Research in Autism Spectrum Disorders 3 (2009) 607–618

Contents lists available at ScienceDirect

Research in Autism Spectrum

Disorders
Journal homepage: http://ees.elsevier.com/RASD/default.asp

Review

Toilet training individuals with autism and other

developmental disabilities: A critical review
K.A. Kroeger *, Rena Sorensen-Burnworth
Kelly O’Leary Center for Autism Spectrum Disorders, MLC 4002, Cincinnati Children’s Hospital Medical Center,
University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH 45229, United States

A R T I C L E I N F O A B S T R A C T

Article history: The following article reviews the current literature addressing toilet
Received 8 January 2009 training individuals with autism and other developmental dis-
Accepted 9 January 2009 abilities. The review addresses programs typical to toilet training
the developmental disability population, most of which are
Keywords: modeled after the original Foxx and Azrin [Azrin, N. H., & Foxx,
Toilet training R. M. (1971). A rapid method of toilet training the institutionalized
Continence retarded. Journal of Applied Behavior Analysis 4, 89–99; Foxx, R. M., &
Autism
Azrin, N. H. (1973). Toilet training persons with developmental
Developmental disabilities
disabilities: A rapid program for day and nighttime independent
Review
toileting. Harrisburg, PA: Help Services Press] rapid toilet training
methods. Components of such programs are isolated and described
in their contribution to toilet training models. Studies are then
reviewed and compared for participant and study characteristics.
Individual studies validating toilet training programs are then
discussed in light of their program components and efficacy.
Shortcomings to currently available programs are highlighted and
future areas of study are suggested.
ß 2009 Elsevier Ltd. All rights reserved.

Contents

1. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
1.1. Graduated guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
1.2. Reinforcement-based training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
1.3. Scheduled sittings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
1.4. Elimination schedules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612

* Corresponding author.
E-mail address: Kimberly.Kroeger-Geoppinger@cchmc.org (K.A. Kroeger).

1750-9467/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2009.01.005
608 K.A. Kroeger, R. Sorensen-Burnworth / Research in Autism Spectrum Disorders 3 (2009) 607–618

1.5. Punishment procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612

1.6. Hydration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
1.7. Manipulation of stimulus control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
1.8. Nighttime training for diurnal continence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
1.9. Priming and video modeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
2. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
2.1. Participant characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
2.2. Program characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
2.3. Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617

Competent toileting is a critical life skill. Twenty years ago, 63% of the empirical research on self-
help skills focused on toileting and feeding (Konarski & Diorio, 1985). This skewed emphasis is likely to
be maintained today as the social and practical ramifications of incontinence have not changed over
time. Incontinence is problematic to individuals with developmental disabilities in that it places limits
on socialization, and residential and vocational placements. Quality of life impairments can include
inadequate hygiene, stigmatism, physical discomfort and irritation of the genitals, diminished self-
confidence, and restriction from typical daily activities (e.g., Cicero & Pfadt, 2002; Hyams, McCoull,
Smith, & Tyrer, 1992; Lott & Kroeger, 2004; McCartney, 1990). Toileting is a critical skill necessary for
independent living, and incontinence is a significant quality of life barrier for individuals with autism
and developmental disabilities.
Given the magnitude of establishing and maintaining continence for individuals with
developmental disabilities, it is important to consider individual characteristics associated with
toileting competence. Researchers indicate that individuals who are chronologically younger and
measured at an IQ score of 20 or higher are more likely to achieve success with behavioral toileting
programs (Lohmann, Eyman, & Lask, 1967). However, operant learning procedures have
demonstrated efficacy with a diverse range of functioning in the mentally retarded population
(Osarchuk, 1973). A number of prerequisites have also been cited as ‘‘necessary’’ to initiate training of
toileting including regular urinary and bowel voiding (‘‘with infrequent dribbling;’’ Lowenthal,
1996), child ability to void urine in large amount, demonstrated ability to sit on the toilet, absence of
counter-indicated medical conditions (e.g., spina bifida), and diapering at night as diurnal continence
typically precedes nocturnal continence (this appears to be more of an observation and suggestion
than actual prerequisite proper; Baker & Brightman, 1997; Lowenthal, 1996; Snell & Brown, 2000).
However, data to support the necessity of such prerequisites are not referenced. Foxx and Azrin
(1973) also suggest a set of skills present before attempting toileting training, however, these skills
appear to be a minimum of physical capacity (e.g., ability to walk, see, grasp) rather than toileting-
behavior specific.
In training toileting, two goals must be met in order to achieve independent and appropriate
toileting skills: (1) continence, where an individual must be able to recognize the sensation for
elimination and (2) mastery of the entire chain of behaviors accompanying a toilet visit (i.e., going to
the bathroom, removing clothes, excreting into the toilet, redressing, flushing, and washing hands;
Lott & Kroeger, 2004; Taras & Matese, 1990). It should be noted that these two goals are the end result
of successful toilet training, not prerequisite skills to initiate toilet training.
The published history of toilet training individuals with mental retardation began in 1963 when
Ellis offered a predominantly behavioral paradigm for continence acquisition in the developmentally
disabled population, setting the stage for empirically validated studies to follow. The premises of
toileting success were systematic presentation of response cues and contingent positive reinforce-
ment (Cicero & Pfadt, 2002; Ellis, 1963). Early studies demonstrating this behavioral efficacy were
conducted by Hundziak, Maurer, and Watson (1965), Kimbrell, Luckey, Barbuto, and Love (1967),
Levine and Elliot (1970), and Van Wagenen, Meyerson, Kerr, and Mahoney (1969). In 1971, Azrin and
Foxx furthered the literature with the development of the most cited and comprehensive toilet
training protocol, the rapid toilet training (RTT) method (McCartney, 1990). However, despite the
success of RTT and others as whole protocols, components of the procedures are often disaggregated
 K.A. Kroeger, R. Sorensen-Burnworth / Research in Autism Spectrum Disorders 3 (2009) 607–618 609

