Research On Toileting Difficulties Among Individuals Living With Autism Spectrum Disorders

Intro: This podcast is brought to you by the LeafWing Center. Helping children and families since 1999. Brought to you by the Clinical Treatment team at the LeafWing Center, this is the Autism Treatment Professional Podcast.

Sevan Celikian: Hi everyone and welcome to the LeafWing Center podcast. Here, we’re interested in all matters ABA and all matters autism. My name is Sevan Celikian, I’m a BCBA at the Leaf Wing center and I’m here with my colleagues.

Rei Reyes: My name is Rei Reyes. I’m a BCBA.

John Lubbers: Hello everybody. My name’s John Lubbers and I’m a board certified behavior analyst with the LeafWing Center.

Manjit Sidhu: And I’m Manjit Sidhu, I’m also a behavior analyst at the LeafWing Center.

John Lubbers: What are we talking about today?

Rei Reyes: Exactly. What are we talking about today?

Manjit Sidhu: Potty training.

John Lubbers: We’ll have to do our best not to be obnoxious with jokes, right?

Rei Reyes: But it is difficult. It is one of those,difficulties that we encounter when working with families in our practice, along with, our first podcast was about feeding. Potty training, toileting is pretty much up there as well. So any information we have on this topic, let’s go over them.

John Lubbers: Yeah, definitely. It’s something that you know I’m sure we’ve all faced clinically. Where are our families, I can remember many times over my career that a family has called me and said, you know John, we had something happen. We don’t know what to do this weekend. My, my son or daughter where we were in the grocery store and my son or daughter all of a sudden started jumping up and down and ran over into the fruit section and used the bathroom and that mortified us and everybody else. And so, it happens. And I think, statistically there’s some numbers about people that, with autism spectrum disorders and how frequent these potty problems are. So it’s definitely a relevant issue in something that we hear a lot from our parents.

Sevan Celikian: Absolutely. And toileting, as we all know, it’s a very critical life skill. It’s absolutely necessary for many reasons, first of all, for hygiene but it can also improve an individual’s quality of life, self-confidence, and it can also reduce bullying and other altercations that individuals may come across if they don’t have the appropriate toileting skills after a certain age. So why don’t we define what we mean by toileting? So the definition of toileting based on the studies that are out there is two fold. It refers to recognizing the need to go to the toilet and also the ability to complete the steps necessary to eliminate in the toilet.

John Lubbers: And that’s also super important. There’s further discussion on both. So when you say recognizing what’s kind of implied right there is that I can sense internally in my body when I need the bathroom and I can respond accordingly. Now the response part is kinda, what do they say? The devil in the details, right? There’s a lot of skills that we’re finding are involved in the response. You have to, you have to get up. Yeah. And that’s not so easy for some of our individuals, you have to get up, you have to identify the location of the bathroom, you have to go into the bathroom, you have to undress at some levels so that you can use it. Then you use it. That’s a skill. You engage in hygiene behaviors afterwards and then you leave. So it’s a complex series of steps.

Rei Reyes: It is a very complex chain of behaviors. If we’re going to go off behavior analytically about it, it is quite complex and that’s where I think the difficulty lies. Teaching one of those steps, like walking to the bathroom is something, but walking to the bathroom, turning on the light and then walking to the faucet, to the sink, is another thing and that’s where I’m most, well, most of our, the families we work with is a difficulty they’re having in teaching that chain of behavior.

John Lubbers: Given how complex it is, it’s almost kind of amazing. I say this kind of jokingly, but it’s almost kind of amazing the two year olds and three year olds are able to get this.

Sevan Celikian: It’s not just the physical process, it’s the social process.

John Lubbers: Yeah. That’s an important thing.

Rei Reyes: Yeah. I think for our typically developing children, this is usually picked up around the age of three and four I believe. Yes.

Manjit Sidhu: Mostly by the time they start preschool.

Sevan Celikian: But it’s important to note that individuals with developmental disabilities such as autism spectrum disorder, they’re more likely to have ongoing difficulties and more difficulties than your typically developing child. Yeah. So that’s where some of the difficulties come into play, which is what we’re going to get more into detail in today’s podcast.

Rei Reyes: There was a study out there in ’96 and basically what the researchers had said is that at least about 82% of individuals living with autism have some form of difficulty in this area. 82%. That’s pretty high for me. Thinking about it now, over the years working in this field, it’s pretty accurate. Because I very rarely encounter a family with a child who’s got those skills down already. More often than not, there is something lacking, in the way they do things in the bathroom. And, so what do you think guys, is that 82%, you think that’s a stretch or pretty much where you think, it really is in your own own experience?

Sevan Celikian: In my practice, that seems like an accurate figure, especially with the younger population.

John Lubbers: Yeah, definitely.

Sevan Celikian: And speaking of a studies Rei, Matson in 2010, used the profile of toileting issues, the “POTI,” which is a 153 point questionnaire. The results of that indicated that there were five common or most commonly reported problems, in terms of toileting, which were having toilet accidents during the day, having toileting accidents during the night. Having had wet underwear in the past month.

John Lubbers: Well, can I just interject really quickly guys? I think too that, when we’re talking about toileting is a problem or a challenge and we’re talking about, specifically, our population of autism spectrum disorders, I think, we probably want to like it conceptualize it in two ways. One, conceptualize it in terms of assessment of the problem and then maybe secondarily conceptualize it or think about it in terms of what are we going to do about that problem? Okay. Do we have a problem? What is the problem and what are we going to do about it? So I think that that’s what you were kind of getting at Sevan was this really nice article by Matson and colleagues and it’s a recent article in the last 10 years, I believe, if I remember correctly and it looks at, it’s a nice comprehensive assessment. 56-question assessment, right? A lot of the issues with respect to assessment and a lot of what with potty problems.

Rei Reyes: I think for that study, really the driving force there is like what John touched upon earlier is having something to really define how hard or difficult the toileting is for a specific person. Because normally in our practice we say, okay mom, dad, what’s the problem with your child? What does he not do in the bathroom? And so we kind of like just approach it that way head on, without some, well, we do try to consider as much information that we probably don’t know at the moment. We try to find out, like medical conditions, medication, all that. But we don’t really have a specific tool that we can use, more like a standard, even for our own company, we have different approaches and how to tackle this area. And that’s where, that’s where POTI comes into play.

Rei Reyes: These authors, really their goal was to have a standardized assessment to define what the problem or difficulties are in the area of toileting. Inform us that way and in a way, have a, make it drive the program or the intervention package that we have for toileting. What drive? What does that mean? Basically, one of the authors there mentioned that, if there is something, if there is a medical condition that will prevent the person from having having a successful potty program, toileting program, then address that first instead of just blindly getting into a toileting program, which will likely fail if you don’t address whatever the POTI has identified. So in a way, I like POTI, from that perspective it is an effective tool. I think. I haven’t used it yet, but I can see where the utility is going to come from if I’ll be using this.

John Lubbers: And specifically the authors describe the POTI as a screening measure that examines toileting problems common to those with ID standing for intellectual disabilities and the problems ranging from constipation to exhibiting challenging behaviors while toileting. So it covers a wide range of things and parents, you may know that if you have some psychotropic medications, if you’re a child, or the individual that and your loved one has some psychotropic medications that they’re taking, sometimes the side effects of those medications can be constipation and that can really complicate things or sometimes with certain diets, it can be maybe self-imposed or maybe even, self-selected. If an individual only eat certain foods and avoids fibers and what have you, or things that would facilitate, digestion and passage, avoiding of solids sometimes by choice, diets can can contribute to constipation, which can be a problem and that can be something that we have to address, one way or another. Additionally, taking into consideration problem behaviors and that’s an important thing as well. So the POTI assessment and the article that we looked at this week, it looks like to be a nice comprehensive assessment in terms of gathering information about potty problems.

Rei Reyes: Yes. So I know listeners have noticed this but Dr. Lubbers did say ID, intellectual disability, someone help me out here, but there is a study out. I think it was the same authors. They did mention that a good number of individuals living with autism have some form of ID as well, some degree of ID. (That’s true). Although this study did not specifically have individuals living with autism in their study, that diagnosis can transfer over to our ASD population as well. I just want to bring that up since some of may have thought about that question.

John Lubbers: Yeah, that’s a great point, Rei and what I would imagine the authors, Mattson and colleagues will do with respect to this is they’ll re-run studies like this and include individuals with other disabilities. I think it’s reasonable to expect they’d probably, you’ll get similar outcomes. There’s not a big difference that we’ll find statistically between the populations is at least is what I would see and what I’ve seen in research in the past. So very good point with respect to that.

Sevan Celikian: That’s true. The research has shown that up to 75% of individuals living with ASD do show some level of ID and this was found by Matson, Shum, and Croen in the early 2000s. So it is typically co-occurring, which is important to note.

