teaching independent toileting to profoundly retarded deaf-blind children

BEHAVIOR THERAPY 11, 234-244 (1980)

Teaching Independent Toileting to Profoundly Retarded Deaf-Blind Children

G I U L I O E . LANCIONI

University of Nijmegen, Holland

Nine profoundly retarded deaf-blind children were trained to initiate and exe- cute toileting activities independently. The training procedure included increase in the subjects' intake of liquid, food reduction, positive reinforcement for in- dependent and partially-independent toileting as well as for remaining dry be- tween toileting actions, punishment for pants wetting, limitation of environmental stimulation, and increasing distance between subjects' position and toilet bowl. All subjects were able to achieve independence, and the rate of accidents dropped to zero. The acquired skills were also displayed for that part of the day during which training was not applied and were retained, with the exception of one case, after the intervention was discontinued.

The acquisition of toilet habits is generally a great problem for individ- uals with severe neuropathology (Azrin & Foxx, 1971; Baumeister & Klosowski, 1965; Dayan, 1964; Ellis, 1963; Foxx & Azrin, 1973; Giles & Wolf, 1966). Although in some circumstances the problem may be con- nected with physical abnormalities, in the majority of cases the accidents can be related to behavioral dysfunctions and thus treated with behavioral techniques (Ellis, 1963; Foxx & Azrin; Giles & Wolf). Some of the treat- ment approaches have concentrated on preventing accidents rather than promoting independent toileting (Baumeister & Klosowski; Dayan; Hundziak, Maurer, & Watson, 1965; Kimbrell, Luckey, Barbuto, & Love, 1967). Other treatment approaches, especially those implemented by Azrin and Foxx (1971) and Foxx and Azrin (1973) were aimed at stimulating independent toileting.

The previous studies have reported successful results with mental re- tardates. However, so far no evidence is available on the feasibility of

The author would like to thank the staff of the Institute Nostra Casa, Osimo, Italy for their collaboration and patience during the execution of the study. In addition, the author is grateful to L. Giacco, P. Ceccarani, and D. Cerioni for their help as experimenters, and M. Angeletti, D. Belli, M. Baldini, S. Cappeletti, S. Gasparroni, I. Giampieri, M. Manci- nelli, V. Tappa, and V. Toso for their help as observers. Reprints may be obtained from the author, Institute of Orthopedagogics, University of Nijmegen, Erasmuslaan 40-16, 6500 HD Nijmegen, Holland.

234 0005-7894/80/0234~)24451.00/0 Copyright 1980 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

TEACHING INDEPENDENT TOILETING 235

teaching toilet habits to profound retardates who are also afflicted with severe sensory deficits. Although visual and auditory impairments in ad- dition to mental retardation would create enormous problems for the implementation of a training procedure, such impairments might not con- stitute an absolute impediment to the acquisition of toilet habits. The purpose of this study was to explore the possibility of training profoundly retarded deaf-blind children to be independent in their urinary behavior; that is, to start and execute toileting actions involving urination on their own initiative. The procedure adopted was based on increased liquid intake, food reduction, positive reinforcement, punishment, limitation of environmental stimulation, and distance fading--increasing the distance between the children's position and the toilet.

METHOD Subjects

The subjects participating in this study were nine profoundly retarded deaf-blind children, six females and three males, whose ages varied from 8.1 to 16.3 years (~" = 14.3). The children's hearing losses (best ear) ranged from 80 dB to 110 dB. All were either blind or were merely able to avoid large obstacles. While the children were untestable on standard intelligence tests, their Social Quotients on the Vineland Social Maturity Scale ranged from 9 to 18 (X = 15.4). Their behavior was characterized by a high incidence of self-stimulation, such as rocking, rubbing them- selves and objects, flapping their hands, and poking their eyes. After prolonged and intensive training they were capable of dressing and un- dressing (underwear, pants with elastic waistbands, shirt, and coat); of orienting within the classroom, bedroom, and bathroom; and of under- standing the meaning of a few gestures. They had never been observed to direct themselves to the toilet on their own initiative. In addition, all of them still had urinary accidents even though (a) they were brought to the toilet several times during the day and night and were reinforced with edibles for voiding into the toilet bowl, and (b) their urinary tracts, as confirmed by an urologic examination, did not present any abnormalities.

