1159903

research-article2023
OTJXXX10.1177/15394492231159903OTJR: Occupation, Participation and HealthLittle et al.

Special Issue - Telehealth

OTJR: Occupational Therapy Journal

A Telehealth Delivered Toilet Training

of Research
1­–9
© The Author(s) 2023
Intervention for Children with Autism Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/15394492231159903
DOI: 10.1177/15394492231159903
journals.sagepub.com/home/otj

Lauren M. Little1 , Anna Wallisch2 , Winnie Dunn3,

and Scott Tomchek4

Abstract
Background: Independence in toileting is a vital skill, yet toilet-training interventions for children with autism are limited.
Objectives: We investigated the acceptability and preliminary efficacy of a hybrid telehealth intervention that used
synchronous individualized coaching sessions and asynchronous online educational materials to support parents in toilet
training their children with autism.
Method: Participants included 34 families of children with autism ages 2 to 8 years. Measures were administered at pre- and
postintervention (10–12 weeks) and included the Toileting Behavior Questionnaire, Goal Attainment Scaling, and Canadian
Occupational Performance Measure.
Results: Twenty-five families completed all intervention procedures. Parents found the intervention highly acceptable and
reported significant improvements in child toileting behaviors; however, families accessed the asynchronous intervention
materials at a low rate.
Conclusion: A parent coaching model delivered through telehealth may be a promising method to increase toileting
independence among families of young children with autism.

Keywords
activities of daily living, autism, family-centered practice, pediatrics

Introduction Therefore, more research is warranted to understand inter-

vention strategies that successfully promote adaptive
Independence in toileting is an essential skill. Children’s behavior skills via telehealth for young children with
toileting independence leads to more community, social, autism.
and educational opportunities that positively influence lon- While evidence is limited, studies show that typically
gitudinal developmental trajectories (Cicero & Pfadt, 2002; developing children take 6.9 to 14.6 months to achieve com-
Richardson, 2016). Many children with autism show sig- plete toileting independence for urination and bowel move-
nificant delays in toileting independence (Dalrymple & ments (Schum et al., 2002). In comparison, children with
Ruble, 1992; Richardson, 2016). While typically develop- autism have been reported to take 18 to 25 months to demon-
ing children gain independence in toileting by 3 to 4 years strate gains in toileting skills, though the majority of children
(Blum et al., 2003; Schum et al., 2002), studies suggest that continue to urinate in places other than the toilet after the
the majority of children with autism do not reach this mile- time of toilet training (Dalrymple & Ruble, 1992). A recent
stone by 3.5 years (Dalrymple & Ruble, 1992; Niemczyk review (Niemczyk et al., 2018) of 19 studies of incontinence
et al., 2018). However, interventions to address toilet train-
ing among young children with autism are limited.
1
Given the limited access to intervention services for Rush University, Chicago, IL, USA
2
University of Kansas, Kansas City, USA
families of children with autism (e.g., Boyd et al., 2010), 3
University of Missouri, Columbia, USA
the efficacy of telehealth delivered interventions are becom- 4
University of Louisville, KY, USA
ing increasingly investigated. The COVID-19 pandemic,
Corresponding Author:
however, unveiled the limited evidence from which provid-
Lauren M. Little, Associate Dean of Research, College of Health Sciences,
ers have to draw on to deliver efficacious interventions dur- Associate Professor, Department of Occupational Therapy, Rush
ing the rapid shift to telehealth, particularly related to University, 600 S. Paulina St., Chicago, IL 60612, USA.
children’s adaptive behavior (Ramos et al., 2020). Email: [email protected]
2 OTJR: Occupational Therapy Journal of Research 00(0)

