In my line of work we do toilet training with our clients (i.e., children with autism) regularly. We only use methods that are supported by research, so the 2 main methods we use are Azrin and Foxx’s rapid toilet training or a wet-alarm training. Because Azrin and Foxx’s method has shown great success, and is the most widely used, that’s the method we chose with our 2 children in training them, and the method I’m going to talk about now. Nathan Azrin and Richard Foxx developed a rapid toilet training method for the clients they worked most with in the 70’s, for children and adults with developmental disabilities. Because it was so successful they figured it should work well for typically functioning children as well. They tested their theory, and it was replicated by independent researchers several times both using professional trainers as trainers and parents as trainers, and the method was successful. Researchers found that there were some challenges to untrained parents that weren’t addressed in the book, but also found that by the pediatricians having a preparatory conversation with the parents, the concerns were largely avoidable. Not a lot of recent research has been conducted, I suspect because this is research that showed children could be trained in about a day (with some maintenance to follow afterwards) – how much better could it get? – and also because children usually eventually become trained by the age of 5 it’s not a huge area of concern for researchers. It’s too bad really, because it would be nice to get an analysis of the components that are necessary to the training and which wouldn’t matter if were dropped since it is a package that has a number of components. Azrin & Foxx (1976) published a book that is still available today outlining in a very clear way for parents the steps you need to know to follow the method successfully, called “Toilet training in less than a day.” It’s a little outdated in terms of some of the language, so it could stand to be written in today’s culture; however, the components in the training are all still relevant and very effective.
Curious yet? The training involves ensuring your child has met some readiness criterion for toileting (e.g., showing signs of being interested in toileting, can pull pants up and down independently), ensuring your child will follow your instructions well and teaching you how to teach that if he or she has difficulty, making the toileting experience very rewarding and motivating, and setting up the conditions to ensure maximum toileting need and maximum success. This includes getting your child to drink lots of fluids, doing wet-dry pants checks and providing reinforcers for being dry, scheduled sittings on the toilet to increase chances of peeing happening while on the toilet, positive practice/overcorrection for being wet (i.e., doing repeated practice trials of going to the toilet from a number of different locations) and a brief and gentle reprimand when wet, a lot of verbal rehearsal of being dry and the people or characters the child cares about who would care about her being dry, lots of reinforcement for all successes on the toilet, and a plan for fading out the reinforcement.
When my son turned 2 and was showing some interest in toileting we decided to take the plunge (pardon the pun). We took a weekend and started the Azrin & Foxx procedure, and were hugely successful the first day. By the second day he had no accidents, and generalized well to other locations (e.g., different washrooms at the mall). However, the Monday he was back at daycare full time, and they were neither equipped or willing to follow the maintenance phase of the training. They said they would take him every few hours to the bathroom (like what 2 year old only goes to the bathroom every 2 hours??!!). Needless to say, everything we did intensively and successfully over the weekend went down the toilet (again, with the pun :)). We have since had a long history with difficulty keeping our son dry on a daily basis, which I firmly believe is a result of the inconsistency in his early training, but also because with child care you have to pick your battles, and toileting was one I lost and I adopted a laissez-fair attitude to retain my sanity!
So! When our daughter turned 2, we decided we would do it RIGHT this time and learn from what went wrong the first time with our son. We started her training the weekend before 2 weeks of holidays from work. This way we could ensure that what she worked so hard at for the first day wouldn’t be undone. She did amazing! Within half a day she was independently telling me she had to pee (she may have called it “fart” or whatnot, but whatever, I’m just happy she’s telling me!). By the end of the day she wasn’t having accidents and her independent initiations had increased. On day 2 we started with some successes, some difficulty generalizing to public toilets (I have to say, at the zoo this took a lot of patience and reinforcing being in the toilet) but no accidents. Day 3 she had no problem going to the toilet anywhere, and had zero accidents all day! Leaving her with babysitters the few days following that resulted in a few bumps, but were quickly resolved. We just had to make sure the overcorrection was still used, and occasional dry checks continued.
Here are some tips from my experience with my kids and clients that may be helpful:
Tip #1: use the Azrin & Foxx method without eliminating any of the components.
Tip #2: make sure the “rewards” you’re using as motivators are actually reinforcing!! All too often I hear comments from parents like “oh it worked for a few days and then it wore off, so rewards don’t work.” Keep in mind that preferences change frequently for all of us and depend on how much opportunity we’ve had to imbibe in them. For example, I love cupcakes. But if I’ve already eaten 2 cupcakes today and you offer me a third one and expect it to motivate me to do something specific, you’re off your rocker (well then again, I really love cupcakes!). What I’m saying is, you have to offer a variety of reinforcers that your child can choose from, and if you get the impression they aren’t working anymore, you need to change up your supply. With my daughter I started by giving her a chocolate chip after peeing on the toilet, but when I saw her get interested in the marshmallows that were in the panty, I used those instead. I also sometimes offered her the iPad or a story.
Tip #3: you may need to reinforce “other” behaviours in order to get your child to sit on the toilet. For example, my daughter started throwing a small tantrum the third time I had her sit on the toilet, so I had to pair sitting on the toilet with reinforcement. I brought the iPad in and let her pick a video, and also gave her chocolate chips just for sitting on the toilet – both of these things were faded out quickly. If you can’t get your child in the bathroom without crying (never mind sitting on the toilet), you can provide reinforcers for closer and closer approximations to being near the toilet and then on the toilet. You might want to get these behaviours established before even starting the training.
Tip #4: the method includes 10 overcorrection trials. With my kids I found they got upset by about 3 trials, so I left it at that. I would definitely do more than one, but I’m unsure if 10 are necessary.
Tip #5: one other concern that comes up in the literature with regards to toilet training is poop withholding. There are a number of ways you can get creative with this. For example, if your child will poop in her diaper but not on the toilet, you can reinforce sitting on toilet and pooping in her diaper, and start cutting a hole in the diaper so that over time you have cut a bigger and bigger hole until she isn’t wearing the diaper anymore and is pooping in the toilet (making sure of course to provide lots of reinforcement for all poops on the toilet as you fade the diaper by cutting it). There are a number of different ways to use this concept to eventually get your child to be successful. Of course, when it comes to withholding poop, you should always keep your pediatrician in the loop to make sure there isn’t something else going on, and that frequency is monitored by a professional in case there may be medical concerns.
Tip #6: track successes and accidents. This will keep you motivated because you will be able to see your child’s progress. The Azrin & Foxx book has a couple of sample tracking sheets in the back you can use.
Tip #7: have a bottle of wine on the counter to keep yourself motivated for when your child goes to bed. Just kidding. But not. Seriously though, it is a lot of work, and it does try your patience. Plan your own reinforcers for later, and get social support from others throughout the day. For example, I texted my daughter’s progress (and some cute pics) to my husband throughout the day. Be prepared that you will have frustrating moments and may even want to give up at some points, but it will be worth it and it’s really only one day with some follow up work for the next week or so. I did follow up my day with a glass, I’ll tell you that!