Humera Aziz & Seema Ghauri[1]
ABSTRACT
Independent toileting is an important developmental skill which individuals with developmental disabilities often find a challenge to master. There is no magic age for toilet training. Depending on the developmental level of the child, toilet training can begin as early as 2½ years. By 6 or 7 years of age most children with mental retardation are trained. However, if you continue to have problems or if the child is very resistant, then rule out medical problems and consider getting professional help.
INTRODUCTION:
Toileting skills are an important part of a child's development and are a necessary skill that enables independence and acceptance in social settings (i.e. community environments such as school). A variety of procedures have demonstrated to be successful in reducing the urinary incontinence of young children. Rubin and Fisher (1982)[2] concluded that typically developing children learn bowel control first, followed by bladder control, and are finally capable of nighttime bladder control. For toilet training procedures to be effective, the program must provide increased opportunities for increased child responding and include reinforcement. In addition, these authors suggested toilet training usually progresses faster if the child has bowel movements at the same time each day. Given this requirement, McClurg (1986)[3] suggested strict adherence to an established toileting schedule. If a schedule is not followed, toilet training often becomes a frustrating task for the child and the care providers. Thus, to maximize toilet training success, a toileting schedule appears to need to be in place that provides opportunities to engage in appropriate toileting behaviors.
As children begin to show an interest in using the toilet, Mather (1976)[4] advises the use of a tangible consequence, such as an edible treat or free time, for appropriate toilet usage. Mather further suggests that consequences should initially include the use of small token rewards that can be faded until the use of the natural consequence of verbal praise is used to maintain treatment gains. He believed that tokens reward early in the toilet training process encouraged self-motivation.
In some cases, toilet training can be problematic because the child fails to emit toileting behaviors (i.e. he or she rarely uses the toilet). To further complicate toileting, a parent or caregiver cannot easily set the occasion for a child to empty their bladder. To increase the likelihood of urination, Azrin and Foxx (1971)[5], advocated frequent liquid intake with scheduled periods of sitting on the toilet. In addition, they also recommended increased intake to increase the likelihood of urinating during toileting sessions. Lastly, Azrin and Foxx (1971)[6] note the need for interventions to be to conduct on a daily basis until the child displayed 100% toileting success. This method, although intense, requires a great deal of time, and supervision by a trained professional. These factors might make it an impractical treatment implemented in naturalistic settings such as public schools. Specifically, the time and effort involved may be to intense for an already busy teacher. Despite the effort involved in toilet training, parents have been shown to implement effective toilet training programs in the home setting (Feldman, Case, Garrick, MacIntyre-Grande, Carnwell, & Sparks, 1992[7]; Mahoney, Van Wagenen, & Meyerson, 1971[8]).
Toilet training implemented in the home is not without difficulty and can be very time consuming (Steinberg, Williams, & DaRos, 1992[9]). Also, parents often find that training their child to not eliminate in clothing and in locations other than the restroom can be a difficult and frustrating task (Foxx & Azrin, 1972[10]).
To transfer the toilet training program to the home setting, Honig (1993)[11] recommended that therapists first provide tips that facilitate a parent’s understanding of the actions needed. For example, it is important for parents to resort to punishment procedures when the toilet training efforts become more difficult. In fact, punishment can be ineffective method for promoting successful behavior in children (Clark, Rowbury, D. M. Baer, & A. M. Baer, 1973)[12]. Honig (1993) found that consistent toilet use during the day and increasing the liquid intake to be effective.
Foxx and Azrin (1971) have discovered that the key to long-term maintenance of toileting skills is to provide opportunities for the child to use various toilets throughout the house and school; this promoting generalization of toileting skills. In order expedite toilet training, Foxx and Azrin (1971) also suggested the use of imitative learning in addition to shaping.
