Perceptrtal and Motor SkiLl~,1975,41,63-69. @ Perceptual and Motor Skills 1975
A NEW METHOD FOR TOILET TRAINING DEVELOPMENTALLY DISABLED CHILDREN1 CLARA LEE EDGAR, H U G H F. KOHLER A N D SCOTT HARDMAN
Pacific Slate I-lospitdl Summary.-20 profoundly retarded children ( 4 to 12 yr.) were trained, using a variety of relaxation and tension activities designed to help them differentiate and gain control of the toileting musculature. Operant techniques were used to reinforce appropriate urination. The post-training scores of the experimental and control groups differed significantly for both accidental and appropriate urination.
Teaching adequate toileting skills is one of the major problems facing those who seek to habilitate institutionalized retarded individuals. This task has been the subject of many studies, most of which have utilized an operant conditioning approach (Baumeister & Klosowski, 1965; Dayan, 1964; Ellis, 1963; Giles & Wolf, 1966; Hundziak, Maurer, & Watson, 1965). There is abundant evidence to support the claim that desirable toileting habits can be taught through shaping and the use of positive reinforcement. More recently, several studies have concentrated on the use of electronic devices in toilet [raining ( A u i n & Foxx, 1971; Mahoney, Van Wagenen, & Meyerson, 1971; Van Wagenen, Meyerson, Kerr, & Mahoney, 1969). In these studies, urination training devices were used to alert the trainer when accidental urination occurred. Operant conditioning techniques were also used, with the combined effect of helping the subject more quickly associate certain internal bodily cues with appropriate voiding, which led to a dramatic reduction in toileting accidents. A possibly useful approach, and one which has been ignored by researchers up to this point, is suggested by the work of Kephart (1969). In his work with normal children who showed learning disabilities, Kephart has referred to use of a series of "relaxation" exercises which provide a step in helping the child in the development of gross body differentiation.' After relaxation, children are able to sort out their body parts and to use them more proficiently. Kephart explains this in terms of the development of an internal kinesthetic figure-ground mechanism, whereby the child (once relaxed) can begin to attend selectively 'This study was supported in part by Grant No. 51-P-70826-7-03 from the Social and Rehabilitation Service of the United States Department of Health. Education and Welfare. 'Additional information regarding techniques-may be obtained .from the senior author. While crediting Jacobson for his contribution, Kephart's use of relaxation is somewhat different. Having "found" the part, for example, an arm, leg, head, or abdomen in order to "let it go," "drop it," or "just let it go loose," the child has acmally differentialed the part. In addition, against a totally relaxed background of all body parts, he can then experience tension only from one moving part, which Kephart (1969) labeled hifledbeticfigure gzound. In the present study the child was taught to alternate the experience of tension and relaxation in the abdomen and upper thighs.
64
C. L. EDGAR, ET AL.
to kinesthetic feedback from his muscles, joints, and tendons as he tenses or moves various body parts. The child can then use his body for problem solving, since he now can feel how the parts of his body work and are related. Severely and profoundly retarded children usually have a poor understanding of themselves. Their ability to use their bodies as tools for learning is typically limited. In Kephart's terms, they have not developed kinesthetic figure-ground relationship. The child cannot attend selectively to internal kinesthetic information but must rely on external information provided by his eyes and ears ro help him perform simple tasks which demand smooth control of movement. Such control can only come from monitored internal kinesthetic feedback. The present study employed relaxation training in the promotion of kinesthetic figure-ground relationships. It concentrated on a regimen of relaxation and -physical exercises which drew attention to the muscles involved . in a particular activity. In this case, relaxation, alternated with tension, was induced in the lower abdomen, which hypothetically then may be recognized by the subject as a kinesthetic figure. Exercises were next used to heighten this figure. In this way, the child was made aware of the feelings to which, although always present in the abdominal region, he could not selectively attend. The most significant advantage of such an approach is that the child is actually taught something about his body; he learns to attend to internal information which was previously not processed or was too diffuse to recognize. He then can respond to these internal cues rather than to external cues. This relaxationtension exercise regimen was not intended to replace the use of operant conditioning with electronic devices but rather to be used in conjunction with them. It was predicted that: ( a ) the experimental or trained group would show a greater reduction of accidents than the control group; ( b ) the experimental group would have a greater increase in incidence of appropriate urination than the control group; and ( c ) more experimental subjects than control subjects would reach the criterion of successful self-initiation.
