Toilet training for children with Autism Spectrum Disorders
Toileting successfully is a skill that has a significant and long-term impact on an individual’s quality of life outcome. By actively teaching toileting skills, we can have an immediate impact on levels of independence at home and school; increase opportunities for social & group acceptance; widen options for work and school that may not otherwise be possible; and decrease frustration and the risk of abuse as they become adults. Interventions presented will focus on how to identify and implement the most appropriate toilet training strategy for your child/student.
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[00:00:11.560]Welcome to the webinar,
[00:00:12.740]Toilet Training for Children on the Autism Spectrum.
[00:00:15.810]I am Melinda Henson, BCBA, behavior analyst
[00:00:18.940]for the Nebraska Autism Spectrum Disorders Network.
[00:00:22.110]This webinar has been developed
[00:00:23.550]in collaboration with Jamie Lewis,
[00:00:25.500]special education and central region coordinator
[00:00:28.120]for the Nebraska ASD Network.
[00:00:31.820]Learner objectives for the toilet training webinar lesson
[00:00:34.790]will include the ability to identify the importance
[00:00:37.730]of toilet training and common barriers
[00:00:39.780]for individuals with an ASD.
[00:00:42.330]Recognize child readiness, environmental,
[00:00:44.670]and visual routines to build success.
[00:00:47.620]Develop an understanding of three different types
[00:00:50.090]of evidence-based toilet training techniques.
[00:00:52.790]and to understand how to teach initiations
[00:00:55.240]and enhance generalization success.
[00:00:59.420]Why focus on toileting in school settings?
[00:01:02.100]Some primary reasons include goals
[00:01:04.010]for increasing social acceptance, and independence,
[00:01:07.180]while decreasing potential health risks
[00:01:09.040]such as skin breakdowns.
[00:01:10.810]Teams may also want to consider the cost
[00:01:12.780]associated with not including toileting
[00:01:14.940]as a priority IEP goal
[00:01:16.930]that include time spent assisting the child
[00:01:19.140]rather than engaging in other educational activities,
[00:01:22.230]the energy of staff and family,
[00:01:24.460]and resources required physically and monetarily.
[00:01:30.320]Common barriers to teaching toileting
[00:01:32.140]to individuals with an ASD include difficulties
[00:01:35.140]in communication and understanding.
[00:01:37.320]Teachers must tailor instruction
[00:01:39.200]to a range of potential skills
[00:01:40.840]as students may include non-vocal individuals
[00:01:43.600]to those that repeat words or phrases without meaning
[00:01:46.410]or those that have very literal interpretations of language.
[00:01:49.700]Additionally, learners often need to be explicitly taught
[00:01:52.530]and reinforced for asking to use the bathroom,
[00:01:55.150]and fears of bathroom related stimuli
[00:01:57.280]may cause a few initial roadblocks.
[00:02:01.750]It is important to note that what may appear to be
[00:02:04.090]a lack of motivation for toileting independently
[00:02:06.970]may actually be masking related skill deficits.
[00:02:09.960]For example, an altered perception of social appropriateness
[00:02:13.240]may stem from a lack of awareness of social norms,
[00:02:16.250]and of the stigmatizing impact of not being toilet trained.
[00:02:19.390]Challenges with attention, organization, and sequencing.
[00:02:22.790]Motor difficulties that include
[00:02:24.310]inconsistent or absent imitation skills,
[00:02:27.210]as well as difficulty managing clothing
[00:02:29.160]as needed for toileting success.
[00:02:34.260]Individuals with ASD often have a preference for routine,
[00:02:38.040]including non-functional or potentially detrimental routines
[00:02:41.620]and may engage in repetitive actions,
[00:02:43.650]show resistance to change, and possibly have a history
[00:02:46.880]of related health issues such as
[00:02:48.460]constipation or loose stools, urinary tract infections,
[00:02:52.040]irregular bowel movements, or a history of discomfort.
[00:02:58.200]Sensory issues could include sensitivity to certain stimuli
[00:03:01.600]like texture of toilet paper,
[00:03:03.600]sensitivity to cold with no clothes on,
[00:03:06.010]sensitivity to sensations of voiding,
[00:03:08.550]lack of awareness of body sensations,
[00:03:11.040]gravitational insecurity while sitting on the toilet
[00:03:13.710]with feet not touching the ground,
[00:03:15.650]or an aversion to loud or unpredictable noises
[00:03:18.080]in the bathroom setting.