and used as toilet training protocols in and of themselves (e.g., Cicero & Pfadt, 2002; Hyams et al.,
1992; Jason, 1977; Williams & Sloop, 1978).
Toileting skills acquisition will be critically discussed herein by individual methodology, and study
and participant characteristics will follow subsequently. In addition, shortcomings of the toileting
literature, and relatedly, directions for future research will be discussed.

1. Method

A comprehensive literature review was conducted where the major psychology (e.g., PsychoInfo),
educational (e.g., ERIC), and medical (e.g., Medline) search engines were queried for toileting articles
using a combination of the following search words: ‘‘toileting, toilet, and (in)continence’’ and ‘‘autism,
developmental disability and disorder, intellectual disability and mental retardation.’’ The years
searched began with (Fall) 2008 and a lower year limit was not set. Sixty-eight citations were returned
in the search. All returned documents were reviewed for pertinence and divided into two categories:
theoretical or statement papers (including book chapters) and data-based studies (peer-reviewed
journal submissions only). A total of 28 data-based papers were reviewed and included herein based
on clear description of toileting procedure, participant description and inclusion of toileting data. All
included data-based studies were then reviewed for training program components, participant
characteristics, and study characteristics. Training components will be discussed in the order of which
they are cited; that is, the most frequently used strategy will be reviewed first and all subsequent
strategies discussed in descending order of citation frequency. The following behavioral components
will be described and reviewed: graduated guidance and prompting, reinforcement based training,
scheduled sittings, elimination schedules, overcorrection and punishment, hydration, manipulation of
stimulus control, nighttime training for diurnal continence, and priming. Table 1 lists included studies
and summarizes each study by component teaching strategies.

1.1. Graduated guidance

Graduated guidance, inclusive of prompting, is the most frequently incorporated behavioral

component for toilet training individuals with autism and other developmental disabilities (e.g., Azrin,
Bugle, & O’Brien, 1971; Azrin & Foxx, 1971; LeBlanc, Carr, Crossett, Bennett, & Detweiler, 2005; Van
Wagenen et al., 1969). Given the frequency of its use, it is obvious that prompting is inherent to
teaching toileting and a highly successful program component. Azrin and Foxx’s (Azrin & Foxx, 1971;
Foxx & Azrin, 1973) RTT is the most cited example of graduated guidance, a behavior-shaping
technique designed specifically for toileting (Taras & Matese, 1990). Graduated guidance is a
prompting hierarchy utilizing (forward or backward) behavioral chaining to achieve mastery of the
necessary steps, or behaviors, to appropriate toileting. The least intrusive prompt is used to elicit the
target behavior in a chain of behaviors (undressing, voiding, redressing, flushing, and washing hands).
Prompting hierarchies are graduated in level of required assistance and follow accordingly: no
prompt, obvious pause, point to the target (e.g., pants down), verbal prompt, increasing presence of
physical prompts. The literature is rich with prompting components, including verbal, gestural,
physical, and modeling. Most studies employ a combination of prompting hierarchies, least restrictive
prompts, and rapid fading of prompts. However, Smith (1979) offered the precaution of abrupt
removal of prompts associated with skills regression due to unstable toileting behaviors.