Setting and Apparatus The children's bathroom, a wide corridor connecting the classroom

with the bathroom, and the classroom were the settings used for the three different phases of the study, respectively.

From shortly before baseline to the end of the study potty-alert and pants-alert devices were employed to detect the subjects' urination. 1 In addition, a stopwatch was employed to time possible interruptions during the execution of the toileting actions.

i These two devices, which are similar to those used by Foxx and Azrin (1973), are available through the BRS/LVE Division of Tech. Serv. Beltsville, Maryland 20705.

236 LANCIONI

Experimenters, Observers, and Target Behaviors Three experimenters and nine observers were used to conduct the

study. The experimenters were a psychologist and two teachers with extensive experience in the field of rehabilitation and behavior modifi- cation. The observers were six teachers and three evening caretakers who were working with these children.

The behaviors recorded included independent toileting, partially-inde- pendent toileting, incomplete toileting, attempted toileting, assisted toi- leting, and urinary accidents. Independent toileting was defined as fol- lows: the children direct themselves to the toilet on their own initiative and lower their pants, sit on the toilet bowl, arise after voiding, re-dress, and return to the starting place all by themselves. They execute the afore- mentioned sequence of steps without interruptions longer than 1 min in their performance, except for the interval between sitting on the toilet bowl and voiding, which may reach a maximum of 3 min, and the interval between voiding and arising, which (normally less than 1 rain) may be as long as 5 rain if defecation is occurring. Partially-independent toileting was recorded when the children started a toileting action on their own initiative, but interrupted its execution at some point after voiding; e.g., they continued to sit on the toilet bowl after voiding even though defe- cation was not taking place, did not start to re-dress after arising, inter- rupted the re-dressing process, or paused while walking back to the start- ing place.

Incomplete toileting was recorded when the children failed to void within the allotted 3-min period during an action that they started and executed on their own initiative. Attempted toileting was recorded when the children reached the toilet bowl on their own initiative, but inter- rupted their action for more than 1 min at some point before sitting on the toilet bowl. Assisted toileting was scored whenever the children start- ed a toileting action after the presentation of the toilet gesture (i.e., their right hand was made to touch their pubic area), regardless of whether they would void or interrupt the execution of the toileting sequence. Urinary accidents consisted of voiding in the pants or pajamas. During the day the children wore the pants-alert device so that accidents could be detected immediately. During the night the caretakers checked the children's pajamas every 20 min.

Baseline During the baseline phase data were collected daily for 22 hours. Data

were not collected from 8:00 a.m. to 9:00 a.m. and from 8:00 p.m. to 9:00 p.m. because during these periods the children were helped in performing routine washing and toileting. From 9:00 a.m. to 8:00 p.m. the children were engaged in normal activities (i.e., rehabilitation, recreation, and dining) in their classroom, which also constituted their living and dining area. From 9:00 p.m. to 8:00 a.m. they were in bed. Normally, all subjects were provided with assisted toileting twice in the morning, three times in the afternoon, and four times during the night. An assisted toileting

T E A C H I N G I N D E P E N D E N T T O I L E T I N G 237

action was omitted if the children had successfully voided within the preceding 30 min.

Voiding was reinforced with edibles (e.g., ice cream and yogur0 im- mediately after the urination had been signalled by the potty-alert device and after the children's return to the classroom or bedroom.

When an accident was detected the children were (a) made to touch their wet clothes, (b) accompanied to the linen room, (c) required to take off their wet clothes, (d) cleaned with a damp sponge, (e) required to put on dry clothes, and (f) accompanied back to the original situation.

The baseline conditions remained in effect during the afternoon and night throughout the course of the morning treatment except that rein- forcement after voiding was eliminated for all forms of toileting by the end of the second phase of the morning treatment. From then on, the children were reinforced only after their return to the classroom or bed- room.