[00:03:22.750]Some signs of toileting readiness
[00:03:24.590]include physical skills such as
[00:03:26.260]the ability to sit upright unassisted
[00:03:28.280]for at least five minutes at a time,
[00:03:30.470]hold urine for at least an hour,
[00:03:32.470]having no medical conditions that would
[00:03:35.970]and having some ability to help undress themselves.
[00:03:39.070]Other significant cues for readiness
[00:03:40.940]such as staying dry for one to two hours at a time
[00:03:43.830]and having regular bowel movements
[00:03:45.460]can indicate to us child readiness.
[00:03:51.160]Individuals show best success with toileting
[00:03:53.560]when they have a mental age greater than two years,
[00:03:56.300]can follow one-step directions within context,
[00:03:59.210]have shown some interest in the toilet or bathroom,
[00:04:01.900]and may have begun to show awareness of being wet
[00:04:04.560]although this awareness can be hindered
[00:04:06.330]by the use of diapers and/or Pull-Ups.
[00:04:09.070]Please note that these are general guidelines
[00:04:11.140]and exceptions may exist for those
[00:04:12.840]who are physically or cognitively
[00:04:14.550]unable to complete these steps.
[00:04:19.520]Toilet training can be challenging for children with ASD
[00:04:22.370]for a variety of reasons.
[00:04:24.230]It may take a long time,
[00:04:25.590]but many children learn to use the toilet.
[00:04:28.010]Most children with ASD learn to urinate
[00:04:30.210]and have bowel movements in the toilet
[00:04:32.040]later than other children.
[00:04:33.670]While this can take time, there is always something
[00:04:35.820]a child with ASD can do independently as part of toileting.
[00:04:39.520]Training may have to look different
[00:04:41.030]than it does with typically developing children.
[00:04:46.460]During the remainder of this webinar,
[00:04:48.370]I will discuss different phases of toilet training.
[00:04:51.200]These phases include increasing awareness of toileting,
[00:04:55.070]adding supports visually and reinforcement-based,
[00:04:58.780]defining the problem medical versus non-medical issues
[00:05:02.120]and how to use the elimination record.
[00:05:04.500]An introduction to the toilet,
[00:05:06.250]choosing your toilet training technique,
[00:05:08.560]teaching initiation skills, and fostering independence
[00:05:11.920]within natural settings.
[00:05:15.840]What do you think?
[00:05:17.110]What common barriers come to mind
[00:05:18.940]when you think of your focus student?
[00:05:21.100]Let's take a moment to consider.
[00:05:36.810]Before you get started,
[00:05:38.280]first evaluate any needs for proper dress
[00:05:40.840]and how to create an appropriate bathroom environment.
[00:05:46.590]First thing's first, toileting success begins
[00:05:49.470]with eliminating diapers or Pull-Ups
[00:05:51.340]from the training time periods.
[00:05:53.450]Learners must be able to feel wetness
[00:05:55.300]when they have an accident.
[00:05:56.820]Adults may want to consider the use
[00:05:58.530]of thicker training underwear that will hold some urine
[00:06:01.540]but still allow the child to feel damp,
[00:06:03.650]or use regular underwear,
[00:06:05.070]potentially with favorite characters on them,
[00:06:07.330]alone or with plastic protectors
[00:06:09.150]that can be worn outside of the underwear.
[00:06:11.510]Of course, change any wet or soiled clothing
[00:06:14.050]immediately following any accident.
[00:06:18.610]A study conducted in 2004 asked the question,
[00:06:21.960]do diapers just capture urinary accidents,
[00:06:24.830]or do they also set the stage for their occurrence?
[00:06:28.090]Researchers found that significantly more accidents
[00:06:30.530]happened while wearing a diaper than when in underwear,
[00:06:33.470]and concluded that wet diapers often provide a rationale
[00:06:37.230]for their own continued use.
[00:06:39.220]Because diapers and Pull-Ups are designed
[00:06:41.060]to take away the sensation of being wet,
[00:06:43.350]they may actually contribute to continued incontinence
[00:06:46.130]and lack of bladder control and body awareness.
[00:06:51.980]When planning to start toilet training,
[00:06:54.100]talk with families about dressing their child for success.
[00:06:57.270]Choosing clothing that is easy for the learner to remove,
[00:07:00.230]while avoiding clothing that can be distracting
[00:07:02.300]or based primarily on attractiveness,
[00:07:04.230]will help the child find success.
[00:07:06.570]Clothing that has elastic waistbands,
[00:07:08.560]fits loosely, and shorter shirts are all good choices.