1.2. Reinforcement-based training

Also inherent to toileting protocols is the implementation of reinforcement (e.g., Azrin & Foxx,
1971; Cicero & Pfadt, 2002). Most commonly used is positive reinforcement where a stimulus (such as
a preferred edible or activity) is provided following a successful void. Positive reinforcement was
present in the original Foxx and Azrin studies (Azrin & Foxx, 1971; Foxx & Azrin, 1973) and continues
to take precedence in training protocols currently. More recently, negative reinforcement, in the form
of response restriction, has entered toilet training protocols as a primary treatment component
(Averink, Melein, & Duker, 2005; Duker, Averink, & Melein, 2001). In these studies, the participants
 610
Table 1
Critical components summary of reviewed empirical studies.

Citation Population Ages Treatment components Setting Length of training Key findings

Ando (1977) Autism; profound MR 5–10 yr ES; GG; PR; P; ScS Inpatient/residential 2–3 months, 4 of 5 SS trained
4–10 months

K.A. Kroeger, R. Sorensen-Burnworth / Research in Autism Spectrum Disorders 3 (2009) 607–618

Averink et al. (2005) Moderate to severe MR 0–4 yr, 5–10 yr, GG; PR; P; H; RR School/residential; 0–1 month 48% of 40 SS trained;
11–18 yr, adults outpatient clinic Defecation not targeted
Azrin and Foxx (1971) Profound MR Adults ES; GG; H; P; PR; Residential 0–1 month 100% of 9 SS trained
ScS; UA
Azrin et al. (1971) Profound MR 0–4 yr, 5–10 yr SS; H; P; PR; UA School/residential 0–1 month, 4 SS trained; double urine
2–3 months, alarm primary treatment
4–10 months
Azrin et al. (1973) Profound MR Adults H; GG; P; PR; ScS; UA Residential 0–1 month 12 SS nocturnal trained
Bainbridge and Autism 0–4 yr ScS; PV Home 0–1 month Increased initiations in
Myles (1999) 3-year-old boy
Barmann et al. (1981) Moderate to severe MR 0–4 yr, 5–10 yr PR; P; Home 0–1 month Trained 3 irregular
enuretic SS; maintained
Cicero and Pfadt (2002) Autism; unspecified MR 0–4 yr, 5–10 yr GG; PR; ScS; P; H School 0–1 month 3 SS trained; Reinforcement
primary treatment
Dalrymple and Autism; profound MR 11–18 yr GG; PR; ScS; P; MSC Inpatient/residential Not reported Trained adolescent girl
Angrist (1988)
Didden et al. (2001) Angelman syndrome 5–10 yr, 11–18 yr GG; H; P; PR; ScS Residential; home 0–1 month 6 SS trained; long term
maintenance
Duker et al. (2001) Moderate to severe MR 0–4 yr, 5–10 yr, GG; H; P; PR Unclear 7 of 8 SS trained; response
11–18 yr restriction primary treatment
Hagopian et al. (1993) Profound MR 5–10 yr GG; PR; ScS; MSC Inpatient clinic 2–3 months Trained 9-year-old boy with
water prompt
Jason (1977) Severe to profound MR 5–10 yr, 11–18 yr Foxx and Azrin (FA) School 4–6 months 14 SS trained; comparison
protocol v. ScS v. study; FA best method; mixed
no treatment social validity
Keen et al. (2007) Autism; unspecified MR 0–4 yr, 5–10 yr ES; GG; H; P; PR; Home, school 2–3 months, 2 of 5 SS schedule trained,
PV; ScS 4–10 months none of SS were independent
continent
Lancioni (1980) Deaf-blind profound MR 5–10 yr, 11–18 yr GG; H; P; PR; UA Not reported 0–1 month 8 of 9 SS trained; disability
modifications; collateral
fecal continence
Lancioni and Profound MR 5–10 yr, 11–18 yr GG; H; ScS; P; PR; UA Residential Not reported Trained 9 SS; focus on
Ceccarani (1981) initiation and effects of P
LeBlanc et al. (2005) Autism; unspecified MR 0–4 yr GG; PR; ScS; ES; P; H Outpatient clinic 0–1 month Trained 3 children
(2 boys, 1 girl)
Luiselli (1994) Unspecified MR; sensory 5–10 yr GG; PR; ScS; ES; MSC School/residential 2–3 months Trained 2 boys with
deficits 4–10 months deafness, 1 blind
Luiselli (1996a) PDD-NOS; unspecified MR 5–10 yr GG; PR; ScS; MSC School/residential 4–10 months Trained a 7-year-old girl
Luiselli (1997) PDD-NOS; unspecified MR 5–10 yr GG; PR; ScS; MSC School/residential 2–3 months Trained 8-year-old boy
Mahoney, Van Wagenen, Neuro-typical; 0–4 yr, 5–10 yr UA; PR; H; P; GG School Not reported 7 of 8 SS trained; group training
and Meyerson (1971) unspecified MR
Matson (1977) Autism 11–18 yr P; PR Residential 0–1 month Fecal trained SS; simple
overcorrection
Post and PDD-NOS 0–4 yr GG; PR; ES Home 0–1 month Trained 3 1/2 year-old boy
Kirkpatrick (2004)