METHOD:
Setting:
Presently in the city of Karachi, there are only two residential facilities catering to the children with mental retardation. One is Darul Sukoon run by the Christian Community, catering to a capacity of 125 severely and profoundly persons with mental retardation. These people require long term nursing or medical care or both. Of these, 27 retardates have lived there for more than 15 years. The other residential facility, Bulkhi Memorial Centre, is run by a voluntary organization. It has a capacity for 150 residents who may be moderate to profound in their mental retardation. Nineteen (19) of these 50 residents are long term residents, some of whom have lived since the inception of the Home, i.e. nearly 2 decades ago. All of these residents in both settings are either orphans or have been rejected by their families or whose families are unable to care for them. A small number of cases are there for a maximum of up to 10 months’ duration. Short-term residential care is provided to families facing a crisis like death or hospitalization of the main care person or simply to provide relief for the main care person.
Participant and Setting:
The participants were 237 residents have moderate to profound mental retardation and selected through cluster sampling method. On a general observation, they show multitude of aberrant behaviors, cognitive deficits, and poor self-help skills had limited acquisition of independent toileting skills. The participants had limited verbal communication and academic skills, also. The characteristics of the participants are shown in Table 1.
Table 1
Sex and Age Group
| Age Group (Years) | Male (No.) | Female (No.) | Total (No.) | Percentage (%) |
| 05 – 07 | 12 | 08 | 20 | 2.25 |
| 08 – 10 | 12 | 08 | 20 | 2.25 |
| 11 – 13 | 37 | 29 | 66 | 13.1 |
| 14 – 16 | 32 | 44 | 76 | 29.5 |
| 17 – 19 | 28 | 14 | 42 | 18.6 |
| 20 – 22 | 03 | 07 | 10 | 29.5 |
| 23 – 25 | 02 | 01 | 03 | 01.3 |
| Total | 126 | 111 | 237 | 100 |
| Percentage | 53.2 | 46.8 | | 100 |
Diagnostic Procedure:
When diagnosis a mentally retarded child suspend of having problems in daily living skills, the investigator seek to meet the following objectives:
1. To describe the problem: What are the dimensions of the problem with respect to toileting, dressing, feeding & grooming?
2. To estimate its severity: How large a problem is it?
3. To identify factors that are related to the problem: What are the antecedents and consequences of it?
4. To estimate the prospects for improvement: What estimate can we make of the external of possible recovery?
5. To derive a plan of treatment: What are the specific targets for therapy and how can the child best is approached?
INSTRUMENT OF THE STUDY:
The Adaptive Behavior Scale is a clinically useful scale that provides information about important areas of competence for mentally retarded persons. Practitioners and researchers have found the scale to be useful, especially in describing individual’s daily living performance and adequacy of complex social and interpersonal behavior.
Adaptive behavior has been defined by the American Association on Mental Deficiency as; behavior that is effective in meeting the natural and social demands of one’s environment. The assessment of adaptive behavior focuses on two functions:
· The degree to which individuals are able to function and maintain themselves independently.
· The degree to which they meet satisfactorily the culturally imposed demands of personal and social responsibility. Thus, adaptive behavior reflects a person’s competence in meeting independence needs and the social demands of his or her environment.
Adaptive behavior may be reflected primarily in terms of maturation during the preschool years, academic performance during the school years, and social and economic independence in adulthood. Adaptive behavior covers a wide range of behaviors including perceptual abilities, motor skills, physical fitness, speech proficiency, vocational competence, and academic achievement. Adaptive behavior scales have been developed to provide information about individuals, primarily those who are mentally retarded, that is helpful for classification, training, and treatment decisions.
The Adaptive Behavior Scale used for this study was developed by a team of experts at Jinnah Post Graduate Medical Center during the project on “Rapid Epidemiologic Assessment of Childhood Disability in Pakistan” (Z. Mehar Hasan, 1992).
RESULTS:
The number of appropriate toileting and dry behaviors are shown in Table 2. The number of toilet success or independent during assessment was less than 38%. The overall dependency percentage was 18 percent. Majority of the residents with mental retardation performed their toileting needs with some assistance (44 %) including people who are above 40 years.
