Toileting Training for Easter Seals Midwest 12/7/15 Toileting Training for Children with ASD Megan Tregnago, M.Ed., MHA, BCBA, LBA Toileting Workshop

Pre-Workshop Worksheet Please complete the pre-workshop worksheet to begin thinking about your child and his/her toilet training experience

Identifying Reinforcers Getting Started Intensive Elimination Training Easter Seals Midwest 12/7/15 Outline Setting Goals Data Identifying Reinforcers Getting Started Intensive Elimination Training Trouble-Shooting Our intent of this workshop is that by the end of this program, you will be confident and successful in addressing your child’s toileting problems. It will take continued focus and practice to see long-term changes. We encourage you to remain committed to the program. With that commitment, it can and will work for you and the individual for whom you provide care. Toileting Workshop

Commitment Toilet Training is intensive no matter how you go about it! Are you committed to… Learning about proper toileting habits? Giving your child a balanced, high-fiber diet? Giving your child increased drinks? Giving your child regular exercise? Frequent pants checks? Frequent toilet sits? Reinforcement for toileting behavior? Cleaning up after accidents?

Be Positive “I’ll give it a try” vs. “That’ll never work.” Progress not perfection! Toilet training takes time and patience If the experience turns negative for you or your child, step back and try again later

Applied Behavior Analysis (ABA) Focuses on the application of the science of behavior. Effective, evidence-based, therapeutic approach for helping individuals with ASDs and other developmental disabilities gain the communicative, social and behavioral skills they need. Provides positive reinforcement to teach for appropriate, desirable behaviors

Challenges in Children with Autism Communication delays Decreased receptive language Sensory sensitivities Impaired social interaction Routine Others?

Benefits to Toilet Training Less time and effort spent changing soiled diapers Saves money Decreased skin irritations (diaper rash) More independence More time to engage in other activities More pride and dignity Decreased stress

SETTING GOALS

Setting Goals Setting goals will allow you to objectively track changes. When setting goals: Be realistic Start small Focus on improvement rather than perfection Be positive

Toileting Skills Notifying caregiver Entering the bathroom Easter Seals Midwest 12/7/15 Toileting Skills Notifying caregiver Entering the bathroom Turning on/off light Pulling clothes up/down Sitting on toilet Getting toilet paper Wiping with toilet paper Standing up Throwing toilet paper in toilet Pulling clothes up Flushing toilet Washing hands In addition to elimination, caregivers may also set goals related to skills on this list Toileting Workshop

3 Behavioral Goals In addition to “elimination in the toilet”, list 3 target behaviors/goals. Target Behavior Behavioral Goal 1. 2. 3.

DATA: Collect Record Graph Data

Importance of Data Take baseline (3-7 days) to know where to start Compare changes to baseline to chart success and detect small changes Allows you to objectively detect change Shows whether training is helping or not Tells you whether to continue what you’re doing or to make a change

Baseline: Wet/Dry Checks Check diaper every half-hour Record whether diaper is wet, dry, or soiled Tell child “Good job staying dry” or “You’re wet/dirty.” Use these checks to determine whether your child has a consistent elimination pattern.

Baseline Data If no pattern is found, consider contacting physician or child may not be ready. Examples: Child is wet for several 30-minute checks in a row, child has more than 2-3 bowel movements per day.

Data Sheet

Graph

IDENTIFYING REINFORCERS

Preference Assessments Your child may not be able to tell you what he likes/does not like Use preference assessments to identify what might serve as reinforcers Important to rotate reinforcers to prevent boredom Limit access to reinforcers used for toileting (keep them in the bathroom)

Types of Reinforcers Food or Drink Object, Toys Activities Breaks/Rest 21 Food or Drink Object, Toys Activities Breaks/Rest Social Interaction (nods, smiles, tickles, praise) Feedback/Praise Tokens/Money to earn other reinforcers

GETTING STARTED: ARE YOU READY?

Reflect on toileting history Assess readiness Before You Start Medical Exam Consider side effects of any medications Do not give too much fluid with seizure disorders Reflect on toileting history Fear, sensitivities, successes, habits Assess readiness

Is My Child Ready? Able to sit on toilet for 2-5 minutes Does not resist the bathroom Able to pull pants up and down Has regular, well-formed bowel movements Stays dry for 1-2 hours and during naps Shows interest in toileting Show indication that he/she is wet/dry Has a way to initiate

Increase Awareness Change diapers in the bathroom Read stories about the act of toileting A Potty for Me! Pirate Potty Super Pooper Watch videos about toileting The Potty Book and DVD I Go Pee and Poop on the Potty Signing TImes: Potty Time Introduce a toileting doll Potty Monkey Betsy Wetsy

Guidelines for Success Set aside a weekend to devote to training – start on a Friday or Saturday morning Train all day or until you and your child are too tired to continue Devote all your attention to toileting Eliminate distractions, minimize interruptions Use consistent vocabulary Create a positive environment

Check-In Do you think you will be able to adhere to these guidelines? Are there any obstacles you are facing? How can you address those obstacles to be more successful?

Data and Graphing Keep going!

