Allison Parker, MA, BCBA

Puberty can be an anxious time for any parent, and feminine hygiene is a seldom discussed topic; therefore, your question is an incredibly important one. As behavior analysts and practitioners, we recognize that any skills related to hygiene that we teach girls with autism will equip them to have access to a higher level of independence, privacy, and dignity. We hope the following recommendations provide some guidance on helping your daughter become independent and confident with these skills.

Talking about Feminine Hygiene

As with any skill you teach children and adolescents, it is important to use plain language and to avoid abstract terms as much as possible. It is also important to become comfortable with all of the terms involved in feminine hygiene, such as period, pad, blood, etc. As uncomfortable as it may seem at first, speaking about these things becomes a normal part of the teaching process over time. Due to the fact that taking care of your period is a sensitive and private event, you may consider beginning by explaining to your daughter what it is and why you need to go over essential hygienic practices. Work a few basic facts into a conversation, or visual aid if you feel it will be helpful to your daughter’s acceptance of the teaching program. Explanations may include a basic outline such as, “as we get older, our bodies change, and one day you will get your period. When you get your period, there will be blood in your underwear when you go to the bathroom. We are going to practice how to clean it up and take care of your period.” Because of the range in communication ability and level of understanding among individuals with autism, and accounting for family, cultural, and personal preferences on this topic, the advice here will need to be tailored to match your daughter’s specific skillset.

Materials

• Hygiene products As a caretaker, you will decide what products to use to teach your daughter to protect her garments from menstrual blood. Published research and clinical experience will limit my recommendations to the use of various pads, but other products available on the market include tampons, menstrual cups, and menstrual underwear. If you don’t plan to use the same type or brand of your product on a permanent basis, then you will want to teach your daughter with a few different types in order to expose her to the different features and options these products offer. For example, have a few types and brands of pads available to use such as panty liners, thicker pads, and pads with and without wings. It is best to train your daughter to use a range of products and brands from the beginning to avoid potential issues should a specific product be unavailable or be discontinued by the manufacturer.
  
  
• Purse and clean underwear If your daughter does not carry a bag such as a purse or backpack with her, it is a good idea to begin teaching this skill right away. She will need a place to keep hygiene products and a change of underwear. She may also need to learn to keep track of her purse and keep it with her during trips to the bathroom. Make sure that hygiene products and a clean pair of underwear are always available in the purse, especially before each teaching opportunity.
  
  
• Trashcan and hamper Make sure a trashcan is easily accessible in the bathroom. Because most public restrooms have a waste disposal bin inside of the stall, it may be helpful to teach with a small trashcan next to the toilet. It may also be helpful to make a clothing hamper or basket available nearby the bathroom you’re teaching in. Consider what you will want your daughter to do with soiled underwear in most conditions. It may be helpful to teach her to keep them in a plastic bag or to throw them away if a hamper is not available.
  
  
• Fake blood Finally, if you are teaching your daughter before her menstrual cycle begins, you will need to simulate this experience using fake blood. Be sure to use items that are safe for contact with genitals and consult with your gynecologist to ensure that ingredients will not cause infection or irritation. A realistic and safe option may include a mixture of canned beats, prune juice, and water. Keep in mind that these foods are natural dyes and may stain surfaces and linens.

Teaching

There are a few different scenarios your daughter may encounter during her menses, so it is recommended that you teach for each of these scenarios. Recommended teaching conditions include what to do when:

1.     The underwear is soiled with blood

2.     Only the pad is soiled

3.     Both the pad and the underwear are soiled, and

4.     Nothing is soiled (both underwear and pad are free from blood).

5.     Before approaching the bathroom to teach each scenario, place the corresponding items (including fake blood) on your daughter in another room so that the practice closely simulates a natural situation in which she goes to the bathroom to care for her menses.

Since these skills are complex and include many steps, it is important to break them down into smaller units. Create a detailed list of steps, otherwise known as a “task analysis”, involved for responding to each teaching condition. A board certified behavior analyst can assist you with creating a task analysis based on the steps you want to teach, determining how to assist your daughter to complete each step (these are usually called response prompts), and teach you how to correct any errors she may make. Methods can be adapted from the study developed by Veazey, Valentino, Low, McElroy, and LeBlanc (2016). A sample task analysis is provided below for reference.

