Research in Autism Spectrum Disorders 3 (2009) 607–618

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Review

Toilet training individuals with autism and other developmental disabilities: A critical review K.A. Kroeger *, Rena Sorensen-Burnworth Kelly O’Leary Center for Autism Spectrum Disorders, MLC 4002, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH 45229, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 8 January 2009 Accepted 9 January 2009

The following article reviews the current literature addressing toilet training individuals with autism and other developmental disabilities. The review addresses programs typical to toilet training the developmental disability population, most of which are modeled after the original Foxx and Azrin [Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied Behavior Analysis 4, 89–99; Foxx, R. M., & Azrin, N. H. (1973). Toilet training persons with developmental disabilities: A rapid program for day and nighttime independent toileting. Harrisburg, PA: Help Services Press] rapid toilet training methods. Components of such programs are isolated and described in their contribution to toilet training models. Studies are then reviewed and compared for participant and study characteristics. Individual studies validating toilet training programs are then discussed in light of their program components and efficacy. Shortcomings to currently available programs are highlighted and future areas of study are suggested. ß 2009 Elsevier Ltd. All rights reserved.

Keywords: Toilet training Continence Autism Developmental disabilities Review

Contents 1.

Method . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Graduated guidance . . . . . . . . 1.2. Reinforcement-based training 1.3. Scheduled sittings . . . . . . . . . 1.4. Elimination schedules . . . . . .

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* Corresponding author. E-mail address: [email protected] (K.A. Kroeger). 1750-9467/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2009.01.005

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1.5. Punishment procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6. Hydration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7. Manipulation of stimulus control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8. Nighttime training for diurnal continence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9. Priming and video modeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Participant characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Program characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Competent toileting is a critical life skill. Twenty years ago, 63% of the empirical research on selfhelp skills focused on toileting and feeding (Konarski & Diorio, 1985). This skewed emphasis is likely to be maintained today as the social and practical ramifications of incontinence have not changed over time. Incontinence is problematic to individuals with developmental disabilities in that it places limits on socialization, and residential and vocational placements. Quality of life impairments can include inadequate hygiene, stigmatism, physical discomfort and irritation of the genitals, diminished selfconfidence, and restriction from typical daily activities (e.g., Cicero & Pfadt, 2002; Hyams, McCoull, Smith, & Tyrer, 1992; Lott & Kroeger, 2004; McCartney, 1990). Toileting is a critical skill necessary for independent living, and incontinence is a significant quality of life barrier for individuals with autism and developmental disabilities. Given the magnitude of establishing and maintaining continence for individuals with developmental disabilities, it is important to consider individual characteristics associated with toileting competence. Researchers indicate that individuals who are chronologically younger and measured at an IQ score of 20 or higher are more likely to achieve success with behavioral toileting programs (Lohmann, Eyman, & Lask, 1967). However, operant learning procedures have demonstrated efficacy with a diverse range of functioning in the mentally retarded population (Osarchuk, 1973). A number of prerequisites have also been cited as ‘‘necessary’’ to initiate training of toileting including regular urinary and bowel voiding (‘‘with infrequent dribbling;’’ Lowenthal, 1996), child ability to void urine in large amount, demonstrated ability to sit on the toilet, absence of counter-indicated medical conditions (e.g., spina bifida), and diapering at night as diurnal continence typically precedes nocturnal continence (this appears to be more of an observation and suggestion than actual prerequisite proper; Baker & Brightman, 1997; Lowenthal, 1996; Snell & Brown, 2000). However, data to support the necessity of such prerequisites are not referenced. Foxx and Azrin (1973) also suggest a set of skills present before attempting toileting training, however, these skills appear to be a minimum of physical capacity (e.g., ability to walk, see, grasp) rather than toiletingbehavior specific. In training toileting, two goals must be met in order to achieve independent and appropriate toileting skills: (1) continence, where an individual must be able to recognize the sensation for elimination and (2) mastery of the entire chain of behaviors accompanying a toilet visit (i.e., going to the bathroom, removing clothes, excreting into the toilet, redressing, flushing, and washing hands; Lott & Kroeger, 2004; Taras & Matese, 1990). It should be noted that these two goals are the end result of successful toilet training, not prerequisite skills to initiate toilet training. The published history of toilet training individuals with mental retardation began in 1963 when Ellis offered a predominantly behavioral paradigm for continence acquisition in the developmentally disabled population, setting the stage for empirically validated studies to follow. The premises of toileting success were systematic presentation of response cues and contingent positive reinforcement (Cicero & Pfadt, 2002; Ellis, 1963). Early studies demonstrating this behavioral efficacy were conducted by Hundziak, Maurer, and Watson (1965), Kimbrell, Luckey, Barbuto, and Love (1967), Levine and Elliot (1970), and Van Wagenen, Meyerson, Kerr, and Mahoney (1969). In 1971, Azrin and Foxx furthered the literature with the development of the most cited and comprehensive toilet training protocol, the rapid toilet training (RTT) method (McCartney, 1990). However, despite the success of RTT and others as whole protocols, components of the procedures are often disaggregated

