Toilet Training Children with Moderate-Severe Disbility


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Toilet Training Children with Moderate-Severe Disbility

  1. 1. Toilet Training Non-ambulatory Students Cindy Myers Comprehensive Behavior Specialist [email_address]
  2. 2. Who Can Be Trained? <ul><li>Students with a variety of physical disabilities including cerebral palsy </li></ul><ul><li>Students who use wheelchairs for mobility </li></ul><ul><li>Students who are verbal or non-verbal </li></ul>
  3. 3. Cautions & Exclusions <ul><li>Students on Neurogenic bowel & bladder programs </li></ul><ul><li>Check with doctor before considering students with spinal cord injuries </li></ul><ul><ul><li>Paraplegia, quadriplegia, spina bifida </li></ul></ul>
  4. 4. Determining Readiness <ul><li>Maintains dry diaper for ½ hour or more </li></ul><ul><li>Age over 4 ½ </li></ul><ul><li>Displays no fear of being in, on, or around the bathroom or toilet </li></ul><ul><li>Communication system in place </li></ul>
  5. 5. Determining Readiness cont. <ul><li>Consultation with physical therapist: </li></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><li>Transition to the toilet </li></ul></ul><ul><ul><li>Weight bearing </li></ul></ul><ul><ul><li>Adaptive equipment issues </li></ul></ul><ul><ul><li>Issues specific to the student </li></ul></ul><ul><ul><ul><li>Address issues before beginning! </li></ul></ul></ul>
  6. 6. General Philosophy <ul><li>Track the child’s natural schedule of elimination </li></ul><ul><li>“ Predict” the time episodes of elimination are likely and toilet the child around those times </li></ul><ul><li>Use of positive reinforcement </li></ul><ul><li>No punishment component </li></ul><ul><li>Training occurs in the classroom and is then generalized or trained in the home </li></ul><ul><li>Minimizes stress to families & caregivers for training responsibility </li></ul>
  7. 7. General Philosophy cont. <ul><li>Uses consistent “signals” or communication mands to develop relationships between action & consequences </li></ul><ul><li>Uses routines and environmental S D to elicit appropriate toileting response </li></ul>
  8. 8. Making “toileting” a Routine <ul><li>Task analyze the steps involved for that student to “toilet” </li></ul><ul><li>Develop a routine or procedures to be followed in a consistent manner each time the student is toileted </li></ul><ul><li>Standardize presentation of environmental or artificial stimuli that will be used as S D for steps in the toileting chain. </li></ul>
  9. 9. Communication System <ul><li>Evaluate the communication needs of the student </li></ul><ul><ul><li>Consult with a SLP if appropriate </li></ul></ul><ul><li>Make a list of vocabulary, mands, or signals that are associated with all tasks around toileting </li></ul><ul><ul><li>Moving from work area to toilet </li></ul></ul><ul><ul><li>Lifting, carrying </li></ul></ul><ul><ul><li>Undressing/dressing </li></ul></ul><ul><ul><li>Urination, defecation </li></ul></ul><ul><ul><li>“ finished” </li></ul></ul><ul><ul><li>Hygiene </li></ul></ul>
  10. 10. Getting Started <ul><li>Review and understand each procedure in the training protocol </li></ul><ul><li>Schedule a meeting to present your plan to the student’s parents </li></ul><ul><li>Provide a copy of the protocol for parents to keep </li></ul><ul><li>Ask parents to contact the student’s physician regarding medical feasibility of toilet training </li></ul><ul><li>Modifying the student’s IEP to include a toilet training goal </li></ul>
  11. 11. Getting Started cont. <ul><li>Obtain written permission </li></ul><ul><li>Agree on a starting and review date </li></ul><ul><li>Discuss terminology that will be used </li></ul><ul><li>Agree on signals & communication mands that will be used (if applicable) </li></ul><ul><li>Provide parents with a materials list of items you want them to supply </li></ul>
  12. 12. <ul><li>Vocabulary List for Toileting </li></ul><ul><li>Urination: __________________________________ </li></ul><ul><li>Defecation: _________________________________ </li></ul><ul><li>Toilet: _____________________________________ </li></ul><ul><li>Body Parts: _________________________________ </li></ul><ul><li>Other: _____________________________________ </li></ul><ul><li>Communication Mands/Cues </li></ul><ul><li>Lifting: _____________________________________ </li></ul><ul><li>Up/down: ___________________________________ </li></ul><ul><li>Toilet: ______________________________________ </li></ul><ul><ul><ul><li>Other: ______________________________________ </li></ul></ul></ul><ul><ul><ul><li>Other: ______________________________________ </li></ul></ul></ul><ul><ul><ul><li>Other: ______________________________________ </li></ul></ul></ul>
  13. 13. Permission for Toilet Training I give permission for my child, ______________________ to participate in the schedule based toilet training procedures described in this document. I know of no medical or physical reason that would preclude toilet training for my child. I have discussed toilet training with my physician. ______________________________________ _______________ parent signature date _______________________________________ _________________ teacher signature date _______________________________________ __________________ principal/administrator signature date ________________________________________ __________________ physician signature (if applicable) date
  14. 14. Meet With Physical Therapist Discuss Equipment Needs <ul><li>Consider </li></ul><ul><ul><li>Potty chair, commode, adaptations to regular toilet </li></ul></ul><ul><ul><li>Seat/safety belts </li></ul></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><li>Head, truck support </li></ul></ul><ul><ul><li>Wall bars </li></ul></ul><ul><ul><li>Transition to/from toilet </li></ul></ul><ul><ul><li>Issues specific to the student </li></ul></ul><ul><ul><ul><li>Seizures, spasticity, etc. </li></ul></ul></ul>