For example, you may want to wait a few seconds before each step to allow your daughter to complete it independently. If she does not move on to the next step, use assistance to prompt the correct response. If she completes the step incorrectly or goes to the wrong step, you should walk her through the correct step, and then allow her the opportunity to complete it herself. In a task analysis, each step serves as a reminder for what comes next, so it is important that your daughter experiences each step in the correct order. Provide specific praise such as “great job get ting the clean pad from your purse” and preferred items for steps done correctly, especially those that are done independently. Remember to identify items that can be provided in the bathroom and will not interfere with the process, such as tokens or stickers that can be traded in for a favorite activity.

Task analysis for soiled pad

1.     Walks into the bathroom

2.     Pulls down underwear and sits on toilet

3.     Removes soiled pad from underwear

4.     Wraps toilet paper all the way around pad at least once

5.     Disposes of pad in trashcan

6.     Wipes vaginal area with toilet paper until clean to remove possible residual blood and drops paper in toilet

7.     Removes sanitary napkin from purse

8.     Opens clean sanitary napkin

9.     Disposes of outer covering in trashcan

10. Removes covers from adhesive areas of sanitary napkin

11. Disposes of covers from adhesive areas in trashcan

12. Fastens sticky side of napkin lengthwise in underwear and presses into place

13. Wraps wings of sanitary napkin around underside of underwear and presses into place (if applicable)

14. Pulls up underwear

15. Pulls up and fixes outer clothing

16. Flushes toilet

17. Holds soiled underwear by the waist band and puts into laundry basket

18. Washes hands

Additional Considerations

Always keep in mind the teaching techniques that work best for your daughter. You may need to use visual aids or change instructions and prompts as necessary. You may find that you need to specifically teach these steps in school and in the community, so I suggest teaching in a variety of bathrooms from the beginning. You may also need to gradually remove yourself from the bathroom in order to teach independence with these steps. Gradually fade out your praise and proximity. Check to see if steps were done independently by making sure the clean pad is placed correctly, items are placed in the trashcan and hamper, and clothes are fastened correctly.

We applaud you for considering this important skill for your daughter, and hope these steps will assist in her self-care as she transitions into a young woman. 

Bobby Newman, PhD, BCBA

Yes! ABA can certainly help your son to learn new skills and to manage behavior that is interfering with his ability to partake in whatever life has to offer. Now, let’s expand a bit. ABA is not limited in its effectiveness to only autism spectrum disorders (ASDs), nor to any specific age group. Many ABA professionals do not work with individuals diagnosed with autism spectrum disorders at all, or any other form of developmental disability. ABA professionals work in business and industry, sports, education (typical or special), and other fields. The fact that ABA works so well with people diagnosed with ASDs and can achieve such amazing gains is, in part, an historical accident.1

As I prepared to answer your question, I found myself thinking back to a symposium in which I took part at the 2001 ABA convention in New Orleans. ASAT past-president Catherine Maurice was the discussant, and she reminded us (I’m paraphrasing here) that while we must celebrate, popularize, and testify to the reality of recovery from autism, we must be no less enthusiastic describing how ABA can help individuals, regardless of age, to make amazing achievements. A student who learns to tie his shoes, or to achieve another step towards independence, must be held in no less regard and celebrated no less enthusiastically than the child who recovers. Both individuals are testaments to the power of this science, and to the humanistic ends to which it is directed. In my own books of case studies2 , many of the procedures described were used to help teenage and adult clients to learn greater independence, or to overcome crippling or physically dangerous rituals and behavior. Many of the people who taught me about ABA had never worked with anyone under 15 in their lives. As Skinner always reminded us, the laws of behavior are universal (so far). We can apply our science equally, regardless of the age or the behavior of the individual.

Goals and teaching techniques will differ, depending upon the skills that need to be taught, and upon the behaviors interfering with independent functioning. Which brings us to more about ABA most people don’t realize:

1.     ABA is not discrete trial teaching (DTT).

2.     ABA is not a “related service.”

“How many hours of ABA is he getting?” is a nonsensical question. ABA is the applied science of human behavior, and more generally, a way of looking at behavior, and a literature of proven techniques that are in effect 24 hours a day. That’s not to say that you are providing intensive programming 24 hours a day, but rather that you are carrying out general behavior management strategies, setting up and taking advantage of teaching and generalization opportunities, performing functional analyses of behavior, and shaping and chaining new skills whenever possible.

Find a well-trained Board Certified Behavior Analyst (BCBA)3 and forge ahead with no less enthusiasm than you would if your child were in Early Intervention.