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and used as toilet training protocols in and of themselves (e.g., Cicero & Pfadt, 2002; Hyams et al., 1992; Jason, 1977; Williams & Sloop, 1978). Toileting skills acquisition will be critically discussed herein by individual methodology, and study and participant characteristics will follow subsequently. In addition, shortcomings of the toileting literature, and relatedly, directions for future research will be discussed. 1. Method A comprehensive literature review was conducted where the major psychology (e.g., PsychoInfo), educational (e.g., ERIC), and medical (e.g., Medline) search engines were queried for toileting articles using a combination of the following search words: ‘‘toileting, toilet, and (in)continence’’ and ‘‘autism, developmental disability and disorder, intellectual disability and mental retardation.’’ The years searched began with (Fall) 2008 and a lower year limit was not set. Sixty-eight citations were returned in the search. All returned documents were reviewed for pertinence and divided into two categories: theoretical or statement papers (including book chapters) and data-based studies (peer-reviewed journal submissions only). A total of 28 data-based papers were reviewed and included herein based on clear description of toileting procedure, participant description and inclusion of toileting data. All included data-based studies were then reviewed for training program components, participant characteristics, and study characteristics. Training components will be discussed in the order of which they are cited; that is, the most frequently used strategy will be reviewed first and all subsequent strategies discussed in descending order of citation frequency. The following behavioral components will be described and reviewed: graduated guidance and prompting, reinforcement based training, scheduled sittings, elimination schedules, overcorrection and punishment, hydration, manipulation of stimulus control, nighttime training for diurnal continence, and priming. Table 1 lists included studies and summarizes each study by component teaching strategies. 1.1. Graduated guidance Graduated guidance, inclusive of prompting, is the most frequently incorporated behavioral component for toilet training individuals with autism and other developmental disabilities (e.g., Azrin, Bugle, & O’Brien, 1971; Azrin & Foxx, 1971; LeBlanc, Carr, Crossett, Bennett, & Detweiler, 2005; Van Wagenen et al., 1969). Given the frequency of its use, it is obvious that prompting is inherent to teaching toileting and a highly successful program component. Azrin and Foxx’s (Azrin & Foxx, 1971; Foxx & Azrin, 1973) RTT is the most cited example of graduated guidance, a behavior-shaping technique designed specifically for toileting (Taras & Matese, 1990). Graduated guidance is a prompting hierarchy utilizing (forward or backward) behavioral chaining to achieve mastery of the necessary steps, or behaviors, to appropriate toileting. The least intrusive prompt is used to elicit the target behavior in a chain of behaviors (undressing, voiding, redressing, flushing, and washing hands). Prompting hierarchies are graduated in level of required assistance and follow accordingly: no prompt, obvious pause, point to the target (e.g., pants down), verbal prompt, increasing presence of physical prompts. The literature is rich with prompting components, including verbal, gestural, physical, and modeling. Most studies employ a combination of prompting hierarchies, least restrictive prompts, and rapid fading of prompts. However, Smith (1979) offered the precaution of abrupt removal of prompts associated with skills regression due to unstable toileting behaviors. 1.2. Reinforcement-based training Also inherent to toileting protocols is the implementation of reinforcement (e.g., Azrin & Foxx, 1971; Cicero & Pfadt, 2002). Most commonly used is positive reinforcement where a stimulus (such as a preferred edible or activity) is provided following a successful void. Positive reinforcement was present in the original Foxx and Azrin studies (Azrin & Foxx, 1971; Foxx & Azrin, 1973) and continues to take precedence in training protocols currently. More recently, negative reinforcement, in the form of response restriction, has entered toilet training protocols as a primary treatment component (Averink, Melein, & Duker, 2005; Duker, Averink, & Melein, 2001). In these studies, the participants

