptive and behavioral functioning in individuals with mild mental retardation. Research in Developmental Disabilities, 30, 433–444. Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland adaptive behavior scales (2nd ed.). San Antonio, TX: Pearson. Tenneij, N. H., Didden, R., Stolker, J. J., & Koot, H. M. (2009). Markers for aggression in inpatient treatment facilities for adults with mild to borderline intellectual disability. Research in Developmental Disabilities, 30, 1248–1257. van den Hazel, T., Didden, R., & Korzilius, H. (2009). Effects of personality disorder and other variables on professionals’ evaluation of treatment features in individuals with mild intellectual disabilities and severe behavior problems. Research in Developmental Disabilities, 30, 547–557. Von Wendt, L., Similia, S., Niskanen, P., & Jarvelin, M. R. (1990). Development of bowel and bladder control in the mentally retarded. Developmental Medicine and Child Neurology, 32, 515–518.
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Assessment of toileting difficulties in adults with intellectual disabilities: An examination using the profile of toileting issues (POTI) Johnny L. Matson *, Daniene Neal, Julie A. Hess, Alison M. Kozlowski Louisiana State University, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 August 2010 Accepted 9 September 2010
A lack of toileting skills is one of many impairments that individuals with intellectual and developmental disabilities experience. Unfortunately, little research has focused on problems in this area including assessment, function, and treatment. A newly developed checklist, the Profile of Toileting Issues (POTI), is being considered for use to screen for toileting issues in this population, and to identify potential functions to target in treatment. The purpose of the current study was to examine the reliability of the POTI. Internal consistency was sound (a = .83) and interrater reliability was significant. The implications of these findings are included. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Enuresis Encopresis Toileting problems Assessment
1. Introduction Individuals with intellectual disabilities (ID) are susceptible to a number of impairments including those in social and daily living skills (Chen, Tseng, Hu, & Cermak, 2009; Iacono, Tracy, Keating, & Brown, 2009; La Malfa, Lassi, Bertelli, Albertini, & Dosen, 2009). While many researchers have examined issues of challenging behaviors and psychopathology within this population, little has focused on daily living skills such as toileting (Matson & Lovullo, 2009). The lack of these essential skills can be just as detrimental to an individual’s social and occupational functioning as many of the other well-studied conditions (e.g., comorbid psychopathology; Ashworth, Hirdes, & Martin, 2009; Bamburg, Cherry, Matson, & Penn, 2001; Kroeger & Sorensen-Burnworth, 2009; Rose, Bramham, Young, Paliokostas, & Xenitidis, 2009; Tenneij, Didden, Stolker, & Koot, 2009; van den Hazel, Didden, & Korzilius, 2009). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), a diagnosis of enuresis may be warranted if the individual at least 5 years of age, repeatedly voids in inappropriate places at least twice a week for a period of at least 3 consecutive months, or there is a significant impairment in daily functioning, and medical/physiological factors have been ruled out. The diagnostic criteria for encopresis are similar except that the individual must be only 4 years of age or older and experiences repeated passage of feces in inappropriate places at least once a month for 3 consecutive months (APA, 2000). ID, by definition, results in delayed motor and cognitive skills (Munde, Vlaskamp, Ruijssenaars, & Nakken, 2009; Soenen, Van Berckelaer-Onnes, & Scholte, 2009). However, very little research has examined the extent to which toileting problems are present in an ID population (Matson & Lovullo, 2009). Studies that have looked into differences in meeting this particular developmental milestone (i.e., toilet trained) have had very mixed results (Joinson et al., 2007; Von Wendt, Similia, Niskanen, & Jarvelin, 1990).
* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States. E-mail address: [email protected] (J.L. Matson). 0891-4222/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2010.09.014
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177
The assessment of toileting problems varies widely and usually consists of informal measures or use of individual items from larger measures of adaptive behavior (e.g., Vineland Adaptive Behavior Scales; Matson & Lovullo, 2009). In addition, assessment of these problems is rarely used to drive treatment. As many individuals with toileting problems see a pediatrician or primary care physician first, interventions are largely psychopharmacological (Bohmer, Taminiau, Klinkenberg-Knol, & Meuwissen, 2001; Borowitz et al., 2005). However, researchers have found that behavioral intervention is the empirically supported treatment of choice (Matson & Lovullo, 2009). As such, the field is in need of more research in this area and the development of standardized assessments that can better guide diagnosis and treatment. The purpose of the current study was to examine the reliability of a new measure for assessing toileting issues: The Profile of Toileting Issues (POTI; Matson, Dempsey, & Fodstad, 2010). The POTI is a new informant-based measure that screens persons with a current diagnosis of ID for problems with toileting that are more commonly found to occur with ID. The POTI is an individually administered checklist using informants to report on item endorsement. Items for the POTI were derived theoretically through a thorough literature review, looking at other instruments with items that assess toileting issues (e.g., Vineland Adaptive Behavior Scales, Second Edition; Sparrow, Cicchetti, & Balla, 2005), and reviewing medical assessments for toileting problems as well. Internal consistency as well as interrater reliability of the POTI were examined in this study. 2. Method 2.1. Participants The participants for this study were individuals residing in two large developmental centers in central and south Louisiana. Participants included 108 individuals (67 males, 41 females) ages 16–89 years (M = 48.89; SD = 12.23) who did not currently wear attends. Although individuals wearing attends certainly display toileting difficulties, the current assessment scale requires information that would not be readily available to caregivers of those individuals who rely on attends. Diagnoses of intellectual disability included mild (n = 12), moderate (n = 18), severe (n = 15), profound (n = 62), and unspecified (n = 1) levels of impairment. Ethnic classifications were Caucasian (n = 69), African American (n = 27), and Other (n = 12). A subset of participants was utilized for the interrater reliability analysis. Twenty-nine individuals (8 males, 21 females) ages 21–65 (M = 48.89; SD = 12.23) were randomly selected for interrater reliability. Diagnoses of intellectual disability included mild (n = 2), moderate (n = 6), severe (n = 5), and profound (n = 16) levels of impairment. Ethnic classifications were Caucasian (n = 22) and African American (n = 7). 2.2. Measures Profile of Toileting Issues (POTI; Matson, Dempsey and Fodstad, 2010). The POTI is a paper-based checklist scale that is completed by clinicians with the individual’s primary caregiver serving as the informant. The POTI contains 56 items that sample content reflecting diagnostic criteria for enuresis and encopresis and potential functions including pain, avoidance, internal cues, noncompliance, shame/deception, aversive parenting, peer rejection, and medical problems. Respondents are asked to rate each question as either ‘‘no problem present’’ (0), ‘‘problem present’’ (1), or ‘‘does not apply’’ (X). Scoring is completed by summing the responses (i.e., 0 or 1) for each POTI item. A higher total score is more indicative of a significant toileting problem. Interpretation of the results should only be made by a trained professional. The target population for the POTI is individuals with ID between the ages of 4 years through adulthood who are suspected of having a diagnosis of enuresis or encopresis based on chronological age criteria. 2.3. Procedure Doctoral students in clinical psychology with a master’s degree or at least one year post-bachelor’s degree experience administered the POTI with direct care staff serving as informants. The assessor read each item aloud to direct care staff members who were familiar with the individual for at least 6 months. Reviews of medical records were used to confirm answers to some of the POTI items. For a subset of the individuals, an additional POTI was administered to a different direct care staff member in order to examine interrater reliability. 2.4. Data analysis To determine internal consistency, Cronbach’s alpha was calculated for the POTI using SPSS 16. Any items with a coefficient below .30 were removed if alpha was increased by its removal (Leech, Barrett, & Morgan, 2008). To determine interrater reliability, Pearson-product moment correlation was calculated for the total POTI score between raters 1 and 2. 3. Results Cronbach’s alpha was used to assess internal consistency. Clark and Watson (1995) recommend using alpha levels of .8 for adequate internal consistency of a new scale. The internal consistency of all 56 items of the POTI was .79. Coefficients for
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items 23, 28, and 39 were unable to be calculated as there was zero variance for those items. Therefore, those items were removed from the measure. Next, each item with a coefficient value less than .30 was removed if data analysis indicated that the total scale alpha increased by its deletion. This resulted in the removal of an additional 21 items. Cronbach’s alpha was then calculated for the remaining 32 items and yielded an alpha of .83. Refer to Table 1 for those items that were retained in the POTI after the analysis. Nest, Pearson-product moment correlations were calculated between the total POTI scores for two independent raters. A significant correlation was found between the total POTI score for rater 1 and the total POTI score for rater 2, r (29) = .44, p < .05.
