Toilet Training

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NYBAPS offers empirically-based toilet training for children and adolescents ages 3-15 years. Children with special needs, as well as typically-developing children, sometimes need expert assistance in learning how to use the toilet appropriately. Learning this skill doesn’t get easier with the child’s age, because longer one delays training, the longer it will take to achieve continence, and longer the child’s dependence upon caregivers. Moreover, longer time will be needed to learn new skills for the older children due to past history of failures. Additionally, lack of toileting skill can lead to problems related to school entry and reaching milestones such as going to camp or having sleepovers with friends.

Enuresis (307.6) is the persistent inability to control urination that is not consistent with one’s development age. 

• Repeated voiding of urine into bed or clothes (whether involuntary or intentional)
• Behavior must be clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
• Chronological age is at least 5 years of age (or equivalent developmental level).
• The behavior is not due exclusively to the direct physiological effect of a substance (such as a diuretic, antipsychotic or SSRI) or to incontinence uncured as a result of polyuria or during loss of consciousness.
• These symptoms must not be due to a general medical condition.
• Specific types: nocturnal (night-time) only, diurnal (daytime) only, nocturnal and diurnal

​Encopresis (307.7) is a repeated passage of feces into inappropriate places, such as on clothing or the floor. While typically the passage is involuntary in nature, it can be intentional in some cases. If the passage is involuntary, it is often related to constipation, impaction and retention with a resultant overflow. Some children also engage in secretive behavior related to the act of having a bowel movement. 
A repeated passage of feces into inappropriate places, e.g., clothing or floor. This can be either intentional or involuntary   
At least one such event must occur every month for at least 3 months 
Chronological age must be at least 4 years 
The behavior is not attributable to the effects of a substance (e.g., laxative, or another medical condition, with the exception of a mechanism involving constipation)
Specific types: With (or without) constipation and overflow incontinence
The most effective treatment for is behavior-analytic therapy. A bed-wetting alarm may be used for enuresis, which has a moisture sensor to alert the child of the start of urination. In some cases, a combination of behavior-analytic therapy with pharmacotherapy may be used.  

​Initial Evaluation
The process begins with a careful review of your child’s records to determine if there is a need to refer you for additional medical evaluations. A primary goal of our services is to determine if additional medical assessments need to be completed in order to ensure the health and safety of your child. We may refer you to a physician to rule out medical conditions and/or to clean out the gastrointestinal tract if indicated.

Assessment
Once possible medical issues are resolved or addressed, you will be asked to give us detailed information on the process of their child’s behavior around toileting. A detailed interview is conducted that focuses on both day-time and night-time routines and behavior. This will also require recording accurate information about toilet behavior for 7-14 days in order for a detailed analysis of patterns and routine.

Treatment
Once sufficient information is collected, and the team will present a detailed plan for toilet training your child. Our therapist work individually with families during a 7-hour, intensive program that focuses on hands-on parent training. Parent education and instruction in various techniques may be a part of the plan developed jointly by the parents and our team.
The training is then individualized for each child and his/her family. Our intensive behavioral program based on the methods developed by Azrin and Foxx (1974), which include:

• Reviewing past toileting history (success & failure)    
• Increasing fluid and fiber intake    
• Teaching proper toileting habits 
• Scheduling toilet sitting and pants checks 
• Reinforcing appropriate toileting behavior  
• Positive practice  
• Cleaning the soiled area, bathing, and washing of the clothes after the accident
• Parent training
• Gradually fading treatment once the child is continent

Azrin and Foxx’s toilet training technique for typically-developing children 

• The parent must be fully ready and prepared for training.   
• Devote a full day (5-8 continuous hours) to training. 
• Set up the bathroom area with a potty chair, a doll with a removable diaper (a doll that can drink and “urinate” is preferred)
• Gather necessary items: preferred snacks, drinks, sticker chart, wipes, foot stool, data sheet.  
• Eliminate all distractions, including TV. The siblings and other family members should not be in the vicinity during training. 
• Dress your child in loose-fitting shorts (and no other layers of clothing) 
• Absolutely no diapers during training.
• Encourage your child to drink plenty of fluids, to encourage frequent urination.

Phase I   

• Use the doll to demonstrate the toileting routine. 
• Give the doll a drink. 
• Tell your child that the doll has to pee. 
• Guide your child through the process of removing the doll’s diaper, sitting the doll on the potty, waiting for the doll to pee, and praising and rewarding the doll for elimination. 
• Continue with the potty “script,” like flushing and washing hands. 
• Check the doll’s diaper. 
• If the diaper is dry, the doll gets another reward. 
• If it’s wet, explain that big kids don’t wet their pants. Overcorrect for this mistake by guiding the doll through a quick practice version of the potty routine. 
• Encourage your child to guide the doll himself. Repeat the doll demonstration until your child understands the steps. 

Phase II 
Your child (rather than the doll) will now go through the steps from Phase I.  
If your child correctly eliminates, he/she is reinforced. 
If your child has accidents, he/she performs practice drills. 

References                          

1. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: APA.
2. Azrin, N. H., & Foxx, R. M. (1974). A rapid method of toilet training the institutionalized retarded. Journal of Applied Behavior Analysis, 4, 89-99.
3. Azrin, N. H., & Foxx, R. M. (1974). Toilet training in less than a day. New York: Pocket Books.
4. U.S. National Library of Medicine, MedlinePlus (2012). Encoporesis.