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Richmond (1983) Profound MR 0–4 yr GG; ScS; P; PR School 0–1 month 4 SS reduced accidents;
fading ScS primary treatment
Saloviita (2000) Profound MR Adult DB; UA School/residential Not reported Trained 28-year-old woman
Taylor et al. (1994) Autism severe MR 5–10 yr GG; PR; ScS; ES; Home Not reported Trained 10-year-old boy
P; H; MSC
Van Wagenen Profound MR 0–4 yr, 5–10 yr GG; H; P; UA Outpatient 0–1 month 9 SS trained; 5 maintained
et al. (1969) post 1 month
Wilder et al. (1997) Profound MR Adult GG; PR; ScS; ES; P; H School/residential 2–3 months Trained 21-year-old man

Note: Treatment component abbreviations are as follows in alphabetical order: DB = Dry Bed Nighttime training; ES = elimination schedule; GG = graduated guidance; H = hydration;
MSC = manipulation of stimulus control; P = punishment; PR = positive reinforcement; PV = priming/video modeling; RR = response restriction; ScS = scheduled sitting; UA = urine alarm.

611
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were restricted from making any response incompatible with appropriate toileting behaviors when in
the toilet vicinity. As with positive reinforcement, negative reinforcement strategies are
demonstrating continence success with individuals of varying ages and functioning levels, while
also allowing for successful training implementation without the use of aversives or punishment
procedures.

1.3. Scheduled sittings

Scheduled sitting is a procedure where individuals are placed on (or in front of depending on sex
and training protocol) the toilet and then positively reinforced when voiding occurs. Scheduled
sitting is also a frequent program component in successful training protocols (e.g., Bainbridge &
Myles, 1999; LeBlanc et al., 2005; Luiselli, 1994, 1996a, 1997). Scheduled sitting serves a multitude of
functions and is introduced at various intervention times in toilet training protocols. Scheduled
sittings can be implemented at predetermined elimination-likely times based on the elimination
schedule findings (e.g., Baumeister & Klosowski, 1965), or at regular, non-contingent time intervals,
typically every 15–30 min (e.g., Wilder, Higbee, Williams, & Nachtwey, 1997). In both schedules,
once voiding occurs the individual is reinforced and allowed to leave the toileting area. A comparison
study conducted by Smith (1979) found that both were comparable in obtained results, but that
regularly scheduled (not elimination schedule based) potting was easier to implement. However,
further validation of findings has not been established, as comparative replication of Smith’s work
has not been conducted to date. Wilson (1995) proposed a modified scheduled sitting protocol,
referred to as a Generic Habit-Training Program, where sitting is initially scheduled only one time per
day at what is considered an optimum time for urination likelihood (i.e., elimination-based
schedule). Additional sittings are added once the child is voiding in the toilet shortly after reaching
the bathroom. While the program shows preliminary success with the participant child,
generalization of procedure to other children is called into question regarding a potentially low
reinforcement rate via infrequent scheduled sitting rate.