[00:07:11.950]Conversely, clothing with difficult closures,
[00:07:14.250]tight bottoms, or overalls that require extra steps
[00:07:17.200]may hinder the process.
[00:07:21.040]Deciding whether to begin toilet training for boys
[00:07:23.640]seated or standing is a frequent question
[00:07:25.880]from parents and teachers.
[00:07:27.650]Initial steps in toilet training typically has the learner
[00:07:30.410]seated on the toilet until they have
[00:07:31.870]established successful habits.
[00:07:33.950]At that point, team members will want to consider
[00:07:36.320]the best way to build long term functional routines
[00:07:38.990]and can start by answering questions such as
[00:07:41.750]does he distinguish between urination and bowel movements?
[00:07:44.600]Are their male role models
[00:07:45.920]available to demonstrate standing?
[00:07:47.770]And how do we build social awareness in public?
[00:07:52.230]When evaluating your bathroom environment,
[00:07:54.510]identify any potentially dangerous items
[00:07:56.790]such as hot water temperature or poisonous materials,
[00:07:59.950]ensure that the learner can access
[00:08:01.620]the sink, soap, toilet, and toilet paper independently
[00:08:05.190]and consider modifications such as step stools
[00:08:07.680]that allow feet to reach the ground,
[00:08:09.600]a toilet seat riser to place arms for stability,
[00:08:12.370]and possibly a sticky note or cup with cutout
[00:08:14.950]to place over an automatic flusher
[00:08:16.770]if the learner is sensitive to unexpected noises.
[00:08:21.500]When building a bathroom routine,
[00:08:23.080]predictability is essential.
[00:08:25.090]Establish a routine by completing a task analysis
[00:08:27.970]and running through each step before creating
[00:08:30.060]visual supports and beginning training.
[00:08:32.470]Follow a schedule as determined by the elimination record
[00:08:35.480]or intensive toileting timing sequence,
[00:08:38.070]and increase fluid intake close to the time scheduled
[00:08:40.780]for toileting opportunities.
[00:08:44.960]An example of a toileting task analysis
[00:08:47.450]includes steps such as entering the bathroom,
[00:08:50.590]undressing, sitting on the toilet,
[00:08:52.700]voiding the bladder and/or bowels,
[00:08:54.830]get the toilet paper, wipe, dispose of toilet paper,
[00:08:57.940]get off the toilet, pull up clothing,
[00:09:00.230]flush once, wash hands, dry hands,
[00:09:02.950]indicate completion, and exiting the bathroom.
[00:09:08.400]Visual schedules may be presented vertically,
[00:09:10.630]horizontally, or in columns or rows.
[00:09:13.340]Some learners may be successful
[00:09:14.930]with representative pictures or written steps
[00:09:17.170]while others may require real pictures.
[00:09:19.700]Teams will want to initially shape behavior
[00:09:21.770]by reinforcing successive steps of the sequence
[00:09:24.360]rather than waiting for the entire chain to be complete.
[00:09:27.360]For example, reinforce sitting on the toilet,
[00:09:29.660]then urinating, and each step thereafter
[00:09:31.730]until entire sequence is achieved.
[00:09:33.980]Also, know that backward chaining can be useful
[00:09:36.580]if forward chaining is not working well.
[00:09:42.840]Begin teaching toileting skills
[00:09:44.640]by actively reinforcing the earliest
[00:09:46.840]or weakest step in the process.
[00:09:49.160]Reinforcement is best when it is immediate,
[00:09:51.600]powerful, and not accessible in other situations.
[00:09:55.040]Always pair delivery of tangible items with social praise
[00:09:58.550]and gradually fade tangible reinforcement
[00:10:00.890]as toileting successes increase and accidents decrease.
[00:10:07.040]Toileting success can be most effectively achieved
[00:10:09.760]with good communication between home and school.
[00:10:12.600]Ideally, promote consistent strategies across environments
[00:10:15.830]and share observations and techniques.
[00:10:18.300]Do your best to avoid blame or anger
[00:10:20.170]and keep team members informed
[00:10:21.740]of any dietary or medical changes.
[00:10:24.200]It is important to note, however,
[00:10:25.770]that toileting success can still be achieved
[00:10:27.990]if either party is unable to secure follow through.
[00:10:31.090]But the process will likely be slower
[00:10:32.900]and with more difficulty than it would otherwise.
[00:10:37.460]Pre-teaching or priming lets the learner preview a skill
[00:10:40.900]before it is to be used.