rates of children with autism showed that up to 57% of sam- activities to promote the child’s participation in learning
ples demonstrated urinary continence, while fecal inconti- experiences (Division for Early Childhood [DEC], 2014).
nence ranged from 2% to 70.6%. While the aforementioned Parents may need support in understanding the toilet training
prevalence rates of incontinence and toilet training time are process holistically and how children’s individual character-
quite variable, it remains clear that many children with istics (e.g., sensory processing, communication level, pre-
autism demonstrate difficulties and extended training needs ferred interests) may be relevant during different parts of the
for toileting independence. toilet training process.
Delayed toilet training is associated with difficulties with Taken together, the evidence points to the need for inves-
peer interactions, personal hygiene, skin irritation, increased tigations of family-centered interventions that target toilet
cost in diapers, and can have a negative impact on school and training among young children with autism. Alternate ser-
community inclusion (Leader et al., 2018; Vermandel et al., vice delivery models such as telehealth and self-directed
2008). Toileting independence allows for increased access to technology-based applications have emerged as evidence-
after school programs, day camps, and other extracurricular based methods to provide intervention services (AOTA,
activities. Adaptive behavior difficulties, like toileting, con- 2018; Cason et al., 2012). Currently, the available hybrid
tribute to parent stress (Hall & Graff, 2011; Rivard et al., (i.e., self-directed modules coupled with coaching) telehealth
2014) and may influence engagement in interventions intervention models are largely focused on social-communi-
designed to target core features of the disorder. While we cation skills for children with autism (Ingersoll et al., 2016;
have a myriad of parent-implemented, evidence-based inter- Pickard et al., 2016), while telehealth delivered parent coach-
ventions to address core symptoms of autism spectrum disor- ing interventions focused on specific areas of adaptive
der (i.e., social communication, restricted and repetitive behavior, such as toileting, remain limited. Evidence exists
behaviors; for a review, see Steinbrenner et al., 2020), there for synchronous telehealth sessions, but we have little under-
remains limited evidence on parent-mediated intervention standing of utilization asynchronous materials as well as
approaches to address adaptive behavior. how outcomes may be related to such utilization (for review,
Existing toilet training interventions for young children see Simacek et al., 2021). In addition, few studies have used
with autism are limited in their use of holistic, family-focused a hybrid model with a mix of both synchronous and asyn-
approaches. For example, the most commonly used interven- chronous material. Given that much of our evidence for tele-
tion approaches to address toilet training for children with health is based on synchronous models, it is critical to
autism include behavior-based strategies outlined in the examine hybrid models of delivery.
Azrin & Foxx Rapid Toilet Training (RTT) protocol (Azrin Therefore, the purpose of this study was to investigate
& Foxx, 1971). However, such methods are time-intensive the acceptability and preliminary efficacy of a hybrid tele-
and research suggests that a rapid method of toilet training health delivered toilet training intervention with synchro-
may not have long-lasting effects (for review, see Kroeger & nous and asynchronous components among families of
Sorensen-Burnworth, 2009). In addition, one review of mea- young children with autism ages 2.5 to 8 years. Drawing
surement issues in toilet training interventions showed that from Division of Childhood Recommended Practices
the majority of toilet training studies reported dichotomous (DEC, 2014) and Occupation-Based Coaching (OBC; Dunn
findings (either children were toilet trained or not) (Francis et al., 2018; Little, Pope, et al., 2018), we implemented a
et al., 2017). The combination of rapid toilet training proce- 10- to 12-week telehealth intervention that used both syn-
dures with measures that are not sensitive to children’s incre- chronous coaching sessions with an occupational therapist
mental changes in toileting independence does not set up and access to asynchronous educational materials about toi-
children or families for long-term success (de Carvalho et al., leting development. Our research questions included the
2021; Klassen et al., 2006). following:
Parent-implemented interventions are considered an evi-
dence-based practice to promote developmental outcomes in Research Question 1 (RQ1): How did caregivers rate the
young children (Steinbrenner et al., 2020). Many studies on acceptability of the toilet training intervention?
toilet training interventions for young children with autism Research Question 2 (RQ2): How often did caregivers
use a parent-implemented model (Francis et al., 2017) to report they accessed asynchronous materials?
support parents’ use of behavior-based strategies for gaining Research Question 3 (RQ3): To what extent did the toi-
urination independence (e.g., Kroeger & Sorensen, 2010) let training intervention influence child toileting skills?
and decreasing encopresis (Mevers et al., 2020). However,
many of the existing toilet training intervention studies do
Method
not consider how young children learn best through every-
day experiences and interactions with familiar people in This study used a quasi-experimental, pre- to posttest design
familiar contexts. In addition, practitioners that support toilet to evaluate the feasibility and preliminary efficacy of a syn-
training must consider the family’s environment to provide chronous coaching with asynchronous education interven-
support in the authentic context, during routines and tion program for achieving toileting skills. All parents
Little et al. 3

