Friday, August 1, 2014

"Poop Candy" (overcoming toilet fear)

Here's another of my favorite stories about using behavior modification to solve a common problem in early childhood: toilet training.

I had a parent come into my office because of a number of different behavior problems that a child was experiencing, but one of them had a pretty fast solution (we were kind of lucky it was this easy). The child refused to sit on the toilet. In fact, the child was so afraid, that he would not tell his mother when he needed to go to the toilet. As a result, there was a lot of soiling of clothing ("pooping the pants"). We needed a way to get the child to be willing to even sit on the toilet first. Then we needed to get him to sit on it for longer periods of time (so he could actually do his business).

Our solution turned out to be pretty simple. We identified his absolute favorite candy, and he would get a piece of it every time he sat on the toilet. We started calling it "poop candy" in our meetings, though I'm not sure what the mother told the child it was called. Here's the important key to this though: it didn't matter if he needed to use the toilet, it didn't matter if he actually did anything, and at first it didn't matter if he took his pants off. If he put his bottom on the toilet, he got the candy. Basically, we were giving him a button to push to get candy whenever he wanted it. Naturally, he took advantage of the situation some, but that's fine, he's still sitting on the toilet. After a little while, the problems stopped entirely. He was willing to sit on the toilet, he actually used it, and the fights were over (and fewer dirty clothes). As time passed, his mother could reduce how often he got the candy: not every time he sits on it, but sometimes; not for just sitting on it, but taking pants off, and so on...

Like I said, this turned out to be a pretty simple problem and solution. We were lucky that it was just a fear of sitting on the toilet (the same approach can be used with a child who is afraid of entering the bathroom). If the child didn't have language to indicate when he needed to use the toilet, that would have to be addressed, such as teaching some way for the child to communicate it. If the child wasn't aware of when he needed to go, that would also have to be addressed, which can be challenging (there are good techniques for that too though).

There are many problems that come up in toilet training. Naturally, there are many different solutions as a result. However, a common problem I've heard is a child developing a fear of the toilet. This can take many forms, including refusing to sit on the toilet, running from the toilet when it is flushed, and refusing to enter the bathroom at all. The way we handled the anxiety in the story above is "counter-conditioning." In counter-conditioning we provide something desirable and enjoyable (a "reinforcer") to counter the fear. This can be done with many different fears or even things the child simply doesn't like (for example, school). We have to match the reinforcer to the aversion (fear or dislike). If the child is extremely afraid of something, then the reinforcer must be extremely desirable to the child. We want to start off by making the reinforcer available every time the child encounters the aversion. Eventually we don't have to make it available every time; we can start to reduce it and make it inconsistent (maybe available once, but not until two or three times later). This is called "fading" and it is a common technique so the child does not become dependent on the reinforcer.

There are some other recommendations for toilet training here: Toilet Training

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