J Dev Phys Disabil (2007) 19:449–455

DOI 10.1007/s10882-007-9062-8
O R I G I N A L A RT I C L E

Modified Version of Azrin and Foxx’s Rapid

Toilet Training

Kyong-Mee Chung

Published online: 1 May 2007

# Springer Science + Business Media, LLC 2007

Abstract A modified version of Azrin & Foxx’s Rapid Toilet Training (RTT) was
implemented with a 12-year-old boy with developmental disabilities. Modifications
included (1) shortened training hours (i.e., from 8 to 3 h/day), (2) omission of the
overcorrection procedure, and (3) omission of the urination detection devices. After
2 weeks of the modified RTT at school, the participant demonstrated a marked
increase in successful urination in the toilet, which continued throughout the
maintenance periods at school. His performance generalized to the home setting
without formal training. The participant, however, continued to show incontinence,
showed no evidence of self-initiation, and was prompt-dependent for other toileting
subskills. Clinical implications for using the modified RTT, possible explanations for
his lack of progress in certain subskills, an alternative treatment component to
address those areas of difficulties, and future research directions are discussed.

Keywords Toilet training . Rapid toilet training . Developmental disabilities .

Urination . Intensive toilet training

Toilet training is a major goal for caregivers of individuals with developmental

disabilities for various reasons, including practical concerns (e.g., difficulty in
finding placement for and staff members to work with people who are not toilet
trained) and safety concerns (e.g., reducing the possibility of being abused). Bladder
control is usually obtained between 24 and 48 months of age for typically
developing children (Berk and Friman 1990). For individuals with mental
retardation, bladder control typically occurs later, if at all. A study of 105 people
with mental retardation (IQ <70) showed that only 62.9% of the group achieved full
bladder control by 7 years of age and 82.9% by 20 years of age (Von Wendt et al.

K. Chung (*)
Department of Psychology, Yonsei University,
134 Shinchondong, Seodaemoongu,
Seoul, 120-749, Korea
e-mail: kmchung@yonsei.ac.kr
450 J Dev Phys Disabil (2007) 19:449–455

1990). This suggests that persons with developmental disabilities often experience
toileting difficulties and are likely require additional training to achieve indepen-
dence in this area. This is supported by the finding that individuals with
developmental disabilities, on average, require about 1.6 years of additional training
to achieve toileting independence (Dalrymple and Ruble 1992). Amount of
additional training required increases significantly for individuals with more severe
levels of cognitive impairment, multiple disabilities, and sensory impairment
(Scisson et al. 1987). Duration of toilet training is also affected by other factors,
including severe behavior problems, such as aggression and self-injurious behaviors,
problems with stimulus control (Luiselli 1996), and toileting phobia (Luiselli 1977).
Numerous behavioral training procedures have been used effectively to establish
toileting skills with individuals exhibiting severe to profound developmental
disabilities (McCartney 1990). One of the more successful programs is Rapid Toilet
Training (RTT), an intensive toilet training program for people who are typically
institutionalized with severe developmental disabilities (Azrin and Foxx 1971; Foxx
and Azrin 1973). Primary components of this training program include a minimum
of 8 h of training, a schedule of frequent sits (e.g., every 30 min initially), increased
fluid intake for increasing training opportunities, positive reinforcement of
appropriate voiding, overcorrection procedures for toileting accidents, routine use
of urine detection devices, and embedded training factors (e.g., pants up, pants
down, self-initiation, etc.) to prompt independence. RTT has been used successfully
in numerous settings to train toileting skills in persons with a variety of
developmental disabilities (Bettison et al. 1976; Sadler and Merkert 1977; Trott
1977; Williams and Sloop 1978). In addition to its effectiveness, RTT has other
merits, including a detailed manual and significantly short training periods required
to accomplish toileting goals.
Despite its documented utility, concerns have been raised about use of RTT,
including amount of trainer’s time and effort required (Sadler and Merkert 1977) and
trainee’s resistance to certain components of the training, such as drinking fluid and
sitting on the toilet (Bettison 1986; Lancioni 1980). A recent emphasis on the use of
positive approaches makes it difficult to justify the standard use of punishment
procedures for training with persons with DD. Modification of the RTT program is
necessary to address these concerns and practical difficulties in implementation.
Recent efforts have been made to examine effectiveness of modified versions of
RTT (Didden et al. 2001; Lancioni 1980; Luiselli et al. 1979; Wilder et al. 1997)
including reduced training hours, omission of pants alarm, and omission of
overcorrection procedure. With these modifications, successes in toilet training have
been reported; however, these findings are not as clear or robust as those obtained by
Azrin and Foxx (1971) (Burgio and Burgio 1989). Developing a less intensive, more
socially acceptable, and similarly effective toilet training program is needed to
provide better toileting programs for persons with DD.
The purpose of this study is to examine the effectiveness of a modified RTT
program to teach toileting skills to a 12-year-old boy with a long history of urinary
incontinence and failed toilet training efforts. Several modifications were made to
the RTT procedure based on previous research findings and practical limitations.
First, the punishment component (i.e., overcorrection for accidents) was removed
because the use of punishment in training violated school policy. Also, given the
J Dev Phys Disabil (2007) 19:449–455 451