completed a consent form and this study was approved by tip sheets about specific domains related to children’s toilet
the university’s institutional review board. training. The first two authors created and recorded the pod-
casts, all of which capitalized on research related to chil-
dren’s toilet training, common myths related to toilet training,
Intervention
and many of which featured interviews from experts in their
Synchronous Coaching Sessions.  The intervention consisted of respective fields (e.g., sensory processing and communica-
five live, video conferencing sessions that occurred via the tion strategies). See Table 1 for content of podcasts. All pod-
Zoom™ platform every other week for 10 to 12 weeks with cast and tip sheet materials were based on empirical evidence
each session lasting approximately 30 to 45 min. Parents for toilet training (e.g., for review, see Kroeger & Sorensen-
were the primary attendee of the sessions, and children Burnworth, 2009), and used family friendly language to edu-
attended depending on parent preference. Interventionists cate parents about discrete strategies for facilitating children’s
consisted of three licensed occupational therapists with independence in toileting. The podcasts and tip sheets were
approximately 1 to 3 years of experience using OBC to made available to parents on a website, and during the syn-
deliver services to families. During the weeks in which the chronous sessions, parents were instructed on the podcasts
interventionist did not videoconference with the parent, the that may be most relevant to their child’s toilet training pro-
interventionist emailed the parent to check in about strategy cess (e.g., communication or sensory processing).
use and problem solve any difficulties. The content and
structure of the live, video conferencing sessions was rooted
in OBC (Dunn et al., 2018; Little, Pope, et al., 2018), which
Recruitment Procedures
is drawn from Early Childhood Coaching (Rush & Shelden, We recruited families of children ages 2 to 8 years through a
2020) and incorporates elements of positive psychology flyer sent to local autism specific agencies and posted on
(Biswas-Diener, 2020). All OBC sessions follow a similar social media (e.g., Facebook). We included a wide age range
procedure which include (a) greeting and discussing a posi- of children consistent with the literature reporting ages of
tive event related to the child, (b) discussing the joint plan toileting independence for children with autism, regardless
from the previous session, (c) reflective questioning to deter- of severity (Leader et al., 2018). We excluded families if they
mine next steps and problem solve new strategies to support were not fluent in English or if the child had a co-existing
the family and child in toilet training, and (d) creating a joint genetic condition (e.g., Fragile X Syndrome and Down
plan of strategies to support the child’s toilet training for the Syndrome). All families reported that they were receiving
family to try until the next session. simultaneous services through early intervention, school,
Overall, OBC is a structured method of intervention that and/or clinics.
uses families’ naturally occurring routines and everyday
interests as a basis for achieving child goals. By ensuring that
all intervention opportunities occur in families’ authentic
Participants
contexts, the interventionist can support the caregivers’ ideas We enrolled 34 families in the intervention study; 25 families
for how to structure the daily routine to provide the child completed all intervention activities. Five families did not
opportunities for skill development. In addition, OBC uses complete all intervention sessions but did provide follow-up
elements of positive psychology coaching to consistently data, and four families dropped out of the study completely.
support the caregiver to use the child’s strengths as a basis All autism diagnoses were parent-reported, and parents pro-
for intervention to promote parent responsiveness and vided information about the diagnostic clinic, clinician, and
warmth toward the child. Using OBC as a method to address date of the child’s diagnosis. Participant characteristics are
toilet training skills is a natural fit; interventions to promote shown in Table 1.
independence in toilet training must draw on families’ every-
day environments and routines. Thus, OBC uses reflective
Measures
questions to collaboratively problem solve with parents to
derive solutions that match the authentic routine of the fam- To characterize the sample, we used a Demographic Form
ily and child. (unpublished questionnaire), which included questions about
families’ race/ethnicity, parent education, socioeconomic
Asynchronous Educational Materials.  We drew from the litera- status, and family composition. We also used the Social
ture to conceptualize eight domains related to toilet training, Responsiveness Scale–Second Edition (SRS-2; Constantino
as we intended for the intervention to be accessible to fami- & Gruber, 2007), a caregiver report quantitative measure of
lies of children at any level of toileting independence and the core features of autism, as a measure of autism severity
cover a range of topics that may influence toilet training suc- (see Table 1).
cess (e.g., dressing and sensory processing; see Online Sup- We administered the Telehealth Acceptability Questionnaire
plemental Table 1). Parents had access to online materials, (Little, Wallisch, et al., 2018) postintervention, which has two
which included eight 20- to 30-min podcasts and associated subscales: telehealth acceptability (i.e., parents’ satisfaction
4 OTJR: Occupational Therapy Journal of Research 00(0)

Table 1.  Participant Characteristics.

Completed all sessions Did not complete all sessions Dropped out of study
Group (n = 25) (n = 5) (n = 4)X

Mean (SD) range

  Child CA 66.88 mos 56.00 mos 71.25 mos
(21.4 mos) (22.90 mos) (13.52 mos)
32–104 mos 33–94 mos 62–91 mos
 SRS t-scorea 76.4 (9.02) 75.6 (10.78) 85.25 (6.95)
53–90 57–84 75–90
  % male 88% 60% 100%
  Baseline Child Toileting 115.36 (16.23) 110.40 (19.80) 100.75 (12.97)
Behavior Questionnaire Scoreb 89–161 87–131 91–119

n (%)
  Child race/ethnicity
  White 21 (84.0) 4 (80.0) 2 (50.0)
  Black 2 (8.0) 1 (20.0) 2 (50.0)
  Asian 1 (4.0) 0 0
  Hispanic 1 (4.0) 0 0
  Mother education
   Some High School 1 (4.0) 0 0
  High School 4 (16.0) 1 (20.0) 1 (25.0)
  Associates 5 (20.0) 0 1 (25.0)
  Bachelors 7 (28.0) 3 (60.0) 1 (25.0)
  Masters 8 (32.0) 1 (20.0) 0
   Prefer not to answer 0 0 1 (25.0)
  Family income
  <20k 3 (12.0) 0 1 (25.0)
  20–39k 7 (28.0) 3 (60.0) 0
  40–59k 2 (8.0) 0 0
  60–79k 3 (12.0) 0 2 (50.0)
  80–99k 4 (16.0) 1 (20.0) 0
  >100k 4 (16.0) 1 (20.0) 1 (25.0)

Note. CA = chronological age; SRS = social responsiveness scale.

a
t-score 75 to 90 = severe; 66 to 74 = moderate; 59 to 65 = mild. bHigher scores indicate more toileting difficulties.

