Toilet Training: Strategies Involving Modeling and Modifications of the Physical Environmental

Part of the Autism and Child Psychopathology Series book series (ACPS)


Toilet training is a social learning process requiring interactions between young children and their parents and caregivers over extended periods of time, typically in the first 2 to 4 years of life. It is a complex process involving both developmental maturation and learning, and not all children respond sufficiently to the conventional techniques encountered in their specific family and cultural context to achieve excretory continence and culturally appropriate toileting practices (Kaerts et al., Scandinavian Journal of Urology and Neophrology 46:424–430, 2012). Thus, for some, additional strategies are needed in order for continence and toileting to be learned (Kaerts, et al., Scandinavian Journal of Urology and Neophrology 46:424–430, 2012). Such strategies may include motivating and prompting the behavior, manipulation of antecedent stimulus control, and/or facilitative environmental modifications, as well as providing salient consequences for correct performance. In this chapter, selected strategies will be described, guidelines for implementing them provided, and the research base supporting their use evaluated. First, to put these intervention options in context, the chapter begins with a brief biobehavioral analysis of the development of bladder and bowel continence and of the key skills that must be acquired for toileting to be done reliably and independently.


Toilet training Intervention strategies In vivo modeling Video modeling Environmental stimuli Structural toileting aids Visual prompts 


  1. Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied Behavior Analysis, 4, 89–99.CrossRefPubMedPubMedCentralGoogle Scholar
  2. Bainbridge, N., & Smith-Myles, B. S. (1999). The use of priming to introduce toilet training to a child with autism. Focus on Autism & Other Developmental Disabilities, 14, 106–109.CrossRefGoogle Scholar
  3. Baker, S. D., O’Reilly, M., & Lang, R. (2009). Review of video modeling with students with emotional and behavioral disorders. Education and Treatment of Children, 32, 403–420.CrossRefGoogle Scholar
  4. Bakker, E., & Wyndaele, J. J. (2000). Changes in the toilet training of children during the last 60 years. The cause of an increase in lower urinary tract dysfunction? BJU International, 86, 248–252.CrossRefPubMedGoogle Scholar
  5. Banda, D. R., Neisworth, J. T., & Lee, D. L. (2003). High-probability request sequences and young children: Enhancing compliance. Child & Family Behavior Therapy, 25, 17–29.CrossRefGoogle Scholar
  6. Bandura, A. (1977a). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.Google Scholar
  7. Bandura, A. (1977b). Self-efficacy: Toward a unifying theory of behavior change. Psychological Review, 84, 191–215.CrossRefPubMedGoogle Scholar
  8. Bandura, A. (1978). Social learning theory of aggression. Journal of Communication, 28, 12–29.CrossRefPubMedGoogle Scholar
  9. Bandura, A., Ross, D., & Ross, S. A. (1961). Transmission of aggression through imitation of aggressive models. Journal of Abnormal and Social Psychology, 63, 575–582.CrossRefPubMedGoogle Scholar
  10. Brazzelli, M., Griffiths, P. V., Cody, J. D., & Tappin, D. (2011). Behavioral and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database of Systematic Reviews, 2. doi: 10.1002/14651858.CD002240.pub3
  11. Bryan, L. C., & Gast, D. L. (2000). Teachign on-task and on-schedule behaviors to high-functioning children with autism via picture activity schedules. Journal of Autism and Developmental Disorders, 30, 553–567. doi: 10.1023/A:1005687310346 CrossRefPubMedGoogle Scholar