Water or preferred drinks Reinforcers Underwear Snacks Easter Seals Midwest 12/7/15 Materials Needed Water or preferred drinks Reinforcers Underwear Snacks Gloves, paper towels, wipes Foot stool and chair Data sheet Timer Pen Toileting Workshop

Environmental Supports Easter Seals Midwest 12/7/15 Environmental Supports 30 Potty seat Potty seat with ladder to help child push Stool to help child reach sink Whiz kids tablets – put in toilet to help with “aim” Faucet extender to help child wash hands Malem enuresis alarm (urine alarm) Toileting Workshop

No More Diapers! 31 Some research shows that putting a child in a diaper makes it more likely that they will eliminate in the diaper The only exception is for naps, long car rides, or bedtime. Even then, be wary! By doing this, you are reducing confusion and increasing the child’s chances for success by teaching them diapers and pull ups are only for these times

In the Bathroom Place all materials in the bathroom Keep your child in or near the bathroom throughout the training Your child should wear clothes that are easy to take off (e.g., elastic waistband shorts) Have several changes of clothing available Make it fun!

Increase Liquids Check with doctor first about providing increase liquid. If the individual refuses to drink more water, try a different drink. Provide saltine crackers or other snacks. Use a variety of snacks, but do not provide the highly preferred edibles from the preference assessment. Those are reserved for successful voiding in the toilet.

Toilet Training Procedure Time Fluid Intake Toilet Sitting 1-hour before training Full cup None 30 minutes before training ½ cup Training starts 5-10 minutes ½ hour after training starts

Sits and Dry Pants Checks Provide a half-cup of water and sit on the toilet every 30 minutes Tell child “It’s time to potty” or prompt him to produce request Check your child every 5 minutes afterwards If your child kept dry during the 5 minutes, provide a brief praise and brief reinforcement Set the timer to help you remember

Example

Success! If your child begins to eliminate in the toilet, give him immediate attention with praise and provide a reinforcer from the Preference Assessment. Be overly animated and enthusiastic (congratulate, smile, clap, etc.) Continue with dry pants checks every 5 minutes Sit again after 30 minutes

Accidents If your child urinated or defecated in his pants: Say "No wet/soiled pants" in a neutral voice. Have your child place the dirty clothes in the hamper/washer. Limit attention during this time. Have the child assist with clean up (to extent safe and possible) and put on clean clothes. Limit attention during this time. Prompt child to sit for 5 minutes or until he eliminates (whichever comes first). Do not provide snacks for the next 30 minutes following an accident.

WHAT ABOUT…

Bowel Training BMs rarely occur without urination Increase exercise, fiber, and liquids, decrease dairy Consult physician if constipation or diarrhea exists Record data to get routine Set child on toilet 30 minutes after meals, repeat every 30 minutes until success Provide a step-stool or Squatty Potty

Problem Behavior TELL, SHOW, DO Training should be a POSITIVE experience We do not want to associate toileting with negative experiences If child becomes extremely upset and resistant, back up and try again

Guided Compliance No Praise If Not TELL me (Verbal instruction) Wait 5-10 Seconds Praise and Reinforce Abundantly if Compliant If Not SHOW me (model) Praise and/or reinforce briefly if compliant Help me DO it (physical guidance) No Praise

Lunch Eat lunch in or near the bathroom If child starts to void during the meal, immediately escort him to the toilet. After the meal, resume training by placing your child on toilet for 5-10 minutes (if dry, begin 5-min pant checks).

Urine Alarms A wetness detecting monitor can significantly cut down on the effort and time required for training. Attach the monitor to the individual. When the monitor beeps or vibrates to indicate wetness, simply follow the protocol for accidents Wet stop ($50, http://www.wet-stop.com/ or www.amazon.com) is an example of a commonly available wetness sensor. Check with insurance company or funder for reimbursement

Functional Communication Training Teaches child a way to communicate the to use the bathroom Choose form of communication Procedure: Prompt child to communicate (Tell-Show-Do) Once the request occurs, reinforce Immediately take child to bathroom Have child sit for 1 minute or less Reinforce any success Repeat about 10 times in10-15 minutes

Reinforce longer durations of sitting Refusal to Sit SHAPE: May need to start with reinforcing just being in bathroom/next to toilet/touching toilet Reinforce longer durations of sitting 1 second, 5 seconds, 10 seconds…. Try a variety of toilet training seats Place a piece of cardboard under the seat and gradually increase size of hole cut in cardboard

Refusal to Flush Prepare individual – Ready, set, flush! De-sensitize (watch videos) Play background music or wear headphones Put lid down to hide water

Accidents after Continence Rule out any physical conditions “You wet your pants. You need to use the toilet.” Have child help with clean-up Reinforce any success Do NOT go back to diapers

References Toilet Training for Individuals with Autism and Related Disorders by Maria Wheeler Toilet Training Caregiver Manual, NYS Office for People with Developmental Disabilities Toilet Training in Less than a Day by Azrin & Foxx Intensive Outpatient Behavioral Treatment of Primary Urinary Incontinence of Children with Autism by LeBlanc et al.

Megan Tregnago, M.Ed., MHA, BCBA, LBA Easter Seals Midwest |Autism Services 918 Bernadette Dr. Columbia, MO 65203 573-874-3777 (office) Megan.Tregnago@esmw.org