with the use of telehealth to communicate and work with the associated with toileting (5 = Always/Almost Always, 4 =
interventionist) and OBC satisfaction (i.e., parents’ perceptions Frequently, 3 = Sometimes, 2 = Once in a While, 1 =
of the effectiveness of the content and process of the OBC inter- Never/Almost Never). Higher scores indicate increased
vention). The measure used a Likert-type scale (1 = strongly independence in toilet training, and possible scores range
agree to 6 = strongly disagree), and we added two questions from 36 to 180. Rasch analysis results show that the mea-
about the asynchronous components of the intervention (i.e., I sure is a valid and reliable measure of the developmental
like the email check-ins with my interventionist and I like the sequence of toileting skills among children with (n = 139)
online materials of the intervention). and without developmental conditions (n = 160)
We collected data pre- and postintervention, and used the (BLINDED FOR MASKED REVIEW). Rasch analysis of
following assessments as outcome measures. difficulty of items on the measure showed a progression of
skills that ranged from easy, or beginning of toilet training
Toileting Behavior Questionnaire (Little et al., under review).  The independence (e.g., “My child will stay bowel-movement
measure consists of 36 items which were designed to span free overnight,” “My child will enter the bathroom at
a continuum of specific behaviors associated with toilet home”) to difficult, or gaining independence in toilet train-
training, based in the nine domains of toilet training as ing (e.g., “My child is able to tear off the right number of
shown in Table 2. Each of the items was rated on a 5-point sheets of toilet paper,” “My child can independently wipe
scale, which measured the frequency of behaviors after pooping”).
Little et al. 5

Table 2.  Telehealth Acceptability Questionnaire Item and Subscale Results.

Completed intervention (n = 25) Did not complete intervention (n = 5)

Mean (SD)a Mean (SD)a
Scale/Item Range Range
Telehealth Acceptability Subscale 1.56 (0.74) 2.13 (1.13)
1.00–4.50 1.00–3.63
Occupation-based Coaching Satisfaction Subscale 1.84 (1.01) 2.23 (0.79)
1.00–5.57 1.43–3.57
I liked the email check-ins with my interventionist. 1.40 (0.65) 1.80 (0.84)
1.00–3.00 1.00–6.00
I liked the online materials used in the intervention. 2.16 (1.55) 2.80 (1.79)
1.00–3.00 1.00–5.00

1 = highly agree to 6 = highly disagree.

a

Canadian Occupational Performance Measure (COPM; Law they accessed asynchronous materials?), we used descrip-
et al., 1998).  The COPM is an outcome-based assessment in tive analyses to determine which asynchronous materials
which persons/caregivers identify goals in self-care, produc- (i.e., podcasts and tip sheets) were accessed the most by
tivity, and leisure. Parents rate performance and satisfaction parents. To address Research Question 3 (i.e., To what
on a scale from 1 to 10 (not satisfied to extremely satisfied). extent did the toilet training intervention influence child
We adapted this measure to specifically align with a parent’s toileting skills?), we used paired sample t-tests to examine
report of the child’s performance in toilet training, asking changes in child toileting skills, child performance in toilet
parents about their satisfaction with their child’s current level training (i.e., GAS, COPM) and parent satisfaction (i.e.,
of performance in toilet training as well as asking how, given COPM). Finally, as an exploratory analysis, and due to the
the parent’s perceptions of the child’s level of functioning, small sample size, we used Wilcoxon Signed Rank tests to
the child is currently performing in toilet training. examine changes in Toileting Behavior Questionnaire
scores among the n = 5 families that did not complete all
Goal Attainment Scaling (GAS).  GAS is a method to document, synchronous coaching sessions.
quantify and chart progress on goals in everyday life. In this
method, a parent identified the child’s current behavior, and
then scaled behavior descriptions that illustrate progressive
Results
behavioral improvements. The 4-point scale was used for Children enrolled in the intervention were aged 32 to 104
this study, which includes: 0 = what does the child behavior months, and approximately 83% of the sample was male (see
look like now? −1 = what would the child behavior look like Table 2). There were no baseline differences between fami-
if it got worse?; 1 = what would the behavior look like if it lies that completed and those that did not complete interven-
got slightly better?; 2 = what would the behavior look like if tion sessions based on the Mann–Whitney U test results for
it were perfect?. Across pediatric studies, the GAS method SRS-2 severity (p = .676), chronological age (p = .303), and
demonstrates sound psychometric properties (for review, see toileting behavior questionnaire baseline score (p = .645).
Steenbeek et al., 2007). During the first online session, par- While not significant, participants that dropped out of the
ents set goals related to their child’s toilet training behaviors study completely (n = 4) had the lowest baseline Toileting
that they believed would be achievable within 10 weeks. Behavior Questionnaire scores.