Rei Reyes: One thing that I, well a few things actually that I find interesting with this potty assessment is that they found a correlation between the level of ID and the degree of the difficulty. So basically the higher the degree of the ID is of the ID diagnosis is the higher the scores on the assessment, which means more difficulty. Another thing that they have found is that non-verbal, I’m assuming individuals who cannot talk, since we can get into what verbal means. So individuals who do not talk, non-ambulatory, on fiber or laxatives, are also likely to have higher POTI scores as well. So this study was quite informative when it comes to those aspects. So anything else on POTI guys, folks?

John Lubbers: Well, there were four big results from that. And you talked about Rei which is great, which is really interesting. So the big significant results they found were non-verbal, individuals had significantly higher scores, non-ambulatory or folks that can’t walk easily or walk much at all and then, third, was, individuals that were using, fiber or laxatives also scored significantly higher or meaning they had more difficulties with potty issues and then like you said, Rei, the last thing was the level of intellectual disability and those that were more disabled had more problems, more intellectually disabled, more profoundly effected and then those who had less, were less profoundly effected. So those are four kinds of interesting conclusions. It was really, interesting to see that they came together with those results.

Rei Reyes: In terms of function, we mentioned this earlier, this assessment tries to figure out function. The potential functions, that can be assessed by the POTI are avoidance, pain, social difficulties, non-compliance, internal cues, peer rejection, aversive parenting, shame, deception, and medical conditions. And as we’ve said earlier, if the assessment finds that one or more of these are a difficulty then if applicable, it’s best to address those difficulties first before getting into an actual intervention.

John Lubbers: Yeah, that makes sense. Always rule out the medical and those other potential contributing variables. I think it’s kind of interesting, probably for our listener to kind of understand, we’re talking in the abstract about the POTI, assessment. But let’s give, if you don’t mind, I think we’d be worth maybe giving some examples of some questions on it and explaining to the listener a little bit about how you respond on the POTI, the assessment. So, it says the scale is completed by clinicians with individuals, primary caregiver. So in other words, a parent or a caregiver would do it with somebody with a pediatrician, with a behavior analyst, with somebody to do it. So not uncommon in terms of the administration and the questions are answered as either, a zero, no problem present, one problem present or X does not apply. So, and here are some of the questions guys. For example, question number one essentially is does not urinate in the toilet. And so the caregiver responds zero, no problem present. One, problem present. Or X does not apply. Another question is only urinates or defecates a small amount. So same answers, strategy there. Another one is has food allergies. Another one is hides wet clothes and then it goes all the way down to things like, has a lack of appetite, or does not independently perform post self-help tasks. So it covers a lot of things and it’s fairly easy to read, fairly easy to understand. And the response how you respond to it, it’s fairly easy as well. So I, I’m really liking it.

Rei Reyes: Yes and unlike other, assessments that we have used over time with our clients, this has a lot of very specific detailed questions that we don’t usually, I guess, see in other assessments. Like for us clinicians, we use Vineland. Some of you folks may have already heard about it or maybe even done it. If you recall, there was probably a couple of questions about toileting there and that’s what makes the POTI, I guess more powerful assessment to use than other assessments available out there.

Sevan Celikian: That’s true. That’s one of the major advantages of full-scale measures like the POTI. It really helps to guide intervention simply because there is so much detail included in the questions and the answers and it’s so simple to administer. Basically, the higher the score on the POTI, the greater the toileting difficulty is. And so this is why using this in our practice or in other clinicians’ practices can really have a positive effect on guiding effective interventions.

John Lubbers: So I think as a clinician, I would say that I’m, I’m inclined to begin using this assessment (Yeah, definitely) and I think I would probably recommend it to our families that work with your clinicians, your pediatrician or your behavior analyst. If you’re struggling with these kinds of issues at home with your son or daughter or loved one and you are not sure how to approach it, obviously I would suggest reaching out and starting this type of assessment. This would be good. Go a long way towards providing some initial information.

Manjit Sidhu: Yeah. It’ll definitely help the parents and the practitioners gain a comprehensive insight on what the function and that way you can put together an effective treatment plan if you know what the function is.

Rei Reyes: Speaking of intervention, can we introduce this topic?

John Lubbers: Yeah. I guess one last thing I’ll say is just that, Matson, Horvitz and Sipes in 2011, the article that we’re referring to, do you discuss in there, in the article that they’re going to do further research and that they will further refine their scale. So like all good researchers, they’re going to work on that and get that assessment better tooled in tuned up.

Rei Reyes: This concludes Part One of LeafWing Center’s podcast regarding toileting issues. We encourage you to continue on with Parts two and three. These segments are readily available to you for your listening convenience.

Outro: For more insight from the LeafWing Center, please visit the LeafWing Center website and blog page at LeafwingCenter.org. Email us at [email protected] or visit us at your favorite social media outlet. Feel free to submit questions or comments about this or future podcasts and we will put links to information discussed in today’s show on the website. We look forward to next time. Thank you.

Intro: This podcast is brought to you by the LeafWing Center helping children and families since 1999 brought to you by the clinical treatment team at the Leaf Wing Center. This is the autism treatment professional podcast.

Announcement: Welcome back. This is part two of our podcast regarding toileting issues.

John Lubbers: Let’s talk about intervention.

Rei Reyes: Intervention. So, so when we first started this, the research part for this podcast, so all, well six of us, they do our own research online and one thing that I have noticed at least from my experience is that there’s not a lot, there’s really not a lot of research or papers out there regarding intervention and then that’s why even for our research, for the assessment we had to go back, way back to 2010. Normally they would like a three year old or even a three year old paper for this one because there is nothing available on the topic. We used Matson’s 2010 paper. Now how about your thoughts guys?

John Lubbers: I’ll speak, I’ll speak really off the cuff on this one as a behavior analyst. You know, probably why I feel that is the case is maybe because we had this study in 1971, the Azrin and Foxx study, it was so effective and such a seminal, foundational study that as a profession we haven’t really felt the need to kind of reinvent the wheel.
John Lubbers: So it’s already there to some degree and we don’t need to reinvent it. And now we are in the process of, you know, Hey, let’s do things better. What can we do better? And so we were looking at, you know, we’re going to look today, we’re going to talk about that Azrin and Foxx study in 71 and we’re going to talk about a couple of other studies that are more, more modern, more current. And but I think, you know, we’ll point out some differences and some similarities and some strengths and but I think that maybe in behavior analysis that we may feel that we have a, a pretty solid approach right now and we’re just at the tweaking stage. I dunno, that’s just my thoughts. I could be totally off base.

Rei Reyes: Well, I believe that is indeed the case, cause even for me, I probably read as Azrin and Foxx when I was in grad school, which was years ago. But in practice, although I’m not really using their work as a source of information directly, in a way, I lean towards that direction anyway. Like using some of the techniques that they’ve used as a behavior analyst. Our training leads us to get to that to those interventions. And that’s, before I get into that, let’s talk more about this study. So this was done like Dr. Lubbers has said back in the 1970s.

John Lubbers: Yeah.

Rei Reyes: Right.

John Lubbers: Yeah.

Rei Reyes: There were nine males in a hospital ward. All incontinent uh ages were between 20 and 62 years of age, all with a diagnosis of intellectual disability and anything else that I’ve missed there?

John Lubbers: I think you kind of covered, got it all covered there. Yeah. There, I mean, we’ll, as we talk with maybe a little bit more, we may get in a little bit more about the, the individuals in terms of their intellectual functioning. Some were lower, some were, you know,unot as profoundly affected. You know, I think we can get later on into, you know, some folks required more training, longer periods of training, and then longer periods of maintenance. Ubut what was so interesting, you know, to me at least is, you know, there’s essentially what I kind of gleaned from it. There’s about six components to this assessment. Uand uand then one particular component that when I was rereading this article for our podcast today,uthat I found so,uinteresting to me was in 1971, they were using electronic devices to assess,usoiling. And I, and I kinda got the impression, I didn’t really see this in the article, you know, but I kinda got the impression that they almost kind of like they, they almost kind of had this thing made just for this purpose for this article, which is, you know,uI, I was quite impressed, you know, I was like, wow, they really went. That was pretty good.

Rei Reyes: Yeah. I mean if you look, if you remember the actual article has a couple of diagrams as to how they made those gadgets

John Lubbers: Hand-Written by the way.

John Lubbers: Hand written!

Rei Reyes: Yeah. Haha!. Hand drawn. One of them is I believe a moisture detector for pants. A pants moisture detector.

John Lubbers: Yes.

Rei Reyes: Uh which pretty much a wire attaches to the insides of let’s say an underwear. Yeah. And then it will attack a moisture. Yeah. A little bit of moisture. It will trip. It will sound an alarm. Yeah. I believe there will be a circuit box somewhere, somewhere attached to a, another pair and a garment. Yeah. Yeah. And then once it detects moisture, it will go off. And the other one is…

John Lubbers: Well, so a couple more details, sorry Rei to interrupt, but there was, I found this really, I found this, I found this so interesting.