  15. 15. Materials List (May change for individual student) <ul><li>Diapers, wipes, disposable gloves </li></ul><ul><li>Highly desired reinforcer to be used only to R+ appropriate toileting </li></ul><ul><li>Items to entertain student as s/he sits on the toilet </li></ul><ul><li>Items recommended by the physical therapist unique to the student (neck brace, foam pads, etc.) </li></ul><ul><li>Data sheets, clipboard, pen or pencil </li></ul><ul><li>Timer </li></ul>
  16. 16. Data Sheets (There are two data sheets) <ul><li>Baseline Data </li></ul><ul><ul><li>Data Sheet 1 </li></ul></ul><ul><ul><ul><li>Collect baseline data and develop a high probability toileting schedule </li></ul></ul></ul><ul><ul><ul><ul><li>Mark data at ½ hour intervals </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Indicate if diaper is (D) Dry, (W) Wet, or (S) Soiled </li></ul></ul></ul></ul><ul><ul><ul><li>Look for: </li></ul></ul></ul><ul><ul><ul><ul><li>Trends or patterns of dry diapers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Trends or patterns in time or urination/defecation </li></ul></ul></ul></ul>
  17. 18. Data Sheets (cont) <ul><li>Program Data </li></ul><ul><li>Data Sheet 2 </li></ul><ul><ul><li>Determine schedule of high probability times that elimination is likely to occur </li></ul></ul><ul><ul><ul><li>Indicate if diaper is (D) Dry, (W) Wet, or (S) Soiled when taken to the toilet </li></ul></ul></ul><ul><ul><ul><li>Indicate if student (U) Urinated, (BM) Bowel Movement, or (O) No Production while on the toilet </li></ul></ul></ul><ul><ul><li>Review data to confirm accuracy of high probability schedule </li></ul></ul>
  18. 20. The Training <ul><li>Place student on toilet at times indicated by the high probability schedule </li></ul><ul><li>Use consistent routines and communication mands associated with toileting </li></ul><ul><li>Use techniques for transfer as identified by the physical therapist </li></ul>
  19. 21. If Success Occurs <ul><li>Reinforce student with social praise paired with the highly desired reinforcer </li></ul><ul><li>Immediately remove student form toilet (using identified communication mands) and put in a clean diaper </li></ul><ul><li>Return student to regular programming </li></ul><ul><li>Mark data sheet </li></ul><ul><li>Place student on toilet at the next “high probability” time </li></ul>
  20. 22. If No Elimination Occurs: <ul><li>Leave student on the toilet for 15 minutes </li></ul><ul><li>Remove student from the toilet after 15 minutes (using appropriate communication mands) and put in a clean diaper </li></ul><ul><li>Return student to regular class routine </li></ul><ul><li>Wait ½ hour and place student on the toilet again (using appropriate communication mands) for 15 minutes of toilet sitting </li></ul><ul><li>Repeat ½ hour intervals until elimination occurs (either on the toilet or in the diaper) </li></ul><ul><li>Return to the original “high probability” schedule </li></ul>
  21. 23. For Wet or Soiled Diapers: <ul><li>Give informational feedback (use designated mands if appropriate) “Your pants are wet, you need to use the toilet” </li></ul><ul><li>Place student on the toilet for 15 minutes of toilet sitting </li></ul><ul><li>If elimination occurs on the toilet, treat as a toilet success and R+ </li></ul><ul><li>Remove student from the toilet after elimination or 15 minutes, whichever happens first </li></ul>
  22. 24. Wetting & Soiling cont. <ul><li>Place in a clean diaper using communication mands and routines </li></ul><ul><li>Return student to regular programming and mark data sheet </li></ul><ul><li>Continue with original “high probability” toileting schedule </li></ul>
  23. 25. Generalizing to Home <ul><li>When the student is successfully urinating on the toilet >75%, generalization to the home should occur </li></ul><ul><li>Meet with parents to discuss progress at school </li></ul><ul><li>Discuss what adaptations would be necessary for toileting to occur at home </li></ul><ul><li>Help parents locate resources, equipment for use at home </li></ul>
  24. 26. Generalizing to Home <ul><li>Provide parents with a data sheet to track ½ hour intervals of wet/dry at home </li></ul><ul><li>Meet again and review baseline data and establish a “high probability” schedule </li></ul><ul><li>To assist parents in tracking wet/dry </li></ul><ul><ul><li>May have to check at hourly intervals </li></ul></ul><ul><ul><li>May have to check at ½ hour intervals for a predetermined period of time (2 hours) </li></ul></ul>
  25. 27. Toilet Training at Home <ul><li>Parents toilet student based on the high probability schedule </li></ul><ul><li>Parents place student on toilet for 15 minutes of toilet sitting (using appropriate communication mands associated with the toileting routine) </li></ul><ul><li>Parents R+ successful elimination on the toilet with social R+ paired with highly desired R+ </li></ul><ul><li>Place student in clean diaper and return to normal activities </li></ul>
  26. 28. Training at Home cont. <ul><li>If accident occurs, give informational feedback. Clean student then place on toilet for 15 minutes of toilet sitting (using communication mands). </li></ul><ul><ul><li>If elimination occurs while toilet sitting, treat as a success an R+ </li></ul></ul><ul><li>Place student in clean diaper, return to regular activity (using communication mands), and continue with high probability schedule </li></ul><ul><li>Use highly desired reinforcer for successful toileting only </li></ul><ul><li>Students should continue to wear diaper between toilet trips and at night until toilet use is well established </li></ul>