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Issues in toilet training normal children
BEHAVIOR THERAPY 8, 549--553 (1977)
Issues in Toilet Training Normal Children JOHNNY L . MATSON AND THOMAS H . OLLENDICK
Indiana State University The toilet training method described by Azrin and Foxx in Toilet Training in Less Than a Day was employed with five children whose mothers were supervised and five children whose mothers were not supervised. All children were between 20 and 26 months of age. Supervised mothers received pretreatment training as well as assistance during training, while nonsupervised mothers trained their children on the basis of their reading of the book. Training was more effective and the number of emotional side effects was less for both mothers and children in the supervised condition.
A rapid toilet training method has been developed by Foxx and Azrin (1973) and presented to the lay audience in Toilet Training in Less Than a Day (Azrin & Foxx, 1974). In a review of this book, Kimmel (1974) expressed reservation about its usefulness for parents wishing to train their own children. Specifically, Kimmel (1974) listed three precautions: (1) the need for research to support Azrin and Foxx's contention that parents using just the book could train their children, (2) the impression that not many mothers would be able to "acquire the self-control and manage the disciplined and subtle guidance required by the method solely by reading the book," and (3) the possibility that unforeseen emotional problems might arise from the use of the method by the parents. Foxx and Azrin (1973) reported that experienced trainers successfully trained 34 children, ranging in age from 20 to 36 months, in an average of 4 hr. Parents were specifically excluded from the training process and no unusual emotional reactions were reported in the children. However, Matson (1975) and Butler (1976) have made informal observations of parents failing to train their own children using just the book. In a controlled study wherein parents read the book and received extensive training and follow-up, Butler (1976) reported that 10 of 49 children were not trained. Six of these ten children had emotional reactions to the Requests for reprints should be addressed to Thomas H. Ollendick, Department of Psychology, Indiana State University, Terre Haute, IN 47809. This study was supported in part by a grant from the University Research Committee. Special thanks to Ann Ford for typing the manuscript. 549 Copyright© 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any formreserved.
ISSN 0005-7894
550
MATSON AND OLLENDICK
positive practice and four others did not self-initiate after one full day of training. Most of these failures were between 20 and 25 months of age. Similarly, Matson (1975) reported emotional reactions consisting of temper tantrums, hitting, and avoidance behavior in six children between the ages of 20 and 26 months. These children were being trained by the parents following suggested reading of the Azrin and Foxx book. Eventually, assistance on the part of an experienced trainer resulted in successful training. Thus, while the Foxx and Azrin (1973) method is successful, questions remain as to whether or not the lay parent can effectively implement the method and whether or not significant emotional side effects result. The present study investigated these issues in a group of children whose parents assimilated the material described in Azrin and Foxx (1974) and in a group of children whose parents not only assimilated the material but also received direct supervision during the training process. METHOD Ten normal children between 20 and 26 months of age, seven boys and three girls, were recruited for training by a newspaper ad. All children and their mothers were individually interviewed by the authors. Previous toilet training attempts were assessed, the rationale for the Azrin and Foxx method was presented, and the children were screened on the readiness test (Azrin & Foxx, 1974, p. 36). Mother and child were then randomly assigned to one of the two groups and an attempt was made to establish equally high expectations for both treatment methods. Finally, the mothers were given a copy of the book, instructed to read it, and told that they would be recontacted via phone in 1 week. Knowledge of the toilet training method for both groups was assessed at that time (Azrin & Foxx, 1974, pp. 135-146) and found to be acceptable. Mothers were instructed to conduct training in a series of daily 4-hr sessions and told that training should take no longer than one (4 hr) to five sessions (20 hr). Additionally, they were asked to keep a record of accidents and bedwetting. Four-hour sessions were employed in that Azrin and Foxx (1974) have indicated that the average time for toilet training is around 4 hr. Mothers in the book-only condition were instructed to train their children (three boys, two girls) solely on the basis of their reading of the book. Mothers in the book-plus-supervision condition were instructed to train their children (four boys, one girl) on the basis of reading the book and by having an experienced trainer available for supervision and prompting during the actual training. Following the five training sessions, maintenance was initiated for those successfully trained. For those not trained, follow-up consisted of ignoring but recording accidents with no attempt at continuing the treatment.
RESULTS
The mothers recorded the number of accidents by counting the number of times the child was wet during the dry pants inspection procedure or the number of times the child had to be changed each day. Following training, the mothers were contacted every week for 9 weeks by telephone. Prior to training, the children averaged about seven accidents per day per child (Fig. 1).
