A WAY OF TOILET TRAINING
RETARDED CHILDREN
By W. D. FEWTRELL,
Assistatit Psychologist, Lerr Hospital, Bromsgrove
There are many published examples of the successful
application of behaviour modification techniques to
the mentally subnormal, particularly in the laboratory
and other well controlled situations. However, in the
long term, if behaviour modification methods are to
become generally used they must be seen to bc
applicable not only in the ideal experimental con-
ditions but also in the ward and other living situations.
The following is an account of a programme to
reduce incontinence on a ward of twenty-one severely
subnormal children.
A necessary first step in any behaviour modification
programme is to determine very precisely the goals
or ‘target behaviours’. In this instance the target
behaviour was for the children to use the toilet in a
socially acceptable manner.
Adoption of the programme by staff
Having decided on the target, the staff on a ward
in which the unacceptable behaviour is a major
problem must be persuaded to accept the programme.
Some changes and alterations in attitude will be
necessary and ward staff will have to be convinced
that these changes in approach are worthwhile. I n
an initial trial of this sort, therefore, it will probably
facilitate the whole operation if some initial instruction
is provided, as a result of which it is not unusual for
ward staff themselves to request the programme.
The usual arguments which tend to belittle
behaviour modification techniques are based on the
assumption that traditional methods are similar, e.g.
reward and punishment. Superficially they may be,
but in essence they differ considerably in method and
application. In this instance if normal toilet habits
have not been reduced or obliterated by the old
methods there is a strong case for attempting a new
approach as the disadvantages of incontinence should
bc evident to all. It is essential, however, that the
system should come through conversinn and accept-
ance rather than by imposition.
Pleasure and reward
The principle on which the process works is that
when a child consistently gets pleasure as a result
of doing something he will ultimately associate the
act with the pleasure or reward and will repeat it.
Here, therefore, we must find some way of rewarding
him for using the toilet and also establishing in his
mind that he gets nothing for being incontinent, thus
dissuading him from the latter habit.
The most acceptable system of reward for the
desired behaviour must be decided upon. These were
found to vary for each individual though attention,
physical contact, sweets and in some instances cereals
were amongst the most effective.
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Rewards must be provided immediately for the
appropriate action. In the severely subnormal, with
limited understanding of speech, explanations are of
no avail. The relationship between the acceptable
response and the reward must therefore be immediate
and very clear. In this way urination and defaecation
on the toilet quickly become associated by the child
with pleasant consequences. After several weeks of
consistently rewarding every act of correct toileting
behaviour, children will usually become habituated to
the new pattern because in itself it produces less
discomfort and is more pieasing. At this stage, when
i t is producing its own reward the artificial ones may
be gradually reduced and finally withdrawn.
Base line information
Initially it is necessary to know more about the
child’s present habits, when does he dirty or wet
himself? How often does he do it and is there any
other fact about these habits that may help? In other
words a baseline or level of present function must be
established .
The collection of baseline data usually requires thc
full-time commitment of at least two members of
staff. Each child is checked at half-hourly intervals
and a record made. A child found to be soiled is
changed into fresh nappies immediately, so that any
further soiling will not be confused with that already
recorded. In order to establish the time of soiling, this
half hourly data should be obtained for at least two
weeks, though under conditions of staff shortage
hourly recordings for one week could provide
adequate information.
Routine
Toilet training by this method will usually involve
changes in ward routine - strict daily toileting times
must be arranged using the baseline data already
collected and ward staff must be present to administer
rewards following the appropriate toileting behaviour.
It was found that if staff carried small sweet-wallets
it ensured the availability of rewards. After the
establishment of a new and acceptable habit, social
reinforcement, physical contact and praise will often
become more appreciated by the children. Initially,
however, the immediate effect of a sweet or food is
usually most effective.
The efficiency of a training programme will depend
on at least one member of the staff being in the toilet
and at least one other being available to help children
to and from the toilet during the special times.
Allocating specific groups of children to particular
members of staff has proved a successful system.
though the system must remain flexible to overcome
periods of severe staff shortage.
costs
In-miably the additional costs of rewards and the
method of obtaining them will cause some adminis-
trative difficulties but there is no good reason why
the child's own pocket money cannot be utilised for
this purpose.
