Evaluation of An Outpatient Parent-Lead Toilet Training Program for Children with Autism Spectrum Disorders

Background: Children with autism spectrum disorders frequently exhibit delays in adaptive functioning.  Toilet training can be an especially challenging process for parents of children with ASDs.  In fact, more than half of parents of children with autism report toileting problems (e.g. Whiteley, 2004). Incontinence in children can create further social isolation, negative reactions from caregivers and school staff, and may limit participation in mainstream educational opportunities or community activities, making it an important target of intervention.  Recent research has provided strong support for behavioral interventions for toilet training in this population (for a review see Kroeger and Sorensen-Burnworth, 2009) however parents are rarely included in the treatment process and few studies include treatment acceptability data. 

Objectives: The goal of the current study, therefore, was to evaluate the effectiveness and treatment acceptability of a behavioral treatment package targeting urinary incontinence using a parent training model conducted in an outpatient clinic.

Methods: Children ages 3-7 participated in the study with their primary caregivers.  All children had previously been diagnosed with an autism spectrum disorder, had been unsuccessful with previous attempts at toilet training, and did not exhibit significant findings related to bowel or bladder on physical exam. The treatment package consisted of the following components: sitting schedule, positive reinforcement for voiding, negative reinforcement for sitting & voiding, communication training (pairing), graduated guidance and prompting, use of a urine alarm, positive practice/overcorrection, and fluid loading. Parents were trained to implement the treatment during a 6 hour in-clinic training day and were expected to implement procedures and collect data in the home setting.  On the third day after treatment was implemented, a therapist visited the home to ensure treatment fidelity and to collect interobserver agreement data. Treatment acceptability data and long term follow-up data were collected by paper and pencil parent report.

Results: All three children achieved continence within 10 days of starting the program. Data on the rate of continent and incontinent voids during training, treatment acceptability, and long term follow-up will be presented.

Conclusions: Behavioral toilet training programs including those adapted from Azrin & Foxx’s (1971) protocol are effective in helping children with ASDs achieve urinary continence.  Furthermore, with adequate training and supervision by clinicians, these treatments can be implemented effectively by caregivers in the home setting, have lasting effects, and are viewed as acceptable treatment procedures by parents.