ISSUES IN TOILET TRAINING
7° 'rootmeet
551
lalntenm¢T Follow-Up ",e
"-@.. 43. E
i
~
,' ~
| Noosupervlsed IF- - -0 . /Sepervise. .
2
i
1 2 3 4 Days
2 3 4 5 6 ? 8 9 10 Weeks
FIG, 1. Mean number of accidents for each child in the supervised and nonsupervised groups. During the five treatment days, the number of accidents was recorded only for the sessions. Thereafter, the number was recorded during all waking hours. Maintenance was employed only following successful training. The slash indicates that one child and mother terminated treatment.
In the book-only condition, one child (male) was successfully trained in 1½ sessions (6 hr) and another (female) was partially trained following the five sessions (20 hr). Three of the unsupervised mothers met with failure in their efforts to train their children. Conversely, four of the five supervised mothers were able to train their children (three male, one female) within the five sessions (range was 4 to 18 hr). One of these mothers, however, reported relatively frequent accidents during maintenance and follow-up. The fifth mother discontinued treatment after the first session because she and her child (male) were too upset to continue. She decided to forego training with her child until he was older. This child had six accidents during his first and only training session. In general, children under 24 months of age required more training time even though all children passed the readiness test. Of the five children successfully trained, four maintained their gains during the maintenance period and three stopped wetting at night. All of the mothers reported emotional side effects consisting primarily of tantrums and avoidance behavior. These behaviors were more evident and nonfacilitating in the group of nonsupervised mothers and in the younger children. These negative reactions were most often attributed to the positive practice procedure and the graduated guidance required to keep their children on the potty. Mothers, too, reported on their own emotional response to the treatment. Four of the mothers felt "'uncomfortable" and sought to terminate the training. Encouragement, however, resulted in three of the four continuing. One mother terminated treatment due to her reaction to her son's tantrum behavior.
552
MATSON AND OLLENDICK
DISCUSSION One of the five mothers in the book-only condition was able to train her child, while four of the five mothers in the book-plus-supervision condition were able to do so. The average time required for these five children was 8 hr. Thus, the time for the successful cases was longer than that previously reported. Azrin and Foxx (1974) and Butler (1976) reported a mean training time of between 4 and 5 hr for this age group. A possible reason for this extended duration might be the use of daily 4-hr sessions in the present study. In previous studies, even though mean training time was around 4 hr, sessions of up to 10 hr in length were employed. Massed practice may facilitate the reduction of accidents by providing a more intensive learning experience (Foxx & Azrin, 1973). The elimination of bedwetting for three of the five children successfully trained is somewhat higher than the 30% reported by Foxx and Azrin (1973) and the 20% reported by Butler (1976). But it should be noted that this finding is only for those children successfully trained. Further, certain negative emotional side effects were present. While overcorrection is (among other things) a mild punisher (Foxx & Azrin, 1973) and such side effects are not uncommon with the use of punishment, these effects have been either unattended to or not reported by most researchers using overcorrection. Matson (1975) and Butler (1976) are exceptions, and in their studies similar side effects were reported. While such problems were evident in both groups in the present study, they were dealt with by support and encouragement of the mother in the supervised group. The book-only group, however, received no such support. This support, along with delaying the training until 24 months of age, may circumvent some of these negative reactions. In summary, the present results suggest that the use of the book alone is probably not sufficient to toilet train most children. While no direct observation was made of just what methods were used by the mothers in the book-only condition, their knowledge of the method was assessed to be on a par with those of the book-plus-supervision condition. While it may seem obvious that supervised mothers would do better than nonsupervised ones, the results clearly reaffirm Kimmel's (1974) reservations about the usefulness of the method when in the hands of a lay audience.
REFERENCES Azrin, N. H., & Foxx, R. M. Toilet training in less than a day. New York: Simon and Schuster, 1974. Butler, J. F. The toilet training success of parents after reading "'Toilet Training in Less Than a Day." Behavior Therapy, 1976, 7, 185-191. Kimmel, H. D. Review of "Toilet Training in Less Than a Day." Journal of Behavior Therapy and Experimental Psychiatry, 1974, 5, 113-114.
ISSUES IN TOILET TRAINING
553
Matson, J. L. Some practical considerations for using the Foxx and Azrin rapid method of toilet training. Psychological Reports, 1975, 37, 350. Foxx, R. M., & Azrin, N. H. Dry pants: A rapid method of toilet training children. Behavior Research and Therapy, 1973, 11, 435-442. Foxx, R. M., & Azrin, N. H. The elimination of autistic self-stimulatory behavior by overcorrection. Journal of Applied Behavior Analysis, 1973, 6, 1-14. RECEIVED: January 1, 1976; REVISED: May 17, 1976 FINAL ACCEPTANCE:June 10, 1976
Issues in Toilet Training Normal Children JOHNNY L . MATSON AND THOMAS H . OLLENDICK
Indiana State University The toilet training method described by Azrin and Foxx in Toilet Training in Less Than a Day was employed with five children whose mothers were supervised and five children whose mothers were not supervised. All children were between 20 and 26 months of age. Supervised mothers received pretreatment training as well as assistance during training, while nonsupervised mothers trained their children on the basis of their reading of the book. Training was more effective and the number of emotional side effects was less for both mothers and children in the supervised condition.