Table 2
Ability to Perform Activities of Toileting
| Age Group (Years) | Independent | With Assistance | Totally Dependent | Number |
| 05 – 07 | 05 | 09 | 06 | 20 |
| 08 – 10 | 08 | 07 | 05 | 20 |
| 11 – 13 | 21 | 32 | 13 | 66 |
| 14 – 16 | 28 | 37 | 11 | 76 |
| 17 – 19 | 19 | 15 | 08 | 42 |
| 20 – 22 | 07 | 03 | - | 10 |
| 23 – 25 | 01 | 02 | - | 03 |
| Total | 89 | 105 | 43 | 237 |
| Percentage | 37.56 | 44.30 | 18.14 | 100 |
DISCUSSION:
The process of teaching a child to use the toilet can be frustrating. The challenge of teaching children with a developmental disability, like mental retardation can increase the frustration associated with toilet training. Although there are a number of challenges related to toilet training children with mental retardation.
There are some characteristics common to many individuals with mental retardation that may add to toilet training difficulties:
- Most children with mental retardation have difficulties understanding language; therefore, a child may not understand what is being expected of him in the toileting routine.[13]
- Difficulty organizing and sequencing information and attending to relevant information is hard for many children with mental retardation.[14] This may make it difficult for the child to follow all the steps required in toileting and to stay focused on the task itself.
- Accepting a change in routines can be hard for many children with mental retardation.[15] Therefore, the change in the familiar routine of wearing a diaper to using the toilet can be difficult.
- A child with mental retardation may also have difficulty integrating sensory information and establishing the relationship between body sensations and everyday functional activities.[16] Therefore, he or she may not know how to "read" the body cues that signal when to use the toilet. In addition, the sensory environment of the bathroom including a cold hard floor and toilet, loud flushing noises, echoes, and rushing water may also overwhelm the child. A further consideration is that the removal of clothing for toileting may trigger exaggerated responses to the change in temperature and the tactile feeling of clothes on versus clothes off.
Successful toilet training of a child with mental retardation requires a number of behaviors and abilities to be in place. Signs of readiness include:[17]
- the ability to physically perceive that there is a wet or soiled panty/diaper and the skills to communicate this,
- significant periods of dryness (about 2 hours),
- recognition of a full bladder or the need to have a bowel movement, and
- the motor skills to get to the bathroom and sit on the toilet.
Any program designed to help a child learn to toilet independently should be considered only as a set of guidelines and suggestions and not necessarily as a recipe that will be successful for every child. Each child, including a child with mental retardation, is unique and there is a wide range of variability when children will be toilet trained.
Specific Steps to Toilet Training a Child with Mental Retardation:
In general, toilet training the child with mental retardation often takes the same form as it does with other children. Specific steps in toilet training the child with mental retardation are outlined below.[18]
Pre-Training:
- Help the child learn about "wet" and "dry" by checking the diaper/panty, letting the child know what you feel by saying "Good, your pants are dry," and placing his hand in the diaper/panty to feel that it is dry. If the diaper is wet, allow the child to feel that it is wet.
- Allow the child to see other children using the toilet, and use observational remarks and questions like "he is sitting on the potty now" to narrate what is happening.
Bowel Training:
- Keep a schedule of the child's elimination patterns to determine appropriate toileting times.
- Begin by placing the child on the toilet about the time of his usual bowel movement.
- Leave your child on the toilet for about 10 minutes then help him off the toilet and praise him for trying and/or succeeding.
- Continue until a pattern has been established.
Urinary Training:
- Begin after bowel training is established.
- Record elimination patterns to determine when it is best to place the child on the potty.
- Switch to training pants during the day.
- Using the elimination schedule place the child on the potty periodically.
- After 5 or 10 minutes praise the child for trying and/or succeeding.
- Eventually, tell the child to go to the bathroom instead of bringing him or her there.
Nighttime Training:
- Begin after daytime training has been established.
- Restrict fluid intake before bedtime.
- Wake the child one or two times a night and have him sit for 5 or 10 minutes. Praise the child.
Other suggested techniques for successful toileting include a program designed by researchers at Division TEACCH, a program of the University of North Carolina at Chapel Hill designed specifically for children with autism or autistic-like behaviors. Structured Teaching for toilet training can be found on the Division TEACCH website and includes a readiness checklist, a 7-day chart for tracking toileting habits, information on planning the toilet training "journey", a picture schedule for children, a task analysis of the toilet training procedure, and a trouble shooting guide for toileting problems.