Rei Reyes: I liked it too, but I think you like this one much more than I do.

John Lubbers: I guess so, yeah. I really, I really like these, these, these old seminal articles, you know, Baer Wolf and Risley. That’s what I mean. I really like, so so you were talking about the moisture scene. So the one of the caveats, one of the problems they had in the study was that excessive perspiration resulted in a false positive. So meaning that the alarm went off when somebody who had excessive perspiration was sweating too much. So they fixed that. The authors fixed that by putting a little piece of tape over the sensors and it made them a little less sensitive and work just as they were intended to. The other thing I think is important to kind of mention about one particular and also the second one that Rei would tell us about in a second, I’m sure. But the intention for these was not to alert the individual with the alarm that they were wet. So you know, so Bob who’s wearing the device and Bob who has a a toileting accident and wets himself the, the intention of the, the device that he’s wearing, the, the undergarments with the electronic notification is not to let Bob know that he’s wet because the assumption was Bob knew that was to let staff know or somebody knows so that they could come and intervene and implement the, the procedure immediately without delay.

John Lubbers: So previous to this, this device being used, it was assumed or implied in the article that at times there would be a soiling and that individual in this particular setting might be wet or soiled for some period of time before it was noticed. And that’s important for us in behavior analysis because we know when things happen we want to react kind of quickly. Yeah. We’re both in a reinforcing way and also in a corrective way. So the longer we let it go without responding right away, the, the, the weaker, the connection is between our, the event and our actions. So I thought it was really interesting on that stuff. Yeah.

Sevan Celikian: Absolutely, it’s a great feedback tool for caregivers and practitioners because it gives us the opportunity to provide immediate feedback. And as we know in ABA, it’s all about immediacy when it comes to reinforcement and punishment. For those two concepts that have the desired effect, the feedback does need to be immediate. And also it takes into consideration the well-being of, of, of the participants of the clients because then an adult knows, okay, there’s been an accident, so then they don’t have to be in soiled clothing for, for a very long time and the intervention can be applied.

John Lubbers: So the other device was the, the was a, and you guys chime in here, I’ll use everybody’s help right now.

Rei Reyes: I can tell, go for it.

John Lubbers: I’m embarrassed, really, um the other one was and correct me, you guys, if I’m not getting this right, but it was a device that was put inside the toilet itself. So it was a, yeah, the toilet chair. Yeah. And so it was a plastic piece that was put in there. I don’t know if there was you know, while there was a center put on it that went behind the toilet. And the purpose for this was for when a an individual successfully toileted either urine or feces that the sound, the buzzer would sound or the notification would be given and staff would be able to provide reinforcement in the form of, you know, primaries or edibles or, you know, treats. I think this was a half of a candy bar or three quarters of a candy bar. Is that what they said?

Sevan Celikian: Social praise.

John Lubbers: And social praise. Yeah, exactly. And hugs. I think they even said, maybe they gave him a hug or something or, or something to that effect. So again, you know, I gotta I have to say this is, this is kinda ingenuity at its best. You know, this is 1971. We’re not long out of the 60s. This is before the computer age, before artificial intelligence, before Elon Musk and, and all our, you know, super tech brilliant people. And in 1971, Azrin and Foxx, you know, got the idea and then created this, the sensors I believe in. And that was, that’s pretty impressive to me.

Sevan Celikian: Yeah. And very innovative.

John Lubbers: Yeah.

Sevan Celikian: Even though the wet alarm and the toilet signal are not as commonly used today, they are still available in wireless versions with, you know, the higher technology that are capable of sending the same signals and, and creating the same systems for practitioners or caregivers to provide immediate feedback.

John Lubbers: Yeah. The, there’s probably an app for that now on the app store. Right. so the, the, the interesting thing about this, and again, why I, you know you guys are right in joking with me about that. I’m really interested in this article, this, this Azrin and Foxx article in 71 is because it’s, it has informed and been cited and influenced so many of our more modern potty training approaches. So I really wanted to revisit this and look at it and see what was being used, what was still current and relevant. And and so there was essentially there were six components of this, you know so one of the things they did, there was a I don’t want to say unique to this study, but you know, at least in my understanding of the literature was kind of newish or novelish was the artificial increasing of the frequency of urinations by encouraging fluid consumption.

Sevan Celikian: And I think that’s just a great use of motivating operations, which is a big principle in applied behavior analysis. And what that basically means is I’m creating situations in which motivation functions to evoke a behavior that we’re trying to, to increase. So increased fluid intake is, is a great way to increase the motivation of having to go to the bathroom. And I think they were using a fixed interval time schedule every half an hour. And this has been replicated in a lot of different studies, whether it’s every half an hour or every 90 minutes, but the frequent and ongoing fluid intake. And body training has been used and is effective in increasing the motivation.

John Lubbers: Do I remember reading in the article, guys, correct me again if I’m wrong. Do you remember reading in there that what they were saying that sort of the logic or the notion or what was underlying so, you know, and if we’re all wondering like, well why did they think that, you know, feeling the kids or the, in this case, the adults full of liquids would be a good thing. What made him think that? Well, if I remember right, I read in the article, I was saying something to the effect of that they thought more opportunities would be, you know yeah, better. And they would allow them to use more reinforcement or provide more

Rei Reyes: Exactly. Along the lines of more practice, I guess, you know, for behavior and bringing reinforcement to come into contact and all those associations to start clicking together, you know?

John Lubbers: Yeah. Yeah.

Rei Reyes: And that’s what they tried to do with that the sit, the sit schedule is to make that associated association between, I go pee, something good happened, I go poop. Something good happens. And that’s what’s missing, I guess that connection. Like Dr. Lubbers had said earlier before, maybe, you know these individuals who are left pretty much half the day soiled, there is no clicking, there is no reinforcement happening. At least this way they void, they get a treat or snack or whatever it is that those individuals were getting way back then and that is pretty awesome for this study. Yeah actually.

John Lubbers: Uh-Hum. Another component too, which I thought was really cool was the positive reinforcement and this is, so part of behavior analysis was they used positive reinforcement for appropriate toileting. And we’ll get a little bit more into that in a bit. But, you know, they, they’re, they’re everything from candy bars to sugared cereal to a social praise, you know, good jobs and, you know, great job, this and that. And if I remember right, maybe even hugs, you know, so some, some, some physical reinforcement as well. So and then additionally they use the shaping of independently toileting. So that was kind of developing the skills of walking to the toilet. And taking clothes down, you know, and sitting on the toilet and, and putting clothes back on. And of course, you know, wiping and washing hands and all those things that are associated with that, that make this a complex set of behaviors. And again, why I was saying it’s kind of interesting that our two year olds get this, you know, are doing, three-year-olds can learn this sometimes and that, so that was another one of those things. They also taught cleanliness training and then provided some staff reinforcement procedures as well. So six components to this overall intervention. And they said immediately the results of this were immediately 90% reduced incontinence or incontinence was reduced by 90% and then eventually decreased to near zero.

Rei Reyes: One of the benefits of RTT is having an intensive toilet training program for a short period of time for the acquisition of these toileting skills to be observed. I believe it’s about one to 14 days for all the participants also regarding maintenance.

John Lubbers: Mmm.

Rei Reyes: Like, yes, they were doing so well and the three days that they were on, but two weeks after the training, it’s all back to nothing. So that’s really where it counts. And when there is less supervision happening, when there is less support happening, what really happens to the behavior and that’s the strength Foxx and Azrin’s RTT method, the maintenance program is really working. Yeah. To the point that they were pretty much off all nine participants were off the program in a matter of weeks and these individuals were considered one of the toughest to work with. I mean, yeah. During that time for the study.

John Lubbers: Yeah. And then then, you know, of course we’ll talk about this again a little bit more and, and down the line. But the maintenance was like you said, Rei, it was, it was pretty when I read the article again,uI was again from press that how detailed it was, you know, it was pretty structured, pretty planned out. And so it was a really well written maintenance program and I’m sure that contributed to these, these gains, you know, lasting longer periods of time.

Rei Reyes: Also this study focused mostly on urination. They did not focus much on number two, but it was also effected by the training program or there was some gains there too. And in terms of generalization, although there was really no data on this, on the report, on the paper the staff from the hospital did report that a nighttime toileting has improved as well. That was not originally addressed by the study, but apparently uh, some of these folks were getting up at night to go to the bathroom on their own, which is pretty good. I mean, you teach one behavior in one setting one time, you get same behaviors or similar behaviors in a different time. And that’s okay. Generalization is a lot of ABA going on in this paper. And that’s why I share my feelings on this paper with Dr. Lubbers. It is one of those awesome ABA based interventions.

