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“Too Many Accidents!”

Case from S.D.                Ennio’s Response


Case from S.D.

I am involved with a very challenging student with severe intellectual disabilities, who likes to spend inordinate amounts of time in the bathroom. I used a simple procedure with behavioral momentum and a timer to reduce his time in the bathroom, and that seems to be working. However, he has many other self-stimulatory type behaviors, like picking skin, including his penis, spitting continually, etc. One problem that is particularly discerning lately is that he will pee in his pants, where he is. The data shows no pattern yet, at least to me, in regards to time of day, particular demands, and other antecedent conditions. He will change himself in a neutral manner, in terms of his mood. However, we cannot keep changing him 3-5 times a day. We recommended a full medical checkup, whereupon his urinary tract infection (UTI) examination came up fine. Any other ideas? A shower has been proposed as an aversive and natural consequence, but this will be too complicated at school. I am looking into edible rewards, as nothing else appears reinforcing.

S.D. BCBA


Ennio’s Response

Dear S.D.

Thank you S.D. for your submission. First, let me congratulate you on solving the bathroom duration problem using behavioral momentum. Dr.Phillip Belfiore (a very good friend of mine) was one of the original applied researchers on the classic study that uncovered this principle’s utility in clinical practice (Mace, Lalli, West, Belfiore, Pinter, & Brown, 1988). He would be happy to hear of your successful implementation of such. I would like to select the problem you delineate above as urinating in his pants for my analysis. Thank you for clarifying that a medical exam revealed no basis of this problem with a medical condition. You were very wise to have that checked out.

Here is the $64,000 question. “Why does he urinate in his pants?” From my early days as a clinician and behavioral consultant, I would be asked by other consultants and professionals how I approached the solving of problem behaviors in school and home settings. I conveyed to them the importance of viewing the problem as an operant behavior (unless the problem represents a respondent function). In doing so, I can assume that understanding the properties of operant behavior will lead me to a theoretical solution. Operant behaviors operate on the social and/or physical environment, thereby having functions under specific antecedent conditions. I believe a conceptual framework should be delineated prior to deploying any descriptive or experimental assessment method to verify function.

I have designed a uniform operant framework for behavioral functions (Cipani, 1990, 1994, 2017; Cipani & Schock, 2011) to help in the theoretical construction of the problem. I use my classification system as a model and framework for examining a variety of potential behavioral functions. The Cipani Behavioral Classification System (BCS) has 13 separate classification categories under the four major operant functions.1 Half of the four functions entail socially mediated functions. Let me examine if this behavior might be rendered functional via social mediation of the desired outcome.

Is it socially mediated?

Socially mediated functions involve the abolishing of a specific establishing operation (EO), by the behavior of the student affecting the behavior of an adult mediator. The adult mediator, who becomes discriminative for the specific type of relevant reinforcement, then provides the event (or removes an event from the student’s environment), that abolishes the EO for a certain length of time.

In order to proceed with this analysis, let me make some hypotheses. If urinating on oneself is maintained because it escapes an aversive instructional condition (EO), the following would be observed. An instructional condition is in effect, and such serves as an aversive EO to this student. Therefore, upon the student urinating in his pants, this instructional condition is temporarily terminated by the staff person (happens when the person changes the soiled clothing). To reiterate, the presentation of the instructional condition constitutes the operative aversive EO. With such an antecedent motivating condition, behaviors that have historically been effective in producing the desired outcome (removal of aversive EO) become very probable. If urinating on oneself is the most effective and efficient manner of having a classroom staff person remove him from the current instructional condition, a reliable function develops and strengthens. When the instructional condition becomes sufficiently aversive (the escalating progression of the aversive EO), urinating on himself occurs subsequently. The outcome of this event is that someone takes him away from the instructional condition (i.e., socially mediated escape or SME function). Further, other behaviors are less likely (or unlikely) to affect the social environment in such a way, i.e., they are ineffective in terminating the instructional task.

How would we move beyond conjecture to establish some supportive evidence? I would suggest using a scatter plot to collect data as a function of two distinct settings. The scatter plot should calculate the occurrence of this behavior according to whether such happened during one of two conditions: (a) instructional or (b) non-instructional times (e.g., recess, PE, lunch, transitions to activities, etc.) If the occurrence of the behavior is very probable during instructional times, and sporadic or non-existent during other times, you have some initial data to suggest that an SME function is operable with this behavior2. This response differentiation would be essential for considering this function, since several stimulus changes also occur with accidents (e.g., being naked for a while, getting a change of clothes to possibly something more preferable, etc.). Your case presentation seems to indicate that this is not the case, since you indicate that you have collected data that shows accidents by time of day to have no pattern.

While this hypothesis may have some appeal, I do not see this function (escape from an instructional condition) as a viable putative function for “toileting accidents” in this particular case. I rule out this possibility based on an analysis of behavior and its efficiency to produce the desired outcome. Behaviors that are historically the most effective and efficient (length of time to reinforcer) become functional. Behaviors that are either ineffective and/or inefficient (relative to other behaviors) undergo extinction. I would contend that there are usually more efficient behaviors to escape instruction. For example, running out of the classroom (what I term a Direct Escape function or DE) or hitting staff or self (SME Function) are often quite functional under this aversive EO. Urinating in one’s pants would require a reservoir of urine in the bladder to be available whenever the EO is presented (instructional task). In contrast, running out of the classroom involves a behavior that is always at the student’s disposal; hence, its occurrence can readily coincide with the advent of the aversive EO.