Experimental Intervention

The daily treatment, which also was continued throughout the week- ends, lasted from 9:00 a.m. to 1:00 p.m. At about 8:20 a.m. the experi- menters gave the subjects a very light breakfast (half the normal portion to make the edible reinforcers more effective) and began to administer water and a variety of soft drinks, approximately V4 cup every 5 rain, so that by the time the treatment session started the subjects had already drunk 2 cups of liquid. The administration of liquid continued at the same rate until 11:30 a.m. Such a large quantity of liquids was aimed at in- creasing the frequency of urinations, thus providing numerous occasions for contingent reinforcement.

Phase 1. In the first phase of treatment, the subjects, free from stim- ulation and activities, were seated in close proximity to the toilet door so that they would often touch it by accident. Since the subjects had pre- viously been trained to touch the toilet door on their way to the toilet bowl, this door (which was much rougher than the others) had become both a spatial cue and a means of anticipating the toilet bowl. On the first day of treatment the experimenters prompted toileting every 20 rain if none of the other forms of toileting had taken place. Assisted toileting then was discontinued until the second phase of treatment.

In the beginning of treatment the children were reinforced with edibles for self-initiated (independent and partially-independent) toileting (a) after they had started voiding, (b) after they had raised their pants, and (c) after they had returned to their chairs. Furthermore, the completion of partially-independent toileting was prompted by briefly (but repeatedly if necessary) bringing the edible substance in contact with the children's lips. The conditions in effect for incomplete and attempted toileting re- mained the same as during baseline, with the exception that reinforce- ment for attempted toileting followed by voiding was totally eliminated.

When independent toileting was shown consistently, and the other forms of toileting and accidents had dropped to zero, reinforcement after

238 LANCIONI

urination was omitted. Shortly af terwards, if neither accidents nor the other forms of toileting were present , re inforcement after re-dressing was also omitted.

In addition to the edible re inforcement provided for independent toi- leting and part ial ly-independent toileting, tactile re inforcement was ad- ministered for remaining dry. The tactile stimulation consisted of deli- cately rubbing the subjects ' back for l0 sec and was administered on a var iab le- in te rva l schedule. The average in terval be tween dry-pan ts checks was 5 rain. This procedure allowed the children 48 occasions of re inforcement if they did not have any accident. When they did have an accident, the next dry-pants check was skipped, and the opportuni ty for tactile re inforcement was lost.

I f the pants-alert device signalled an accident, the exper imenters dis- connected the device, and made the subjects touch their wet pants , and immediately af terwards walk on a row of 10 large wooden blocks placed at a distance of 20 cm f rom each other. The base of the blocks was 30 cm x 30 cm and the height was 20 cm. The blocks were glued to the ba th room floor so that they would not slide away when the children s tepped onto them. The children were required to walk the whole row first in one direction then in the other (the exper imenters held their hands to prevent them from falling), before being al lowed to take off their wet clothes. This form of punishment was preferred to minimal cleanliness training and posit ive practice after pilot work with two retarded deaf- blind children indicated that both procedures had disadvantages when used with these children. 2

Phase II. Phase two was initiated when the subjects consistently per- formed independent toileting with only a single re inforcement (from the posit ion of close proximity to the toilet door) and were no longer having accidents or engaging in any of the other forms of toileting. The only change in the second phase was the removal of the children f rom the ba throom. N o w they were seated in the corr idor leading f rom the bath- room to the c lassroom, at a distance of approximate ly 8 m f rom the toilet door. The blocks to be used in case of accidents were now glued to the corridor floor. The second phase, which was star ted with an occasion of assisted toileting, was continued until independent toileting was the only target behavior displayed.

Phase III. In the third phase of t rea tment the subjects were brought

2 Cleanliness training had the following three disadvantages: the quantity of urine released was often small so that it was impossible to clean the chair or the floor: even when the urination was more abundant and wet spots were visible, deaf-blind children did not have any visual cue and had to be helped to touch the wet spots before they could be required to clean them; given the lack of vision and the limited abilities of these children, massive physical guidance was needed throughout the whole cleaning. This massive body contact appeared to function as a reinforcer for one of the children. The positive practice seemed to be problematic with these subjects because it interfered with the acquisition of the association between the toilet bowl and voiding.