Rei Reyes: So in terms of the reinforcement to those are, these are awesome results, unexpected and great results. Going back to the reinforcement a little bit, you know, just to kind of give the listener a little bit of an idea of what, how it was structured. The authors say when inappropriate urination was signaled by the toilet bowl apparatus, remember that was the electronic device that sensed liquid in the toilet bowl. The resident was given a large piece of a candy bar, hugged and praised. So successful toileting, they earned a, a large piece of the candy bar. Who knows whether that was a quarter, a half or two thirds of that candy bar. But they got a large piece of a candy bar. And assuming too that the candy bar was a, was a, you know, a preferred edible, you know, something that that person wanted to eat.

John Lubbers: But additionally there was another layer of reinforcement and that was for remaining dry. And here for remaining dry. And this is, I think what the you guys were talking about with respect to the intervals. They set these intervals of, you know we’re going to check and see if you’re dry. The individual is dry. And if they were dry at these intervals, they were given more at more edibles and they were can state those edibles consisted, Oh, sugar, frosted cereal, you know, and M&M candies. And, and then they were also praised for having dry pants and and that was on an interval like about every five minutes. So again, for the listener if we wanted to think about what does this mean, how does this translate to real world, our kids? It, the idea would be essentially if we set up a system where we checked our, you know, son or daughter every five minutes and then every five minutes if they were dry when we checked them, they got to earn a little bit of cereal or a little bit of M&M’s.

John Lubbers: So they got reinforced for that. So there were two layers of this reinforcement that were going on. And I it was really, really interesting. And I think they also go on to, to say another layer of reinforcement. Maybe not initially intended, but that was, was was the drinks that were given out every half an hour that the individuals enjoyed those drinks. So, so again, I guess why I’m saying this is that a good part of this intervention plan, this Azrin and Foxx intervention was reinforcement based. So it was positive behavior supports, it was positive programming, reinforcement based and and probably that contributed to its success. And it, the, the way that everybody seemed to like the study and the results at the end.

Rei Reyes: Someone might say, well, Rei, John, Sevan, and Manjit, it’s not really all positive, isn’t it? It’s not. No, no. They did have some punitive consequences there. However, [Some correction procedures], however, they’re very natural. Right. You know, it’s not like, Oh, you dirtied yourself, you clean the house, or you wash my car, no, it’s still within reason. For example they’ll have to undress themselves or take a bath, put away the dirty clothes that they’ve soiled and clean up the area. And these are very acceptable. I will say consequences. So it’s not out there. Right. And they’re very informative. They’re very corrective in a way.

Sevan Celikian: The idea being, like you pointed out earlier Rei, we want, or the researchers wanted successful toileting incidents to be paired with desirable items and behaviors and actions. On the other hand, when there were accidents [That very rich schedule of reinforcement is there]. Absolutely. But on the other hand, they wanted for accidents to be associated with, okay, this is not so fun to clean up and I have to change and take a shower in the middle of the night. And so they both kind of work in tandem to create the positive result. [And It was faster because of that].

Manjit Sidhu: They also followed with a one hour period after the accident where it was kind of like a timeout phase where no preferred drinks or edibles no social reinforcement was offered as well.

Rei Reyes: Yeah, and while we’re on the topic of punishment, let’s have a little clarification on that, okay, punishment really is something that happens that pretty much stops or eliminates the, the behavior that we don’t want to happen. Punishment is not about hitting or slapping. No, it is, it can be anything. Right. And for this study, it is really just that corrective measures that they implemented. But when I, like I said earlier, it’s still within reason, you know, so is it fine for me as a behavior analyst? It’s fine, you know for the study back then in the 1970s [Oh definitely]. Absolutely. That’s why I said 1970s we would be more creative probably this era, but back then that’s what they did.

Manjit Sidhu: But even for back then, right. It’s still within reason.

Rei Reyes: That’s within reason. [Oh Yeah]. The word punishment. It’s a very strong word to use in our field. And so for us and as behavior analysts, we, when we get a chance, you want to clarify that topic, you know, when we get a chance

John Lubbers: Yeah. And furthermore guys, just to, you know, to kind of round out the components of this intervention. So they taught dressing skills, which we talked about a little bit in the beginning, but you know, they were the, they found that these individuals needed to know how to, to learn how to, to take their clothes off to toilet and then to put their clothes back on to toilet. So there was, there was a skill that needed to be trained as well. They utilize modeling which is kind of early application of modeling here and they use that. They utilize it though, not like we utilize it now. Nowadays we use video and not a lot. And you will talk about some articles later on in our podcast that talk about the use of modeling in the various types of modeling that are most effective.

John Lubbers: But this was modeling where you know, you can imagine maybe sort of a locker room ish kind of bathroom where it was more a multi-person bathroom with multiple toilets. And I’m going to assume, maybe not dividers between toilets. And so they were talking about in this particular setting that the individuals toileting there served, that were toileting appropriately, served as models for each other and that there was a benefit for that. So that was interesting as well. And then of course, like I said earlier, like we said earlier the independent you know, or going to the toilet that actually needed to be trained or taught to these individuals as well because that skill did not exist. So it was a, it was a very interesting, comprehensive and you know, thorough way of looking at teaching toileting to people that needed it.

Rei Reyes: So I’m not sure if we’ve gone this, gone over this information earlier, but so how long did it take? So for this study, they use three days to collect baseline data. A day is eight hours. Just for the training period. The mean, the average for the training for these individuals to learn to toilet is six days. The range is one to 14 days.

John Lubbers: So somebody took one of these participants to be ready in 14 days [inaudible].

Rei Reyes: Yeah, they were ready. Yeah. But 14 days, the maximum [Two weeks] folks, that is awesome for eight hours a day. [Yeah]. Well and uthat’s one of the benefits I guess of this study is that was done in a hospital setting.

John Lubbers: Well, and if you don’t mind if we can talk about that a little bit more as it applies to parents guys cause you guys probably have, we have and then maybe the listener has or has not ever thought about, okay it’s time for me to start potty training my son or daughter. We need to start addressing this when we’ve been asked this. I know I, when I’ve been asked this, I’ve typically said you know, we can potty train whenever we need to, you know, throughout the calendar year. However it might be easiest if we target a school break. [Yes.] So like summer. [Yes, Yes]. Right. And so Manjit and Rei, where you guys are going with this is you know, cause this thing is an eight hour intervention or 12 hours or it takes a good portion of the day. If you’re the child, the son or daughter your son or, or loved one is going to school, then that’s going to limit the amount of time that we can do this potty training program with them. So, so,utypically I’ve recommended in the past that, you know, wait for a wait for a break, wait for spring break, wait for winter break and wait for summer break. Now, now that I’ve read re- familiarize myself with the length of time, this one to 14 days and the fact that one individual needed 14 days,uand the average was six.

John Lubbers: I’m thinking that maybe now I might more often recommend summer is the time to do that in case we have a, we don’t, you know, cause we, we don’t necessarily want to start a training program and then stop or have it being complete or interrupted, you know, so I think more than likely now I’ll make the recommendation of doing it during summer so that we have a good period of time to be able to dedicate to this.

Sevan Celikian: That way the consistency is there and a sufficient number of learning opportunities can be created or captured as well.

John Lubbers: Another thing I just said, little anecdote, a little fact is when they were talking about how much fluids these individuals were taking on any given day and drinking they were talking about 25 cups. So quite a bit, you know, maybe yeah, it’s a lot, a lot of liquid.

John Lubbers: So you can imagine it probably really increased the frequency of how often they needed the bathroom. What about maintenance? You guys, what was the, you know, this is a pretty prescriptive or should we talk about results or should we talk about maintenance? Maybe talk about results a little bit. So they average like I think I’m seeing 15 urinations per day and one bowel movement every third day per resident. So the frequency of bowel movements was fairly low, obviously, you know, so you’re not going to catch that a whole lot and then naturally occurring opportunities. But 15 urinations gives you a reasonable amount of time to practice that behavior. [Accidents Decreased?]. Yep.

Sevan Celikian: In the training procedure, the residents averaged about two accidents per 8- hour recording period per patient. After the training, the number of accidents decreased to about one accident every four days.

Rei Reyes: I think for each resident in the study, it’s at least 80 decrease, 80% decrease the accidents during the first 12 days for the training.

John Lubbers: Hmm. So another thing I want to kind of talk about to you guys, and this is something that also stuck struck me in reminded me again of this is they talk about when they talk a little bit about readiness skills here. And I’m going to read to you what’s said in the article. It says five of the nine residents seem to possess voluntary control, over their bladders in bowels at the very start of training. And that meant and that was indicated by they had no accidents in their pants during the entire first day or almost immediate elimination upon, and excuse me, almost immediate elimination upon sitting on the toilet. If it occurred at all. And then three external signs that the resent resident was straining to eliminate in the toilet. So those three things indicated to them that they had some level of bladder or bowel control.