  12. Cassibba, R., Castoro, G., Costantino, E., Sette, G., & Van Ijzendoorn, M. H. (2015). Enhancing maternal sensitivity and infant attachment security with video feedback: An exploratory study in Italy. Infant Mental Health Journal, 36, 53–61.CrossRefPubMedGoogle Scholar
  13. Chan, J. M., & O’Reilly, M. F. (2008). A social stories intervention package for students with autism in inclusive classroom settings. Journal of Applied Behavior Analysis, 41, 405–409.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Cicero, F. R., & Pfadt, A. (2002). Investigation of a reinforcement-based toilet training procedure for children with autism. Research in Developmental Disabilities, 23, 319–331.CrossRefPubMedGoogle Scholar
  15. Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). Upper Saddle River, NJ: Pearson.Google Scholar
  16. Deitchman, C., Reeve, S. A., Reeve, K. F., & Progar, P. R. (2010). Incorporating video feedback into selfmanagement training to promote generalization of social initiations by children with autism. Education and Treatment of Children, 33, 475–488.CrossRefGoogle Scholar
  17. Delano, M., & Snell, M. E. (2006). The effects of social stories on the social engagement of children with autism. Journal of Positive Behavior Interventions, 8, 29–42.CrossRefGoogle Scholar
  18. Dettmer, S., Simpson, R. L., Smith-Myles, B., & Ganz, J. B. (2000). The use of visual supports to facilitate transitions of children with autism. Focus on Autism and Other Developmental Disabilities, 15, 163–169.CrossRefGoogle Scholar
  19. deVires, M. W., & deVries, M. R. (1977). Cultural relativity of toilet training readiness: A perspective from East Africa. Pediatrics, 60, 170–177.Google Scholar
  20. Dowrick, P. W. (1999). A review of self-modeling and related interventions. Applied and Preventive Psychology, 8, 23–29. doi: 10.1016/S0962-1849(99)80009-2 CrossRefGoogle Scholar
  21. Dowrick, P. W. (2012a). Self modeling: Expanding the theories of learning. Psychology in the Schools, 49, 30–41. doi: 10.1002/pits.20613 CrossRefGoogle Scholar
  22. Dowrick, P. W. (2012b). Self model theory: Learning from the future. WIREs. Journal of Cognitive Science, 3, 215–230. doi:10.1002/ wcs.1156Google Scholar
  23. Drysdale, B., Lee, C. Y. Q., Anderson, A., & Moore, D. W. (2015). Using video modeling incorporating animation to teach toileting to two children with autism spectrum disorder. Journal of Developmental and Physical Disabilities, 27, 149–165. doi: 10.1007/s10882-014-9405-1 CrossRefGoogle Scholar
  24. Egel, A. L., Shafer, M. S., & Neef, N. A. (1984). Receptive acquisition and generalization of prepositional responding in autistic children: A comparison of two procedures. Analysis and Intervention in Developmental Disabilities, 4, 285–298.CrossRefGoogle Scholar
  25. Finn, C. A., & Sladeczek, I. E. (2001). Assessing the social validity of behavioral interventions: A review of treatment acceptability measures. School Psychology Quarterly, 16, 176–206. doi: 10.1521/scpq. CrossRefGoogle Scholar
  26. Freeman, K. A., Riley, A., Duke, D. C., & Rongwei, F. (2014). Systematic review and meta-analysis of behavioral interventions for fecal incontinence with constipation. Journal of Pediatric Psychology, 39, 887–902.CrossRefPubMedGoogle Scholar
  27. Gena, A., Couloura, S., & Kymissis, E. (2005). Modifying the affective behavior of pre-schoolers with autism using in-vivo or video modeling and reinforcement contingencies. Journal of Autism and Developmental Disorders, 35, 545–556. doi: 10.1007/s10803-005-0014-9 CrossRefPubMedGoogle Scholar
  28. Gimpel, G. A., & Holland, M. L. (2003). Emotional and behavioral problems of young children: Effective interventions in the preschool and kindergarten years. New York, NY: Guliford.Google Scholar