T E A C H I N G I N D E P E N D E N T T O I L E T I N G 239

back to the classroom and reintroduced to their normal activities. The blocks were also moved to the classroom. However, the treatment con- ditions remained the same as in the previous phases until independent toileting was the only target behavior observed. From then on, the quan- tity of liquid administered was gradually diminished so that during the last 4 days of treatment the levels reached were only slightly higher than those existing throughout baseline. The number of dry-pants checks was also progressively reduced from 48 (average of one every 5 rain) to 3 (average of one every 80 min) on the last 2 days of treatment.

Maintenance Phase At the end of the last phase of treatment a maintenance schedule was

introduced. Under this schedule, which was in effect from 9:00 a.m. to 8:00 p.m., (a) liquid and food intakes were equal to baseline levels, (b) edible reinforcers followed only instances of independent toileting, (c) tapping the children's shoulder was used to prompt the continuation of a toileting action when this presented interruptions longer than those allowed during baseline and treatment, (d) tactile reinforcement followed three successful dry-pants checks (at 11:00 a.m., 3:00 p.m., and 7:55 p.m.), and (e) changing clothes and suspension of the dry-pants checks for the rest of the day (i.e., loss of additional tactile reinforcement for the rest of the day) followed the occurrence of accidents. The children continued to wear the pants-alert device and were not provided with assisted toileting.

Design The experimental design was a multiple baseline across subjects (Baer,

Wolf, & Risley, 1968). However, in order to avoid long baseline periods, the nine subjects were divided into three groups of three subjects each so that there were only three baselines. The baseline data collected from 9:00 a.m, to 1:00 p.m. corresponded to the time of the day when children were involved in treatment and were adi rec t means of control for the children's urinary behavior during treatment. The baseline data collected from 1:00 p.m. to 8:00 p.m. and from 9:00 p.m. to 8:00 a.m. were used to assess whether the morning treatment would affect the afternoon and night urinary behavior. The follow-up data, which were gathered for 44 days starting immediately after the end of the morning treatment, served to assess the effectiveness of the maintenance program.

Inter-observer Reliability Inter-observer reliability was assessed before baseline and at the be-

ginning of treatment (four sessions in each period for every observer) by scheduling two observers for an observation session, For the teachers the sessions took place in the daytime, while for the caretakers in the daytime as well as nighttime (so as to include all target behaviors in the observation). The percentage of agreements for each of the behaviors

240 LANCIONI

R

6 4 2

=2

~ . v 2

• INDEPENDENT T01LETING

Baseline ~ ~ ~ D-----E3 PARTIALLY-INDEPENDENT

, ~ I ~ , ~ T O I L E T I N G

a~ ACCIDENTS ' I I , 1 , ' , '~ , ,

2 , ~ - * i ' P

II ~' ~ . . . . . . . . . . . . . . G r o u p 2

18

16

14

12

10

, . . . . . . . . . . F, :

• . . . . . . . . . :

' / 1 t

]'%, ,

% i I , ' , J p

I k

L . . . . . . . . . ~ Group 3 L . . . . . . . . . . . . . ~ I

O 5 i0 15 20 25 30 35

Days (in blocks of t w o )

FIG. 1. Morning urinary behavior during baseline and the three treatment phases across groups of subjects. Each data point is the average over 2-day periods for three subjects. The first and second arrow indicate the withdrawal of reinforcement after urination and after arising from the toilet. The third arrow indicates when the quantity of liquids started to be diminished.

displayed (i.e., independent toileting, partially-independent toileting, in- complete toileting, assisted toileting, and urinary accidents) was 100.

R E S U L T S

Morning Treatment The results of the experimental intervention for independent toileting,

partially-independent toileting, and urinary accidents are summarized in Fig. 1 (each data point is the average over 2-day periods for three sub- jects). Attempted toileting never occurred during baseline and treatment, while incomplete toileting appeared sporadically only at the beginning of the first phase of treatment. During baseline none of the subjects showed independent toileting or partially-independent toileting. Furthermore, as- sisted toileting, which often was not followed by voiding, required that the teachers give the children the toilet gesture and provide them with prompts to insure the completion of the toileting sequence. With the

TEACHING INDEPENDENT TOILETING 241

INDEPENDENT TOILETING

ACCIDENTS Baseline ~ ~ ' ~ *----- ~"

o ~ az az

6 '