John Lubbers: Now I say that because then they go on to say the existence of voluntary control over elimination did not assure independent toileting. So what we talk about a lot, you know, the, the, the, the literature here kinda contradicts what we talk about a lot and that is that we need our kids to have readiness skills. I guess that’s probably rooted in the developmental psychology, you know literature, probably the readiness skills. But this study is suggested again, I’ll read it. The existence of voluntary control or the existence of being able to have readiness skills voluntary voluntary control over our elimination did not assure independent toileting. So though the person that those are the person or those people that had those skills did not necessarily learn these skills quickly and those that did not have them, the readiness skills or the voluntary control were not necessarily more delayed or more difficult to train.

John Lubbers: So just a little bit more drilling down on the results. It was saying in terms of the reduction of incontinence, it says before training the residents averaged about two accidents per eight hour a day per patient. So two accidents in an eight hour day per patient or per, per resident after training, the number of accidents decrease to about one accident every fourth day or every four days. Yeah, per resident. Yeah. So it went from two per day to now one every fourth day. So much less frequent, you know, good success. You know, good results there. Additionally, like we said earlier, I think Rei, you mentioned this about the unexpected benefit of with number two as well. It said something before training the most incontinent resident averaged four accidents. Oh, sorry, guys are the majority of the accidents where urinations. Here we go. This is where I notes to myself here. Prior to training, an average of two pants, dedications, soilings occurred per day for all the nine residents combined. So all nine of them there are about two accidents per day. After training they averaged about 1/10th of a soiling per day across all nine of them. So…

Rei Reyes: The gains for defecation was actually higher than the urination, urination, yes. It was not directly or as oftenly addressed during training.

John Lubbers: Yes. Yeah, yeah, yeah, yeah. That’s, we love that in behavior analysis. When we try it we work on one thing and we get another thing [Something for free]. Yeah. Uso really, really interesting study. What, is there anything else we want to, well, Oh, there was also a nighttime benefit, right? Yes. What was the deal with that?

Rei Reyes: I don’t think they collected data on it. It was more like, uhm, self-reports but although they did not address nighttime urination or bedwetting some staff have reported that those individuals included in the program were getting up at night to go to the bathroom [because the correct habits were reinforced]. They didn’t say it is generalization. It is a form of it. I’ll take that as a generalization.

John Lubbers: Yes. That’s a generalization. Yeah. That is in the strictest. Yes.

John Lubbers: And I think bringing it back to our, you know, our families a little bit. Why, you know, that’s an importance. You know, I definitely have heard in the past where you know, we’ve been working on, on interventions, you know and it’s like, okay, we have a plan during the day, but then, you know maybe the family doesn’t feel confident and doesn’t want the bed wet and they’ll put the child back in a pull up or a diaper at night to avoid any nighttime accidents and as we’ll see later, that might be counterproductive, you know, putting the diaper back on. But I think that, that maybe I think there might be a takeaway from this for the parents in the sense that if we work on the training during the day, we may also get a nighttime benefit as well. Yeah. Unexpected but welcomed nighttime benefit. So other thoughts on this guys? Before we transition over to some other more current articles

Sevan Celikian: Also regarding the maintenance? I think it’s super important that, you know, once we have success with a certain intervention or, or a combination of interventions that we really want to maintain those results. So for the parents out there, do you have success using a few different methods that we discussed? Maintain those, have a plan in place, thin it out gradually just like what was done in this study. And that’s a way to do a few things to ensure there is no a reversal of the positive results and to just maintain ongoing success.

John Lubbers: Final comment, you know, to kind of leave us all thinking about this and this is what Azrin and Foxx right on page 98 of their study, it says, thus the present rationale conceptualized continence as a complex operant reaction to social factors rather than as an associative reaction of a single muscle to internal stimuli. What that means in common sense is their feeling was that appropriate toileting was a behavior that was responsive to social variables and consequences and social influence more so than a behavior that was purely under the control of my body is telling me. I need it. I need to go. So in the study, when you look at if you read through this study, you can see where they could make that conclusion based on the results they had with these nine individuals. So I thought that was really interesting because I know a lot also that we sometimes tend to think of that that behavior of toileting is really happening as a result of the signal we get in our body Azrin and Foxx propose slightly different that there are some social mitigating or controlling factors that we can, you know, work with and use to our, our our benefit.

Announcement: This concludes part two of this podcast.

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Rei Reyes: Welcome back to part three of LeafWing Center’s podcast on toileting issues. Let’s continue where we have left off from last.

Sevan Celikian: Even to this day, most of the interventions that are being used in the studies out there, they’re heavily based on Azrin and Fox’s RTT method. A lot of the different components that we discussed, the interventions that we discussed, like the urination alarm, the scheduled sittings, the dry checks, these are all very much used to this day, so that just shows us that it was effective back then and even to this day, it can be effective presently. And also a lot of the studies and and a lot of the approaches that are being used, they usually involve a combination of interventions versus just one singular approach. Kind of like what Azrin and Fox did. And I think that’s an important point as well because with potty training, with toileting and with many other skills, usually a combined effort or, or a component package of different interventions usually produces a desired result. And that’s something for practitioners to keep in mind and for parents to keep in mind as well.

John Lubbers: Okay. So we’ve confirmed, we’ve reconfirmed that this is a great study. Yeah, in 1971, it probably benefited all of us by rereading that and refamiliarizing ourselves with everything there. The concepts, the ideas, the strategies. What shall we talk about next?

Sevan Celikian: Some of the interventions that were not used in the Azrin and Fox study that may be beneficial to teaching toileting skills. We already covered, the alarms. So we went over that. I think we briefly touched on video modeling, but we didn’t, dive in deeper into that one. That can be targeted a couple of different ways. One popular way that’s been talked about in many studies is video hero modeling. And basically what that involves is taking a character or a figure that a child is preoccupied with, and by preoccupied we mean highly interested, always talking about that character. Like a cartoon or a comic book character.

John Lubbers: So for example, could that be a iron man? Iron man? Yeah.

Sevan Celikian: With the idea being that this character is highly, preferred by the child. And so, by creating a model of that character, engaging in the appropriate toileting steps that can motivate the child to engage in those behaviors themselves. Now the challenge with that approach is it’s usually somewhat difficult to find children’s favorite characters, engaging in toileting behaviors.

Rei Reyes: Yeah, I did that yesterday. I researched for two hours. I put down as many common popular characters that I can, I can’t find any, there’s no YouTube videos. I was telling Sevan yesterday, the authors who really pushed for a VHM but I can’t find anything.

Sevan Celikian: But there is a market for it and there is a use for it. And it’s worth for, for parents to know about it and for practitioners to know about it too because this is something maybe they can somewhat create using, you know, even like a mini social story with like pictures and animations and things like that. So it’s worth exploring if the goal is to create a treatment package where we’re using multiple interventions. So with that said, yeah, if your child is into Pokemon and there is a video of Pikachu going to the bathroom..

Rei Reyes: Since you started the topic of video modeling Sevan let’s get right into it, okay now we’re down that slippery slope. I was avoiding it. What is video modeling? Okay, so this is something that, a tool that we can use to teach, our kids, self help skills, independent skills, any play skills, social skills and all that. Obviously there would be prerequisite skills for a video model program to work.

Sevan Celikian: The child has to be able to imitate.

Rei Reyes: Exactly those things have to be in place a they have to be able to follow it and respond to it. Now, that’s video modeling in general. Now let’s get into video modeling – toileting. There was one study out there that brought this up. They used for this one child, they use a video model for toileting. And in the end, I’m just summarizing this, the child learned everything, all the steps for toileting. Wow. Except for the actual act of urinating or defecating. And the authors pointed out that perhaps, maybe because it was not shown in a video. So if we’re going to go that route, will I really video tape someone doing that? Yes. So there’s a lot of implications. Yeah. Those are the things that, I’m not much of a fan. I’m sorry I’m putting my 2 cents on this topic. But, then definitely it did not work at all. Right. Cause the goal is for the child to do things on a toilet, you know, so that’s something implication that needs to be addressed. But it was right there.

Rei Reyes: So the modeling procedure kind of failed because of, and now authors did not videotape. It was not as literal as it needed to be. Yeah. Okay. So that’s something to think about. And that’s just for video modeling. Now they’re talking about video modeling, like on a one on one perspective, like a child point of view. Yeah, it was interesting. I’ll just say in general video modeling, that’s something to consider. Do we really want to do that?

John Lubbers: Well, so maybe we should describe what that is. Interesting. So, it essentially is making a video, and I won’t make this specific to toileting, but it’s making a video from the perspective of the person that’s supposed to be like a video game.

Rei Reyes: It’s exactly perspective of the game play.