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Table 1 Critical components summary of reviewed empirical studies. Population

Ages

Treatment components

Setting

Length of training

Key findings

Ando (1977)

Autism; profound MR

5–10 yr

ES; GG; PR; P; ScS

Inpatient/residential

4 of 5 SS trained

Averink et al. (2005)

Moderate to severe MR

GG; PR; P; H; RR

Azrin and Foxx (1971)

Profound MR

0–4 yr, 5–10 yr, 11–18 yr, adults Adults

School/residential; outpatient clinic Residential

2–3 months, 4–10 months 0–1 month

Azrin et al. (1971)

Profound MR

Azrin et al. (1973) Bainbridge and Myles (1999) Barmann et al. (1981)

0–4 yr, 5–10 yr

ES; GG; H; P; PR; ScS; UA SS; H; P; PR; UA

School/residential

Profound MR Autism

Adults 0–4 yr

H; GG; P; PR; ScS; UA ScS; PV

Residential Home

0–1 month, 2–3 months, 4–10 months 0–1 month 0–1 month

Moderate to severe MR

0–4 yr, 5–10 yr

PR; P;

Home

0–1 month

Cicero and Pfadt (2002)

Autism; unspecified MR

0–4 yr, 5–10 yr

GG; PR; ScS; P; H

School

0–1 month

Dalrymple and Angrist (1988) Didden et al. (2001)

Autism; profound MR

11–18 yr

GG; PR; ScS; P; MSC

Inpatient/residential

Not reported

Angelman syndrome

5–10 yr, 11–18 yr

GG; H; P; PR; ScS

Residential; home

0–1 month

Duker et al. (2001)

Moderate to severe MR

GG; H; P; PR

Unclear

Hagopian et al. (1993)

Profound MR

0–4 yr, 5–10 yr, 11–18 yr 5–10 yr

GG; PR; ScS; MSC

Inpatient clinic

2–3 months

Jason (1977)

Severe to profound MR

5–10 yr, 11–18 yr

School

4–6 months

Keen et al. (2007)

Autism; unspecified MR

0–4 yr, 5–10 yr

Foxx and Azrin (FA) protocol v. ScS v. no treatment ES; GG; H; P; PR; PV; ScS

Home, school

2–3 months, 4–10 months

Lancioni (1980)

Deaf-blind profound MR

5–10 yr, 11–18 yr

GG; H; P; PR; UA

Not reported

0–1 month

Lancioni and Ceccarani (1981) LeBlanc et al. (2005)

Profound MR

5–10 yr, 11–18 yr

GG; H; ScS; P; PR; UA

Residential

Not reported

Autism; unspecified MR

0–4 yr

GG; PR; ScS; ES; P; H

Outpatient clinic

0–1 month

Luiselli (1994)

Unspecified MR; sensory deficits PDD-NOS; unspecified MR

5–10 yr

GG; PR; ScS; ES; MSC

School/residential

5–10 yr

GG; PR; ScS; MSC

School/residential

2–3 months 4–10 months 4–10 months

Luiselli (1996a)

0–1 month

48% of 40 SS trained; Defecation not targeted 100% of 9 SS trained 4 SS trained; double urine alarm primary treatment 12 SS nocturnal trained Increased initiations in 3-year-old boy Trained 3 irregular enuretic SS; maintained 3 SS trained; Reinforcement primary treatment Trained adolescent girl 6 SS trained; long term maintenance 7 of 8 SS trained; response restriction primary treatment Trained 9-year-old boy with water prompt 14 SS trained; comparison study; FA best method; mixed social validity 2 of 5 SS schedule trained, none of SS were independent continent 8 of 9 SS trained; disability modifications; collateral fecal continence Trained 9 SS; focus on initiation and effects of P Trained 3 children (2 boys, 1 girl) Trained 2 boys with deafness, 1 blind Trained a 7-year-old girl

