~ i Pergamon

PII:
J. BehaL #her. & Exp. Ps~'chiat. Vol. 28, No. 3, pp. 241-246, 1997

S0005-7916(97)00022-0
1997 Elsevier Science Ltd. All rights reserved
Printed in Great Britain
I~J5-7916/97 $17.0(~+0.00

A SIMPLIFIED M E T H O D OF TOILET T R A I N I N G A D U L T S
IN R E S I D E N T I A L S E T T I N G S

DAVID A. WILDER,* THOMAS S. HIGBEE,* W. LARRY WILLIAMS* and

ANNE NACHTWEYt
*University of Nevada, Reno, U.S.A.
tSierra Regional Center, Sparks, U.S.A.

Summary - - A simplified version of Azrin and Foxx's method of toilet training was
evaluated in an adult with profound mental retardation. An ABAB reversal design was
used to evaluate intervention effects. Results indicated that the procedure was effective in
reducing toileting accidents and in increasing appropriate urinations. Additionally,
continence was maintained at a 3 monlh follow-up evaluation. ~'~ 1997 Elsevier Science
Ltd

There are a variety of procedures that have been developed for the treatment of urinary
incontinence in individuals with developmental disabilities (e.g., Azrin & Foxx, 1971).
However, despite the well established effectiveness of these toilet training procedures, there are
a number of problems inherent in their use. First, the time and effort that is required of many of
these procedures (including the Azrin and Foxx method) is often too much for caregivers in
institutional settings to provide (Sadler & Merkert, 1977). Additionally, the age of the person
being trained is often an important variable. In a retrospective analysis of popular toilet training
procedures for individuals with developmental disabilities, Smith and Smith (1977) reported
that people over the age of 20 often have great difficulty being trained with the Azrin and Foxx
method.
Taken together, these problems concerning the toilet training of individuals with disabilities
call for new, simplified methods of treating incontinence. Although there have been simplified
procedures developed for toilet training children with developmental disabilities (e.g., Taylor,
Cipani, & Clardy, 1994) there is a dearth of research proposing easy, effective toilet training
procedures for adults. The purpose of the present study was to assess the efficacy of a modified
toilet training procedure in an adult with a developmental disability.

Method

Participant and Setting

John was a 21 year old male with a diagnosis of profound mental retardation. All previous
attempts to toilet train John had failed. A physician reported that due to complications resulting

Requests for reprints should be addressed to David A. Wilder. University of Nevada, Department of Psychology-296.
Reno, NV 89557. E-mail: wilder@scs.unr.edu
241
242 DAVID A. WILDER et al.
from seizure activity, toilet training John would be impossible. John resided at a group home
which was on the campus of a residential facility for disabled individuals. He attended a day
training program (workshop) emphasizing prevocational skills training 5 days per week,
6 hours per day. The toilet training program was implemented at both the workshop and the
residence. Although only data from the workshop setting are presented, data from the residence
were similar.

Data Collection

John's wetness or dryness (and whether or not he urinated in the toilet) was established
during "toileting times" which involved a staff member escorting John to the restroom,
checking his undergarments, and prompting him to void. These checks occurred every
30 minutes throughout John's waking hours. A damp or wet undergarment was scored as an
accident. During treatment phases, accidents in between "toileting times" were also recorded.
Interobserver agreement data (IOA) was collected on approximately 50% of follow up
observations. IOA, which was calculated by dividing the number of agreements by the number
of agreements plus disagreements and multiplying by 100%, averaged 100%.

Experimental Design And Procedure

Two conditions, baseline and treatment, were alternated in an ABAB design. Follow-up data
were collected over a 3 day period 3 months later.

Baseline. In both baseline conditions, no aspect of the toilet training procedure was
implemented. Data on accidents and appropriate urinations were gathered during the scheduled
"toileting times" (see above).

Treatment. In both treatment phases, John was provided with increased amounts of liquids
throughout the day and was taken to the restroom every 30 minutes (during toileting times). An
alarm system (a modified Fisher Price Dry Night Training Alarm @) was attached to the inside
of the toilet bowl. Any trace of urine would immediately activate the alarm. If the toilet bowl
alarm was activated, John received social praise and edible rewards.
Throughout the day, a pants alarm (a Fisher Price Dry Night Training Alarm @) was attached
to John's undergarments. If the moisture sensitive system detected liquid, the pant alarm would
sound. When the pant alarm was activated, John was immediately taken to a private area and
mildly but firmly reprimanded (e.g., "No, don't wet your pants!"). John was then taken to the
restroom and his pants were changed by staff members. No eye contact or verbal interaction
between John and staff members occurred during the time when John was being changed and
during the 10 minutes immediately following the changing of John's clothes. After the second
treatment phase, both alarm procedures were discontinued.