Data Analysis How Did Caregivers Rate the Acceptability of the

First, we used Mann–Whitney U tests to examine the poten- Toilet Training Intervention?
tial of systematic differences in autism severity, chrono- Using a Likert-type scale of 1 = highly agree to 6 = highly
logical age, and toileting behavior questionnaire baseline disagree, results showed that parents that completed all
scores between families that completed the intervention (n intervention found the use of telehealth (M = 1.56) and
= 25) versus those that did not (n = 9). To address Research OBC highly acceptable (M = 1.84), while parents that did
Question 1 (i.e., How did caregivers rate the acceptability not complete all intervention sessions rated the acceptability
of the toilet training intervention?), we used descriptive sta- of telehealth (M = 2.13) and OBC (M = 2.23) slightly lower
tistics derived from the Telehealth Acceptability (see Table 2). Parents rated the online materials lower than
Questionnaire (Little, Wallisch, et al., 2018). To address other components of the intervention overall, and parents
Research Question 2 (i.e., How often did caregivers report that did not complete all intervention sessions rated the
6 OTJR: Occupational Therapy Journal of Research 00(0)

Table 3.  Acceptability and Asynchronous Material Utilization.

No. of times podcasts accessed No. of times tip sheets accessed

Toilet training skill domain topic (n = 25) (n = 25)
Advanced Planner 2 2
Readiness: How do I know if my child is ready? 5 2
The Routine: Strategies to get you started 6 4
Communication and Potty Training 8 4
Sensory Processing and Potty Training 10 3
Dressing and Potty Training 3 3
Wiping: Strategies to teach wiping 3 3
Pooping in the potty 4 3
Trouble-shooting: When the going gets tough 5 3

Table 4.  Child and Caregiver Results. did not show significant changes based on the Wilcoxon
Measure t df p Cohen’s d
Signed Rank tests (X = −.674, p = .600). Overall, parents
that completed all synchronous sessions reported a mean
Toileting Behavior Questionnaire 3.321 24 <.01 0.49 9.72 point increase (SD = 13.28) in their child’s toilet train-
Goal Attainment Scaling −8.269 20 <.001 2.39 ing skills, whereas families that did not complete all inter-
COPM child performance −4.788 20 <.001 0.82 vention sessions reported a 5.0 mean point increase (SD =
COPM parent satisfaction −5.475 20 <.001 1.07 7.52) on the Toileting Behavior Questionnaire.
Note. COPM = Canadian occupational performance measure.

Discussion
asynchronous components somewhat lower than those that Novel findings from this study suggest that parents found a
completed all sessions. telehealth delivered intervention to be effective in supporting
development of toileting behaviors in their children with
How Often Did Caregivers Report They Accessed autism. In this study, we used an individualized intervention
Asynchronous Materials? that provided coaching and education to parents of children
with autism. We provided 5 synchronous videoconferencing
Descriptive analyses showed that overall parents did not sessions as well as 9 online, asynchronous educational mod-
have high frequencies of accessing the asynchronous materi- ules to support self-guided learning about toilet training over
als (M = 1.64 podcasts accessed, SD = 2.40; M = .96 tip 10 to 12 weeks. Parents set goals related to their child’s toi-
sheets accessed, SD = 2.23). Twelve parents (48%) reported leting independence, and individualized coaching sessions
that they accessed podcasts and eight parents (32%) of the focused on family-identified priorities and goals related to
sample reported that they reviewed or downloaded tip sheets. the child’s toilet training.
The “Sensory Processing and Potty Training” (n = 10), as This approach to support children’s toilet training devel-
well as the “Communication and Potty Training” (n = 8) opment expands previous interventions by not only includ-
podcasts were most frequently accessed (see Table 3). ing parents throughout the entire intervention process, but
making them the key driver of the intervention. Furthermore,
To what extent did the toilet training intervention this approach adds to the body of evidence supporting par-
ent-implemented interventions (Steinbrenner et al., 2020).
influence child toileting skills?
Given it may take up to or beyond 25 months to reach full
Paired sample t-tests showed significant improvements in toileting independence (e.g., Dalrymple & Ruble, 1992), this
child gains related to toileting skills as well as parent satis- intervention offers a way to build parent capacity to continue
faction with child performance in toilet training (all p < .01; working on children’s toileting independence when the for-
see Table 4). Cohen’s d values showed a medium effect size mal intervention time discontinues.
for the Toileting Behavior Questionnaire and a large effect Many toilet training approaches use short duration, inten-
size for all other measures. GAS scores showed the largest sive procedures that are often too burdensome for families
effect size (d = 2.39), followed by COPM parent satisfaction and heavily rooted in reinforcement and punishment behav-
(d = 1.07), and COPM child performance (d = 0.82). In the ioral techniques. In this study, the intervention utilized a
exploratory analysis, which examined changes in Toileting hybrid (synchronous and asynchronous) model that was lon-
Behavior Questionnaire scores among the 5 families that did ger in duration than other toilet training protocols (i.e., 10–12
not complete all synchronous coaching sessions, the sample weeks) and focused on both increasing parent capacity, and
Little et al. 7