1.4. Elimination schedules

A number of training protocols begin with identifying an individual’s pattern of elimination,

including frequency and timing of voids (Azrin et al., 1971; Langone, 1986; LeBlanc et al., 2005;
Luiselli, 1994; Post & Kirkpatrick, 2004; Saloviita, 2000; Wilder et al., 1997). Detecting a stable
pattern of voiding allows for further, and more individualized, treatment that capitalizes on the
best-timed points to intervene. Establishing and recording the elimination schedule is typically
conducted in one of two ways: mechanical or manual detection. Mechanical devices have been
developed and utilized in treatment protocols that register when moisture is emitted and sound an
alarm (e.g., Azrin et al., 1971). A small sensor is placed in the individual’s undergarments and when
it detects moisture (urine), it rings a bell. Manual detection includes recordings conducted via wet/
dry checks where the individual’s undergarments/clothing are periodically checked for wet or soil
and recorded accordingly (Langone, 1986). That is, at set or random times, someone visually scans
or physically feels the individual’s undergarments to determine if soil/wet has occurred and
records it as a void occurrence. Both recording methods could be considered invasive for the
individual, but are currently the best practice for obtaining reliable and valid data for voiding
schedules.

1.5. Punishment procedures

Reflective of the current philosophical zeitgeist, research and practice in mental retardation and
developmental disability populations focus on positive behavioral (support) interventions. As a result,
overcorrection and punishments procedures have fallen out of use, which is evident in the more recent
literature on toileting (e.g., Cicero & Pfadt, 2002). Positive practice and restitution, however, have a
defined place in toileting history, as well as demonstrated efficacy in rapid teaching of continence
skills. The most common aversive procedure used in toilet training is restitution overcorrection, a
 K.A. Kroeger, R. Sorensen-Burnworth / Research in Autism Spectrum Disorders 3 (2009) 607–618 613

procedure where individuals are required to return the environment to its previous state (see Lott &
Kroeger, 2004). Typically, after an accident or inappropriate voiding occurs, individuals are required to
engage in environmental restitution where they clean themselves, soiled clothing, and any soiled
objects (e.g., floor, furniture). Additionally, individuals may be walked from the spot of the accident to
the toilet a specific number of times after the accident occurs (i.e., overcorrection or positive practice).
While positive support interventions are currently preferred to aversive procedures, restitution
overcorrection has constructive qualities, including rapid acquisition of toileting skills (Azrin & Foxx,
1971), high (residential) staff compliance with protocol (Matson, 1977), and replacement of
maladaptive behaviors with adaptive behaviors (Freeman & Pribble, 1974).
Cicero and Pfadt (2002) cite the paradox in toileting protocols implementing overcorrection
procedures, such as Azrin and Foxx’s (1971), that have high success rates but are only infrequently
referenced in current literature. They state that current policies regarding mental retardation and
developmental disability populations are likely factors (i.e., support for positive behavioral
interventions), and they offer a positive reinforcement-based training protocol. However, it should
be noted that Cicero and Pfadt’s protocol contains verbal reprimands, which is considered a
punishment procedure categorically and topographically. This is not an uncommon occurrence for
current literature where verbal reprimands are used as corrective feedback (e.g., Cicero & Pfadt, 2002;
Wilder et al., 1997), but not necessarily identified as a punishment procedure. In addition, studies that
claim to avoid use of punishment subsequently include the use of positive practice (i.e., Averink et al.,
2005; Duker et al., 2001). Positive practice is indeed a punishment procedure in that through
application it intends to decrease the likelihood of future toileting accidents. Hence, a number of
successful training protocols technically include the use of punishment procedures (Averink et al.,
2005; Azrin & Foxx, 1971; Cicero & Pfadt, 2002; Dalrymple & Angrist, 1988; Duker et al., 2001;
Freeman & Pribble, 1974; Foxx & Azrin, 1973; LeBlanc et al., 2005; Matson, 1977; Saloviita, 2000;
Taylor, Cipani, & Clardy, 1994; Wilder et al., 1997), and the current empirical trend appears to use
‘‘less-aversive’’ positive punishment procedures than those of the past (i.e., using verbal reprimands
instead of overcorrection).

1.6. Hydration

To ensure success during continence training (especially protocols involving scheduled sitting,
whether it be regular- or elimination-timed) hydration procedures are often used in conjunction (e.g.,
Azrin & Foxx, 1971; Cicero & Pfadt, 2002; Taylor et al., 1994; Wilder et al., 1997). Hydration involves
providing individuals with liquids to consume, both in large volume (e.g., Azrin & Foxx, 1971;
Richmond, 1983) and high preference (e.g., Wilson, 1995). Providing free access to liquids and
promoting hydration prior to the scheduled sitting increases the likelihood of urinary voiding, as well
as contingent reinforcement for elimination. Data suggest hydration is effective in training protocols,
especially those involving scheduled sitting. However, there are associated risks (Lott & Kroeger, 2004;
see Thompson & Hanson, 1983). Excessive water intake, especially when ingested volume is
disproportionate to body weight, can lead to hyponatremia, an imbalance of electrolytes. Individuals
with a positive history of seizure disorders, hydrocephaly, spinal cord injury, and/or current
pharmacological regimen with side effects of urinary retention should not be placed on a training
program involving hydration.