Educating for Inclusion

Renita Paranjape, MEd, BCBA

Preparing students for group instruction in inclusion classrooms requires careful consideration of the responses required in that setting as well as the strengths and needs of the child with autism. What follows are some considerations that may ease the transition of students from one-to-one instruction to group-based instruction within inclusion classrooms.

Investigate the next setting

Take time to visit and observe group instruction in the inclusion classroom. There are a few questions to keep in mind when observing the inclusion setting, including:

• What is the content of the group instruction?
• How large are the groups?
• How does the teacher engage the students (e.g., visual stimuli, choral responding)?
• How long are the group activities?
  
• How often are students required to respond during group?
  
• Are there reinforcement systems in place within the group lessons?
  
• What are the teacher’s general behavioral and learning expectations of the students during group instruction?
  

Once you have a clear idea of what transpires during group instruction, attempt to replicate, as closely as possible, the activities observed in the inclusion environment during small-group lessons.

Setting up the group

Here are some pointers for setting up group instruction:

1.     Group children according to their skill level so that those who require skill building in more foundational skills are grouped together, while the students with more advanced skills are placed together.

2.     Alternatively, you may want to consider mixing students by skill level, so that students with more advanced skills can serve as a model for students who require models of responses during the lesson.

3.     All students should have a clear view of the teacher and the instructional material, with distracting items kept to a minimum.

4.     One adult should be the “teacher,” delivering all instructions in front of the group and providing the reinforcers to the students.

5.     Position other adults behind the group to serve as “prompters” of responses. These adults should stand, not sit, behind the students, fading their proximity to the students as independence increases. These adults should only prompt if necessary, and the students should be expected to follow the instructions provided by the teacher who is leading the group.

6.     Have available the student’s individualized motivation system in view of the student. The teacher leading the lesson should provide the reinforcers to the students based on the student’s individualized program.

7.     The other adult or “prompter” can also record data on the responses of the learners during group instruction.

8.     The teacher of the group and the prompters should communicate regularly before and after the group lessons to identify roles and student goals. Discussion should not occur during the lesson.

Readiness skills for small group instruction

The following are a few examples of what learners may benefit from in order to participate in group instruction, but they are not necessarily prerequisites. Some of these goals require group instruction in order for the goals to be taught, whereas other goals can be introduced in smaller groups or in one-to-one instruction.

1.     Attending to the teacher with peers present. In most ABA programs, attending is one of the first foundational skills that is taught. This is accomplished either by teaching students to provide eye contact or teaching them to orient toward the communicative partner. Once this skill is established, the next step for group instruction would be to teach attending even when there are peers present and when the teacher is standing and moving around the classroom.

2.     Tolerating the presence of peers. Since small-group instruction requires the presence of other students, it is important to assess whether the student can sit alongside a peer without being distracted.

3.     Sitting for longer periods of time without frequent breaks. Group instruction will require the student to sit for longer periods of time. Collect baseline data on how long the student will sit appropriately before accessing a reinforcer; then systematically increase that time so that the student can sit for longer periods of time to earn access to a bigger reinforcer (e.g., recess).

4.     Remaining on task for longer periods of time. This may seem similar to number 3 above, but it is not only important to consider how long your students can sit appropriately, but also how long your students will work efficiently before becoming off task and or requiring breaks. In small group settings, students are typically required to complete independent seatwork for upwards of 15 minutes or more. As a readiness skill, assess how long your students can remain on task and systematically increase how long they are required to work independently.

5.     Preparing the student for thinner schedules of reinforcement. Consider your students’ current schedule of reinforcement and develop a plan to thin that schedule. This would apply primarily to appropriate behaviour, such as attending and sitting appropriately, as correct responses in group would likely be reinforced on a continuous schedule initially.

6.     Responding to name and following distal instructions. Can your students respond to their names from varying distances and in different contexts? Can they follow directions given from afar? In addition to being able respond to their name in a classroom setting, students must also learn to not respond in certain situations. Distinguishing between, and responding to, instructions such as “everybody,” “[student’s name]” and “[other student’s name]” are key foundational skills for small-group instruction.

7.     Following complex instructions. Your students should not only be able to complete one-step directions (e.g., “Get a pencil”), and two-step directions (“Get a pencil and write your name”), but they should also be taught to follow even more complex directions (e.g., “Get a pencil, turn to page 5 of your workbook, and write your name at the top”).