Results and Discussion

The number of appropriate urinations per day during the baseline and treatment phases is
presented in Figure 1. During the first baseline condition, appropriate urinating occurred at a
mean of less than one time per day (0.92; range 0 to 3). During the first treatment phase,
 A Simplified Method of Toilet Training Adults 243

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 A Simplified Method of Toilet Training Adults 245
appropriate voiding occurred at a mean of 3.8 times per day (range 0 to 10). During the second
baseline phase, appropriate voiding occurred at a mean of 3.6 times per day (range 2 to 6).
Finally, during the second treatment phase, appropriate voiding occurred at a mean of 5.2 times
per day (range 3 to 7). At follow-up observations, appropriate voiding occurred at a mean of 6.3
times per day (range 6 to 7).
The number of accidents per day during the baseline and treatment phases is presented in
Figure 2. During the first baseline phase, accidents occurred at a mean of 3.0 per day (range 1 to
5). During the first treatment phase, accidents occurred at a mean of 1 per day (range 0 to 6).
During the second baseline phase, accidents occurred at a mean of 1 per day (range 0 to 2).
During the second treatment phase, accidents occurred at a mean of 0.19 per day (range 0 to 1).
At follow-up, accidents occurred at a mean of 0 per day.
A simplified treatment package based on the Azrin and Foxx (1971) toilet training
procedure was effective in increasing appropriate urination and decreasing inappropriate
urination in an adult with profound mental retardation, Further analysis demonstrated that
the effects of the package were maintained at a 3 month follow-up observation. Although
toilet training programs have received a great deal of attention in the research literature,
the present procedure differs from other procedures in four important ways. First, the
procedure was relatively easy to undertake. The participant was successfully trained in
the context of his everyday activities. Second, the procedure was implemented in both
the residence and the workshop environments, thus increasing the likelihood of effect
generalization across environments. Other toilet training procedures (Azrin & Foxx,
1971; Taylor et al., 1994) are typically conducted only at the participant's place of
residence. Third, the procedure involved only minimal use of negative consequences for
inappropriate urination. Other procedures (Azrin & Foxx, 1971) employ overcorrection
and relatively long (one hour) periods of time out from reinforcement. Finally, and perhaps
most importantly, this procedure was shown to be effective with an adult. The literature
(Smith & Smith, 1977) suggests that successfully toilet training adults with disabilities
may be much more difficult than training children with developmental disabilities.
One limitation of the present study is that during baseline phases, it is possible that more than
one toileting accident occurred between the 30 minute checking times. Thus, data on toileting
accidents during these phases may be underrepresented. However, given the relatively short
periods of time between checks (30 minutes) it is unlikely that more than one accident
occurred. Additionally, staff were often able to visually determine whether or not an accident
had occurred, thus decreasing the likelihood that two or more accidents went unnoticed within a
30 minute time period.
The results of this study suggest that, compared to other programs, the use of this procedure
may considerably reduce the time and effort required of staff when conducting toilet training
programs with adults with profound mental retardation. Further research is needed to determine
which toilet training programs are most effective for different populations of adults with
developmental disabilities.

Acknowledgement

The authors are grateful to James E. Cart for his helpful commentson this manuscript.
246 D A V I D A. W I L D E R et al.

References

Azrin, N., & Foxx, R. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied
Behavior Analysis, 4, 89-99.
Sadler, W., & Merkert, F. (1977). Evaluating the Foxx and Azrin toilet training procedure for retarded children in a day
training center. Behavior Therapy, 8, 499-500.
Smith, P. S., & Smith, L. J. (1977). Chronological age and social age as factors in intensive daytime toilet training of
institutionalized mentally retarded individuals. Journal of Behavior Therapy and Experimental Psychiatry, 8, 269-
273.
Taylor, S., Cipani, E., & Clardy, A. (1994). A stimulus control technique for improving the efficacy of an established
toilet training program. Journal of Behavior Therapy and Experimental Psychiatry, 25, 155-160.