supporting parent knowledge related to toilet training. In parent behavior to then implement strategies that reinforce
addition, the intervention is less structured than other toilet child toilet training skills. However, these findings could
training protocols due to its’ reliance on parent-implementa- also mean that parents with incomplete intervention sessions
tion of strategies that are driven by family priorities and may have dropped out of the study because of fewer gains in
authentic routines and contexts. Our findings suggested that child toileting skills. The intervention may not have been the
children made progress on toileting skills even with less “right fit” for families with incomplete sessions, or the dos-
intervention intensity. Research suggests interventions that age and intensity of the intervention may not have best sup-
are less burdensome to families, and are based on the fami- ported the family. Future studies should use Sequential
ly’s context and routines, may result in better maintenance of Multiple Assignment Randomized Trial (SMART) designs
skills (e.g., Pellecchia et al., 2019). Since the toilet training to better tailor the intervention intensity to family needs, as
intervention in our study was guided by parents, and more well as continue to understand why certain families decided
easily embedded into a family’s daily life, it may have the to stop the intervention.
potential to create longer-lasting effects on toileting skills, or Toilet training skills provide children more opportunities
provide parents the skills to continue to support their child’s to participate in community activities, which are linked to
developmental progression through toilet training. better developmental outcomes for children with autism
While the asynchronous online material was not accessed (Cicero & Pfadt, 2002; Richardson, 2016). Furthermore,
frequently overall, it appears information related to commu- when children lack toilet training skills they are more likely
nication and sensory processing were accessed most often, to experience decreased learning opportunities and isolation
and may be more relevant, or of interest, to families during (Leader et al., 2018) from family and peers. Our study dem-
the toilet training process. This means that the live video onstrated an increase in child toileting skills, but also an
conferencing coaching sessions of the intervention may be increase in parent satisfaction with those skills. Interventions
the key ingredient to greater acceptability and possibly effi- guided by parents and use of a reflective coaching model to
cacy. Research suggests that both self-guided and therapist- support parents, may provide parents with a broader range of
led telehealth interventions for parents lead to child gains. skills to use when confronted with difficult toileting behav-
Our findings align with research, however, which suggests iors and ultimately build family capacity.
that therapist-led groups reported greater gains (Ingersoll
et al., 2016; Pickard et al., 2016) and parents may prefer syn-
chronous coaching sessions versus listening to educational
Future Directions and Limitations
materials. In addition, qualitative interviews have found that As a preliminary efficacy study, we used a small sample size
parents in both conditions find the intervention highly with a wide age range, and while we analyzed the limited
acceptable, though, that parents in the therapist-led group sample that did not complete all synchronous coaching ses-
discussed greater acceptability (Pickard et al., 2016). Given sions, this was not a true controlled condition. The lack of a
that parents in our study utilized the asynchronous materials control group is a threat to the study’s internal validity and
infrequently, it may be that the individualized live videocon- future studies should examine this intervention with larger
ferencing coaching and between session check-in compo- sample sizes and a control group. It is noteworthy that chil-
nents of the intervention were the key ingredient to greater dren increased their toilet training skills and parents reported
acceptability. In addition, parents were instructed which significant changes in their child’s performance in toileting
asynchronous material domain may be most related to their skills; however, all children began the intervention with dif-
child; however, interventionists would provide education ferent toileting training skill levels. In addition, future stud-
related to domain topics when parents did not listen to the ies should examine the maintenance effects of this
asynchronous material. Providing an opportunity and more intervention and follow-up with families to determine if
parent accountability to systematically review asynchronous skills continued to increase or decrease over time. While
educational materials would be a necessary future direction most autism interventions have yet to determine the optimal
to understand overall parent acceptability and understanding intensity and duration (e.g., Pellecchia et al., 2019;
of the asynchronous materials. Overall, these findings are Steinbrenner et al., 2020) of interventions, it is unclear if the
especially important as telehealth services expand and more dosage of the current toilet training intervention resulted in
interventions use online materials to support asynchronous, the best treatment response. Future studies should use prag-
or self-guided, parent training. matic trials to tailor the intensity of the intervention based on
Our findings also revealed that families who did not com- child and parent response. This would provide insight into
plete all synchronous coaching sessions, but who did com- creating an intervention that is less burdensome to families,
plete post-assessment data collection, were less likely to see yet yields the greatest child progress. Our study reported on
gains in child toileting skills. Few studies have examined the the usage of asynchronous materials; however, this was
outcome data of individuals who drop-out or do not complete based on parent recall which may introduce bias. Since the
the intervention. These findings may point to the efficacy of number of materials parents reported accessing was rather
the live videoconferencing coaching sessions to influence low, it seems usage of asynchronous materials was not
8 OTJR: Occupational Therapy Journal of Research 00(0)