[00:10:42.600]This can be achieved by modeling actions
[00:10:44.600]for the learner to imitate,
[00:10:46.070]developing social stories about the act of toileting,
[00:10:49.140]watching videos about toileting,
[00:10:50.780]and/or utilizing toilet training apps on devices.
[00:10:54.180]Or even introducing a toileting doll to the learner.
[00:10:57.360]Video modeling has been shown to be most useful
[00:10:59.940]and effective when used immediately before
[00:11:01.980]practicing the skill to be taught.
[00:11:06.570]Individuals with autism may have skill deficits
[00:11:09.250]in body awareness and the ability to label body cues.
[00:11:12.580]Increasing that ability to identify body states
[00:11:15.140]can be helpful to the toileting process.
[00:11:17.680]For example, labeling actions the adult sees
[00:11:20.400]when the child has to void,
[00:11:21.810]such as I see you moving fast,
[00:11:24.270]that means you have to go to the bathroom.
[00:11:26.100]Or, I hear you grunting, that means you have to poop.
[00:11:29.620]Assigning meaning to the feelings the child is experiencing
[00:11:32.600]to the best of your ability can be a helpful strategy.
[00:11:37.950]What do you think?
[00:11:39.010]What is one new idea that will help you
[00:11:41.000]set your student up for success?
[00:11:43.250]Let's take another moment to consider.
[00:11:56.640]An elimination record is a specific type of data collection
[00:12:00.020]that is recorded before beginning intervention efforts
[00:12:03.080]to help identify optimal times for toilet training.
[00:12:08.490]Elimination records can help identify
[00:12:10.640]best times to focus intervention efforts
[00:12:13.290]by tracking frequency and time of day
[00:12:15.410]for urination and bowel movements.
[00:12:17.630]You will want to keep this data sheet in the bathroom
[00:12:19.780]for easy access while focusing first on daytime patterns
[00:12:23.260]and following a fixed schedule for recording information.
[00:12:26.910]You may want to track occurrences for up to two weeks
[00:12:29.430]to identify urination and bowel movement patterns.
[00:12:32.450]Sample data sheets are included
[00:12:34.070]with handouts for this webinar.
[00:12:37.350]After tracking elimination patterns,
[00:12:39.760]it is time to introduce the toilet to the learner.
[00:12:42.570]Use your data to determine a consistent schedule
[00:12:45.140]and take a learner into the bathroom
[00:12:47.180]five to 15 minutes before the time indicated.
[00:12:50.260]During this phase, our job is to make the bathroom routine
[00:12:53.310]fun and comfortable by pairing the environment
[00:12:55.710]with favorite items or activities
[00:12:57.640]and teaching preliminary skills
[00:12:59.470]like sitting on the toilet for up to five minutes at a time.
[00:13:05.070]Evidence-based toilet training techniques
[00:13:07.240]include habit training and intensive toilet training.
[00:13:10.310]Used in combination with bladder and bowel control,
[00:13:13.050]or continence strategies.
[00:13:17.070]Habit training is a specific toilet training technique
[00:13:20.230]that is used to develop continence
[00:13:21.950]by scheduling and regularly providing access to the toilet.
[00:13:25.810]This strategy is recommended
[00:13:27.230]when first introducing toileting
[00:13:29.310]in order to pair the environment with reinforcement
[00:13:31.700]and to teach preliminary skills.
[00:13:34.120]Or to establish routines for learners
[00:13:36.560]without awareness of the need to go
[00:13:38.330]or ability to identify when they are wet.
[00:13:40.850]Often with a mental age of less than three years.
[00:13:45.820]Habit training tips include
[00:13:47.800]refraining from offering the bathroom as a choice,
[00:13:50.720]using words, gestures, or picture icons
[00:13:53.160]the learner can adopt in the future,
[00:13:55.250]taking the learner to the bathroom
[00:13:56.760]based on identified times,
[00:13:58.710]minimizing attention to any accidents
[00:14:00.810]by quickly and neutrally changing the learner,
[00:14:03.530]and continuing to follow the schedule
[00:14:05.580]as if an accident had not occurred.
[00:14:07.730]As always, positive reinforcement works wonders.
[00:14:13.410]Habit training can prepare individuals
[00:14:15.590]for spontaneous access to the bathroom,
[00:14:18.300]may encourage the learner to initiate
[00:14:20.160]going into the bathroom prior to the scheduled time
[00:14:23.120]while pairing the act with the sensation,
[00:14:25.580]and helps to develop regular elimination patterns
[00:14:28.530]or the holding of urine and/or bowel movements
[00:14:30.820]until sitting on the toilet.