A rapid toilet training method has been developed by Foxx and Azrin (1973) and presented to the lay audience in Toilet Training in Less Than a Day (Azrin & Foxx, 1974). In a review of this book, Kimmel (1974) expressed reservation about its usefulness for parents wishing to train their own children. Specifically, Kimmel (1974) listed three precautions: (1) the need for research to support Azrin and Foxx's contention that parents using just the book could train their children, (2) the impression that not many mothers would be able to "acquire the self-control and manage the disciplined and subtle guidance required by the method solely by reading the book," and (3) the possibility that unforeseen emotional problems might arise from the use of the method by the parents. Foxx and Azrin (1973) reported that experienced trainers successfully trained 34 children, ranging in age from 20 to 36 months, in an average of 4 hr. Parents were specifically excluded from the training process and no unusual emotional reactions were reported in the children. However, Matson (1975) and Butler (1976) have made informal observations of parents failing to train their own children using just the book. In a controlled study wherein parents read the book and received extensive training and follow-up, Butler (1976) reported that 10 of 49 children were not trained. Six of these ten children had emotional reactions to the Requests for reprints should be addressed to Thomas H. Ollendick, Department of Psychology, Indiana State University, Terre Haute, IN 47809. This study was supported in part by a grant from the University Research Committee. Special thanks to Ann Ford for typing the manuscript. 549 Copyright© 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any formreserved.
ISSN 0005-7894
550
MATSON AND OLLENDICK
positive practice and four others did not self-initiate after one full day of training. Most of these failures were between 20 and 25 months of age. Similarly, Matson (1975) reported emotional reactions consisting of temper tantrums, hitting, and avoidance behavior in six children between the ages of 20 and 26 months. These children were being trained by the parents following suggested reading of the Azrin and Foxx book. Eventually, assistance on the part of an experienced trainer resulted in successful training. Thus, while the Foxx and Azrin (1973) method is successful, questions remain as to whether or not the lay parent can effectively implement the method and whether or not significant emotional side effects result. The present study investigated these issues in a group of children whose parents assimilated the material described in Azrin and Foxx (1974) and in a group of children whose parents not only assimilated the material but also received direct supervision during the training process. METHOD Ten normal children between 20 and 26 months of age, seven boys and three girls, were recruited for training by a newspaper ad. All children and their mothers were individually interviewed by the authors. Previous toilet training attempts were assessed, the rationale for the Azrin and Foxx method was presented, and the children were screened on the readiness test (Azrin & Foxx, 1974, p. 36). Mother and child were then randomly assigned to one of the two groups and an attempt was made to establish equally high expectations for both treatment methods. Finally, the mothers were given a copy of the book, instructed to read it, and told that they would be recontacted via phone in 1 week. Knowledge of the toilet training method for both groups was assessed at that time (Azrin & Foxx, 1974, pp. 135-146) and found to be acceptable. Mothers were instructed to conduct training in a series of daily 4-hr sessions and told that training should take no longer than one (4 hr) to five sessions (20 hr). Additionally, they were asked to keep a record of accidents and bedwetting. Four-hour sessions were employed in that Azrin and Foxx (1974) have indicated that the average time for toilet training is around 4 hr. Mothers in the book-only condition were instructed to train their children (three boys, two girls) solely on the basis of their reading of the book. Mothers in the book-plus-supervision condition were instructed to train their children (four boys, one girl) on the basis of reading the book and by having an experienced trainer available for supervision and prompting during the actual training. Following the five training sessions, maintenance was initiated for those successfully trained. For those not trained, follow-up consisted of ignoring but recording accidents with no attempt at continuing the treatment.
RESULTS
The mothers recorded the number of accidents by counting the number of times the child was wet during the dry pants inspection procedure or the number of times the child had to be changed each day. Following training, the mothers were contacted every week for 9 weeks by telephone. Prior to training, the children averaged about seven accidents per day per child (Fig. 1).
ISSUES IN TOILET TRAINING
7° 'rootmeet
551
lalntenm¢T Follow-Up ",e
"-@.. 43. E
i
~
,' ~
| Noosupervlsed IF- - -0 . /Sepervise. .