Assessment of progress and results
It is advisable to assess progress throughout a
programme. The measure of success chosen in this
particular project was the time sampling of dirty
laundry. On one day of every week all laundry soiled
due to incontinence on that day was weighed. The
project has been in operation for just over six
months and the progress is presented in the graph
below.
GRAPH OF WEIGHT OF SOILED LINEN A G A I N S T T I M E
(I)
g 100-
TEMPORARY
$ 90-
80-
5 70-
z
- 6 0-
-I
50-
-I
2 'O-
B 3e--
g 20-
'3 10-
2 0
4 1 1 1 ('0 ,I2 I\ 1'6 I"
WEEKS
Though there is considerable week-to-week
variation for a number of reasons the trend towards
a reduction of incontinence, indicated by a decrease
in soiled linen, is clear. The sudden increase between
day 9 and day 11 was due to a transfer of the
children to another building and the failure to apply
their newly learnt habit to the new situation. This
was quickly re-established on the children's return to
the familiar ward. Many studies in the training of
severely subnormal children do indicate this problem
of transfer of training when the two training situations
are very different as was the case here.
Practical problems
Ideally rewards should be presented immediately.
A major difficulty experienced by staff initially was
the fact that they were frequently unaware that the
child had used the toilet. Only experience could
overcome this. An electric device on the lines of
the enuretic alarm attached to the lavatory pan could
help and the be11 or buzzer or light would act as a
reward.
Rewards must be carefully chosen and their
appreciation by the children established before
commencement of training. Once chosen they should
not be easily available in other situations.
One other fact which we discovered after
commencement was that many severely subnormal
chidren require additional cues to indicate the toilet.
Coloured lights or other conspicuous signs can be
used but the same sign should be used wherever the
child may be. Variations produce confusion and a
break down of learning.
Cues to discriminate between the toilet and the
dayroom are essential. Since we are aiming to teach
children the proper use of the toilet they should be
able to distinguish it from other places. Gor some
children this may sometimes be more difficult than
expected. The use of different coloured lights or
other conspicuous signs, specific only to the toilet.
does help.
Summary and Conclusion
This report gives a brief account of how behaviour
modification principles can be, and have been, applied
to the toilet training of severely retarded children in
n ward. If the procedures are carried out accurately
and consistently there is no reason why any child,
no matter how retarded, should not respond to a
programme of this nature, providing that there are
110 pathological disorders which can prevent it.
The gross reduction of incontinence has the obvious
benefit of releasing more staff from the routine
nappy-changing care role, to one which could enable
more time to be spent on other constructive child-
orientated activities.
A large scale programme of this nature does require
tactful and careful administration and entails some
increase in work particularly in the long term. It is
advisable for the sister or charge nurse to be
reasonably familiar with the principles of behaviour
2'0 2'2 ,I modification before the introduction of a programme
so that the significance of each step is fully
appreciated and he/she can keep the other nursing
staff informed. Finally, the provision of a constructive
service in subnormality, by the introduction of
programmes such as this, requires the full participation
and co-operation of all those hospital personnel
involved in child training.
Acknowledgment
The programme would not have been possible
without the help, co-operation and encouragement of
Dr. G . B. Simon, Medical Director, Dr. M. Davies.
Consultant Psychiatrist, and Mr. B. Penton, Ward
Charge Nurse. I must also state that I was very
pleasantly surprised and grateful for the unexpected
keeness of the children themselves.
Suggested reading:
Azrin, N., Foxx, R. M. A rapid method of toilet
training the institutionalised retarded. J.App1.
Behav.Anal., 1971, 4, 89-99.
Ellis, N. R. Toilet training the severely defective
patient: An S-R reinforcement analysis. Amer.J.
Ment.Defic., 1963, 68, 98-103.
Hundziak, M., Maurer, R. A., Watson, L. S. Operant
conditioning in toilet training of severely mentally
retarded boys. Amer.J.Ment.Defic., 1965, 70,
120-124.
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