boy’s level of functioning, it was not clear whether the child would be able to make
the connection between his accidents and the overcorrection procedure. Second, no
urine detection devices were used. Since overcorrection was not included, detecting
accidents through a pants alarm was not a critical component of the intervention.
Another reason for the absence of these devices was related to limited financial
support (e.g., difficulties in obtaining devices at the time of the RTT). Third, the
number of hours spent in toilet training was reduced from 8 to 3 h/day. This was
done primarily to investigate whether shorter time periods can be as effective as the
time recommended. In addition, practically it would be difficult to train 8 h/day due
to staffing considerations and school schedule constraints.

Materials and Methods

Mark was a 12-year-old boy with a seizure disorder who displayed significant
developmental delays. His overall independent behavior skills, measured via an
administration of the Scales of Independent Behavior-Revised (SIB-R) a year prior
to the training, demonstrated that he functioned as a 2-year-old child with negligible
community skills. Mark had a history of failure in toilet training prior to this
training. The study was conducted in a classroom at a private school for children
with exceptional needs and in Mark’s home. Mark’s teacher, one-on-one aide, and
mother served as trainers under the supervision of the author.
Dependent variables included (1) appropriate, in-toilet urination (%) and (2) in-
pants urination (%). At the end of each day, the in-toilet urination rate was calculated
by dividing the number of times Mark urinated in the toilet by the total number of
bathroom visits, and in-pants urination rate was calculated by dividing the number of
times Mark urinated in his pants by the total number of bathroom visits. The rates
were translated to percent scores by multiplying them by 100.
Reliability data were collected for 60% of the modified RTT periods. Reliability
data were not collected during maintenance periods in the school due to limited staff.
Interobserver agreement was established by dividing the number of identical
recordings per target behavior by the total number of ratings and multiplying that
number by 100. Interobserver reliability for Mark was 100% for both in-pants and
in-toilet urination.

Procedures

The study consisted of three periods: pre-training, Modified RTT, and Maintenance
training. During the Pre-training period (Sessions 1–14), Mark was taken to the
bathroom every hour during school hours (i.e., 8:30 A.M.–2:30 P.M.). The same
routine was followed and necessary physical prompts were provided when any
attempts to escape or elope were made. Minimal attention was provided except for
periodic prompts to urinate in the toilet. Mark received assistance with all toilet-
related tasks (e.g., pulling pants up and down, washing hands, flushing, and turning
off light). This phase lasted for 2 weeks, not including weekends. In the Modified
RTT (Sessions 15–30), the procedures were similar to Foxx and Azrin’s (1973) RTT
452 J Dev Phys Disabil (2007) 19:449–455

protocol except for three components: reduced training time per day (8:30 A.M.–
11:30 A.M.), absence of urine detection devices, and absence of overcorrection
procedure. Major components of the training included: (1) periods spent sitting on
the toilet every half hour which lasted 20 min or until in-toilet urination occurred; (2)
ingestion of liquids prior to each half-hour placement following the guidelines from
Thompson and Handson (1983); and (3) contingent reinforcement (e.g., praise,
songs, edibles, tactile reinforcement) for in-toilet urination and for remaining dry
between placements. He was allowed access to his most preferred item contingent on
successful urination and during a 10-min break prior to the next cycle of the training.
After intensive training in the morning, Mark was taken to the bathroom every 2 h,
and he was seated on the toilet for 5 min or until he urinated on the toilet. During
this portion, the same procedure was used aside from extra fluid intake and the
altered time schedule. During the Maintenance Training (Sessions 31–138), three
components were gradually changed over time based on Mark’s performance: (1)
time spent away from the toilet was gradually increased in 30-min increments up to
2 h, (2) his diaper was gradually removed, and (3) he was trained to urinate in a
standing position. The criteria to move to the next phase was an 80% or higher
successful urination rate and a 30% or below accident rate for three consecutive
days. The same reinforcement used during training was provided for successful
urination, while edible and tangible reinforcement components were gradually
withdrawn throughout this phase. (More detailed information about the procedure is
available upon request).