  29. Hagopian, L. P., Fisher, W., Piazza, C. C., & Wierzbicki, J. J. (1993). A water-prompting procedure for the treatment of urinary incontinence. Journal of Applied Behavior Analysis, 26, 473–474.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Hosford, R. E. (1980). Self-as-a-model: A cognitive social learning technique. The Counseling Psychologist, 9, 45–62.CrossRefGoogle Scholar
  31. Howard, B. J. (1991). It’s Potty Time [Video-tape]. Duke family services: Learning Through Entertainment, Inc..Google Scholar
  32. Humm, S. P., Blampied, N. M., Liberty, & K.A. (2005). Effects of parent-administered, home-based, high-probability sequences on compliance by children with developmental disabilities. Child & Family Behavior Therapy, 27, 27–45.CrossRefGoogle Scholar
  33. Kamiyama, T., & Noro, F. (2011). Effectiveness of parent-implemented interventions based on functional assessment of toilet skills in young children with autism. Japanese Journal of Behavior Analysis, 25, 153–164.Google Scholar
  34. Kaerts, N., Vermandel, A., Lierman, F., vanGestel, A., & Wyndaele, J. J. (2012). Observing signs of toilet readiness: Results of two prospective studies. Scandinavian Journal of Urology and Neophrology, 46, 424–430.CrossRefGoogle Scholar
  35. Kazdin, A. E. (1977). Assessing the clinical or applied importance of behavior change through social validation. Behavior Modification, 1, 427–452.CrossRefGoogle Scholar
  36. Kazdin, A. E. (2013). Behavior modification in applied settings (7th ed.). Long Grove, IL: Waveland.Google Scholar
  37. Keen, D., Brannigan, K. L., & Cuskelly, M. (2007). Toilet training for children with autism: the effects of video modeling. Journal of Developmental and Physical Disabilities, 19, 291–303. doi:10.1007/s10882- 007-9044-xCrossRefGoogle Scholar
  38. Kroeger, K. A., & Sorensen-Burnworth, R. (2009). Toilet training individuals with autism and other developmental disabilities: A critical review. Research in Autism Spectrum Disorders, 3, 6070618. doi: 10.1016/j.rasd.2009.01.005 CrossRefGoogle Scholar
  39. Kroeger, K. A., & Sorenson, R. (2010). A parent training model for toilet training children with autism. Journal of Intellectual Disability Research, 54, 556–567. doi: 10.1111/j.1365-2788.2010.01286.x CrossRefPubMedGoogle Scholar
  40. Lam-Cassettari, C., Wadnerkar-Kamble, M. B., & James, D. M. (2015). Enhancing paren-child communication and parental self-esteem with a video feedback intervention: Outcomes with prelingual deaf and hard-of-hearing children. Journal of Deaf Studies in Education, 20, 266–274.CrossRefGoogle Scholar
  41. Lang, R., Shogren, K., Machalicek, W., Rispoli, M., O’Reilly, M. F., Regester, A., & Baker, S. (2009). Use of video self-modeling to teach classroom rules to two children with Asperger’s syndrome. Research in Autism Spectrum Disorders, 3, 483–488. doi: 10.1016/j.rasd.2008.10.001 CrossRefGoogle Scholar
  42. Lee, C. Y. Q., Anderson, A., & Moore, D. W. (2014). Using video modeling to toilet train a child with autism. Journal of Developmental and Physical Disabilities, 26, 123–134. doi: 10.1007/s10882-013-9348-y CrossRefGoogle Scholar
  43. Le Grice, B., & Blampied, N. M. (1995). Using videoprompting to teach video recorder and personal computer operation to pupils with intellectual handicaps. Education and Training in Mental Retardation and Developmental Disabilities, 29, 321–330.Google Scholar
  44. Le Grice, B., & Blampied, N. (1997). Learning to use video recorders and personal computers with increasing assistance prompting. Journal of Developmental & Physical Disabilities, 9, 17–30.CrossRefGoogle Scholar
  45. Luiselli, J. K. (1977). Case report: An attendant-administered contingency management programme for the treatment of a toileting phobia. Journal of Mental Deficiency Research, 21, 283–288.PubMedGoogle Scholar