Twenty subjects were selected from a ward of 45 severely and profoundly retarded children. Ward supervisory personnel were consulted during the selection process, and only those children who showed little or no bladder control were chosen. The chronological ages of the subjects were between 4 and 12 yr., and their developmental ages were between 15 and 2 3 mo. (mean Developmental Age 19.5 mo., mean Developmental Quotient 20) as measured on the Gesell Developmental Schedules. The subjects were randomly assigned to either the experimental group ( 10 subjects) or the control group ( 10 subjects).
TOILET TRAINING DEVELOPMENTALLY DISABLED
Urinary training devices were employed. The main part of the unit was worn on a belt around the subject's waist. It contained a transistorized buzzer and a battery. Attached to the buzzer and battery assemblage were two wires that clipped to the front of h e subject's pants by means of small alligator clips. Whenever accidental urination occurred, the circuit between the two clips was completed by the wet pants, and a whistle-like sound would occur. Two portable children's toilets were also used in the experiment. They were equipped with buzzer devices activated by urination in the toilet. The sounds made by the two devices were quite noticeably different. Procedure The subjects were divided into five training groups of four subjects each. Each training group had two experimental subjects and two control subjeccs. Two technician-trainers were assigned to each training group. All the subjects in training, both experimental and control, wore the urinary training devices during the training period. Training took place 8 hr. a day, 4 days a week. Since trained personnel were drawn from the daily program on the ward, the training groups were run consecutively rather than simultaneously. The technicians employed for the project were not acquainted with the specific hypotheses. They had taken part in several larger toilet training projects employing strictly operant methodology and were well acquainted with these procedures. However, they were also "specialists" in promoting relaxation, differentiation or kinesthetic-figure ground, primary theoretically derived methodology used as the foundation for the sensory-motor and perceptual-motor project on which this study took place. They were also, conveniently, the technicians who had the responsibility for each child's entire daily training program. All the subjects in training were given fluids once an hour. The subjects in the experimental group were given 10 min. of the relaxation-tension exercise regimen 15 min. after receiving their fluids. They were then placed on the toilet at the same time as the control subjects. Prior to the experiment all the technician-trainers received training in relaxation techniques developed by the project staff. The primary relaxation method used with the experimental subjects consisted of several minutes of massage which was applied to the lower abdomen, the thighs, and limbs. The technicians used firm bur gentle massage, which is thought by Kephart to break up tension most expediently. In addition to massage, the techniques of stretching and shaking were also used. In stretching, the child was held by his hands and feet by two technicians and gently pulled, allowing his body to be lifted off the ground. In this way excess tension in the legs, arms, chest, abdomen, head, and neck could be broken up. When the child was lowered back
66
C. L. EDGAR, ET AL.
onto the mat and his hands and feet released, he was allowed to rest for a few seconds before the stretching or shaking techniques were resumed. (Similar results can be obtained by draping the child backward over a firm, rounded surface such as a padded bolster. H e is then stroked and his limbs are gently shaken to encourage relaxation. When using this method it is important not to place undue pressure on the abdomen.) Shaking techniques were used to help loosen stiff arms and legs. The technician grasped an arm at the elbow or a leg at the knee and shook the limb gently to break up excess tension. After shaking the limb for a few seconds the technician rotated the part in various ways to see if relaxation had indeed been brought about in this manner. If so, the technician proceeded to another area and attempted to relax it by either massage, stretching, or shaking. The routine used depended to a great extent on the subject. The technicians found that all techniques did not work equally well with all subjects, and so they used those techniques which seemed to promote relaxation best in each subject. Some subjects were overly tense in the abdominal area and relaxation activities were stressed there. Others maintained more tension in the lower legs, shoulders, or chest, so techniques involving these parts were stressed. Throughout the relaxation phase of the regimen, the progress in attaining relaxation was noted by the technician who gave the child auditory cues if he was having difficulty understanding the purpose of the procedure. The technician would say "relax your leg" or "you're too tense," or instruct the child to "relax," "let go," or to "let me do it," meaning that the child should let the technician manipulate his body and should let the tension go from his body. A child was blindfolded if visual distraction kept him from attending to both relaxation and tension in the key area. When the subject was relatively relaxed, he was given an exercise which produced tension in the abdominal and/or thigh muscles. These exercises incIuded leg lifts. The child, while lying on his back, was told to lift his legs up, hold them up, and then lower them slowly to the ground. The procedure was repeated several times. Sit-ups with the child lying on his back on the mat were also used. He was told to sit up while the technician maintained light contact with the straightened legs in order to signal the child to do the work with his abdomen. Another exercise required the child to spread his legs against tension applied by the trainer. While lying on his back on the mat, the child, with his knees up and feet on the floor, was told to move his legs out from the starting position, with his feet together, to a point where the knees rested on the floor. As he moved his legs, the technician placed her hands on the outside of the child's knees and applied pressure, making the job more difficult for him by having him move against resistance. When the legs were spread wide "Direct communication with N. C . Kephart and James Weddell of the N. C. Kephart Achievement Center.