~ - Group l

i ' ', u . . . . . . . . . . ~ G r o , / p z

~ 8 I i I

~ "* , q t / -"

t 1 ~ . . . . . . . . . . . . Group 3

I u . . . . . . . . . . . i

. . . . . . . . . . . . . . . -] ', L u i

4

O 5 iO 15 20 25 30 35

Days (in blocks of two)

FIG. 2. Afternoon urinary behavior (l:00 p,m. to 8:00 p.m.) during baseline and the three morning treatment phases across groups of subjects. Each data point is the average over 2-day periods for three subjects,

beginning of treatment, because of the contact with the toilet door, the subjects started to initiate toileting. However, most of these self-initiated actions were completed only with the use of prompts. The rate of par- tially-independent toileting decreased to zero during the initial days of the first phase of treatment, to reappear only at the beginning of the second phase of treatment for Groups 1 and 2. Meanwhile, independent toileting, which began during the first 2 days of treatment, was rapidly consolidated and maintained throughout the different phases of the in- tervention.

The rate of accidents dropped to zero by the third day of treatment for Groups 1 and 3, and by the seventh day for Group 2. Group 2 showed accidents again at the start of the second and third phase of treatment, and Group 1 had accidents at the start of the second phase of treatment, while Group 3 did not have additional accidents.

Age, sex, sensory condition, and degree of self-stimulation did not seem to affect the children's behavior on any of the dependent variables.

Generalization and Maintenance The afternoon frequencies of accidents and independent toileting be-

fore and during the implementation of the morning treatment are pre-

242 LANCIONI

sented in Fig. 2 (each data point is the average over 2-day periods for three subjects). Partially-independent toileting, attempted toileting, and incomplete toileting never occurred in the afternoon. Moreover, the sub- jects did not display independent toileting until phase three of the morning treatment; thus they were regularly provided with assisted toileting. How- ever, during the second phase of morning treatment two noteworthy changes occurred in the children's behavior. First, in contrast with the baseline performance, they never failed to urinate on the occasions of assisted toileting, and the withdrawal of reinforcement after voiding did not disrupt this achievement. Secondly, the degree of prompting required for the completion of assisted toileting actions decreased with the pro- gression of the morning treatment. By the second or third afternoon of phase three of the morning treatment, the subjects began to perform independent toileting. This was quickly consolidated by all subjects, as- sisted toileting could be eliminated, and the rate of accidents dropped to zero.

The urinary behavior at night was not profoundly affected by the morning intervention. In fact, with only a few exceptions, none of the subjects initiated a toileting action, and accidents continued to occur. However, the amount of prompting for assisted toileting decreased with the progression of the morning treatment to the point that the toilet ges- ture was all the children needed to execute the entire toileting action.

The results of the follow-up of 44 days indicated that eight of the nine subjects performed independent toileting consistently during the whole period, while partially-independent toileting, incomplete toileting, and attempted toileting were not present, and accidents occurred sporadically only on 2 days. The rate of independent toileting ranged between 5 and 11 with an average of 7.3. A different picture appeared for the ninth subject. His independent toileting had a frequency comparable to that of the other children for 10 days during which neither the other forms of toileting nor accidents were present. Afterwards, his rate of independent toileting decreased and accidents began to occur, especially when he was involved in exciting activities. The principal feature differentiating this child from the others was the high intensity of his self-stimulation.

DISCUSSION The children's toileting behavior before and during baseline suggests

that edible reinforcement by itself was not sufficient to promote indepen- dence when the possibilities for its administration were infrequent and related only to occasions of assisted toileting, when accidents were not followed by any negative consequence, and when the environment did not include cues for toileting. A procedure involving the administration of large amounts of liquid, food reduction, frequent reinforcement, pun- ishment, distance fading, and limitation of environmental stimulation (in the first two phases of treatment) proved to be successful for teaching independent toileting and eliminating urinary accidents in a short period of time. Whether all these procedures were necessary for the final success

T E A C H I N G I N D E P E N D E N T T O I L E T 1 N G 243

of the procedure is not known. One might speculate that the increased frequency of urinations (following the increased liquid intake), the pres- ence of the toileting cue (i.e., toilet door) in the first phase of treatment, and the availability of reinforcement (the effectiveness of which might have been increased by the reduced breakfast) were the crucial variables that promoted the appearence and consolidation of independent toileting.