John Lubbers: Yeah. And for those of us that don’t play a lot of video games, cause I don’t play a lot of video games, I don’t, it’s essentially like if you’re brushing your teeth, what you saw on the video screen where, wow, this is kind of difficult. Assuming you’re not looking into the mirror while you’re brushing your teeth, but, what you would see is essentially your hand in front of your face, moving the toothbrush or pushing the button on the electric toothbrush while you brushed your teeth. And so you would see what it would look like from the first person perspective. Yeah. And they did talk about that and one of these articles about is that’s maybe one thing to explore with respect to toilet training. Now that’s going to be interesting cause that will, that study you were saying Rei about where the modeling fell down, first person perspective doesn’t necessarily get that literal moment that needs to be captured to get everything in place as well.

Manjit Sidhu: I did have a family a few years ago where they videotaped the older brother, the full step and then they would. All of it. And the client would watch this video several times throughout the day. And, no, I don’t know if that was what.

John Lubbers: Was the client watching it for interest purposes or to be?

Manjit Sidhu: I want to say mom used to have him watch it every few hours before she would make him go.

John Lubbers: Got it. So the idea was to prepare him.

Manjit Sidhu: Prepare him. Okay, look, he did it. Your brother did it, you know, and there was reinforcement in the video and you know, the brother went in there like woohoo, look! He went pee-pee. And yeah, he used to follow

John Lubbers: So it worked. It was successful? Interesting.

Rei Reyes: Was it a component or it was a treatment by itself?

Manjit Sidhu: It was a treatment by itself. I mean, it’s not something we were working on. This is just something that you know I was told like this is how we did it and it worked.

John Lubbers: Interesting. Well, it doesn’t seem totally inconsistent with how we’ve probably done that outside of the ABA world. A father sometimes teaches his son, this is how you use the restroom kind of thing and so you could see where that would it’s not too far off from that, from convention.

Rei Reyes: Maybe it all boils out really to the learning capability of the person.

John Lubbers: That is important with modeling, for an individual to be able to really benefit from modeling. They have to be able to attend to and, and do that observational. Exactly.

Sevan Celikian: So video modeling and different types of video modeling like we discussed can be used as a tool to teach many different skills, not just toileting, although with respect to toileting certain issues like privacy and ethical issues do have to be factored in.

John Lubbers: Absolutely. Yeah.

Sevan Celikian: Should we move onto another intervention?

John Lubbers: Yeah, what should we talk about guys? We have a few other things.

Sevan Celikian: The Azrin and Fox study did talk about scheduled sittings. So this is another common intervention used in a lot of different toileting packages, toileting intervention packages. And those will vary based on the protocol, based on the needs of the client. But usually it will include an interval of time at which the learner is prompted or instructed to sit on the toilet for a designated amount of time based on their needs. So that was already covered in the RTT method.

John Lubbers: Got it. Yeah.

Sevan Celikian: The dry checks were also covered.

John Lubbers: Got it. So there was a really nice study. Having said that, Sevan, there’s a study by Greer, Neidert, and Dozier, it’s called: A Component Analysis of Toilet Training Procedures Recommended for Young Children. And this was a great study, it is in the Journal of Applied Behavior Analysis, pretty recent, 2016, and like you said, it has components in it that are, that relate back to Azrin and Fox in 1971. So, it was what it essentially did, is it, it was a component analysis. And what that means is it kind of analyzed the components of a toilet training program to see which was the most, what components individually were the most successful or if they were successful at all or if they needed to be combined to be successful. And in this particular study, the three components that it looked at were one, the use of underwear two, it’s called a dense sit schedule or essentially that’s kind of habit training. You know, I’m going to bring little Johnny or little Janie to the toilet, every two hours or every half an hour, whatever that sit schedule needs to be. And then three, was what we, they call it differential reinforcement or, what we would say is basically reinforcing, dryness probably. Good elimination and appropriate eliminations. Exactly right. Exactly. So the great thing about this study is it looked at them in terms of their separate things. So looked at, Hey, let’s try underwear only for this group of kids. Let’s try a dense sit schedule for a different group of kids and let’s try a differential reinforcement or a reinforcement program only for yet a third group of kids. And then, hey, you know what, let’s have a group of kids where we try all three, all three together.

Rei Reyes: This is very interesting. The result of this study was unexpected.

John Lubbers: It was.

John Lubbers: Yeah. Yes, yeah. Yes.

Sevan Celikian: The underwear was the big star of the study.

John Lubbers: Yeah. So you, so you started it.

Rei Reyes: You started it, Sevan.

John Lubbers: So I got to tell you this. When I read this study and I read some other, like we’ll, we’ll talk about, you know, a lit review study in a little bit probably. But when I was going through this and I saw recurring that underwear was an important component, it made me rethink my professional practice a little bit in the sense that, okay, when I start to comment on this and, and when parents ask me about this, I’ll make sure to emphasize that recent research and the body of research seems to be suggesting that that might be the most important component of this intervention. And that is wearing underwear, getting out of pull-ups, getting out of diapers and putting on underwear. You know, usually at my personal, when I toilet train my kids and then when my own children, and then when in professional practice, when I’ve done this, usually the concern is, Oh, we’re going to have a lot of mess.

John Lubbers: We’re going to have stuff to clean, tons of laundry to do, tons of mess around the house and then so it becomes a little bit of an issue of I guess maybe family tolerance to that potential threat, you know, that potential problem and then maybe even the realistic, temporary problem being there but then as we see in the article, like you said, Sevan, it seems like that is a pretty powerful, intervention for starting to potty appropriately and I think the article was kind of saying that that had some immediate effects to contribute to potty training.

Rei Reyes: You know what, guys, before we continue, should we go over the results?

John Lubbers: Sure. Okay. Or even should we start before that and go over a little bit the participants?

Rei Reyes: Okay. Participants.

John Lubbers: So we talk a little bit about that. So, like I said, it looked at three groups of kids, so there was one group of kids that were in one component. And let’s see, let me tell you a little bit about this. And just for discussion they used, some prompting procedures least to most in all cases the least amount of prompting that was necessary in all of those. So the total study, this study had 20 children, the preschool setting or a daycare? Yeah, some, some early school setting. They called it early childhood education, ECE setting I think. The average age of the kids was 26 months, so a little over two years, and the range was 19, so not too much younger, up to 39. So a little over three years old. There was one, all 19 that the kids were undiagnosed, neuro-typical or, no diagnosis yet of anything. One child, carried a diagnosis of autism spectrum disorder. Okay. and then they broke them into groups and it says the children were assigned to conditions or groups based on the number of children already assigned to each condition and teacher convenience. So, Hey, we’re gonna put three kids in the underwear only group. And we’ve already got three there. So now let’s put these other kids in the, the dense sit schedule group. And then, since we have, you know, six kids or three kids left over, let’s put them in the, the third group, which is the reinforcement only group and oh, you know, now we have 11 leftover, let’s put them in the, the combined group. So that’s kinda how they did it. It wasn’t super scientific, in terms of the assignment of kids to groups, but no problem with respect to that.

John Lubbers: So let’s talk a little bit about the different things. So underwear, the underwear was moving over from pull ups and diapers over into, either your typical cotton underwear or I believe there was something they called a plastic pant. Which was a pullup kind of thing. But the article, the authors implied in the article that it was pretty similar to a more typical thing and not so similar to a diaper or pull up. That’s what I garnered from the article when I read it.

Rei Reyes: I think something that they put over the underwear.

Manjit Sidhu: I actually looked it up a little bit going into it. So what it is, it’s kind of a halfway between a diaper and underwear, but, if you have an accident, you’re able to feel it, but it won’t leak. They mimic more visually, I mean, it feels like a regular underwear. So the inside of that is more like a real underwar. Where as a diaper is more like. Plasticy? So the feel of it is more definitely like underwear.

John Lubbers: We thought about this in terms of like intrusiveness, just, I’m just going to say this out loud, so I get this in my brain, but the most sort of intrusive would be a diaper and then we’d have next most would be a pull up, and then this, plastic pant or, okay. So that’s kind new.

Manjit Sidhu: With these new diapers and all that, even with pull-ups, when you’re wet, you don’t feel it, right? That’s the idea. That they can go several times in the same diaper and they’re not, irritated, or become upset by it. Whereas with these underwear, these plastic underwear, you feel it.

John Lubbers: Okay. Got it.

Manjit Sidhu: But it kind of helps the parent where nothing leaks or there’s no, you don’t, yeah.

Sevan Celikian: So now we’re seeing in some ways it can actually be a setback after a certain point. Right?

John Lubbers: Yeah. Yeah. Interesting. So maybe that’s another thing to add to our repertoire as practitioners is to find this and..

John Lubbers: Specialty websites. Okay. So not Amazon this time?

Manjit Sidhu: No, no. I looked to see if you can find it on Amazon.