TOILET TRAINING DEVELOPMWTALLY DISABLED
67
the technician directed the child to move his legs back together. As the child did this, the technician placed her hands on the inside of the child's knees and applied pressure during this movement. This procedure was repeated several times. Upon completion of the tension exercises, the subject was "relaxed" again. This cycle was continued for 10 min. The control subjects were given individual attention and were aided in playing with educational toys while the experimental subjects were trained in relaxation-tension. All the subjects were rewarded for appropriate urination ( i n the toilet) with primary and secondary reinforcers. Primary reinforcers included favorite food items of individual Ss including sweet-sour candies, pretzels, marshmallows, and M&Ms. When accidental urination occurred, the technician sharply told the subject to "stop," mrned off the buzzer, led the subject to the toilet and told him or her to "go potty." A chart for each child was posted in the toilet training room and records for all toileting incidents, both accidental and successful urinations, were kept. Daily visits to the toilet training room were made by the investigators, and progress or problems were discussed. At this time, the toileting records were checked and children were either released or continued in the training program, depending on results. The criteria for successful removal from the toilet training program were these: the subject must have only one accident in two days; that accident must occur on the first of the two days; and he or she must have shown self-initiated toileting. The training group was ended whenever two subjects met these criteria and neither of the two remaining subjects met them within the next three days. N o group could continue over 2 wk.
RESULTS AND DISCUSSION Analysis of covariance was applied to the pre- and post-training scores of the experimental and control groups for incidence of both accidental and appropriate urination. These scores were the total number of toileting incidents of each kind recorded by the technician using an 8-hr. period. Scores for the last day of training served as post-training scores (the criterion). Pre-training scores were those obtained during a baseline period of 1 wk. just prior to training ( the covariate) . TABLE 1 SUMMARY OF ANALYSES OF COVARIANCE OF SCORESFOR ACCIDENTALAND APPROPRIATE UR~NATION Source
df
Between groups Within groups "One-tail test.
1 17
Accidental Response MS F 14.35 3.99* 3.60
Appropriate Response MS P 82.34 3.77 21.86
fi .05*
C. L. EDGAR, ET AL.
68
The adjusted means of the experimental and control groups for accidental urination were .37 and 2.13, respectively, a difference significant at the .05 level (one-tail) in the direction predicted. The adjusted means of the experimental and control groups for appropriate urination were 8.00 and 3.90, respectively, a difference that is also significant at the .05 level (one-tail) in the direction predicted. TABLE 2 MEAN SCORES FOR ACCIDENTAL AND APPROPRIATE URINATION Urination Group
Pre
n -
Appropriate Experimental Control Difference Accidental Experimental Control Difference
-
-
- --
Post
Adjusted Post
-- -
10 10
1.10 .80 .30
8.10 3.80 4.30
8.00 3.90 4.10
10 10
5.70
.70 1.60 -.70
.37 2.13 - 1.76
2.50 2.20
Ten of the 20 subjects met the criterion of reduction in accidents (only one accident in two days). Eight of these subjects were in the experimental group, whereas only two were in the control group. The Fisher exact probability test (Siegel, 1956) showed that this difference was significant at the .05 level (one-tail) . The criterion of self-initiation was met by two control subjects and by two experimental subjects. Since the children were severely and profoundly retarded, with primitive sensory-motor integration, this criterion was evidently too stringent for most of them. Self-initiation entails an ability to move toward the toilet, remove the training pants, and sit down once disrobed. Rudimentary dressing and undressing skills are prerequisites for self-initiation, but no specific training was given in these areas. I t is interesting to note that the relaxation-tension program worked well with those subjects who showed a tendency to retain fluids, sometimes for long periods of time. Perhaps with these children, the building of the kinesthetic discrimination proved helpful in getting them to appreciate the internal feelings present in the abdominal area so chat they could respond to them. They could then selectively relax the area. The method was also appropriate for those children who constantly dribbled and showed no control over the musculature involved in urination. For them we suggest the regimen proved an aid in learning to control the contraction and release of the musculature. The procedure for the experimental group in this study was designed to aid discrimination of a full bladder and the surrounding musculature from other
TOILET TRAINING DEVELOPMENTALLY DISABLED
69
kinesthetic input. Awareness of the muscles in the abdominal area was increased at the time when the child had the greatest probability of becoming aware of them; i.e., a full bladder and tense abdominal muscles and relaxed limbs and other body parts. When kinesthetic awareness and muscle control were achieved, the child was well on the way to appropriate urination. The operant procedure is seen to be an adjunct to the promotion of appropriate behavior which can be used in conjunction with other developmentally oriented procedures. Replication is encouraged. REFERENCES
AZRIN,N. H.,
& FOXX,
R. M. A rapid method of toilet training the institutionalized
rerarded. Journal o f Applied Behavior Analysir, 1971, 4 , 88-89.