Table 1 Descriptions, means and standard deviations (Std. Dev.) and item correlations for the POTI items. POTI item number and description 1. Does not urinate in toilet 2. Does not defecate in toilet 3. Has daytime toileting accidents 4. Has nighttime toileting accidents 5. Had wet underwear in past month 6. Had soiled underwear in past month 7. Does not experience bowel movement once every three days 8. Lost toileting skills 9. Notice smears in underwear 10. Others complain of odor 11. Has a gastrointestinal disease 12. Had constipation prior to age three months 13. Urinates/defecates when coughing/sneezing 14. Only urinates/defecates small amount 15. Has strong urge before toileting accident 16. Has difficulty starting to urinate 17. Has weak or ‘‘stop–go’’ stream 18. Has excessive post-urination dribbling 19. Requires use of laxatives 20. Complains of feeling full after toileting 21. Has food allergies 22. On medication with side effect of constipation 23. Purposely withholds stool 24. Expresses fear about toileting 25. Communicates ‘‘I do not have to go to the bathroom’’ 26. Refuses to use the restroom 27. Hides wet clothes 28. Gets yelled at for not using restroom 29. Complains of social problems 30. Does not stop activity to use restroom 31. Complains of stomach aches 32. Does not communicate need to use restroom 33. Hides soiled clothes 34. Gets teased about accidents/odor 35. Complains of pelvic aches 36. Does not let caregiver know about wet/soiled clothes 37. Has lack of appetite 38. Blames self for accidents 39. Rejected by peers 40. Motor problems interfere with toileting 41. Not independent in self care 42. Requires encouragement to toilet 43. Exhibits problem behaviors when asked to toilet 44. Complains of pain while toileting 45. Attempts to toilet even if they have not defecated in 24–48 h 46. Gets yelled at to use restroom 47. Does not become upset after accident 48. Attempts to defecate in toilet 49. Attempts to urinate in toilet 50. Has urinary tract diagnosis 51. Frequently wakes to toilet 52. Has cloudy urine 53. Has bloody stool 54. Has bloody urine 55. Has hard stool 56. Has soft or runny stool Bolded items indicate those items that were retained.
Mean .14 .06 .40 .29 .35 .23 .06 .05 .37 .07 .35 .31 .03 .12 .04 .05 .01 .02 .66 .01 .07 .63 – .02 .19 .10 .05 – .01 .12 .05 .18 .01 .01 .03 .18 .05 .02 – .09 .27 .10 .06 .03 .06 .01 .25 .02 .02 .14 .17 .02 .02 .01 .06 .13
Std. Dev.
Item-total correlation
.35 .25 .49 .45 .48 .42 .23 .21 .49 .26 .48 .47 .17 .33 .19 .21 .10 .14 .48 .10 .26 .49 – .14 .40 .30 .21 – .10 .33 .21 .38 .10 .10 .17 .38 .21 .14 – .29 .45 .30 .25 .17 .25 .10 .44 .14 .14 .35 .37 .14 .14 .10 .25 .34
.03 .08 .77 .57 .72 .48 .13 .18 .46 .28 .04 .37 .00 .16 .23 .18 .09 .25 .23 .09 .01 .15 – .02 .18 .30 .30 – .12 .53 .19 .40 .15 .15 .03 .55 .08 .17 – .17 .31 .32 .30 .07 .14 .18 .44 .04 .04 .12 .25 .16 .02 .13 .12 .04
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4. Discussion Deficits in social and adaptive skills are recognized as problematic for persons with ID (Bossaert et al., 2009; Lin et al., 2009; Matson, Rivet, Fodstad, Dempsey, & Boisjoli, 2009). However, despite the fact that toileting issues are common in this population, little research has been published which addresses these issues. The POTI introduces a new assessment measure for toileting problems in adults diagnosed with ID. Unfortunately, no other assessment measures have been developed to assess for these problems. This is the case despite the fact that such difficulties have the potential to significantly impede independent living. A strength of the POTI is that it attempts to fill this void, by providing clinicians with a screening tool to assist in detecting these problems and thus serve as a screener. Additionally, this data should prove useful in identifying possible functions to target in treatment. Other strengths include the ease of administration and scoring and the quick administration time. These data provide a preliminary indication that the POTI has promise as a tool for clinicians to utilize when screening for toileting issues in individuals diagnosed with intellectual disabilities. The scale has strong internal consistency, and interrater reliability was encouraging. Given these findings, it appears that additional research regarding the psychometric properties of the POTI and an examination of its factor structure is warranted. The scale fills an important niche and will hopefully prove useful for identifying and prioritizing this important set of self-help skills. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders-text revision (4th ed.). Washington, DC: American Psychiatric Association. (Author). Ashworth, M., Hirdes, J. P., & Martin, L. (2009). 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