John Lubbers: No. Okay. All right. Give them A year or so. Okay. So there were four children in the underwear group and then the dense sit schedule also had four children. It says the teachers prompted the children to sit on the toilet every 30 minutes. Okay. Instead of every 90 minutes. So the dense schedule means the group of kids sat on a toilet every 30 minutes. And then the differential reinforcement group, when the kids remain dry, at undergarment check times, or self initiating, they received teacher delivery of preferred items. So a tangible something that they could hold in play. Whether that be, I dunno, I’m just giving an example. I don’t know that this is the case, but it could be anything from a hot wheels car to an iPad or something that they could have in their hand. And then of course there was a toilet training package and six kids were in that group, including our child that was diagnosed with ASD. That was all three things. So both the underwear, the dense sit schedule and the reinforcement. Okay. Now shall we talk about results of this study?

Rei Reyes: Yes.

John Lubbers: We should put some dramatic music in there because it was so, it was a little unexpected for us.

Rei Reyes: For, I guess this will be for the training package combined after baseline. Two out of six kids responded well to that treatment. For underwear only after baseline, two out of four kids, 50%, on the lines of that. Underwear added as a second or third component. The benefits, the benefits was four out of six kids. Now. Dense sit schedule after baseline, no improvement.

John Lubbers: Interesting.

Rei Reyes: No improvement. Like no one, none of the kids benefited from it.

John Lubbers: So this is so common in schools. This is what almost..

Rei Reyes: It’s like a default. It’s a default treatment program. They all go there every hour or whatever.

John Lubbers: In preschool, it’s almost like ABCs and colors.

Rei Reyes: Go to circle time before snack after snack before sleep time. Yeah. So common. What a surprise. No improvement. And for me, differential reinforcement. No improvement.

John Lubbers: Us BehaviorAnalysts

John Lubbers: So I started to think about that a little bit more. And do you remember that I was saying that the reinforcer was a, a preferred, toy or activity kind of thing. What I was thinking there, you know, is a, if a behavior analyst really drilled down on that, you know, particular thing and I think it said they did preference assessments and that’s how they determined what was the reinforcer. But I would, I would probably comment that maybe that wasn’t a strong enough reinforcer to be able to kind of get that behavior and that’s why. So, and maybe there weren’t these types of strong behaviors. Contrast that with Azrin and Fox, which we talked about to start the podcast. Remember they were using, a large portion of a candy bar, powder coated sugar coated cereal and M&Ms for these, the correct behaviors, the appropriate behaviors. This is more a of a manipulative or some sort of toy so..

Rei Reyes: Perhaps.

John Lubbers: There’s something to the type of reinforcer, the strength of it and its ability to change behavior.

Rei Reyes: And also, you folks will remember this from grad school, DRO, they are reinforcing the non occurrence of that behavior. It’s not advice. I mean, that’s the way I’ve always been trained. If a dead person can do the behavior, do not target it for acceleration. So I think along with what Dr. Lubbers had said, I think the fact that they were reinforcing dry checks probably more often than the actual urinating behavior kinda like led to that. However though, underwear plus differential reinforcement.

John Lubbers: Well, if I can make one more comment before, because you just suggested to me something and it was kind of like.

John Lubbers: Yeah. Interesting to do. And again, relating this back to Azrin and Fox remember, Azrin and Fox used the electronic devices, the apparatus or the apparatuses, to be able to provide immediate feedback so that staff could go over and reinforce immediately and so, and then the interval for the reinforcement of dry was, what was that? Do we recall what that was? Was that, that was a pretty short interval. Was it not short? It may have been five minutes. I’m thinking it may have been like five minutes. I think in this study, the interval was longer. So perhaps the, the lack of the immediacy of the dryness and or the lack of the density of the reinforcement schedule might have also contributed there. So there could have been a couple of tweaks that might have resulted in some different, outcomes in this study, which it would be a great replication study but that was just some thoughts that you just made me think of right now. Right.

Rei Reyes: No problem. No problem. So coming back to that, the last results was underwear with differential reinforcement had a gain of three out of six, so 50%. So there it is. Underwear, underwear, keeps coming back. Who would have thought, but you know, in a way though, I mean, from my own experience, I have had the pleasure to work with some families over the years who had just jumped right into underwear. They just decided one morning during a potty party, let’s take it off. And the kids immediately just ran to the bathroom when they needed to void. So I can see where this is coming from. It is a big jump. And I think Dr. Lubbers has mentioned this earlier about the messes. Cause I have an experience with families that have one group were open to just jumping into underwear. And the other group that will say no, that’s probably the folks with hardwood floors. So I’m thinking about this. So it just boils down to really that, I mean this research had shown it that, you know, underwear only is, you know, pretty good idea to start. But the hardest part really is having caregivers be in that correct mindset. You gotta be ready for messes.

Sevan Celikian: Thinking of the cost benefit aspect of it. It almost might be worth it to deal with one or two or three messes. However, in the long run it may speed up the toileting process. Cause it will function as an adversive to the learner.

Manjit Sidhu: But then It comes to the readiness of the family.

Rei Reyes: However they did bring up that new hybrid underwear. So maybe that in combination with, actually just that alone, forget the underwear, just use of that hybrid underwear to, to, to use instead. Maybe the best of both worlds. Exactly. Parents will know. Okay. No, not too much mess but at the same time.

John Lubbers: But you get the effect.

Rei Reyes: Exactly. I don’t think there is a study about that.

John Lubbers: Okay. Alright. Seeds are being planted. So let me, let me just state that again for for effect because I think that’s really important in this really, you know, to use a quote, my, my high schooler, I was shook when I read this, she said, all right, it says here, the underwear component seemed to facilitate toilet training for at least two of the four children. So and just on its own on its own, putting underwear on these kids kind of facilitated or helped contribute to toilet training for two of the four. That’s pretty good. That’s a pretty easy intervention and that’s pretty good you’re batting 500 or 50% success rate there just by putting on underwear. So, no other component seem to be as successful right?

Sevan Celikian: So even though there isn’t necessarily empirical data out there on the effect of why underwear is so effective right off the bat, I guess we can discuss why that’s the case. Obviously there is an aversion, it’s most likely aversive for the learner to experience the feeling of, of wetness and, and you know, the, the, the messiness of it where it becomes a learning experience for, for the following time or the following couple of times where they wanto to escape that feeling.

John Lubbers: Yeah. Yeah. I might throw into this kind of brings us back to our behavior analysis theory, but, I think that it may become what we call in our world a discriminative stimulus, or, or essentially in layman’s terms, it’s a cue, like, you know, to the kids, they kind of realize, Hey, something’s different, I’m not wearing pull-ups or diapers anymore. I got my boy boy underwear, I got my, Cinderella or my, Ironman underwear on and things are different now. So it may serve as some sort of trigger or cue to our kids that, Hey, you know, now we do things a little differently.

Rei Reyes: More social, I guess.

John Lubbers: Yeah. Perhaps. I think they also talked about like, I think the authors in this article we’re talking about, they also thought that sometimes that the kids found it unpleasant if they had soiled their favorite underwear, and kids do get their favorite underwear, like, Oh I have my iron man and I want those. I want, you know, like the boy who wants to wear iron man all week long, you know, so you have to have five pairs of them or something like that or wash every night. If they had to, if they soiled them and had to take them off and change them, they were, the authors were hypothesizing because a couple of the kids cried when they, they didn’t get to wear them anymore, but that was unpleasant. So that became a motivation for them to stay dry.

Sevan Celikian: That makes sense. That’s interesting. It’s like a response cost they have an accident, they miss out on their favorite underwear for a certain amount of time.

Rei Reyes: They also said that, along the lines of that, you know, when they have an accident, they get changed. Basically they get pulled away from their favorite activity or whatever they engage in at the moment. So in a way they avoid that by going on a toilet from from an ABA perspective, it does make sense.

John Lubbers: Yeah. So talking about the dense sit schedule and the results there, let me read what the authors write here. It says overall the dense Sit schedule. And remember that was the taking the child to the bathroom every 30 minutes, did not produce overall improvements in toileting performance for any of the four children. So that was okay. So the underwear did two out of the four, dense sit schedule did zero out of four, no improvement at all just in and of itself. And then of course our behavior analytic stuff, which was the, reinforcement based stuff. Okay. Overall, differential reinforcement failed to produce overall improvements in the toileting performance of any of the four children. So it really didn’t have any effect either. It was just like a dense sit schedule. It really didn’t do much. Again, compare that with a underwear which had two of the four kids have some success.

John Lubbers: And now with respect to the package guys, what do we see with respect to a package?

Rei Reyes: I believe they said two out of six.

John Lubbers: Two out of six of those. Okay.

Rei Reyes: So second.