BAUMEISTER, A., & KLOSOWSKI, R. An attempt to group train severely retarded patients. Mental Retardation, 1965, 3 , 24-26. DAYAN. M. Toilet training retarded children in a state residential institution. Retardation, 1964, 2 , 116-117.
Mental
ELLIS,N. Toilet training the severely defective patient: an S-R reinforcement analysis.
American Journal o f Mental Deficiency, 1963, 68, 98-103. & WOLF, M. W. Toilet training institutionalized, severe retardates: an application of operant behavior modification techniques. American Journal of Mental Deficiency, 1966, 70, 766-780. HUNDZIAK, M., MAURER, R., & WATSON,L. Operant conditioning in toilet training of severely mentally retarded boys. American Journal o f Mental Deficiency, 1965, 70, 120-124. JACOBSON, E. Progressive relaxation. Chicago, Ill,: Univer. of Chicago Press, 1929. KEPHART,N. C. Syllabus learning disabilities. Evergreen, Co!o.: Learning Pathways, Inc., 1969. KEPHART,N . C. T h e slozu learner in the clarrroom. (2nd ed.) Columbus, Ohio: Merrill, 1971. MAHONEY, K., VAN WAGENEN, R. K., & MEYERSON, L. Toilet training of normal and retarded children. Journal o f Applied Behavior Analysis, 1971, 4 , 173-181. SIEGEL,S. Nonparametric statistics for the behavioral sciences. New Yotk: McGrawHill, 1956. VAN WAGENEN, R. K., MEYEUSON, L., KERR,U.,& MAHONEY, K. Field trials of a new procedure for toilet training. Journal o f Experimental Child Psychology, 1969, 8, 147-159.
GILES,D. K.,
Accepted April 29, 1975.
A NEW METHOD FOR TOILET TRAINING DEVELOPMENTALLY DISABLED CHILDREN1 CLARA LEE EDGAR, H U G H F. KOHLER A N D SCOTT HARDMAN
Pacific Slate I-lospitdl Summary.-20 profoundly retarded children ( 4 to 12 yr.) were trained, using a variety of relaxation and tension activities designed to help them differentiate and gain control of the toileting musculature. Operant techniques were used to reinforce appropriate urination. The post-training scores of the experimental and control groups differed significantly for both accidental and appropriate urination.
