2. Spontaneous requests (in school) or independently accessing the toilet (at home) at least a few times a day, and

3. Voids following requests at least 90% of the time.Using these criteria, Subjects 1, 2, and 3 were successfully toilet trained (Subject 1 by day 82, Subject 2 by day 37, and Subject 3 by day 56). Besides adding rigor to the determination of successful toilet training, these criteria may be used as a basis for designating success criteria to guide experimental or clinical interventions. Though the data presented here are preliminary and depict only four subjects, they provide an important step in introducing experimental rigor to the process of training and refining procedures to improve the technology of training toilet training skills to children and adults with Autism Spectrum Disorders. INTRODUCTION Independent toileting skills are essential to personal independence, well-being, self-worth and social integration. Independently performing toileting skills is often deficient for persons with autism spectrum disorders (ASD). Current research has offered limited treatment options, the most frequently used consisting of rapid method (Azrin & Foxx, 1971), response restriction training (Avernick, Melein, & Duker, 2005), and interval training (Chung, 2007). This and other research has not identified the necessary and sufficient treatment components, including dimensions of these components, which reliably result in positive toileting outcomes for individuals with ASD. Common criticisms of current research include limited number of studies and studies with limited participants or power. Rapid toilet training (Azrin & Foxx, 1971) methods are included in several studies over the past 40 years, however, they continue to have similar criticisms or limitations such as use of punishment, lack of generalization components and maintenance data. The exact components and implementation methods of a successful toileting protocol remain unclear. Too often, toilet training is ignored or not addressed by those working with individuals diagnosed with autism. The reasons for this include: (1) the toilet training component skills have not been well identified, (2) empirically demonstrated effective training techniques are not well known, (3) instructors do not have the knowledge or skills to design and/or implement a program likely to be successful, (4) the demands of an effective program are perceived to be incompatible with the individual’s natural environment (i.e. home or school), (5) independent toileting is seen as “unimportant” past a certain age, and (6) use of diapers or pull-ups is perceived to be more efficient or economical than toilet training. Toileting is an important personal skill which contributes to a person’s self-worth and their ability to achieve optimal social integration. Research is needed in order to identify personal skills and characteristics (of individuals) which are predictive of successful toilet training and those which indicate “readiness” for toilet training. Research would also identify the training conditions and variables that affect the rate and outcome of toilet training. It is especially important to identify the differential effects of these (personal and environmental) variables on the acquisition of toileting skills by children, adolescents, and adults with autism. This series of research studies will lead to meeting these key objectives: 1. Develop age appropriate screening and assessment tools to inform treatment 2. Establish treatment protocols and materials with sensitivity to potential different implementers (agency, parent, other caregiver, school, etc.) 3. Develop and pilot protocols across ages and environments 4. Develop effective and efficient training methods and materials to transfer essential skills to personnel within large systems serving individuals with ASD. In this study, we evaluate the effectiveness of the Toilet Training Treatment Protocol (TTTP) and the Toilet Training Readiness Assessment Inventory (TTRAI) developed at The Vista School. Preliminary results from the current study are presented. Procedure. Baseline 1 and 2. Conducted during a period of two weeks prior to the start of training, baseline included two phases (a minimum of three days for each phase) with and without increased liquid intake and occurred along with the participant’s daily routines. During baseline, a specially designed, commercially available sensor is used in the participant’s underpants to indicate when a toileting accident has occurred. Staff records the exact time and nature (urine or feces) of voids throughout baseline. During the first phase of baseline, the individual eats and drinks as usual. During the second phase, the individual is given access to salty foods and encouraged to drink more than usual. The generated data include frequency, nature, and time of voids. These data generate an individual protocol as described below. Limitations and Implications. Data from current participants indicate the importance of the connection between voiding in the toilet and remaining free from accidents. Following this learning, subsequent training progresses at a steady pace. Communication training leads to increased requests to toilet self, resulting in decreases in accuracy. Study 2 will manipulate the “time-on toilet” interval based on the ceiling latency (i.e. highest latency) from the previous day and eliminating prompts to request the bathroom once a learner requests and voids in the toilet reliably. Determining the “time-on toilet” interval based on the current studies criteria appears to delay skill acquisition. Following the current criteria of this study takes up to 21 treatment days to reach this time-on interval. In study 2, the investigators propose to determine the time-on interval based on the ceiling latency from the previous day. This number would relate to the student’s behavior and skill acquisition, potentially decreasing the duration of training. Participants have demonstrated some prompt dependency when requesting access to the bathroom. This is evidenced by the decrease in accuracy shortly after the participants demonstrate