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Citation

PDD-NOS; unspecified MR Neuro-typical; unspecified MR Autism

5–10 yr 0–4 yr, 5–10 yr

GG; PR; ScS; MSC UA; PR; H; P; GG

School/residential School

2–3 months Not reported

Trained 8-year-old boy 7 of 8 SS trained; group training

11–18 yr

P; PR

Residential

0–1 month

Post and Kirkpatrick (2004) Richmond (1983)

PDD-NOS

0–4 yr

GG; PR; ES

Home

0–1 month

Fecal trained SS; simple overcorrection Trained 3 1/2 year-old boy

Profound MR

0–4 yr

GG; ScS; P; PR

School

0–1 month

Saloviita (2000) Taylor et al. (1994)

Profound MR Autism severe MR

Adult 5–10 yr

School/residential Home

Not reported Not reported

Van Wagenen et al. (1969) Wilder et al. (1997)

Profound MR

0–4 yr, 5–10 yr

DB; UA GG; PR; ScS; ES; P; H; MSC GG; H; P; UA

Outpatient

0–1 month

Profound MR

Adult

GG; PR; ScS; ES; P; H

School/residential

2–3 months

4 SS reduced accidents; fading ScS primary treatment Trained 28-year-old woman Trained 10-year-old boy 9 SS trained; 5 maintained post 1 month Trained 21-year-old man

Note: Treatment component abbreviations are as follows in alphabetical order: DB = Dry Bed Nighttime training; ES = elimination schedule; GG = graduated guidance; H = hydration; MSC = manipulation of stimulus control; P = punishment; PR = positive reinforcement; PV = priming/video modeling; RR = response restriction; ScS = scheduled sitting; UA = urine alarm.

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Luiselli (1997) Mahoney, Van Wagenen, and Meyerson (1971) Matson (1977)

611

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were restricted from making any response incompatible with appropriate toileting behaviors when in the toilet vicinity. As with positive reinforcement, negative reinforcement strategies are demonstrating continence success with individuals of varying ages and functioning levels, while also allowing for successful training implementation without the use of aversives or punishment procedures. 1.3. Scheduled sittings Scheduled sitting is a procedure where individuals are placed on (or in front of depending on sex and training protocol) the toilet and then positively reinforced when voiding occurs. Scheduled sitting is also a frequent program component in successful training protocols (e.g., Bainbridge & Myles, 1999; LeBlanc et al., 2005; Luiselli, 1994, 1996a, 1997). Scheduled sitting serves a multitude of functions and is introduced at various intervention times in toilet training protocols. Scheduled sittings can be implemented at predetermined elimination-likely times based on the elimination schedule findings (e.g., Baumeister & Klosowski, 1965), or at regular, non-contingent time intervals, typically every 15–30 min (e.g., Wilder, Higbee, Williams, & Nachtwey, 1997). In both schedules, once voiding occurs the individual is reinforced and allowed to leave the toileting area. A comparison study conducted by Smith (1979) found that both were comparable in obtained results, but that regularly scheduled (not elimination schedule based) potting was easier to implement. However, further validation of findings has not been established, as comparative replication of Smith’s work has not been conducted to date. Wilson (1995) proposed a modified scheduled sitting protocol, referred to as a Generic Habit-Training Program, where sitting is initially scheduled only one time per day at what is considered an optimum time for urination likelihood (i.e., elimination-based schedule). Additional sittings are added once the child is voiding in the toilet shortly after reaching the bathroom. While the program shows preliminary success with the participant child, generalization of procedure to other children is called into question regarding a potentially low reinforcement rate via infrequent scheduled sitting rate. 1.4. Elimination schedules A number of training protocols begin with identifying an individual’s pattern of elimination, including frequency and timing of voids (Azrin et al., 1971; Langone, 1986; LeBlanc et al., 2005; Luiselli, 1994; Post & Kirkpatrick, 2004; Saloviita, 2000; Wilder et al., 1997). Detecting a stable pattern of voiding allows for further, and more individualized, treatment that capitalizes on the best-timed points to intervene. Establishing and recording the elimination schedule is typically conducted in one of two ways: mechanical or manual detection. Mechanical devices have been developed and utilized in treatment protocols that register when moisture is emitted and sound an alarm (e.g., Azrin et al., 1971). A small sensor is placed in the individual’s undergarments and when it detects moisture (urine), it rings a bell. Manual detection includes recordings conducted via wet/ dry checks where the individual’s undergarments/clothing are periodically checked for wet or soil and recorded accordingly (Langone, 1986). That is, at set or random times, someone visually scans or physically feels the individual’s undergarments to determine if soil/wet has occurred and records it as a void occurrence. Both recording methods could be considered invasive for the individual, but are currently the best practice for obtaining reliable and valid data for voiding schedules. 1.5. Punishment procedures Reflective of the current philosophical zeitgeist, research and practice in mental retardation and developmental disability populations focus on positive behavioral (support) interventions. As a result, overcorrection and punishments procedures have fallen out of use, which is evident in the more recent literature on toileting (e.g., Cicero & Pfadt, 2002). Positive practice and restitution, however, have a defined place in toileting history, as well as demonstrated efficacy in rapid teaching of continence skills. The most common aversive procedure used in toilet training is restitution overcorrection, a