Teaching adequate toileting skills is one of the major problems facing those who seek to habilitate institutionalized retarded individuals. This task has been the subject of many studies, most of which have utilized an operant conditioning approach (Baumeister & Klosowski, 1965; Dayan, 1964; Ellis, 1963; Giles & Wolf, 1966; Hundziak, Maurer, & Watson, 1965). There is abundant evidence to support the claim that desirable toileting habits can be taught through shaping and the use of positive reinforcement. More recently, several studies have concentrated on the use of electronic devices in toilet [raining ( A u i n & Foxx, 1971; Mahoney, Van Wagenen, & Meyerson, 1971; Van Wagenen, Meyerson, Kerr, & Mahoney, 1969). In these studies, urination training devices were used to alert the trainer when accidental urination occurred. Operant conditioning techniques were also used, with the combined effect of helping the subject more quickly associate certain internal bodily cues with appropriate voiding, which led to a dramatic reduction in toileting accidents. A possibly useful approach, and one which has been ignored by researchers up to this point, is suggested by the work of Kephart (1969). In his work with normal children who showed learning disabilities, Kephart has referred to use of a series of "relaxation" exercises which provide a step in helping the child in the development of gross body differentiation.' After relaxation, children are able to sort out their body parts and to use them more proficiently. Kephart explains this in terms of the development of an internal kinesthetic figure-ground mechanism, whereby the child (once relaxed) can begin to attend selectively 'This study was supported in part by Grant No. 51-P-70826-7-03 from the Social and Rehabilitation Service of the United States Department of Health. Education and Welfare. 'Additional information regarding techniques-may be obtained .from the senior author. While crediting Jacobson for his contribution, Kephart's use of relaxation is somewhat different. Having "found" the part, for example, an arm, leg, head, or abdomen in order to "let it go," "drop it," or "just let it go loose," the child has acmally differentialed the part. In addition, against a totally relaxed background of all body parts, he can then experience tension only from one moving part, which Kephart (1969) labeled hifledbeticfigure gzound. In the present study the child was taught to alternate the experience of tension and relaxation in the abdomen and upper thighs.
64
C. L. EDGAR, ET AL.
to kinesthetic feedback from his muscles, joints, and tendons as he tenses or moves various body parts. The child can then use his body for problem solving, since he now can feel how the parts of his body work and are related. Severely and profoundly retarded children usually have a poor understanding of themselves. Their ability to use their bodies as tools for learning is typically limited. In Kephart's terms, they have not developed kinesthetic figure-ground relationship. The child cannot attend selectively to internal kinesthetic information but must rely on external information provided by his eyes and ears ro help him perform simple tasks which demand smooth control of movement. Such control can only come from monitored internal kinesthetic feedback. The present study employed relaxation training in the promotion of kinesthetic figure-ground relationships. It concentrated on a regimen of relaxation and -physical exercises which drew attention to the muscles involved . in a particular activity. In this case, relaxation, alternated with tension, was induced in the lower abdomen, which hypothetically then may be recognized by the subject as a kinesthetic figure. Exercises were next used to heighten this figure. In this way, the child was made aware of the feelings to which, although always present in the abdominal region, he could not selectively attend. The most significant advantage of such an approach is that the child is actually taught something about his body; he learns to attend to internal information which was previously not processed or was too diffuse to recognize. He then can respond to these internal cues rather than to external cues. This relaxationtension exercise regimen was not intended to replace the use of operant conditioning with electronic devices but rather to be used in conjunction with them. It was predicted that: ( a ) the experimental or trained group would show a greater reduction of accidents than the control group; ( b ) the experimental group would have a greater increase in incidence of appropriate urination than the control group; and ( c ) more experimental subjects than control subjects would reach the criterion of successful self-initiation.
Twenty subjects were selected from a ward of 45 severely and profoundly retarded children. Ward supervisory personnel were consulted during the selection process, and only those children who showed little or no bladder control were chosen. The chronological ages of the subjects were between 4 and 12 yr., and their developmental ages were between 15 and 2 3 mo. (mean Developmental Age 19.5 mo., mean Developmental Quotient 20) as measured on the Gesell Developmental Schedules. The subjects were randomly assigned to either the experimental group ( 10 subjects) or the control group ( 10 subjects).