an emerging independence to request the bathroom. Future research would eliminate all prompts to request the bathroom once the student demonstrates the ability to request the bathroom consistently. This modification would capture an emerging skill and reinforce requesting and accessing the bathroom only to void. Future research will address bowel training, refine treatment components, and implement toilet training protocol across other training environments. Currently, the procedures delineated in this study do not specifically address bowel training. Throughout the literature, it is suggested to utilize procedures similar to those outlined in this study (Matson, et al, 2009; Boles, et al, 2008; Akande, et al, 1993) or that bowel training may occur as a collateral effect of other toilet training efforts. To support and test the utility and efficacy of the procedures in this protocol, opportunities to increase participants and conduct training in other environments will become the focus. Figure 1. Treatment Phase. Participants were taught to request or access the bathroom independently (without prompts from staff and using reinforcement and prompt fading procedures), independently manipulate clothing (through reinforcement, chaining, and prompt fading), sit on the toilet to allow sufficient time for voiding without attention from staff, and complete age appropriate self hygiene skills such as cleaning self or washing hands. All voids that occurred in the toilet were reinforced using an item or activity that was restricted across environments and was only delivered contingent upon a void in the toilet. The participants were prompted at set intervals to check their pants for accidents and were reinforced for remaining dry during that interval. Following accidents/incontinent episodes, participants engaged in behaviors aimed at restoring the environment and over-practicing toileting skills to build behavioral fluency. As the participants met treatment criteria, dimensions such as amount or complexity of clothing, proximity to the toilet, delivery of reinforcement, volume of fluid intake, and dry pants checks were systematically manipulated to reduce treatment variables slowly without decreasing performance. Figure 2. Figure 3. Toilet Training Readiness and Assessment Inventory. The TTRAI was completed on each participant to determine critical readiness factors or components that need further development prior to starting treatment and information about previous toileting interventions. The TTRAI will be used as a screening tool for future participants. RESULTS AND DISCUSSION Data presented here demonstrate methods for assessing progress in toilet training providing a first step in identifying the factors that contribute to effective and efficient training of skills associated with urinary continence. Data for four subjects are present in Figures 1 through 6. The subjects whose data are presented here are in various stages of acquisition and mastery of toileting skills. Subject 4 is in the early stages while Subjects 1 and 2 have progressed through a structured program of training. Figure 1 (Cumulative Treatment Days by Phase of Training) shows that each student shows the same pattern of progress as they progresses through the training program. Progress is slowest in the beginning of training and becomes more rapid as training progresses suggesting that skills covered in later phases of training are reliant upon more basic skills acquired in the earlier phases. Ultimately, parents and teachers want to know when their child or student is “toilet trained.” Data collected during this study may provide an objective foundation for answering that question. Data presented in Figures 4 through 5 suggest that for each subject, skills are acquired in the same order. Though not depicted in these figures, it was found that each subject first learns to void when placed on the toilet. This is reflected in the relatively immediate reduction in “accidents” shown by each subject at the beginning of training. Subsequently, each subject learned to request access to the toilet, and for all but subject 4 (who is still relatively early in training), initial rates of requesting diminished as subjects learned to reliably void on the toilet after each request. Figure 6 (% Successful Requests For the Bathroom) shows, in fact, that after some period of training, each subject begins to urinate after each request to do so (depicted by 100% Success). SELECTED REFERENCES Akande, A. (1993). Improving toilet-use (encopresis) in a nine-year-old male through full-cleanliness training and token reinforcement. Early Child Development and Care, 86(1), 123-130. Avernick, M., Melein, L., & Duker, P. C. (2005). Establishing diurnal bladder control with the response restriction method: extended study of its effectiveness. Research in Developmental Disabilities, 26, 143-151. Azrin, N. H. and Foxx, R. M. (1971). A rapid method of toilet training the institutionalized retarded [Electronic version]. Journal of Applied Behavior Analysis, 4, 89-99. Boles, R. E., Roberts, M. C., & Vernberg, E. M. (2008). Treating non-retentive encopresis with rewarded scheduled toilet visits. Behavior Analysis in Practice, 1(2), 68-72. Chung, K. M. (2007). Modified version of Azrin and Foxx’s rapid toilet training [Electronic version]. Journal of Developmental Disabilities, 19, 449-455. METHOD Participants and Setting. The population of participants for the overall project will consist of individuals with a primary diagnosis of ASD whose ages range from 3 years to adulthood that do not reliably, independently, and appropriately use the toilet (e.g. have diurnal incontinence). The data currently being presented is that of four participants ranging in age from 5-20 who have a primary diagnosis of ASD. Three of the participants attended a private school for children with Autism (i.e., The Vista School), and the remaining participant attending a full time Autistic Support classroom in his neighborhood school district. Figure 5. Figure 4. Table 1. Descriptive Statistics This research was in part supported by the Pennsylvania DPW Bureau of Autism Services.