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procedure where individuals are required to return the environment to its previous state (see Lott & Kroeger, 2004). Typically, after an accident or inappropriate voiding occurs, individuals are required to engage in environmental restitution where they clean themselves, soiled clothing, and any soiled objects (e.g., floor, furniture). Additionally, individuals may be walked from the spot of the accident to the toilet a specific number of times after the accident occurs (i.e., overcorrection or positive practice). While positive support interventions are currently preferred to aversive procedures, restitution overcorrection has constructive qualities, including rapid acquisition of toileting skills (Azrin & Foxx, 1971), high (residential) staff compliance with protocol (Matson, 1977), and replacement of maladaptive behaviors with adaptive behaviors (Freeman & Pribble, 1974). Cicero and Pfadt (2002) cite the paradox in toileting protocols implementing overcorrection procedures, such as Azrin and Foxx’s (1971), that have high success rates but are only infrequently referenced in current literature. They state that current policies regarding mental retardation and developmental disability populations are likely factors (i.e., support for positive behavioral interventions), and they offer a positive reinforcement-based training protocol. However, it should be noted that Cicero and Pfadt’s protocol contains verbal reprimands, which is considered a punishment procedure categorically and topographically. This is not an uncommon occurrence for current literature where verbal reprimands are used as corrective feedback (e.g., Cicero & Pfadt, 2002; Wilder et al., 1997), but not necessarily identified as a punishment procedure. In addition, studies that claim to avoid use of punishment subsequently include the use of positive practice (i.e., Averink et al., 2005; Duker et al., 2001). Positive practice is indeed a punishment procedure in that through application it intends to decrease the likelihood of future toileting accidents. Hence, a number of successful training protocols technically include the use of punishment procedures (Averink et al., 2005; Azrin & Foxx, 1971; Cicero & Pfadt, 2002; Dalrymple & Angrist, 1988; Duker et al., 2001; Freeman & Pribble, 1974; Foxx & Azrin, 1973; LeBlanc et al., 2005; Matson, 1977; Saloviita, 2000; Taylor, Cipani, & Clardy, 1994; Wilder et al., 1997), and the current empirical trend appears to use ‘‘less-aversive’’ positive punishment procedures than those of the past (i.e., using verbal reprimands instead of overcorrection). 1.6. Hydration To ensure success during continence training (especially protocols involving scheduled sitting, whether it be regular- or elimination-timed) hydration procedures are often used in conjunction (e.g., Azrin & Foxx, 1971; Cicero & Pfadt, 2002; Taylor et al., 1994; Wilder et al., 1997). Hydration involves providing individuals with liquids to consume, both in large volume (e.g., Azrin & Foxx, 1971; Richmond, 1983) and high preference (e.g., Wilson, 1995). Providing free access to liquids and promoting hydration prior to the scheduled sitting increases the likelihood of urinary voiding, as well as contingent reinforcement for elimination. Data suggest hydration is effective in training protocols, especially those involving scheduled sitting. However, there are associated risks (Lott & Kroeger, 2004; see Thompson & Hanson, 1983). Excessive water intake, especially when ingested volume is disproportionate to body weight, can lead to hyponatremia, an imbalance of electrolytes. Individuals with a positive history of seizure disorders, hydrocephaly, spinal cord injury, and/or current pharmacological regimen with side effects of urinary retention should not be placed on a training program involving hydration. 1.7. Manipulation of stimulus control The abovementioned toileting component interventions are highly effective in training individuals with autism and mental retardation. There are, however, individuals within the population who are resistant to training under the traditional protocols. More recent literature focuses on these individuals and the use of systematic problem solving to achieve the goal of successful toilet training. When designing these interventions, the core basics of the established protocols (e.g., graduated guidance, scheduled sitting, reinforcement for appropriate voiding) are preserved and augmented with additional or varied training components, namely, manipulation of the discriminative stimulus (Dalrymple & Angrist, 1988; Hagopian, Fisher, Piazza, & Wierzbicki, 1993; Luiselli, 1994, 1996a, 1997;