1.7. Manipulation of stimulus control

The abovementioned toileting component interventions are highly effective in training individuals
with autism and mental retardation. There are, however, individuals within the population who are
resistant to training under the traditional protocols. More recent literature focuses on these
individuals and the use of systematic problem solving to achieve the goal of successful toilet training.
When designing these interventions, the core basics of the established protocols (e.g., graduated
guidance, scheduled sitting, reinforcement for appropriate voiding) are preserved and augmented
with additional or varied training components, namely, manipulation of the discriminative stimulus
(Dalrymple & Angrist, 1988; Hagopian, Fisher, Piazza, & Wierzbicki, 1993; Luiselli, 1994, 1996a, 1997;
614 K.A. Kroeger, R. Sorensen-Burnworth / Research in Autism Spectrum Disorders 3 (2009) 607–618

Taylor et al., 1994). Common to these studies is the initial use of traditional toileting protocols, such as
Azrix and Foxx’s (Azrin & Foxx, 1971; Foxx & Azrin, 1973), followed by the individuals’ failure to
become continent. All referenced studies maintained use of the established training protocol and then
manipulated stimulus control to achieve appropriate voiding in the toilet. Transferring stimulus
control involves investigating the individuals’ tendencies to void outside the toilet and to then take the
findings and gradually change the controlling antecedents from ‘‘other’’ to the toilet. The ‘‘other’’
controlling antecedents included submersion into water (i.e., bath time; Hagopian et al., 1993)
clothing and undergarments (Taylor et al., 1994), diapers (Luiselli, 1996a,b, 1997), and the act of
cleaning a fecally smeared environment (rather a consequent controlling stimulus; Dalrymple &
Angrist, 1988). All of the studies successfully transferred the stimulus control from these antecedents
to the toilet to achieve appropriate toileting skills acquisition.

1.8. Nighttime training for diurnal continence

Saloviita (2000) reported a case of spontaneous generalization from nocturnal to diurnal training.
In his case, nocturnal enuresis was the target behavior for an adult woman with profound mental
retardation. Azrin, Sneed, and Foxx (1973) present a nighttime training protocol for toileting in
persons with mental retardation, which was used in the current study. While the protocol was
ineffective in treating the nocturnal enuresis symptoms in the Saloviita study, the training procedures
appeared to have a generalized effect where the woman became continent during the daytime after
the nighttime procedures were implemented. It was noted that diurnal enuresis was not targeted
during the nocturnal training time period. Additionally, this was not a controlled study and therefore,
true treatment effects cannot be determined.

1.9. Priming and video modeling

A case of using the predominantly associated cognitive-behavioral method of priming

(Bainbridge & Myles, 1999) was also included in the review based upon pertinence and scientific
presentation. Priming is the intervention whereby information is provided to a subject in order to
prepare the subject for the performance of an activity. Hence, the information is provided before the
behavior is completed in order to increase the likelihood that the behavior will be completed
successfully. In this study, the priming material used was a toilet training video. The authors note
that this procedure was implemented to introduce toilet training to a child with autism and the study
found positive results. The empirical question remains as to whether this is a necessary step in
effective toilet training. A later study reinvestigated the use of video modeling as an effective tool in
teaching toilet training (Keen, Brannigan, & Cuskelly, 2007). The children demonstrated faster
acquisition (than control participants) when video modeling is used. However, these results are
tentative in that none of the trained children were independently continent at the conclusion of the
study or during follow-up. Both studies focused on children with autism and used videos in order
capitalize on the associated correlate of strength in learning via visual presentation. While further
study is warranted to determine if priming is a critical component to successful continence in the
autism spectrum populations, preliminary data are supporting the use of video medium in teaching
toileting.