inflated. Future research should examine usage through web- Cason, J., Behl, D., & Ringwalt, S. (2012). Overview of states’ use
site analytics to provide a more in-depth understanding of the of telehealth for the delivery of early intervention (IDEA Part
amount of time parents spent accessing the materials, num- C) services. International Journal of Telerehabilitation, 4(2),
ber of website visits, and obtain exact counts of podcast 39–46. https://doi.org/10.5195/IJT.2012.6105
Cicero, F. R., & Pfadt, A. (2002). Investigation of a reinforcement-
plays and “tip sheet” downloads.
based toilet training procedure for children with Autism.
Research in Developmental Disabilities, 23(5), 319–331.
Conclusion https://doi.org/10.1016/S0891-4222(02)00136-1
Constantino, J. N., & Gruber, C. P. (2007). Social responsiveness
Occupational therapy practitioners are increasingly using scale (2nd ed.). Western Psychological Services.
telehealth to serve children and families, and independence Dalrymple, N. J., & Ruble, L. A. (1992). Toilet training and behav-
in activities of daily living is vital to practice. OBC delivered iors of people with Autism: Parent views. Journal of Autism
via telehealth, along with education activities, may be an and Developmental Disorders, 22(2), 265–275. https://doi.
effective intervention to promote independence in toileting org/10.1007/BF01058155
training young children with autism. de Carvalho Mrad, F. C., da Silva, M. E., de Oliveira Lima, E.,
Bessa, A. L., de Bessa Junior, J., Netto, J. M. B., & de Almeida
Declaration of Conflicting Interests Vasconcelos, M. M. (2021). Toilet training methods in children
with normal neuropsychomotor development: A systematic
The author(s) declared no potential conflicts of interest with respect
review. Journal of Pediatric Urology, 17, 635–643. https://doi.
to the research, authorship, and/or publication of this article.
org/10.1016/j.jpurol.2021.05.010
Division for Early Childhood. (2014). DEC recommended prac-
Funding tices in early intervention/early childhood special education
The author(s) disclosed receipt of the following financial support 2014. http://www.dec-sped.org/recommendedpractices
for the research, authorship, and/or publication of this article: This Dunn, W., Little, L. M., Pope, E., & Wallisch, A. (2018).
study was funded by an American Occupational Therapy Foundation Establishing fidelity of occupational performance coaching.
Intervention Research Grant. OTJR: Occupation, Participation and Health, 38(2), 96–104.
https://doi-org.ezproxy.rush.edu/10.1177/1539449217724
Ethical Approval Francis, K., Mannion, A., & Leader, G. (2017). The assessment and
treatment of toileting difficulties in individuals with Autism
Approved by Rush University Medical Center IRB #18031904
spectrum disorder and other developmental disabilities. Review
-IRB01.
Journal of Autism and Developmental Disorders, 4(3), 190–
204. https://doi.org/10.1007/s40489-017-0107-3
ORCID iDs Hall, H. R., & Graff, J. C. (2011). The relationships among adap-
Lauren M. Little https://orcid.org/0000-0003-0995-0531 tive behaviors of children with Autism, family support, par-
Anna Wallisch https://orcid.org/0000-0003-0951-8810 enting stress, and coping. Issues in Comprehensive Pediatric
Nursing, 34(1), 4–25. https://doi.org/10.3109/01460862.2011
Supplemental Material .555270
Ingersoll, B., Wainer, A. L., Berger, N. I., Pickard, K. E., & Bonter,
Supplemental material for this article is available online.
N. (2016). Comparison of a self-directed and therapist-assisted
telehealth parent-mediated intervention for children with
References autism: A pilot RCT. Journal of Autism and Developmental
American Occupational Therapy Association. (2018). Telehealth Disorders, 46, 2275–2284. https://doi.org/10.1007/s10803-
in occupational therapy. American Journal of Occupational 016-2755-z
Therapy, 72(Suppl2), 7212410059. https://doi.org/10.5014/ Klassen, T. P., Kiddoo, D., Lang, M. E., Friesen, C., Russell, K.,
ajot.2018.72S219 Spooner, C., & Vandermeer, B. (2006). The effectiveness of
Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet train- different methods of toilet training for bowel and bladder con-
ing the institutionalized retarded. Journal of Applied Behavior trol. Evidence Report/Technology Assessment, 147, 1–57.
Analysis, 4(2), 89–99. https://doi.org/10.1901/jaba.1971.4-89 Kroeger, K. A., & Sorensen, R. (2010). A parent training model
Biswas-Diener, R. (2020). The practice of positive psychology for toilet training children with autism. Journal of Intellectual
coaching. The Journal of Positive Psychology, 15(5), 701–704. Disability Research, 54(6), 556–567. https://doi.org/10.1111/
https://doi.org/10.1080/17439760.2020.1789705 j.1365-2788.2010.01286.x
Blum, N. J., Taubman, B., & Nemeth, N. (2003). Relationship Kroeger, K. A., & Sorensen-Burnworth, R. (2009). Toilet training
between age at initiation of toilet training and duration of train- individuals with Autism and other developmental disabilities:
ing: A prospective study. Pediatrics, 111(4), 810–814. https:// A critical review. Research in Autism Spectrum Disorders,
doi.org/10.1542/peds.111.4.810 3(3), 607–618. https://doi.org/10.1016/j.rAutism.2009.01.005
Boyd, B. A., Odom, S. L., Humphreys, B. P., & Sam, A. Law, M., Baptiste, S., Carswell-Opzoomer, A., McColl, M. A.,
M. (2010). Infants and toddlers with autism spectrum Polatajko, H., & Pollock, N. (1998). Canadian occupational
disorder: Early identification and early intervention. performance measure (2nd ed.). CAOT.
Journal of Early Intervention, 32(2), 75–98. https://doi. Leader, G., Francis, K., Mannion, A., & Chen, J. (2018). Toileting
org/10.1177/1053815110362690 problems in children and adolescents with parent-reported
Little et al. 9

diagnoses of autism spectrum disorder. Journal of https://www.childtrends.org/wp-content/uploads/2021/01/