TOILET TRAINING DEVELOPMENTALLY DISABLED
Urinary training devices were employed. The main part of the unit was worn on a belt around the subject's waist. It contained a transistorized buzzer and a battery. Attached to the buzzer and battery assemblage were two wires that clipped to the front of h e subject's pants by means of small alligator clips. Whenever accidental urination occurred, the circuit between the two clips was completed by the wet pants, and a whistle-like sound would occur. Two portable children's toilets were also used in the experiment. They were equipped with buzzer devices activated by urination in the toilet. The sounds made by the two devices were quite noticeably different. Procedure The subjects were divided into five training groups of four subjects each. Each training group had two experimental subjects and two control subjeccs. Two technician-trainers were assigned to each training group. All the subjects in training, both experimental and control, wore the urinary training devices during the training period. Training took place 8 hr. a day, 4 days a week. Since trained personnel were drawn from the daily program on the ward, the training groups were run consecutively rather than simultaneously. The technicians employed for the project were not acquainted with the specific hypotheses. They had taken part in several larger toilet training projects employing strictly operant methodology and were well acquainted with these procedures. However, they were also "specialists" in promoting relaxation, differentiation or kinesthetic-figure ground, primary theoretically derived methodology used as the foundation for the sensory-motor and perceptual-motor project on which this study took place. They were also, conveniently, the technicians who had the responsibility for each child's entire daily training program. All the subjects in training were given fluids once an hour. The subjects in the experimental group were given 10 min. of the relaxation-tension exercise regimen 15 min. after receiving their fluids. They were then placed on the toilet at the same time as the control subjects. Prior to the experiment all the technician-trainers received training in relaxation techniques developed by the project staff. The primary relaxation method used with the experimental subjects consisted of several minutes of massage which was applied to the lower abdomen, the thighs, and limbs. The technicians used firm bur gentle massage, which is thought by Kephart to break up tension most expediently. In addition to massage, the techniques of stretching and shaking were also used. In stretching, the child was held by his hands and feet by two technicians and gently pulled, allowing his body to be lifted off the ground. In this way excess tension in the legs, arms, chest, abdomen, head, and neck could be broken up. When the child was lowered back
66
C. L. EDGAR, ET AL.
onto the mat and his hands and feet released, he was allowed to rest for a few seconds before the stretching or shaking techniques were resumed. (Similar results can be obtained by draping the child backward over a firm, rounded surface such as a padded bolster. H e is then stroked and his limbs are gently shaken to encourage relaxation. When using this method it is important not to place undue pressure on the abdomen.) Shaking techniques were used to help loosen stiff arms and legs. The technician grasped an arm at the elbow or a leg at the knee and shook the limb gently to break up excess tension. After shaking the limb for a few seconds the technician rotated the part in various ways to see if relaxation had indeed been brought about in this manner. If so, the technician proceeded to another area and attempted to relax it by either massage, stretching, or shaking. The routine used depended to a great extent on the subject. The technicians found that all techniques did not work equally well with all subjects, and so they used those techniques which seemed to promote relaxation best in each subject. Some subjects were overly tense in the abdominal area and relaxation activities were stressed there. Others maintained more tension in the lower legs, shoulders, or chest, so techniques involving these parts were stressed. Throughout the relaxation phase of the regimen, the progress in attaining relaxation was noted by the technician who gave the child auditory cues if he was having difficulty understanding the purpose of the procedure. The technician would say "relax your leg" or "you're too tense," or instruct the child to "relax," "let go," or to "let me do it," meaning that the child should let the technician manipulate his body and should let the tension go from his body. A child was blindfolded if visual distraction kept him from attending to both relaxation and tension in the key area. When the subject was relatively relaxed, he was given an exercise which produced tension in the abdominal and/or thigh muscles. These exercises incIuded leg lifts. The child, while lying on his back, was told to lift his legs up, hold them up, and then lower them slowly to the ground. The procedure was repeated several times. Sit-ups with the child lying on his back on the mat were also used. He was told to sit up while the technician maintained light contact with the straightened legs in order to signal the child to do the work with his abdomen. Another exercise required the child to spread his legs against tension applied by the trainer. While lying on his back on the mat, the child, with his knees up and feet on the floor, was told to move his legs out from the starting position, with his feet together, to a point where the knees rested on the floor. As he moved his legs, the technician placed her hands on the outside of the child's knees and applied pressure, making the job more difficult for him by having him move against resistance. When the legs were spread wide "Direct communication with N. C . Kephart and James Weddell of the N. C. Kephart Achievement Center.
TOILET TRAINING DEVELOPMWTALLY DISABLED
67
the technician directed the child to move his legs back together. As the child did this, the technician placed her hands on the inside of the child's knees and applied pressure during this movement. This procedure was repeated several times. Upon completion of the tension exercises, the subject was "relaxed" again. This cycle was continued for 10 min. The control subjects were given individual attention and were aided in playing with educational toys while the experimental subjects were trained in relaxation-tension. All the subjects were rewarded for appropriate urination ( i n the toilet) with primary and secondary reinforcers. Primary reinforcers included favorite food items of individual Ss including sweet-sour candies, pretzels, marshmallows, and M&Ms. When accidental urination occurred, the technician sharply told the subject to "stop," mrned off the buzzer, led the subject to the toilet and told him or her to "go potty." A chart for each child was posted in the toilet training room and records for all toileting incidents, both accidental and successful urinations, were kept. Daily visits to the toilet training room were made by the investigators, and progress or problems were discussed. At this time, the toileting records were checked and children were either released or continued in the training program, depending on results. The criteria for successful removal from the toilet training program were these: the subject must have only one accident in two days; that accident must occur on the first of the two days; and he or she must have shown self-initiated toileting. The training group was ended whenever two subjects met these criteria and neither of the two remaining subjects met them within the next three days. N o group could continue over 2 wk.