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Taylor et al., 1994). Common to these studies is the initial use of traditional toileting protocols, such as Azrix and Foxx’s (Azrin & Foxx, 1971; Foxx & Azrin, 1973), followed by the individuals’ failure to become continent. All referenced studies maintained use of the established training protocol and then manipulated stimulus control to achieve appropriate voiding in the toilet. Transferring stimulus control involves investigating the individuals’ tendencies to void outside the toilet and to then take the findings and gradually change the controlling antecedents from ‘‘other’’ to the toilet. The ‘‘other’’ controlling antecedents included submersion into water (i.e., bath time; Hagopian et al., 1993) clothing and undergarments (Taylor et al., 1994), diapers (Luiselli, 1996a,b, 1997), and the act of cleaning a fecally smeared environment (rather a consequent controlling stimulus; Dalrymple & Angrist, 1988). All of the studies successfully transferred the stimulus control from these antecedents to the toilet to achieve appropriate toileting skills acquisition. 1.8. Nighttime training for diurnal continence Saloviita (2000) reported a case of spontaneous generalization from nocturnal to diurnal training. In his case, nocturnal enuresis was the target behavior for an adult woman with profound mental retardation. Azrin, Sneed, and Foxx (1973) present a nighttime training protocol for toileting in persons with mental retardation, which was used in the current study. While the protocol was ineffective in treating the nocturnal enuresis symptoms in the Saloviita study, the training procedures appeared to have a generalized effect where the woman became continent during the daytime after the nighttime procedures were implemented. It was noted that diurnal enuresis was not targeted during the nocturnal training time period. Additionally, this was not a controlled study and therefore, true treatment effects cannot be determined. 1.9. Priming and video modeling A case of using the predominantly associated cognitive-behavioral method of priming (Bainbridge & Myles, 1999) was also included in the review based upon pertinence and scientific presentation. Priming is the intervention whereby information is provided to a subject in order to prepare the subject for the performance of an activity. Hence, the information is provided before the behavior is completed in order to increase the likelihood that the behavior will be completed successfully. In this study, the priming material used was a toilet training video. The authors note that this procedure was implemented to introduce toilet training to a child with autism and the study found positive results. The empirical question remains as to whether this is a necessary step in effective toilet training. A later study reinvestigated the use of video modeling as an effective tool in teaching toilet training (Keen, Brannigan, & Cuskelly, 2007). The children demonstrated faster acquisition (than control participants) when video modeling is used. However, these results are tentative in that none of the trained children were independently continent at the conclusion of the study or during follow-up. Both studies focused on children with autism and used videos in order capitalize on the associated correlate of strength in learning via visual presentation. While further study is warranted to determine if priming is a critical component to successful continence in the autism spectrum populations, preliminary data are supporting the use of video medium in teaching toileting. 2. Discussion A number of training protocols have been well established as successful for achieving continence in individuals with autism spectrum disorders and developmental disabilities. Almost all of these protocols are derivatives of the RTT method pioneered by Foxx and Azrin (Azrin & Foxx, 1971; Foxx & Azrin, 1973), with the exception of the earlier training programs that still contain a number of behavioral strategies. Still, it is important to investigate both the participant and study/programmatic characteristics of the analytical studies to determine likelihood of success when generalizing findings to the training of others with similar diagnoses, as well as to note shortcomings with the current state of the literature.