8.     Waiting for attention and instructions. When a student makes the transition from one-to-one instruction to a group setting, the teacher’s focus is no longer solely on one student, but he or she is balancing his/her attention from one student to another. It is important to teach the student how to occupy his or her time without engaging in stereotypic, or other challenging behaviour, as the teacher’s attention is diverted.

9.     Hand raising. Hand raising is a skill that requires attending, performing a gross motor action, inhibition of responding until cued by teacher, and discrimination of instructions. Initially, students can learn to raise their hands to access a preferred item with an embedded prompt in the instruction (e.g., “Raise your hand if you want candy!”). The instructions can then become increasingly more complex and students can learn to raise their hands to answer questions, to refrain from raising their hands when they are not able to answer a particular question, to request an item they might need for a task, and to volunteer to participate in an activity.

10. Observational Learning. One of the benefits of small-group instruction is the abundance of opportunities to learn appropriate responses by attending to the responses of other members of the group. Often times, students with autism need explicit instruction in attending to the responses of others, in differentiating whether those responses were appropriate based on teacher feedback, and in being able to repeat those correct responses when directed by the teacher.

11. Choral Responding. Another key response of small-group instruction is being able to say responses aloud and in unison with other students. For example, the teacher may say, “Everyone tell me what is two times two,” and all of the students would be expected to say, “Four.” This skill can first be introduced in one-to-one instruction.

Effective teaching strategies to include in small-group instruction. The research in small-group instruction has identified specific strategies that have been found to be particularly effective for learners to acquire skills in a group setting (e.g., Heward & Wood, 1989; Kamps et. al, 1991).

1.   Creating many opportunities for learners to respond: Given that the density of instructions will likely be less in a group situation than in a one-to-one teaching interaction, it is important to create as many opportunities as possible for your students to practice responding, and, in turn, acquire skills. Ensure that there are many instructions delivered for each student.

2.    Frequent rotation of materials: This is a necessary strategy to help alleviate boredom with the content of the curriculum, and it also helps to promote generalization of responding across various stimuli.

3.    Interspersing known targets with unknown targets: This strategy creates a momentum for responding fluently, provides the opportunity for reinforcement to occur, and also ensures that mastered targets are maintained.

4.    Choral responding: Having your students respond in unison is a useful strategy, and is important to target, because it occurs frequently in most general education settings. It is beneficial for learners, as it allows them to have more opportunities to respond, as well as allows them to be cued by their fellow classmates rather than their teacher.

5.    Random responding: Random responding refers to presenting instructions in an unpredictable format so that students are not aware of when they might be called upon. This method can improve attention and motivation, as students will not be able to predict when it is their turn to respond.

6.   Repeating peer responses: Requesting that students repeat the correct responses of their classmates can help further observational learning skills by requiring students to attend to and assimilate the responses of others.

7.     Student-to-student interaction: Another effective teaching strategy is to promote interaction among students. Specifically, students can learn to listen and repeat each other’s responses to general curriculum-related questions, ask peers to clarify if an instruction was missed, or ask peers for items needed for a task.

Small-group instruction can be a highly effective way to prepare students for less restrictive settings. With appropriate environmental manipulations, as well as effective teaching strategies, students who participate in group instruction can acquire skills needed for fuller inclusion.

Pica refers to the apparent appetite for non-food items with no nutritional value. It presents a problem when the items are poisonous, pose the risk of infection, are otherwise harmful to health or might produce injury (as a result of swallowing something sharp). Exploring objects by tasting and smelling is a universal human investigative technique, which eventually diminishes based upon experience and learning. Babies explore many things with their mouths until “bitter experience” teaches them caution; many poisonous substances have a bitter taste, and parents are generally alert to prevent, stop or otherwise discourage inappropriate oral exploration. Most children gradually learn to discriminate edible objects visually or based on the social cues and encouragements provided continuously by concerned caregivers.