2
i
1 2 3 4 Days
2 3 4 5 6 ? 8 9 10 Weeks
FIG, 1. Mean number of accidents for each child in the supervised and nonsupervised groups. During the five treatment days, the number of accidents was recorded only for the sessions. Thereafter, the number was recorded during all waking hours. Maintenance was employed only following successful training. The slash indicates that one child and mother terminated treatment.
In the book-only condition, one child (male) was successfully trained in 1½ sessions (6 hr) and another (female) was partially trained following the five sessions (20 hr). Three of the unsupervised mothers met with failure in their efforts to train their children. Conversely, four of the five supervised mothers were able to train their children (three male, one female) within the five sessions (range was 4 to 18 hr). One of these mothers, however, reported relatively frequent accidents during maintenance and follow-up. The fifth mother discontinued treatment after the first session because she and her child (male) were too upset to continue. She decided to forego training with her child until he was older. This child had six accidents during his first and only training session. In general, children under 24 months of age required more training time even though all children passed the readiness test. Of the five children successfully trained, four maintained their gains during the maintenance period and three stopped wetting at night. All of the mothers reported emotional side effects consisting primarily of tantrums and avoidance behavior. These behaviors were more evident and nonfacilitating in the group of nonsupervised mothers and in the younger children. These negative reactions were most often attributed to the positive practice procedure and the graduated guidance required to keep their children on the potty. Mothers, too, reported on their own emotional response to the treatment. Four of the mothers felt "'uncomfortable" and sought to terminate the training. Encouragement, however, resulted in three of the four continuing. One mother terminated treatment due to her reaction to her son's tantrum behavior.
552
MATSON AND OLLENDICK
DISCUSSION One of the five mothers in the book-only condition was able to train her child, while four of the five mothers in the book-plus-supervision condition were able to do so. The average time required for these five children was 8 hr. Thus, the time for the successful cases was longer than that previously reported. Azrin and Foxx (1974) and Butler (1976) reported a mean training time of between 4 and 5 hr for this age group. A possible reason for this extended duration might be the use of daily 4-hr sessions in the present study. In previous studies, even though mean training time was around 4 hr, sessions of up to 10 hr in length were employed. Massed practice may facilitate the reduction of accidents by providing a more intensive learning experience (Foxx & Azrin, 1973). The elimination of bedwetting for three of the five children successfully trained is somewhat higher than the 30% reported by Foxx and Azrin (1973) and the 20% reported by Butler (1976). But it should be noted that this finding is only for those children successfully trained. Further, certain negative emotional side effects were present. While overcorrection is (among other things) a mild punisher (Foxx & Azrin, 1973) and such side effects are not uncommon with the use of punishment, these effects have been either unattended to or not reported by most researchers using overcorrection. Matson (1975) and Butler (1976) are exceptions, and in their studies similar side effects were reported. While such problems were evident in both groups in the present study, they were dealt with by support and encouragement of the mother in the supervised group. The book-only group, however, received no such support. This support, along with delaying the training until 24 months of age, may circumvent some of these negative reactions. In summary, the present results suggest that the use of the book alone is probably not sufficient to toilet train most children. While no direct observation was made of just what methods were used by the mothers in the book-only condition, their knowledge of the method was assessed to be on a par with those of the book-plus-supervision condition. While it may seem obvious that supervised mothers would do better than nonsupervised ones, the results clearly reaffirm Kimmel's (1974) reservations about the usefulness of the method when in the hands of a lay audience.
REFERENCES Azrin, N. H., & Foxx, R. M. Toilet training in less than a day. New York: Simon and Schuster, 1974. Butler, J. F. The toilet training success of parents after reading "'Toilet Training in Less Than a Day." Behavior Therapy, 1976, 7, 185-191. Kimmel, H. D. Review of "Toilet Training in Less Than a Day." Journal of Behavior Therapy and Experimental Psychiatry, 1974, 5, 113-114.
ISSUES IN TOILET TRAINING
553
Matson, J. L. Some practical considerations for using the Foxx and Azrin rapid method of toilet training. Psychological Reports, 1975, 37, 350. Foxx, R. M., & Azrin, N. H. Dry pants: A rapid method of toilet training children. Behavior Research and Therapy, 1973, 11, 435-442. Foxx, R. M., & Azrin, N. H. The elimination of autistic self-stimulatory behavior by overcorrection. Journal of Applied Behavior Analysis, 1973, 6, 1-14. RECEIVED: January 1, 1976; REVISED: May 17, 1976 FINAL ACCEPTANCE:June 10, 1976