  46. Luiselli, J. K. (1996a). A case study evaluation of a transfer-of-stimulus control toilet training procedure for a child with a pervasive developmental disorder. Focus on Autism and Other Developmental Disabilities, 11, 158–162.CrossRefGoogle Scholar
  47. Luiselli, J. K. (1996b). A transfer-of-stimulus control prompting procedure applicable to toilet training programs for children with developmental disabilities. Child and Family Behavior Therapy, 18, 29–34.CrossRefGoogle Scholar
  48. Luxem, M., & Christophersen, E. (1994). Behavioral toilet training in early childhood: Research, practice, and implications. Developmental and Behavioral Pediatrics, 15, 370–378.CrossRefGoogle Scholar
  49. Mace, F. C., Hock, M. L., Lalli, J. S., West, B. J., Belifore, P., Pinter, E., & Brown, D. K. (1998). Behavioral momentum in the treatment of noncompliance. Journal of Applied Behavior Analysis, 21, 123–141.CrossRefGoogle Scholar
  50. MacDuff, G. S., Krantz, P. J., & McClannahan, L. E. (1993). Teaching children with autism to use photographic activity schedules: Maintenance and generalization of complex response chains. Journal of Applied Behavior Analysis, 26, 89–97.CrossRefPubMedPubMedCentralGoogle Scholar
  51. McCoy, K., & Hermansen, E. (2007). Video modeling for individuals with autism: A review of model types and effects. Education and Treatment of Children, 30, 183–213. doi: Scholar
  52. McLay, L., Carnett, A., van der Meer, L., & Lang, R. (2015). Using a video modelling-based intervention package to toilet train two children with autism. Journal of Developmental and Physical Disabilities, 27, 431–451.CrossRefGoogle Scholar
  53. Mead, E. B., Dozier, M., & Bernard, K. (2014). Using video feedback as a tool in training parent coaches: Promising results from a single-subject design. Attachment & Human Development, 16, 356–370.CrossRefGoogle Scholar
  54. Meltzoff, A. N. (1995). Understanding the intentions of others: Reenactment of intended acts by 18-month-old children. Developmental Psychology, 31, 838–850. doi: 10.1037/0012-1649.31.5.838 CrossRefPubMedPubMedCentralGoogle Scholar
  55. Moss, E., Tarabylsby, G. M., St-Georgesc, R., Dubois-Comtoisd, K., Cyr, C., Bernier, A., … Lecompte, V. (2014). Video-feedback intervention with maltreating parents and their children: Program implementation and case study. Attachment & Human Development, 16, 329–342.CrossRefGoogle Scholar
  56. Ollendick, T. H., & King, N. J. (1998). Empirically supported treatments for children with phobic and anxiety disorders: Current status. Journal of Clinical Child Psychology, 27, 156–167. doi: 10.1207/s15374424jccp2702_3 CrossRefPubMedGoogle Scholar
  57. O’Reilly, M. F., O’Halloran, M., Sigafoos, J., Lancioni, G. E., Green, V., Edrisinhaa, C., … Olive, M. (2005). Evaluation of a video feedback and self-management to decrease schoolyard aggression and increase pro-social behaviour in two students with behavioural disorders. Educational Psychology, 25, 199–206.CrossRefGoogle Scholar
  58. Parker, R. I., Vannest, K. J., & Davis, J. L. (2011). Effect size in single-case research: A review of nine nonoverlap techniques. Behavior Modification, 35, 303–322. doi: 10.1177/014544551139147 CrossRefPubMedGoogle Scholar
  59. Pinter, E. B., East, A., & Thrush, N. (2015). Effects of a video-feedback intervention on teachers’ use of praise. Education and Treatment of Children, 38, 451–472.CrossRefGoogle Scholar
  60. Reimers, T., Wacker, D., & Cooper, L. (1991). Evaluation of the acceptability of treatments for children’s behavioral difficulties. Child and Family Behavior Therapy, 13, 53–71.CrossRefGoogle Scholar
  61. Schum, T. R., Kolb, T. M., McAuliffe, T. L., Simms, M. D., Underhill, R. L., & Lewis, M. (2002). Sequential acquisition of toilet-training skills: A descriptive study of gender and age differences in normal children. Pediatrics, 109, 1–7.