Sevan Celikian: And by improvements we’re referring to successful eliminations and fewer accidents.
John Lubbers: Right. Exactly. Yeah. More dry time and more successful potty. Exactly. So interesting, really interesting study to look at this component analysis. Going back to some of the stuff we talked about with respect to the underwear guys, I thought, I was starting to think when I was reading it, the implications of this, remember when we’re talking about, you know, say a three or a four year old, when we’re, training them, they may be in a pre-K or, kindergarten kind of setting a preschool kind of setting. Sometimes, those preschools will say, oh no, you must send your son or daughter in a diaper.

John Lubbers: We won’t accept them otherwise. So we have to think about that with respect to our potty programs, you know, and how they’re gonna affect them. What we’re seeing here in our study so far is getting diapers off, getting pull-ups off and getting, underwear on is really the way to go, the route to go. And to start to, you know, build in these reinforcement schedules, maybe to start to, habit train a little bit. But to teach the other skills as well, the dressing and the hygiene, that’s really what it seems to make a good intervention program for most individuals. I think we have to kind of now take into consideration too, that maybe our school programs or I don’t want to just throw shade at school, but any other environment that the kids will be in that, that may work counter to us to what we see the literature says and we’ll, we’d have to kind of account for that.

John Lubbers: Or maybe it even, contraindicates or suggests to us, hey, maybe now’s not the time to do it. Even though we may feel it’s appropriate, even though maybe, the family may have brought it up. There may be a time where it’s like, Oh yeah, but we’re in a school setting for 12 hours and 12 hours. They want them, you know, because it’s a, a school setting, a preschool or kindergarten and now they’re going into an aftercare. They’re in some school setting or even with grandparents, you know, where grandparents are like, hey, I can watch, grandchild, but I can’t, you know, I have health issues. I can’t, you know, attend to changing their diapers or what have you. So maybe it makes some sense that we really need to kind of take that factor and a little heavier moving forward. What do you think?

Sevan Celikian: Absolutely, especially in the beginning of the intervention, it’s really important to create that consistent environment where everybody can be on the same page where there isn’t really any limitations or inconsistencies. Kind of like the school example that you brought up where numerous learning opportunities, consistent learning opportunities can be created. And once, you know, there’s some success and we move into the maintenance phase, the generalization phase, then some differences in environment, people and you know, different factors can be a little bit easier to work with because the bulk of the skills ideally would have been taught by then. Great. So is there anything else we want to touch on with the Greer study?

John Lubbers: Yeah. Should we talk about Greer or a little bit? I think that was an interesting study. Oh sorry, sorry Francis. Right?

Sevan Celikian: Yeah. So, that one pretty much covered the main assessments that are used out there. We kind of covered the potty a little bit and then some of the different interventions, most of them were already used in the Azrin and Fox RTT approach. Did we miss anything guys? Is there any other interventions or things we want to bring up?

John Lubbers: With respected Greer or outside of Greer?

Sevan Celikian: Greer or Francis.

John Lubbers: Okay. Francis is a nice lit review. Do we want to talk a little bit about that you guys? What is relevant or interesting for our parents from that Francis study? Is there anything that we really, some highlights?

Rei Reyes: It was a good review of all existing current treatment, toileting plans, toileting programs pretty much. Right? And it did cover a lot of those similar same materials we’ve gone over already. So where do we go from here folks?

John Lubbers: Well we have some interesting takeaways. I again, like I said numerous times, this is really an interesting exercise for me to kind of go back and revisit some of these articles, look at some current research. I think usually what we want to end up is giving our listeners some takeaways, some things for them to think about and to take to their particular situation, their children, or loved ones or the people that they work with. What do we think we got out of these?

Rei Reyes: Well I think, one of the things that our folks, our listeners can get from this is about the Greer study, by the component analysis study. I mean, that was the whole point of the researchers then, like, let’s figure out what works. But at the same time, let’s figure out what does not work. Because if we know what does not work, then maybe we can focus on those that will work. Right. So for this study, they did say that, a dense sit schedule alone will not produce the desired results. They did suggest that a differential reinforcement system in their study did not produce a lot of results. However, did it cover some programs, components that appear to work and that will be primarily, mostly underwear. Right. That’s really something to think about and if we think about it too, pairing underwear with differential reinforcement, will produce some results and underwear within the treatment package, will also produce some results. So for me, and I think for our listeners, it’s really to start having that conversation within your family and figure out maybe you should give it a shot and maybe by yourselves or maybe with the assistance of a provider. But it is worth considering given the research.

John Lubbers: Well, can I add just to back it up a little? I’m sorry to jump in there and stop the train but I think pulling it back a level is, when we talked about Matson, we talked about assessment. Yes. So, maybe before we even get to intervention, which is where you are talking a lot there Rei which is great, is maybe we start to look at conducting an assessment of what’s going on. And that assessment could be this POTI assessment by Matson and we can kind of get a global, big picture, 10,000 foot level perspective on what’s going on, where are the problems, what are they essentially. So the professionals are working in this situation can kind of understand that and then we can start looking at it in intervention. Maybe we conduct preference assessments to kind of figure out what are reinforcers. And then when we jump into intervention, we, I think you were saying this Rei, but I think it’s pretty much a given that underwear, it should be a part of the component package. Unless I miss, unless I mispoke for you.

Rei Reyes: From my take on it, that’s pretty much what our study is.

John Lubbers: Yeah. Yeah. I mean there’s probably going to be some individual situations where it’s going to be difficult or what have you in those would need to be brought up and addressed. But you know, maybe some children that don’t like to wear underwear, and they prefer to be without them. What do you do in this situation where a child refuses to wear underwear? Well, that would be something you’d have to address individually.

Rei Reyes: Maybe families can start, using that specialized hybrid underwear that, the one of the researchers had brought up. If just underwear alone is too much of a jump. But I have to say it is quite a big jump. I mean, I don’t want my floor to be dirty. Right. You know, if there is some compromise there, I think the plastic underwear is a place to start is how to look for it. And maybe from there give it a shot. And I’m like, what the researchers have suggested to us, it will make some kind.

John Lubbers: Yeah. And I think with respect to underwear, you know, I think what was suggested in one of our articles is that maybe we try to get some buy in with our kids in the underwear and maybe we try to get a little bit of an effect of, Hey, favorite underwear. So pick an underwear that the kids like, maybe even letting them have a choice in it, you know, so you pick the underwear, you like, these are the Harry Potter underwear, these are the, guardians of the galaxy, underwear, whatever. And then we, maybe we get a little bit of an effect of these are preferred. I want to keep them, I don’t want to soil them, et cetera. And so we can kind of benefit that from that as well. Reinforcement, maybe what we kind of garnered from articles today, at least what I got out of this was that we need to find powerful reinforcers because the reinforcers alone in one study weren’t working. But in Azrin and Fox, the edibles, the candy bar and the cereal and the M&Ms worked just fine. Of course those were adults and we’re talking about kids, you know, maybe there’s something to that then. I know in present day we tend to prefer not to have to resort to edibles because of the, the associated potential health benefits of, weight gain and yeah, nutritional complications there. So sometimes we kind of shun or shy away from that. But maybe in these, really important to the family kinds of things, maybe that’s something that you do explore is really thinking about, using those real powerful edibles again,

Manjit Sidhu: What works for your child.

Rei Reyes: It is very temporary. These reinforcement programs are not designed to last for years at a time. We’re looking at a few days, then the schedule is thinned out or they don’t get as much treats as before. It is a way.

Sevan Celikian: The reinforcement becomes naturally occurring. Successful, toileting.

John Lubbers: Yeah. And then I guess the last part of this was the habit training, right? Was the a sit schedule or bringing that and in, although that’s what they use an awful lot in a lot of preschool settings and stuff like that. That seems to be the least effective or efficacious. Maybe all it really teaches is what was brought in Azrin and Fox was the going to the bathroom actually physically moving into the bathroom. So that’s really what that teaches and not much else about using the bathroom. And then I think, the last thing is we need to teach those skills that are associated self care skills. So undressing, dressing, wiping and cleaning, washing hands, all those things need to be taught as well. So those seem to be like the general takeaways guys. Did I miss anything?

Sevan Celikian: No. To all the listeners out there, to the parents and the caregivers, we hope we gave you, a useful menu of different interventions that can be used or discussed with your providers and some different assessment methods. And hopefully this will be helpful to everybody out there.

John Lubbers: Yeah, and as always, we’ll have a transcript of this on our website and we’re interested in your feedback, your questions, your comments, and if you have suggestions for future shows, we’d be happy to receive those. Thank you again for listening.

Outro: For more insight from the Leafwing Center, please visit the Leafwing Center website and blog page at leafwingcenter.org. Email us at [email protected] or visit us at your favorite social media outlet. Feel free to submit questions or comments about this or future podcasts and we will put links to information discussed in today’s show on the website. We look forward to next time. Thank you.