Toilet Training Nonambulatory Students Cindy Myers Comprehensive Behavior

Toilet Training Non-ambulatory Students Cindy Myers Comprehensive Behavior Specialist cindy. myers@slc. k 12. ut. us

Who Can Be Trained? • Students with a variety of physical disabilities including cerebral palsy • Students who use wheelchairs for mobility • Students who are verbal or non-verbal

Cautions & Exclusions • Students on Neurogenic bowel & bladder programs • Check with doctor before considering students with spinal cord injuries – Paraplegia, quadriplegia, spina bifida

Determining Readiness • Maintains dry diaper for ½ hour or more • Age over 4 ½ • Displays no fear of being in, or around the bathroom or toilet • Communication system in place

Determining Readiness cont. • Consultation with physical therapist: – Positioning – Transition to the toilet – Weight bearing – Adaptive equipment issues – Issues specific to the student • Address issues before beginning!

General Philosophy • Track the child’s natural schedule of elimination • “Predict” the time episodes of elimination are likely and toilet the child around those times • Use of positive reinforcement • No punishment component • Training occurs in the classroom and is then generalized or trained in the home • Minimizes stress to families & caregivers for training responsibility

General Philosophy cont. • Uses consistent “signals” or communication mands to develop relationships between action & consequences • Uses routines and environmental SD to elicit appropriate toileting response

Making “toileting” a Routine • Task analyze the steps involved for that student to “toilet” • Develop a routine or procedures to be followed in a consistent manner each time the student is toileted • Standardize presentation of environmental or artificial stimuli that will be used as SD for steps in the toileting chain.

Communication System • Evaluate the communication needs of the student – Consult with a SLP if appropriate • Make a list of vocabulary, mands, or signals that are associated with all tasks around toileting – – – Moving from work area to toilet Lifting, carrying Undressing/dressing Urination, defecation “finished” Hygiene

Getting Started • Review and understand each procedure in the training protocol • Schedule a meeting to present your plan to the student’s parents • Provide a copy of the protocol for parents to keep • Ask parents to contact the student’s physician regarding medical feasibility of toilet training • Modifying the student’s IEP to include a toilet training goal

Getting Started cont. • • Obtain written permission Agree on a starting and review date Discuss terminology that will be used Agree on signals & communication mands that will be used (if applicable) • Provide parents with a materials list of items you want them to supply

Vocabulary List for Toileting Urination: _________________ Defecation: _________________ Toilet: ___________________ Body Parts: _________________ Other: ___________________ Communication Mands/Cues Lifting: ___________________ Up/down: __________________ Toilet: ______________________________________ Other: ___________________

Permission for Toilet Training I give permission for my child, ___________ to participate in the schedule based toilet training procedures described in this document. I know of no medical or physical reason that would preclude toilet training for my child. I have discussed toilet training with my physician. ___________________ parent signature ________ date ____________________ teacher signature date ____________________ principal/administrator signature ____________________ physician signature (if applicable) date _________ date

Meet With Physical Therapist Discuss Equipment Needs • Consider – Potty chair, commode, adaptations to regular toilet – Seat/safety belts – Positioning – Head, truck support – Wall bars – Transition to/from toilet – Issues specific to the student • Seizures, spasticity, etc.

Materials List (May change for individual student) • Diapers, wipes, disposable gloves • Highly desired reinforcer to be used only to R+ appropriate toileting • Items to entertain student as s/he sits on the toilet • Items recommended by the physical therapist unique to the student (neck brace, foam pads, etc. ) • Data sheets, clipboard, pen or pencil • Timer

Data Sheets (There are two data sheets) • Baseline Data – Data Sheet 1 • Collect baseline data and develop a high probability toileting schedule – Mark data at ½ hour intervals – Indicate if diaper is (D) Dry, (W) Wet, or (S) Soiled • Look for: – Trends or patterns of dry diapers – Trends or patterns in time or urination/defecation

Data Sheets (cont) • Program Data • Data Sheet 2 – Determine schedule of high probability times that elimination is likely to occur • Indicate if diaper is (D) Dry, (W) Wet, or (S) Soiled when taken to the toilet • Indicate if student (U) Urinated, (BM) Bowel Movement, or (O) No Production while on the toilet – Review data to confirm accuracy of high probability schedule

The Training • Place student on toilet at times indicated by the high probability schedule • Use consistent routines and communication mands associated with toileting • Use techniques for transfer as identified by the physical therapist

If Success Occurs • Reinforce student with social praise paired with the highly desired reinforcer • Immediately remove student form toilet (using identified communication mands) and put in a clean diaper • Return student to regular programming • Mark data sheet • Place student on toilet at the next “high probability” time

If No Elimination Occurs: • Leave student on the toilet for 15 minutes • Remove student from the toilet after 15 minutes (using appropriate communication mands) and put in a clean diaper • Return student to regular class routine • Wait ½ hour and place student on the toilet again (using appropriate communication mands) for 15 minutes of toilet sitting • Repeat ½ hour intervals until elimination occurs (either on the toilet or in the diaper) • Return to the original “high probability” schedule

For Wet or Soiled Diapers: • Give informational feedback (use designated mands if appropriate) “Your pants are wet, you need to use the toilet” • Place student on the toilet for 15 minutes of toilet sitting • If elimination occurs on the toilet, treat as a toilet success and R+ • Remove student from the toilet after elimination or 15 minutes, whichever happens first

Wetting & Soiling cont. • Place in a clean diaper using communication mands and routines • Return student to regular programming and mark data sheet • Continue with original “high probability” toileting schedule

Generalizing to Home • When the student is successfully urinating on the toilet >75%, generalization to the home should occur • Meet with parents to discuss progress at school • Discuss what adaptations would be necessary for toileting to occur at home • Help parents locate resources, equipment for use at home

Generalizing to Home • Provide parents with a data sheet to track ½ hour intervals of wet/dry at home • Meet again and review baseline data and establish a “high probability” schedule • To assist parents in tracking wet/dry – May have to check at hourly intervals – May have to check at ½ hour intervals for a predetermined period of time (2 hours)

Toilet Training at Home • Parents toilet student based on the high probability schedule • Parents place student on toilet for 15 minutes of toilet sitting (using appropriate communication mands associated with the toileting routine) • Parents R+ successful elimination on the toilet with social R+ paired with highly desired R+ • Place student in clean diaper and return to normal activities

Training at Home cont. • If accident occurs, give informational feedback. Clean student then place on toilet for 15 minutes of toilet sitting (using communication mands). – If elimination occurs while toilet sitting, treat as a success an R+ • Place student in clean diaper, return to regular activity (using communication mands), and continue with high probability schedule • Use highly desired reinforcer for successful toileting only • Students should continue to wear diaper between toilet trips and at night until toilet use is well established