Results

During the pre-training period, Mark urinated in his diaper 100% of the time and in
the toilet 0% of the time. During the modified RTT program in the morning, in-toilet
urination increased significantly (Mean=64%) with more successful urinations
(Fig. 1a) towards the end (92% over the last 2 days), while the occurrences of in-
pants/in-diaper urination (Fig. 1b) decreased from 100 to 5.8%. Throughout the
various phases of the maintenance period, Mark urinated in the toilet more than 80%
of the time, and in-diaper/in-pants urination occurred less than 20% of the time at
school. Mark’s performance at home fluctuated significantly on both measures. His in-
toilet urination increased significantly and remained at the 100% level until session
106, and then fluctuated between sessions 107 and 140. This coincided with illness
and changes in seizure medication. His in-pants/in-diaper accidents were variable,
although a slight downward trend was noted. During the maintenance phase, his
average successful urination was 79%, and his in-diaper/in-pants urination was 56%.

Discussion

Mark acquired a fundamental skill in urinary continence, the connection between the
toilet bowl and urination, through a modified version of Foxx and Azrin’s (1973)
RTT, clearly supporting the efficacy of this approach. Generalization of this
treatment effect to the home setting was observed, at least in terms of urination in
J Dev Phys Disabil (2007) 19:449–455 453

a Pre- Modified
1hr 1 1/2 hr
Maintenance
2h All Day
RTT 1/2hr
training
100
winter
90
break
80
% Successful Urination

70
60
50
40
30
20
10
0
1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106 113 120 127 134
Days

b Pre- Modified
Maintenance
1/2hr 1hr 1 1/2 hr 2h All Day
training RTT

100
90
% In-Pants/In-Diaper Urination

80
70
60
50
40
30 winter
break
20
10
0
1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106 113 120 127 134
Days

Fig. 1 Frequency of a successful urination and b in-pants or in diapers urination of subject

toilet. While Mark’s incontinence remained variable, there was a significant overall
decrease in inappropriate urination from 100 to 11% at school. Furthermore,
episodes of incontinence appeared related to his school schedule and his physical
conditions: swallowing excessive amounts of water while swimming, avoiding
public restrooms during outings due to caregiver’s concerns regarding hygiene, and
urinating less than usual during periods of illness. Also, he needed frequent physical
prompts to follow the entire process of urination.
Mark’s success with in-toilet urination, but not with continence, through this
modified RTT has several implications. First, additional days may be necessary in
order to teach individuals with DD to urinate successfully in the toilet when
employing less intensive hours (e.g., less than 8 h). Second, Mark’s progress
indicates that punishment is not a necessary component in increasing the rate of
454 J Dev Phys Disabil (2007) 19:449–455

successful urination; however, it may be an important training factor for decreasing

in-pants/in-diaper urination. Mark’s continued accidents, especially at home, may
have partially been due to a lack of structured consequence in the program. Third,
self-initiation was a major component in Foxx and Azrin’s (1973) program for
independent toileting, which helped avoid accidents. For Mark, limited success in
generalization to the home setting, marked by high accident rates, appeared closely
related to his inability to communicate. Fourth, Mark’s continued dependency on
toileting-related procedures (e.g., pants up and down, following the set sequence)
suggests that an additional method that addresses other components of toileting such
as the chaining method developed by Bettison (1982, 1986), may be necessary to
accomplish independent toileting. This would involve teaching the entire sequence
using graduated guidance combined with backward chaining through task analysis.
Fifth, variability in Mark’s toileting behavior across settings supported the findings
from previous studies of limited success in generalization of toilet training (Azrin
and Foxx 1971; Foxx and Azrin 1973). Implementation of a specific program
reflecting each setting or a repetition of the training in each setting would be
necessary for successful generalization of toilet training skills. Finally, as indicated
by several researchers, children have to be at least 24 months to be toilet trained, yet
no information is available on the minimum developmental level for independent
toilet training. Further research on that level is necessary to guide us in developing a
specific toilet training program (e.g., assisted vs. independent) for individuals whose
developmental level is known.
Limitations of this study include: (1) use of only one subject, (2) identification of
reinforcers without formal reinforcement assessment (Pace et al. 1985), and (3) the
absence of treatment integrity data.
Toileting is a complex skill requiring various sub-skills. Only continual and
systematic research will allow clinicians to map the necessary components of an
effective treatment. This type of research will be critical in guiding clinicians to
individually tailor the program to the client’s needs. Many researchers have
demonstrated successful implementation of independent toilet training among people
with severe and profound developmental disabilities. However, they have also
demonstrated that success is only possible if the right program is implemented in the
right way for the right population. More thorough and systematic research will lead
to improved guidelines for effective treatment in this population.

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