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2.1. Participant characteristics In reviewing the literature, two population characteristics are routinely addressed: age and functioning level. The early literature cites individuals with an IQ above 20 and chronologically younger as more likely to achieve successful toileting (Lohmann et al., 1967). The majority of recent studies (1990s to current) focus on children in the prepubescent age range (Averink et al., 2005; Bainbridge & Myles, 1999; Cicero & Pfadt, 2002; Duker et al., 2001; Keen et al., 2007; LeBlanc et al., 2005; Post & Kirkpatrick, 2004; Luiselli, 1994, 1996a, 1997; Taylor et al., 1994), but there are also a number of validated studies for adolescents and adults (Averink et al., 2005; Dalrymple & Angrist, 1988; Wilder et al., 1997). This focus on younger age also appears to keep with the current trend of focus on early intervention in developmental disabilities and particularly in the field of autism. The shift of training focus from older to younger target ages should have longitudinal positive impact on quality of life factors for the affected individuals. Information on functioning level of study participants is less widely available. While a number of studies state the participant functioning level, it is often not explained how the functioning level was determined. Moreover, the majority of studies (especially more current literature) provide participant descriptions such as language ability (e.g., one-word phrases, nonverbal), skill abilities (e.g., imitation, presence of preacademic skills), and history of toileting behaviors (e.g., previous training attempts, diapers worn, pull pants up and down) rather than citing actual standardized classification of abilities. Nonetheless, continence training has been successful with individuals with profound mental retardation (Hagopian et al., 1993; Wilder et al., 1997), severe mental retardation (Averink et al., 2005; Dalrymple & Angrist, 1988; Taylor et al., 1994), and moderate mental retardation (Averink et al., 2005). Studies employing individuals of mild mental retardation were not reported in the literature. However, it is likely that a number of studies did train such individuals given the included participant descriptions (e.g., Bainbridge & Myles, 1999; Cicero & Pfadt, 2002; Post & Kirkpatrick, 2004). It could be conclude though that generalization of training procedures (to others) may be limited in that true participant characteristics are unable to be ascertained. 2.2. Program characteristics Study and program characteristics are also important factors in review. Most report total continence training time and length of follow-up and study setting, followed less frequently by use of adjunctive parent training and administration of social validity measures. It appears that the studies employing original or first-time training programs are shortest in duration for training time (e.g., Cicero & Pfadt, 2002; LeBlanc et al., 2005), while protocols that involve manipulation of stimulus control following unsuccessful previous toileting attempts are of the longest training times (e.g., Hagopian et al., 1993; Luiselli, 1994, 1996a). The following studies cited completed training times in one month or less (Bainbridge & Myles, 1999; Cicero & Pfadt, 2002; LeBlanc et al., 2005; Post & Kirkpatrick, 2004), two to three months (Hagopian et al., 1993; Luiselli, 1994, 1997; Wilder et al., 1997), and four to ten months (Keen et al., 2007; Luiselli, 1994, 1996a). In addition, most studies report follow-up measures of maintenance of acquired skills (Averink et al., 2005; Cicero & Pfadt, 2002; Duker et al., 2001; LeBlanc et al., 2005; Luiselli, 1994, 1996a, 1997; Post & Kirkpatrick, 2004; Taylor et al., 1994; Wilder et al., 1997). Maintenance of toileting acquisition would appear to become an automatic behavior in that the associated affects, that of remaining dry and unsoiled, maintained hygiene, decreased social stigmatization, are inherently reinforcing. Interestingly, Hyams et al. (1992) found that independent initiation of toileting routines was the least likely skill to maintain in a 10-year follow-up. It should be noted that this seems to be a failure in effective implementation of prompt fading as opposed to bladder control in the participants. Additional study into the issue is warranted though in order to ascertain if indeed the individuals were unable to maintain independent initiations or if instead the caregivers became overly prompt-likely in order to avoid incontinent accidents. Regardless, long-term follow-up information should be made available and reported in order to determinedly state that toilet training is a behavior that maintains for the remainder of the lifespan.