RESULTS AND DISCUSSION Analysis of covariance was applied to the pre- and post-training scores of the experimental and control groups for incidence of both accidental and appropriate urination. These scores were the total number of toileting incidents of each kind recorded by the technician using an 8-hr. period. Scores for the last day of training served as post-training scores (the criterion). Pre-training scores were those obtained during a baseline period of 1 wk. just prior to training ( the covariate) . TABLE 1 SUMMARY OF ANALYSES OF COVARIANCE OF SCORESFOR ACCIDENTALAND APPROPRIATE UR~NATION Source
df
Between groups Within groups "One-tail test.
1 17
Accidental Response MS F 14.35 3.99* 3.60
Appropriate Response MS P 82.34 3.77 21.86
fi .05*
C. L. EDGAR, ET AL.
68
The adjusted means of the experimental and control groups for accidental urination were .37 and 2.13, respectively, a difference significant at the .05 level (one-tail) in the direction predicted. The adjusted means of the experimental and control groups for appropriate urination were 8.00 and 3.90, respectively, a difference that is also significant at the .05 level (one-tail) in the direction predicted. TABLE 2 MEAN SCORES FOR ACCIDENTAL AND APPROPRIATE URINATION Urination Group
Pre
n -
Appropriate Experimental Control Difference Accidental Experimental Control Difference
-
-
- --
Post
Adjusted Post
-- -
10 10
1.10 .80 .30
8.10 3.80 4.30
8.00 3.90 4.10
10 10
5.70
.70 1.60 -.70
.37 2.13 - 1.76
2.50 2.20
Ten of the 20 subjects met the criterion of reduction in accidents (only one accident in two days). Eight of these subjects were in the experimental group, whereas only two were in the control group. The Fisher exact probability test (Siegel, 1956) showed that this difference was significant at the .05 level (one-tail) . The criterion of self-initiation was met by two control subjects and by two experimental subjects. Since the children were severely and profoundly retarded, with primitive sensory-motor integration, this criterion was evidently too stringent for most of them. Self-initiation entails an ability to move toward the toilet, remove the training pants, and sit down once disrobed. Rudimentary dressing and undressing skills are prerequisites for self-initiation, but no specific training was given in these areas. I t is interesting to note that the relaxation-tension program worked well with those subjects who showed a tendency to retain fluids, sometimes for long periods of time. Perhaps with these children, the building of the kinesthetic discrimination proved helpful in getting them to appreciate the internal feelings present in the abdominal area so chat they could respond to them. They could then selectively relax the area. The method was also appropriate for those children who constantly dribbled and showed no control over the musculature involved in urination. For them we suggest the regimen proved an aid in learning to control the contraction and release of the musculature. The procedure for the experimental group in this study was designed to aid discrimination of a full bladder and the surrounding musculature from other
TOILET TRAINING DEVELOPMENTALLY DISABLED
69
kinesthetic input. Awareness of the muscles in the abdominal area was increased at the time when the child had the greatest probability of becoming aware of them; i.e., a full bladder and tense abdominal muscles and relaxed limbs and other body parts. When kinesthetic awareness and muscle control were achieved, the child was well on the way to appropriate urination. The operant procedure is seen to be an adjunct to the promotion of appropriate behavior which can be used in conjunction with other developmentally oriented procedures. Replication is encouraged. REFERENCES
AZRIN,N. H.,
& FOXX,
R. M. A rapid method of toilet training the institutionalized
rerarded. Journal o f Applied Behavior Analysir, 1971, 4 , 88-89.
BAUMEISTER, A., & KLOSOWSKI, R. An attempt to group train severely retarded patients. Mental Retardation, 1965, 3 , 24-26. DAYAN. M. Toilet training retarded children in a state residential institution. Retardation, 1964, 2 , 116-117.
Mental
ELLIS,N. Toilet training the severely defective patient: an S-R reinforcement analysis.
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GILES,D. K.,
Accepted April 29, 1975.