2. Discussion

A number of training protocols have been well established as successful for achieving continence in
individuals with autism spectrum disorders and developmental disabilities. Almost all of these
protocols are derivatives of the RTT method pioneered by Foxx and Azrin (Azrin & Foxx, 1971; Foxx &
Azrin, 1973), with the exception of the earlier training programs that still contain a number of
behavioral strategies. Still, it is important to investigate both the participant and study/programmatic
characteristics of the analytical studies to determine likelihood of success when generalizing findings
to the training of others with similar diagnoses, as well as to note shortcomings with the current state
of the literature.
 K.A. Kroeger, R. Sorensen-Burnworth / Research in Autism Spectrum Disorders 3 (2009) 607–618 615

2.1. Participant characteristics

In reviewing the literature, two population characteristics are routinely addressed: age and
functioning level. The early literature cites individuals with an IQ above 20 and chronologically
younger as more likely to achieve successful toileting (Lohmann et al., 1967). The majority of recent
studies (1990s to current) focus on children in the prepubescent age range (Averink et al., 2005;
Bainbridge & Myles, 1999; Cicero & Pfadt, 2002; Duker et al., 2001; Keen et al., 2007; LeBlanc et al.,
2005; Post & Kirkpatrick, 2004; Luiselli, 1994, 1996a, 1997; Taylor et al., 1994), but there are also a
number of validated studies for adolescents and adults (Averink et al., 2005; Dalrymple & Angrist,
1988; Wilder et al., 1997). This focus on younger age also appears to keep with the current trend of
focus on early intervention in developmental disabilities and particularly in the field of autism. The
shift of training focus from older to younger target ages should have longitudinal positive impact on
quality of life factors for the affected individuals.
Information on functioning level of study participants is less widely available. While a number of
studies state the participant functioning level, it is often not explained how the functioning level
was determined. Moreover, the majority of studies (especially more current literature) provide
participant descriptions such as language ability (e.g., one-word phrases, nonverbal), skill abilities
(e.g., imitation, presence of preacademic skills), and history of toileting behaviors (e.g., previous
training attempts, diapers worn, pull pants up and down) rather than citing actual standardized
classification of abilities. Nonetheless, continence training has been successful with individuals
with profound mental retardation (Hagopian et al., 1993; Wilder et al., 1997), severe mental
retardation (Averink et al., 2005; Dalrymple & Angrist, 1988; Taylor et al., 1994), and moderate
mental retardation (Averink et al., 2005). Studies employing individuals of mild mental retardation
were not reported in the literature. However, it is likely that a number of studies did train such
individuals given the included participant descriptions (e.g., Bainbridge & Myles, 1999; Cicero &
Pfadt, 2002; Post & Kirkpatrick, 2004). It could be conclude though that generalization of training
procedures (to others) may be limited in that true participant characteristics are unable to be
ascertained.

2.2. Program characteristics

Study and program characteristics are also important factors in review. Most report total
continence training time and length of follow-up and study setting, followed less frequently by use of
adjunctive parent training and administration of social validity measures. It appears that the studies
employing original or first-time training programs are shortest in duration for training time (e.g.,
Cicero & Pfadt, 2002; LeBlanc et al., 2005), while protocols that involve manipulation of stimulus
control following unsuccessful previous toileting attempts are of the longest training times (e.g.,
Hagopian et al., 1993; Luiselli, 1994, 1996a). The following studies cited completed training times in
one month or less (Bainbridge & Myles, 1999; Cicero & Pfadt, 2002; LeBlanc et al., 2005; Post &
Kirkpatrick, 2004), two to three months (Hagopian et al., 1993; Luiselli, 1994, 1997; Wilder et al.,
1997), and four to ten months (Keen et al., 2007; Luiselli, 1994, 1996a).
In addition, most studies report follow-up measures of maintenance of acquired skills (Averink
et al., 2005; Cicero & Pfadt, 2002; Duker et al., 2001; LeBlanc et al., 2005; Luiselli, 1994, 1996a, 1997;
Post & Kirkpatrick, 2004; Taylor et al., 1994; Wilder et al., 1997). Maintenance of toileting acquisition
would appear to become an automatic behavior in that the associated affects, that of remaining dry
and unsoiled, maintained hygiene, decreased social stigmatization, are inherently reinforcing.
Interestingly, Hyams et al. (1992) found that independent initiation of toileting routines was the least
likely skill to maintain in a 10-year follow-up. It should be noted that this seems to be a failure in
effective implementation of prompt fading as opposed to bladder control in the participants.
Additional study into the issue is warranted though in order to ascertain if indeed the individuals were
unable to maintain independent initiations or if instead the caregivers became overly prompt-likely in
order to avoid incontinent accidents. Regardless, long-term follow-up information should be made
available and reported in order to determinedly state that toilet training is a behavior that maintains
for the remainder of the lifespan.
616 K.A. Kroeger, R. Sorensen-Burnworth / Research in Autism Spectrum Disorders 3 (2009) 607–618