[00:14:35.340]Intensive toilet training means devoting three days
[00:14:38.120]almost exclusively to toileting,
[00:14:40.390]providing higher amounts of liquids,
[00:14:42.210]frequent toilet sit times, and significant levels of
[00:14:45.030]reinforcement for success voiding into the toilet.
[00:14:48.410]This strategy is appropriate for learners
[00:14:50.300]who are not successful at preventing accidents
[00:14:54.400]or the current strategy does not allow
[00:14:56.160]for intensive, frequent reinforcement
[00:14:58.310]in order to motivate toileting success.
[00:15:02.510]Additionally, intensive toilet training is appropriate
[00:15:05.740]when the learner does not voluntarily eliminate.
[00:15:08.490]For example, voiding their bladder or stools
[00:15:10.820]immediately after getting off the toilet
[00:15:13.340]or having intense negative behavior in the bathroom.
[00:15:16.440]Remember that frequently feeling wetness against the skin
[00:15:19.130]may desensitize the learner,
[00:15:20.750]and frequent accidents even when following a schedule
[00:15:23.950]is often another indicator that intensive toilet training
[00:15:32.640]While implementing intensive toilet training,
[00:15:35.150]adults will follow a schedule
[00:15:36.580]to increase liquid intake for the first two days,
[00:15:39.530]will have the learner sit on the toilet
[00:15:41.150]or within immediate proximity until they successfully
[00:15:43.860]eliminate and access reinforcement.
[00:15:46.060]And ensuring that as soon as they do eliminate,
[00:15:48.300]they are able to get off the toilet
[00:15:49.940]and then begin following a systematic
[00:15:52.080]and intensive toilet sit schedule.
[00:15:56.350]Intensive toileting sit schedules
[00:15:58.220]have the learner returning less than 30 minutes
[00:16:00.540]after successful elimination.
[00:16:02.800]The goal is to make accidents impossible
[00:16:04.810]during the first two days by frequently sitting
[00:16:07.090]and staying in very close proximity to the toilet
[00:16:10.070]while increasing fluid intake and providing preferred items
[00:16:13.830]while sitting but getting more desirable items
[00:16:16.940]upon successful elimination.
[00:16:21.240]A study conducted in 2002 examined the effects
[00:16:24.730]of intensive toilet training on three children with autism.
[00:16:28.070]They remained in the bathroom area,
[00:16:29.800]were provided free access to liquids,
[00:16:32.150]and prompted to sit on the toilet every 30 minutes
[00:16:34.760]or immediately upon detection of an accident.
[00:16:37.500]Reinforcement was only given if urination
[00:16:39.830]was completed on the toilet.
[00:16:43.870]Following any spontaneous requests to use the toilet,
[00:16:47.100]prompting by adults was stopped.
[00:16:49.000]After multiple spontaneous requests,
[00:16:51.330]fluid intake was returned to normal
[00:16:53.090]and full clothing was returned
[00:16:55.040]and the child was gradually faded out of the bathroom
[00:16:57.440]and back into their classroom environment.
[00:16:59.850]Results of this study show that it took children
[00:17:02.170]seven to 11 days to achieve self-initiation
[00:17:05.290]with zero accidents.
[00:17:09.750]A study conducted in 2005 on intensive toilet training
[00:17:13.300]for children with autism
[00:17:14.850]focused on learners with some previous experience
[00:17:17.420]with low intensity or habit training techniques.
[00:17:20.410]They were seen in-clinic with a large bathroom,
[00:17:23.040]were provided increased fluids
[00:17:24.700]paired with communication training,
[00:17:26.450]and reinforcement was given for initiations
[00:17:28.990]as well as urination in the toilet.
[00:17:33.780]Children in this study were provided with a urine sensor
[00:17:36.500]placed in their underwear to detect accidents.
[00:17:39.280]At the sound of the alarm,
[00:17:40.500]children were taken to the bathroom
[00:17:42.070]to sit on the toilet for one minute.
[00:17:44.120]If they completed urinating in the toilet,
[00:17:46.190]they received reinforcement
[00:17:47.530]and positive practice was avoided.
[00:17:49.660]However, if an accident was not followed
[00:17:51.950]by urination in the toilet,
[00:17:53.720]the learner was exposed to positive practice
[00:17:56.000]in which they would be prompted to remove pants,
[00:17:58.330]sit, stand, dress, return to site of accident,
[00:18:01.290]and repeat this process four times.
