PS498 Unit 4 Toilet Training Literature Review Example

From an Institution in 1971 to a Clinic Bathroom in Omaha: A PS498 Unit 4 Literature Review

[Student Name]

Purdue University Global

PS498: Bachelor's Capstone in Applied Behavior Analysis

Unit 4 Literature Review

[Instructor Name]

[Date]

The writer, the clinic and the children are composite; the articles reviewed are real.

The Capstone Question

My capstone asks whether a reinforcement-based toilet training protocol, carried out at a center-based autism clinic and continued by parents at home, reduces accidents and increases continent voids and self-initiations for two young children with autism. Before writing a protocol, I needed to know what the research supports, what it leaves uncertain and how its methods have changed.

The Rapid Method

Azrin and Foxx (1971) described a rapid method of toilet training developed with adults with intellectual disabilities living in an institution. Its components included increased fluid intake to create more opportunities to void, scheduled sits on the toilet, immediate reinforcement for voiding in the toilet, checks for dry pants with reinforcement for staying dry, and procedures following accidents that included reprimands and positive practice of the toileting sequence. Accidents decreased sharply within days for most residents, and the method became the foundation for much of the research that followed.

The method's strengths were its intensity and its many opportunities for reinforcement. Its weaknesses, for today's practice, are its setting and its accident procedures, which relied partly on aversive consequences that modern practice tends to avoid when effective alternatives exist.

Adapting the Method for Children With Autism

Cicero and Pfadt (2002) investigated a reinforcement-based toilet training procedure with young children with autism. Their procedure kept scheduled sits and reinforcement for voids, and responded to accidents by interrupting them and guiding the child to the toilet rather than using punishment. Accidents decreased and self-initiated toileting increased, and the gains extended to the home with parent involvement. Their study showed that the core of the rapid method could work without its aversive components.

LeBlanc et al. (2005) evaluated an intensive outpatient program for primary urinary incontinence in children with autism. Their program combined elements of the rapid method, such as increased fluids, scheduled sits and reinforcement for voids, with dry checks, and was delivered in an outpatient clinic over several days, with parents trained to continue it at home. Accidents fell and continent voids increased for the children in their study, and the authors emphasized parent training as necessary for gains to transfer to home.

The method kept its schedule and its reinforcement and lost its reprimands, and it still worked.

A Critical Review

Kroeger and Sorensen-Burnworth (2009) took a critical look at the whole body of toilet training studies with these learners. They found the strongest support for intensive methods based on Azrin and Foxx's work, typically including scheduled sits, reinforcement and increased fluids. They also identified weaknesses in the literature: many studies used designs that limited conclusions, few measured self-initiation as a separate outcome, and generalization across settings and maintenance over time were inconsistently reported. They recommended more attention to these outcomes and to how caregivers carry procedures forward.

How the Studies Differ in Method

The four sources differ in ways that matter for applying them. Azrin and Foxx worked with adults in a residential institution where staff controlled the whole day, which made intensive schedules possible. Cicero and Pfadt and LeBlanc and colleagues worked with young children, in school and outpatient settings, where the training day was shorter and parents carried the program into evenings and weekends. The studies also defined success differently. Some reported accidents per day, some reported the percentage of voids in the toilet, and few set a criterion for calling a child trained. Without a shared definition, comparing results across studies is difficult, and a family may hear "trained" and expect more than a study showed.

For my capstone, this means setting a success criterion in advance rather than declaring success when the graph looks good. My supervisor and I chose a fourteen-day stretch with at most one accident on any clinic day and at least one self-initiation per day, a standard the families helped set by telling us what would make kindergarten and preschool possible.

Synthesis

Read together, the studies point to a consistent core: frequent scheduled sits, immediate reinforcement for voiding in the toilet and a structured response to accidents. Increased fluids appear in most successful programs but raise safety questions for small children, which later programs addressed by limiting the amount. Accident procedures moved over time from positive practice and reprimands toward neutral redirection to the toilet, without apparent loss of effectiveness. Parent training appears repeatedly as the bridge between a clinic and a child's home.

Three points of disagreement or uncertainty remain. First, how quickly sits should be thinned is not settled; programs vary from days to weeks. Second, self-initiation is less consistently produced than continent voids, and children may learn to void on schedule without learning to ask. Third, the long-term durability of gains is rarely measured.

Gaps My Capstone Can Address

My capstone can contribute in a small way to two of the gaps Kroeger and Sorensen-Burnworth identified. It measures self-initiation as a separate behavior, with its own definition and agreement checks, and it collects home data from parents as a generalization measure. It cannot address long-term maintenance beyond a short follow-up, and with two participants it cannot establish evidence on its own.

How the Review Shapes the Protocol

The review shaped four decisions. Sits will be scheduled every thirty minutes at first and thinned only after a set number of dry intervals. Reinforcement for voids will be immediate and drawn from each child's preference assessment. Fluids will be increased modestly within limits set by pediatricians. Accidents will be met with neutral redirection, following Cicero and Pfadt. A fifth decision follows from LeBlanc and colleagues: parents will be trained with behavioral skills training before the home phase begins.

Limits of the Review

This review covers four central sources rather than the full literature, which a longer project would extend to newer studies, including those testing urine alarms, video modeling and caregiver-led programs. It also relies largely on small single-case studies, which are appropriate for this population but limit generalization.

Conclusion

Toilet training research for people with developmental disabilities developed from Azrin and Foxx's intensive institutional method to reinforcement-based programs for children with autism, described by Cicero and Pfadt and by LeBlanc and colleagues. Kroeger and Sorensen-Burnworth's critical review confirmed the core components and identified gaps in self-initiation, generalization and maintenance, two of which the capstone measures directly.

References

Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied Behavior Analysis, 4(2), 89-99. https://doi.org/10.1901/jaba.1971.4-89

Cicero, F. R., & Pfadt, A. (2002). Investigation of a reinforcement-based toilet training procedure for children with autism. Research in Developmental Disabilities, 23(5), 319-331. https://doi.org/10.1016/S0891-4222(02)00136-1

Kroeger, K., & Sorensen-Burnworth, R. (2009). Toilet training individuals with autism and other developmental disabilities: A critical review. Research in Autism Spectrum Disorders, 3(3), 607-618. https://doi.org/10.1016/j.rasd.2009.01.005

LeBlanc, L. A., Carr, J. E., Crossett, S. E., Bennett, C. M., & Detweiler, D. D. (2005). Intensive outpatient behavioral treatment of primary urinary incontinence of children with autism. Focus on Autism and Other Developmental Disabilities, 20(2), 98-105. https://doi.org/10.1177/10883576050200020601