Why do we explore things with our mouths? The organs of taste and smell are fundamental to learning about what is good to eat and where to find it. Babies are born with exquisite sensitivity to, for example, very small changes in sucrose concentration in a liquid solution. They demonstrate this sensitivity by changing the rate at which they suck a nipple to obtain a drink; concentrations increasing in sweetness by as little as 5 to 10 percent can slow the rate of suckling, as though the baby were savoring a more delicious treat. The tongue is almost ready-made for exploration, with more sweet receptors on the tip to guide the mouth toward high calorie and readily energizing sweets; bitter receptors are located at the back of the tongue to give warning not to swallow, and to expel dangerous or poisonous substances. The chemical receptors in the baby’s nose serve to orient the face to accept nutrition efficiently, and they support rapid association of good smells with safe tastes. Mothers who eat distinctive foods throughout the last trimester of pregnancy will find their babies prefer food with similar tastes and smells for a brief period after birth. Taste and smell preference can be maintained if the nursing mother continues to eat the distinctively flavored foods, because some of the chemical distinctiveness is carried in the milk she produces to feed her infant. Infants tend to prefer familiar sensations, with just moderate levels of novelty provoking some exploratory interest beyond the security of familiar sensations.

Furthermore, the lips and tongue are richly innervated with other sensory receptors for touch, pressure, and even pain, indicating that it is a very important information-gathering site for the body. It is so rich with touch sensors, and these so effectively register the consequences of good tastes and good nutrition, that their stimulation is doubtless rapidly associated with goodness early in infant development, and is maintained in close association with good food and other social comforts for life in most people.

Is it any wonder, then, that children explore things with their mouths? This is natural and nearly inevitable provided the sense organs are functioning properly. Unfortunately, the modern world is not free of danger. Some danger is not readily apparent to children or their parents until it is too late. Lead, mercury, and ionizing radiation, for example, are toxic in very small quantities, and can have increasingly deleterious effects as exposure accumulates over time. Lead actually tastes slightly sweet, and a blob of mercury has just that moderate amount of visual change to be endlessly fascinating to a young child. Radioactivity is imperceptible. Other toxic or dangerous substances are insufficiently foul or painful to rapidly teach an alert child to avoid them without adult intervention. It is a dangerous world.

Most children learn to avoid most hazards. They escape poisoning and injuries as a result of parental protection until they know better. Toddlers are most susceptible to harm from pica, with lead poisoning from lead-based paint dust in old housing peaking at those ages when toddlers are ambulatory, but still explore everything with their mouths and eat finger foods from unwashed hands.

Some young children fail to learn to avoid toxic and other dangerous substances. This can be a result of failing to teach children appropriate caution, especially for things that neither look nor taste dangerous to the children. However, it is more likely to represent impaired sensation or a profound learning disability when it persists in the older child. After all, pica is merely the reflection of fundamental nutrition-seeking behavioral tendencies which serve an adaptive function in all children. It is a dangerous behavior because poisons are not always signaled in ways that produce aversion or fear until they are followed by illness or pain. Sometimes this happens too quickly, or it can happen so much later or so gradually that there is no direct association for the child, despite biological preparedness in all healthy people to learn such things quite rapidly.

When children do not learn to avoid ingesting poisonous or dangerous substances they can reach, there is no substitute for protective measures. The home should be thoroughly ‘childproofed’ so that toxic or sharp items are kept securely out of the reach of the child with pica. Toddlers and children who are excessively fascinated by tastes and smells and who cannot be readily taught to avoid such dangers must be closely supervised while they are awake and freely mobile.

Some children can learn to avoid attractive but hazardous tastes by very, very persistently repeated response prevention. The are many possible variations on this general intervention strategy, but the keys to success, as with any behavioral intervention, are in persistence, immediacy, and in the availability of other things to do and other ways to obtain similar stimulation in acceptable ways. Care should be taken, obviously, not to offer an “acceptable” way to obtain oral or nutritional stimulation immediately after an attempt to bring non-food material to the mouth, because this would actually reinforce an instance of pica.

It may also be possible to teach a discrimination based on visual cues, such that the child learns to taste and eat only those things obtained from a brightly colored plate, for example, or from a formal place setting on a distinctive tablecloth. Sometimes children must be actively discouraged from going after certain dangerous objects that represent a marked health risk if swallowed. Such treatment requires a carefully designed, professionally supervised and conscientiously delivered behavior program. The program details for any youngster must be individualized. The necessary teaching resources and people to be involved need to be arranged in advance. Again, these measures should not be undertaken lightly or sporadically because there is a risk from inconsistent implementation that the child could learn to be more secretive about pica, and not actually decrease the dangerous behavior.

James Mulick, PhD

Ohio State University

Lingering issues with bowel training are common in individuals with autism, even if urination training has been successfully completed. As with urination training, the key to success in bowel training will involve behavioral assessment, data collection, and behavioral teaching techniques.