  62. Sibley, M. H., Pelham, W. E., Mazur, A., Gnagy, E. M., Ross, J. M., & Kuriyan, A. B. (2012). The effect of video feedback on the social behavior of an adolescent with ADHD. Journal of Attention Disorders, 16, 579–588.CrossRefPubMedGoogle Scholar
  63. Smeets, P. M., Lancioni, G. E., Ball, T., & Oliva, D. S. (1985). Shaping self-initiated toileting in infants. Journal of Applied Behavior Analysis, 18, 303–308.CrossRefPubMedPubMedCentralGoogle Scholar
  64. Stein, Z. A., & Susser, M. (1967). The social dimensions of a symptom: A socio-medical study of enuresis. Social Science & Medicine, 1, 183–201.CrossRefGoogle Scholar
  65. Stokes, T. F., & Baer, D. M. (1977). An implicit technology of generalization. Journal of Applied Behavior Analysis, 10, 349–367.CrossRefPubMedPubMedCentralGoogle Scholar
  66. Taylor, S., Cipani, E., & Clardy, A. (1994). A stimulus control technique for improving the efficacy of an established toilet training program. Journal of Behavior Therapy and Experimental Psychiatry, 25, 155–160.CrossRefPubMedGoogle Scholar
  67. Tereshko, L., MacDonald, R., & Ahearn, W. H. (2010). Strategies for teaching children with autism to imitate response chains using video modeling. Research in Autism Spectrum Disorders, 4, 479–489. doi: 10.1016/j.rasd.2009.11.005 CrossRefGoogle Scholar
  68. Van Vonderen, A., Duker, P., & Didden, R. (2010). Instruction and video feedback to improve staff’s trainer behavior and response prompting during one-to-one training with young children with severe intellectual disability. Research in Developmental Disabilities, 31, 1481–1490.CrossRefPubMedGoogle Scholar
  69. van Vonderen, A., Didden, R., & Beeking, F. (2012). Effectiveness of instruction and video feedback on staff’s trainer behavior during one-to-one training with children with severe intellectual disability. Research in Developmental Disabilities, 33, 283–290.CrossRefPubMedGoogle Scholar
  70. Wassom, M. C., & Christophersen, E. R. (2014). A clinical application of evidence-based treatments in pediatric functional constipation and incontinence. Clinical Practice in Pediatric Psychology, 2, 294–311.CrossRefGoogle Scholar
  71. Wilder, D. A., Higbee, T. S., Williams, W. L., & Nachtwey, A. (1997). A simplified method of toilet training adults in residential settings. Journal of Behavior Therapy and Experimental Psychiatry, 28, 241–246.CrossRefPubMedGoogle Scholar
  72. Wilson, M. (1995). Generic habit-training program. Focus on Autistic Behavior, 10, 1–8.CrossRefGoogle Scholar
  73. Wolf, M. M. (1978). Social validity: The case for subjective measurement or how behaviour analysis is finding its heart. Journal of Applied Behavior Analysis, 11, 203–214.CrossRefPubMedPubMedCentralGoogle Scholar
  74. Young, J. M., Krantz, P. J., McClannahan, L. E., & Poulson, C. L. (1994). Generalized imitation and response-class formation in children with autism. Journal of Applied Behavior Analysis, 27, 685–697.CrossRefPubMedPubMedCentralGoogle Scholar

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© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.University of Canterbury, College of Education, Health, and Human DevelopmentChristchurchNew Zealand
  2. 2.Psychology DepartmentUniversity of Canterbury, College of ScienceChristchurchNew Zealand

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