[00:18:05.060]The sitting schedule used in this study
[00:18:07.130]was divided into 12 levels, beginning with a 10 minute sit
[00:18:10.800]followed by five minutes off of the toilet.
[00:18:13.550]The schedule progressed by one level each hour day one,
[00:18:17.630]one level each half day, days two and three,
[00:18:20.650]and one level every two days,
[00:18:22.580]day four and until the schedule was removed.
[00:18:25.240]The urine alarm was removed following
[00:18:27.120]specified success criteria.
[00:18:32.270]Participants had not benefited from low intensity
[00:18:35.070]scheduled toileting and reinforcement prior to this study
[00:18:38.470]but did benefit from an intensive treatment package
[00:18:41.110]that included positive practice.
[00:18:43.220]It is worth noting that participants experienced
[00:18:45.510]only six to 15 instances of positive practice
[00:18:48.690]before becoming continent.
[00:18:50.640]Data on initiations suggests that
[00:18:52.580]frequently-prompted toileting events
[00:18:54.470]may remove the opportunity for the child to experience
[00:18:57.740]a full bladder, which could serve as a motivator
[00:19:00.320]for initiating toileting.
[00:19:03.550]Continence strategies are typically used in combination
[00:19:06.550]with habit training or intensive toileting techniques
[00:19:09.620]to develop bladder and bowel control.
[00:19:12.100]Bladder control is easier to teach
[00:19:14.130]because of frequency of opportunities
[00:19:16.060]and ease of manipulating fluid intake.
[00:19:22.010]Bladder control, or continence,
[00:19:23.950]means that the learner can feel a full bladder,
[00:19:26.640]voluntarily start urination, feel their bladder emptying,
[00:19:30.790]voluntarily stop urination, feel an empty bladder,
[00:19:34.270]and feel wet clothing or bedding.
[00:19:36.490]Please refer to the handout, Bladder Control Tips & Tricks,
[00:19:39.740]for additional information on problem solving
[00:19:42.110]for bladder control.
[00:19:45.690]Think about your student and their current environment.
[00:19:48.730]Which toileting technique is a good fit?
[00:19:51.530]Please take a moment to consider.
[00:20:05.380]Let's move now to independence
[00:20:07.150]and generalization of toileting skills.
[00:20:09.710]Adults will need to know how to best handle accidents
[00:20:12.310]when they occur, how to teach initiation
[00:20:14.840]to individuals with autism, and how to prepare learners
[00:20:18.060]for generalization to toileting in unfamiliar settings.
[00:20:24.020]Patience is key, accidents will happen
[00:20:26.640]and may occur for many reasons
[00:20:28.300]including health, diet, sleep, routine,
[00:20:31.470]stress, and possibly even medication.
[00:20:34.150]Reactions to accidents will change
[00:20:35.990]depending on the stage or type of training being implemented
[00:20:39.020]but in general, avoid emotional responses
[00:20:41.900]that include scolding or shaming the child.
[00:20:44.610]Have the child help in the cleanup and changing process,
[00:20:47.520]and make sure that all consequences for accidents
[00:20:53.520]When teaching learners to self initiate toileting needs,
[00:20:56.660]a communication system must be in place.
[00:20:59.440]Provide verbal reminders to use the bathroom
[00:21:01.640]following a thinning schedule,
[00:21:03.400]and have visual reminders present
[00:21:04.990]that show the reinforcement available.
[00:21:07.190]Actively prompt the request form being taught
[00:21:09.750]and provide better reinforcement
[00:21:11.450]for self initiation over prompted sittings.
[00:21:14.270]Increase time between trips to allow for a full bladder
[00:21:17.250]and increase inconvenience of accidents.
[00:21:19.550]For example, by implementing positive practice.
[00:21:24.840]Toilet training can not be considered complete
[00:21:27.270]until learners are able to successfully eliminate
[00:21:29.740]in non-familiar locations.
[00:21:31.860]Plan for generalization by being prepared.
[00:21:34.470]At school, begin to take children
[00:21:36.230]to different bathroom locations to void
[00:21:38.170]when they have established initial toileting success.
[00:21:41.080]At home, encourage children
[00:21:42.830]to use the bathroom before leaving
[00:21:44.430]and look for restrooms when you
[00:21:45.780]first arrive at a new location.
[00:21:47.880]In both settings, consider taking pictures
[00:21:49.990]of different bathrooms and carrying a toileting bag
[00:21:52.420]with familiar items and reinforcers.
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