The first step in any bowel training program is to collect baseline data. Data should be collected every day for at least two weeks. You can make a simple data sheet to record the following:

the date and exact time of all bowel movements (please also record mealtimes);

where the bowel movements occurred;

what the individual was wearing;

the consistency of the stool.

Once data are collected, you will use the information to better understand why the individual continues to have bowel accidents. Unlike a urination training program that takes the form of traditional toilet training, a bowel training plan more often resembles a behavior plan in which the plan is tailored to the function of the bowel accidents. Typically, an individual continues to have bowel accidents for one of the following reasons:

a medical cause;

a skill deficit (lack of generalization from urine training);

noncompliance;

presence of rituals and routines surrounding bowel movements.

For an individual affected by a medical cause, there is usually something atypical with the frequency of bowel movements or the consistency of the stool (e.g., the bowel movement may appear grainy or not well formed). You will notice this in your baseline data. In such cases, a medical examination is indicated, and you should speak with your pediatrician. He or she may refer your son to a specialist for further testing. Medical treatment suggestions should be followed, and you should direct any and all questions to these doctors. If the individual remains untrained after medical issues are cleared, an additional training program will be needed.

If an individual is having accidents due to a skill deficit, you will notice that there is no evidence of him holding his stool and no patterns indicating a ritual or routine. In this case, you will begin a bowel training intervention consisting of positive reinforcement for success and punishment for accidents. Prompt the individual to go to the toilet on a ten-minute schedule starting at the time when they are most likely to have a bowel movement (look at your baseline data to determine an approximate time of day). Choose one highly preferred reward that they can earn if they successfully have a bowel movement on the toilet. It would be important to restrict access to that reward at other times. If, however, they have a bowel accident outside of the toilet, initiate a punishment procedure such as an overcorrection (having them clean their own clothing) or a response cost (taking away a privilege). Although punishment strategies are not always needed, you will find that with only one or two bowel movements per day, opportunities to teach the individual to discriminate between a correct and incorrect response are limited. Adding a punishment component to the training procedure will likely increase the individual’s ability to discriminate between the two responses.

When noncompliance is an issue, you will find that the individual seems to be actively holding stool when asked to have a bowel movement on the toilet. In such cases, it is also common that the individual demonstrates noncompliance in other areas besides bowel training. Although intensive plans employing the use of physical prompts such as suppositories and enemas are successful, I usually recommend starting with a plan similar to the one suggested for skill deficits (simple reinforcement for success and withholding reinforcement for accidents). With noncompliance, you want to make sure that the reward you are delivering is very powerful. One good technique for doing so is to remove all access to the reward for two weeks prior to starting training. This will increase its potency once you reintroduce it for appropriate bowel movements. Because the individual is actively holding stool, you should continue to collect data daily so that any evidence of constipation can be identified and corrected prior to becoming an issue.

Last, there are issues related to rituals and routines. Individuals on the autism spectrum often have an inclination towards establishing and maintaining routines. When having a bowel movement becomes wrapped up in a routine (i.e., the individual will only have a bowel movement after school, while wearing a pull-up and standing behind the couch), that routine can be very hard to break. One strategy is to slowly shape a new routine by introducing steps closer and closer to having a bowel movement on the toilet while reinforcing success at each new step. Keep introducing gradual steps. If you move too quickly, the individual might become resistant to the new routine and constipation could result.

Considering the above mentioned routine (the child always has bowel movements while wearing a pull-up and standing behind the couch), the treatment steps might progress as follows:

prompt and reinforce a bowel movement in a pull-up in front of the couch

prompt and reinforce a bowel movement in a pull-up in the hallway by the bathroom

prompt and reinforce a bowel movement in a pull-up standing in the bathroom

prompt and reinforce a bowel movement in a pull-up sitting on the toilet

prompt and reinforce a bowel movement on the toilet with pull-up at the knees

prompt and reinforce a bowel movement on the toilet while holding the pull-up

prompt and reinforce a bowel movement on the toilet without any pull-up

Keep in mind that the gradual steps you design must be tailored to the routine and needs of your child. The steps listed above are only an example.

With any of the treatment strategies suggested here, remember that it is important to collect data on a daily basis and make treatment decisions based on what your data are telling you. With bowel training, I usually suggest implementing a plan for at least three weeks before deciding whether or not the plan is working.

As you go through the training, make modifications as necessary, keep implementation of the plan consistent across days and maintain a positive attitude.                                                                                                             Frank Cicero, PhD, BCBA-D

Director of Psychological Services Eden II Programs