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Study setting is routinely reported and successful protocols exist for a variety of settings. Studies more recently are also demonstrating success in training across environments simultaneously (e.g., Cicero & Pfadt, 2002; Duker et al., 2001; LeBlanc et al., 2005). Settings of interest and success include training in the home (e.g., Bainbridge & Myles, 1999; Wilder et al., 1997), clinic or outpatient settings (e.g., Averink et al., 2005), and school or residential settings (e.g., Cicero & Pfadt, 2002; Luiselli, 1994, 1996a, 1997). The noteworthy empirical shift is away from institutional settings and toward outpatient clinics. This again appears to reflect the current trend of accessing populations as most clinical services now focus on the early intervention and school-aged populations in typical outpatient clinic settings. Less researched are the use of parent training and measurement of social validity. Studies that mention parent training are innovative in their pursuit of soliciting parents to participate in the training of their children. However, these training models are typically a co-treater model as opposed to a primary parent training model (Cicero & Pfadt, 2002; Keen et al., 2007; LeBlanc et al., 2005; Taylor et al., 1994). In addition, only one study reported measuring social validity (LeBlanc et al., 2005). The paucity of social validity reports could be due to two factors: (1) parents and caregivers are inherently satisfied with successful training programs in that the ultimate end result is continence and the significance of continence has previously been discussed and (2) focus on social validity as a routine measure for intervention protocols has only recently received more popular coverage in research protocols. Also of clinical research interest are behaviors that are not required of successful continence training, but are instead inherent to maintenance of toileting success. Such behaviors include communication (of the need to toilet), self-initiation (for using the toilet), and bowel movement training. These have received more recent attention in the literature, but are not routinely included in protocol description. Regarding communication training and self-initiation training, studies addressing these behaviors often mention them within the context of the protocol description (i.e., training for behaviors is blended into the continence training protocol) as opposed to systematic training for each behavior. While the studies do not note such issues, it does beg the question of how to train for the behaviors in the event that the individuals do not learn through the protocol to communicate or self-initiate while becoming continent. Conversely, Langone and Burton (1987) note that teaching communication to use the bathroom is often the final step in training, but they do not describe or attempt to provide data or protocol for how to accomplish the act of communicating. Nonetheless, it is noteworthy that such studies are beginning to focus on the associated behaviors of communication (Cicero & Pfadt, 2002; LeBlanc et al., 2005; Luiselli, 1994; Post & Kirkpatrick, 2004) and self-initiation (Bainbridge & Myles, 1999; Cicero & Pfadt, 2002; LeBlanc et al., 2005; Luiselli, 1994; Post & Kirkpatrick, 2004). Additionally of low frequency report is bowel movement training. Thus far, studies overtly addressing fecal training are primarily focused on the issue of encopresis proper, as opposed to general toilet training (Dalrymple & Angrist, 1988; Luiselli, 1996b). That is, the main focus of the studies is on bowel movement training as opposed to a comprehensive toilet training program. It should be noted that these studies also fall within the manipulation of stimulus control classification, which indicates that traditional toileting attempts failed. This leaves the issue of whether other referenced studies that do not mention training for bowel movements omit the reference to fecal training because it occurs as a natural result of continent toilet training, or it is not addressed within the training protocol and therefore the participants are not fecally trained as a result. 2.3. Future directions A number of toileting protocols exist within the literature, many of them successful and allegedly capable of generalization to a wide variety of individuals within the autism and developmental disability population. While most of the programs are modified versions of the toileting protocol presented by Foxx and Azrin, studies focus on abbreviating the protocols while also reducing steps, components, and professional training involvement. That is, the trend is to make less complicated the toileting protocols previously originated. Future areas of toileting literature should focus on the following: (1) collateral behaviors pivotal to successful toileting training, including communication,

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self-initiation and bowel movement training; (2) exploration of age and functioning limits (i.e., how young to train and how cognitively low is trainable); and (3) review of necessary prerequisite skills suggested present before initiating toilet training. Such investigations will serve to continue the body of literature surrounding toilet training, while at the same time providing improved quality of life for individuals with autism spectrum disorders and mental retardation. References Ando, H. (1977). Training autistic children to urinate in the toilet through operant conditioning. Journal of Autism and Childhood Schizophrenia, 7, 151–163. Averink, M., Melein, L., & Duker, P. C. (2005). Establishing diurnal bladder control with the response restriction method: Extended study on its effectiveness. Research in Developmental Disabilities, 26, 143–151. Azrin, N. H., Bugle, C., & O’Brien, F. (1971). Behavioral engineering: Two apparatuses for toilet training retarded children. 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