Developmental and Physical Disabilities, 30(3), 307–327. VirtualFEStrategiesBrief_ChildTrends_Jan21.pdf
https://doi.org/10.1007/s10882-018-9587-z Richardson, D. (2016). Toilet training for children with autism.
Little, L. M., Pope, E., Wallisch, A., & Dunn, W. (2018). Occupation- Nursing Children and Young People, 28(2), 16–22. https://doi.
based coaching by means of telehealth for families of young chil- org/10.7748/ncyp.28.2.16.s21
dren with autism spectrum disorder. The American Journal of Rivard, M., Terroux, A., Parent-Boursier, C., & Mercier, C. (2014).
Occupational Therapy, 72(2), 7202205020p1-7202205020p7. Determinants of stress in parents of children with Autism
https://doi.org/10.5014/ajot.2018.024786 spectrum disorders. Journal of Autism and Developmental
Little, L. M., Wallisch, A., Pope, E., & Dunn, W. (2018). Disorders, 44(7), 1609–1620. https://doi.org/10.1007/s10803-
Acceptability and cost comparison of a telehealth inter- 013-2028z
vention for families of children with autism. Infants & Rush, D., & Shelden, M. L. (2020). The early childhood coaching
Young Children, 31(4), 275–286. https://doi.org/10.1097/ handbook (2nd ed.). Paul H. Brookes.
IYC.0000000000000126 Schum, T. R., Kolb, T. M., McAuliffe, T. L., Simms, M. D.,
Little, L. M., Popova, E., Wallisch, A., & Souza, S. (under review). Underhill, R. L., & Lewis, M. (2002). Sequential acquisition
Tolieting Behavior Questionnaire: A Rasch Analysis of Validity. of toilet-training skills: A descriptive study of gender and age
Mevers, J. L., Call, N. A., Gerencser, K. R., Scheithauer, M., differences in normal children. Pediatrics, 109(3), e48. https://
Miller, S. J., Muething, C., . . . McElhanon, B. O. (2020). A doi.org/10.1542/peds.109.3.e48
pilot randomized clinical trial of a multidisciplinary interven- Simacek, J., Elmquist, M., Dimian, A. F., & Reichle, J. (2021).
tion for encopresis in children with autism spectrum disorder. Current trends in telehealth applications to deliver social com-
Journal of Autism and Developmental Disorders, 50(3), 757– munication interventions for young children with or at risk for
765. https://doi.org/10.1007/s10803-019-04305-5 autism spectrum disorder. Current Developmental Disorders
Niemczyk, J., Wagner, C., & Von Gontard, A. (2018). Incontinence Reports, 8, 15–23. https://doi.org/10.1007/s40474-020-00214-w
in autism spectrum disorder: A systematic review. European Steenbeek, D., Ketelaar, M., Galama, K., & Gorter, J. W. (2007).
Child & Adolescent Psychiatry, 27(12), 1523–1537. https:// Goal attainment scaling in paediatric rehabilitation: A criti-
doi.org/10.1007/s00787-017-1062-3 cal review of the literature. Developmental Medicine & Child
Pellecchia, M., Iadarola, S., & Stahmer, A. C. (2019). How mean- Neurology, 49(7), 550–556. https://doi.org/10.1111/j.1469-
ingful is more? Considerations r regarding intensity in early 8749.2007.00550.x
intensive behavioral intervention. Autism, 23(5), 1075–1078. Steinbrenner, J. R., Hume, K., Odom, S. L., Morin, K. L., Nowell,
https://doi.org/10.1177/1362361319854844 S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S.,
Pickard, K. E., Wainer, A. L., Bailey, K. M., & Ingersoll, B. R. (2016). Yücesoy-Özkan, S., & Savage, M. N. (2020). Evidence-based
A mixed-method evaluation of the feasibility and acceptability practices for children, youth, and young adults with Autism.
of a telehealth-based parent-mediated intervention for children The University of North Carolina at Chapel Hill, Frank Porter
with Autism spectrum disorder. Autism, 20(7), 845–855. https:// Graham Child Development Institute, National Clearinghouse
doi.org/10.1177/1362361315614496 on Autism Evidence and Practice Review Team.
Ramos, M. F., Bamdad, T., & Loyd, C. M. (2020). Strategies Vermandel, A., Van Kampen, M., Van Gorp, C., & Wyndaele, J. J.
to virtually support and engage families of young children (2008). How to toilet train healthy children? A review of the
during COVID-19 (and beyond): Lessons from research literature. Neurourology and Urodynamics, 27(3), 162–166.
and considerations for your community. Child Trends. https://doi.org/10.1002/nau.20490