The punishment strategy, which created great tension in the children, but did not provoke crying and tantrums, may not have had any role in the appearence of independent toileting. However, it might have been necessary to eliminate accidents in those subjects who persistently wet their pants despite the consequent loss of tactile reinforcement, and thus it might have greatly contributed to the achievement of full urinary con- trol.

Finally, the limitation of environmental stimulation appeared to have variable effects. While some children seemed to be quieter and probably more responsive to the experimental conditions, others displayed rest- lessness and increased self-stimulation, which might have lessened the effectiveness of the treatment.

The achievement of independent toileting by all subjects in the after- noon, when training was not in effect, and the maintenance of the ac- quired skills by eight of the nine subjects after the end of treatment in- dicate that the effects of an intensive intervention can be satisfactorily generalized across parts of the day and retained over time. The failure of one of the subjects to maintain independence stresses the need for ad- ditional research with children who display extreme forms of self-stim- ulation to find out whether a longer training period or a different training strategy may produce lasting effects.

The absence of any clear influence of the morning treatment on self- initiated nighttime urinary behavior is not surprising if one considers the difference between the training setting and the bedroom. It is interesting to note, however, that as a probable consequence of the morning treat- ment, the toilet gesture was the only prompt the subjects needed to ex- ecute a toileting action.

Although independent defecation was not the purpose of this study (since the majority of the subjects defecated only with the help of sup- positories) three subjects who defecated spontaneously never showed bowel accidents during the morning from shortly after the beginning of the first phase of treatment and during the afternoon from the third phase of treatment. In fact, defecation occurred generally during independent toileting actions.

In conclusion, the procedure elaborated by Azrin and Foxx (1971) and Foxx and Azrin (1973) and adapted in this study for use with profoundly retarded deaf-blind children seems to be a very effective method to teach daytime independent toileting. Nighttime independence for these children will have to be trained separately. Maybe this could be done by combining the procedural steps used for the day treatment with a device that would alert the subjects by vigorously shaking their beds as soon as urination

244 LANCIONI

starts. Lastly, the information available on the three subjects who defe- cated spontaneously suggests that it is not always necessary to train bow- el control with a separate procedure when urination is taught in the seated position. However, to achieve full independence, the children would have to be trained to clean themselves after defecation.

REFERENCES Azrin, N. H., & Foxx, R . M . A rapid method of toilet training the institutionalized re-

tarded. Journal of Applied Behavior Analysis, 1971, 4, 89-99. Baer, D. M., Wolf, M. M., & Risley, T . F . Some current dimensions of applied behavior

analysis. Journal of Applied Behavior Analysis, 1968, 1, 91-97. Baumeister, A., & Klosowski, R. An attempt to group toilet train severely retarded pa-

tients, Mental Retardation, 1%5, 3, 24-26. Dayan, M. Toilet training retarded children in a state residential institution; Mental Re-

tardation, 1964, 2, 116-117. Ellis, N .R . Toilet training and the severely defective patient: An S-R reinforcement anal-

ysis. American Journal of Mental Deficiency, 1963, 68, 98-103. Foxx, R. M., & Azrin, N . H . Toilet training the retarded: A rapid program for day and

nighttime independent toileting. Champaign, IL: Research Press, 1973. Giles, D. K., & Wolf, M.M. Toilet training institutionalized severe retardates: An appli-

cation of behavior modification techniques. American Journal of Mental Deficiency, 1966, 70, 766-780.

Hundziak, M., Maurer, R. A., & Watson, L. S. Operant conditioning in toilet training severely mentally retarded boys. American Journal of Mental Deficiency. 1965, 70, 120-121.

Kimbrell, D. L., Luckey, R. E., Barbuto, P. F. P., & Love, J . G . Operation dry-pants: An intensive habit-training program for severely and profoundly retarded. Mental Re- tardation, 1967, 5, 32-36.

RECEWED: December 18, 1978; REVISED: August 15, 1979 FINAL ACCEPTANCE: October 15, 1979