Study setting is routinely reported and successful protocols exist for a variety of settings. Studies
more recently are also demonstrating success in training across environments simultaneously (e.g.,
Cicero & Pfadt, 2002; Duker et al., 2001; LeBlanc et al., 2005). Settings of interest and success include
training in the home (e.g., Bainbridge & Myles, 1999; Wilder et al., 1997), clinic or outpatient settings
(e.g., Averink et al., 2005), and school or residential settings (e.g., Cicero & Pfadt, 2002; Luiselli, 1994,
1996a, 1997). The noteworthy empirical shift is away from institutional settings and toward
outpatient clinics. This again appears to reflect the current trend of accessing populations as most
clinical services now focus on the early intervention and school-aged populations in typical outpatient
clinic settings.
Less researched are the use of parent training and measurement of social validity. Studies that
mention parent training are innovative in their pursuit of soliciting parents to participate in the
training of their children. However, these training models are typically a co-treater model as opposed
to a primary parent training model (Cicero & Pfadt, 2002; Keen et al., 2007; LeBlanc et al., 2005; Taylor
et al., 1994). In addition, only one study reported measuring social validity (LeBlanc et al., 2005). The
paucity of social validity reports could be due to two factors: (1) parents and caregivers are inherently
satisfied with successful training programs in that the ultimate end result is continence and the
significance of continence has previously been discussed and (2) focus on social validity as a routine
measure for intervention protocols has only recently received more popular coverage in research
protocols.
Also of clinical research interest are behaviors that are not required of successful continence
training, but are instead inherent to maintenance of toileting success. Such behaviors include
communication (of the need to toilet), self-initiation (for using the toilet), and bowel movement
training. These have received more recent attention in the literature, but are not routinely included in
protocol description. Regarding communication training and self-initiation training, studies
addressing these behaviors often mention them within the context of the protocol description
(i.e., training for behaviors is blended into the continence training protocol) as opposed to systematic
training for each behavior. While the studies do not note such issues, it does beg the question of how to
train for the behaviors in the event that the individuals do not learn through the protocol to
communicate or self-initiate while becoming continent. Conversely, Langone and Burton (1987) note
that teaching communication to use the bathroom is often the final step in training, but they do not
describe or attempt to provide data or protocol for how to accomplish the act of communicating.
Nonetheless, it is noteworthy that such studies are beginning to focus on the associated behaviors of
communication (Cicero & Pfadt, 2002; LeBlanc et al., 2005; Luiselli, 1994; Post & Kirkpatrick, 2004)
and self-initiation (Bainbridge & Myles, 1999; Cicero & Pfadt, 2002; LeBlanc et al., 2005; Luiselli, 1994;
Post & Kirkpatrick, 2004).
Additionally of low frequency report is bowel movement training. Thus far, studies overtly
addressing fecal training are primarily focused on the issue of encopresis proper, as opposed to general
toilet training (Dalrymple & Angrist, 1988; Luiselli, 1996b). That is, the main focus of the studies is on
bowel movement training as opposed to a comprehensive toilet training program. It should be noted
that these studies also fall within the manipulation of stimulus control classification, which indicates
that traditional toileting attempts failed. This leaves the issue of whether other referenced studies that
do not mention training for bowel movements omit the reference to fecal training because it occurs as
a natural result of continent toilet training, or it is not addressed within the training protocol and
therefore the participants are not fecally trained as a result.

2.3. Future directions

A number of toileting protocols exist within the literature, many of them successful and allegedly
capable of generalization to a wide variety of individuals within the autism and developmental
disability population. While most of the programs are modified versions of the toileting protocol
presented by Foxx and Azrin, studies focus on abbreviating the protocols while also reducing steps,
components, and professional training involvement. That is, the trend is to make less complicated the
toileting protocols previously originated. Future areas of toileting literature should focus on the
following: (1) collateral behaviors pivotal to successful toileting training, including communication,
 K.A. Kroeger, R. Sorensen-Burnworth / Research in Autism Spectrum Disorders 3 (2009) 607–618 617

self-initiation and bowel movement training; (2) exploration of age and functioning limits (i.e., how
young to train and how cognitively low is trainable); and (3) review of necessary prerequisite skills
suggested present before initiating toilet training. Such investigations will serve to continue the body
of literature surrounding toilet training, while at the same time providing improved quality of life for
individuals with autism spectrum disorders and mental retardation.

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