While it may take some time and require a lot of patience, keep in mind that many children with mental retardation are potty trained by 5 years of age. However, if you continue to have problems or if the child is very resistant, then rule out medical problems and consider getting professional help. First, make sure the child does not have a medical problem that would interfere with toileting behavior. Usually, this can be ruled out by the physician after routine physicals, etc. However, if there are signs of too much or too little urination or painful urination, contact a physician for a referral to a specialist. If you have ruled out medical problems and there is continued difficulty toilet training the child, seek information, help, and advice from other professionals including occupational therapists, special education teachers and behavior therapists.
CONCLUSIONS:
On the basis of the findings dealing with training of toileting in adult with mental retardation living in residential setting, the data reveals:
- Decreased cognitive abilities and problems in physical development are associated with dependency in toilet training.
- Training in toileting mentally retarded persons require structured program and trained personnel.
- Institutionalized persons with mental retardation do not have opportunities to learn daily living skills like other children who are live in family.
- Improvements in medical care have not clearly altered the poor performance for the most severely disabled children.
[1] Cooperative Lecturers, Department of Special Education, University of Karachi
[2] Rubin, R.R., & Fisher, J.J. (1982). Your preschooler. New York: Macmillan Publishing Co., Inc.
[3] McClurg, E. (1986). Your down's syndrome child. Garden City, NY: Doubleday and Company, Inc.
[4] Mather, J. (1976). Learning can be child's play. Nashville, TN: Abingdon Press.
[5] Azrin, N.H., & Foxx, R.M. (1971). A rapid method for toilet training the institutionalized retarded. Journal of Applied Behavior Analysis, 4, 89-99.
[6] Ibid
[7] Feldman, M.A., Case, L., Garrick, M., MacIntyre-Grande, W., Carnwell, J., & Sparks, B. (1992). Teaching childcare skills to mothers with developmental disabilities. Journal of Applied Behavior Analysis, 25, 205-215.
[8] Mahoney, K., Van Wagenen, R.K., & Meyerson, L. (1971). Toilet training of normal and retarded children. Journal of Applied Behavior Analysis, 4, 173-181.
[9] Steinberg, M., Williams, S., & DaRos, D. (1992). Toilet training takes time. Young Children, 48, 56.
[10] Foxx, R.M., & Azrin, N.H. (1973). Toilet training the retarded. Champaign, IL: Research Press.
[11] Honig, A.S. (1993). Toilet learning. Daycare & Early Education, 21, 6-9.
[12] Clark, H.B., Rowbury, T., Baer, A.M., & Baer, D.M. (1973). Timeout as a punishing stimulus in continuous and intermittent schedules. Journal of Applied Behavior Analysis, 6, 443-455.
[13] Roberts, J.E., Mirrett, P., & Burchinal, M. (2001). Receptive and expressive communication development of young males with fragile X syndrome. American Journal on Mental Retardation, 106(3),216-230.
[14] Hodapp, R.M., Dykens, E.M., Ort, S.I., Zelinsky, D.G., & Leckman, J.F. (1991). Changing patterns of intellectual strengths and weaknesses in males with fragile X syndrome. Journal of Autism and Developmental Disorders, 21, 503-516.
[15] Saunders, S. (1999). Teaching children with fragile X syndrome. British Journal of Special Education, 26(2),76-79.
[16] Baranek, G.T., Chin, Y.H., Hess, L.M.G., Yankee, J.G., Hatton, D.D., & Hooper, S.R., (2002). Sensory processing correlates of occupational performance in children with fragile X syndrome: Preliminary findings. American Journal of Occupational Therapy, 56, 538-546.
[17] About Pediatrics (n.d.) Potty training children with special needs. Retrieved February 19, 2003, from http://pediatrics.about.com/library/weekly/aa051401a.htm?once=true&.
[18] Crepeau-Hobson, F. & O'Connor, R. (2002). Toilet training the child with fragile X syndrome. In R.J. Hagerman and P.J. Hagerman (Eds.), Fragile X Syndrome: Diagnosis, treatment, and research. (pp. 527-529), Baltimore: Johns Hopkins University Press.
Pakistan Journal of Special Education (PJSE) Vol. 9, 2008
© Department of Special Education, University of Karachi
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