If an SME function with respect to instructional tasks is not viable, could it be functioning to access some desired event? This possibility would involve a socially mediated access (i.e., positive reinforcement) function or SMA. Obviously, peeing in one’s pants always results in change of clothing at your school (in addition to being naked for some length of time). Could such a reliable outcome be the function? If so, the motivating event would have to be one of two possible EO’s. Having non-preferred clothes on would be the antecedent condition for a behavior that would produce the following: removal of those clothes in exchange for clothes that are more (hopefully) preferred. This possibility seems remote, given that you report he urinates in his pants 3-5 times/day. It seems unlikely that staff would not have figured out that he prefers certain clothes and once they are placed on him, no more wetting himself occurs. A test for such a hypothesis would be to give him a non-preferred change of clothes when he soils himself. If the reinforcer is a preferred change of clothes, what should be the behavioral outcome of receiving another set of non-preferred items? Another incident!

A second related possibility is that he is used to changing clothes at home every hour or so. Going without changing clothes for several hours at school would then create a state of deprivation with respect to changing of clothes, which then makes a behavior that historically has produced the desired outcome very likely. A simple check with the parents with respect to their changing clothes routine might clear that up. However, this also too seems far-fetched.

Schedule trained vs independence

Here is the question at the core of this problem behavior. This query “hit me” when I read your sentence on how many accidents he has on a school day (i.e., 3-5/day). Is this student actually toilet trained to independence? In order to answer this question, the following data is needed. Record urine eliminations in the toilet as occurring under one of the following two conditions: (a) elimination occurred when placed on the toilet as per classroom toileting schedule and (b) elimination occurred spontaneously outside of any schedule toilet bathroom time, i.e., student initiated chain of behaviors ending in voiding in toilet. Based on some of the information you provided, I would like to make a forecast about the results of such data if/when obtained. Eliminations in the toilet when placed there occur, but infrequently and sporadically. Nevertheless, they do occasionally occur, when we get lucky. However, spontaneous eliminations (student walks over to the toilet without being prompted by staff, or requests to be taken) occurs rarely or not at all.

What I believe is the factor explaining his urinating in his pants is the result of a fixed time schedule for elimination. He is probably partially “schedule trained.” If he has to go, and he happens to be on the toilet because someone placed him there, great, he goes. He is willing to eliminate in the toilet if that is where he is when his bladder needs to be emptied. However, the three to five “accidents3” a day indicate to me that he usually has to eliminate at times when he is not by happenstance seated on the toilet. In summary, he is urinating on himself (instead of in the toilet) because he has not acquired the skill of independent toileting under the EO condition (somewhat full bladder or bowel). I would venture a prediction that he is not toilet trained to independence.

What needs to be done?

I assume that this child is in a special day class, and that there is a smaller student/adult ratio. My recommendation for intensive toilet training is usually for such a labor-intensive method to be conducted in the home setting. This would be particularly the case if the underpants have developed strong stimulus control over elimination, and the removal of such across the first few training days is needed. My column in the June newsletter was devoted to this issue (go to www.behaviordevelopmentsolutions.com and search for Ask Cipani). It delineates what needs to be done to transfer stimulus control from the underpants to the toilet seat with pants down.

Does this student require the intensive procedure with the special Taylor et al. (1994) adaptation? I do not believe he needs the adaptation. If this student does not inhibit elimination when on the toilet seat, as evidenced by some eliminations having occurred in the toilet in the past several weeks, then the being naked regimen would not need to be enforced. However, in this case, I do mandate that the intensive training method be deployed. This all-out effort requires that all other training would need to halt. School personnel would provide full and undivided attention to the Azrin-Foxx rapid method each day until acquisition of independent toileting occurs. In contrast, insisting on continuing the time –based toileting routine in hopes of eventual success will most likely lead to this student being incontinent for many years to come.

While I would not rule out conducting this intensive method at school, the need to focus all the staff person’s efforts on this training usually make such an imposition on the routine classroom regimen not viable. The teacher and aide who would conduct the training would need to forego such instructional activities as the “morning circle” with this student, seatwork and even extensive outside free time if they commit to this undertaking.

In addition, I want to inquire about another skill area which when developed, could facilitate accessing the toilet via requesting of such when needed. What is the extent of this student’s mand repertoire?4 Can this student, engage in a vocal or signed request for preferred items and activities (under relevant EO), or exhibit appropriate protests involving undesired activities (again under an aversive EO). I am going to guess that his ability to mand for desired items is minimal to non-existent. If it is non-existent, then the training that should commence immediately in the school setting is mand training in natural context, as well as running some discrete trials by setting up the EO repeatedly.

Once a number of mands have been acquired, in which the designated form of a request occurs in the absence of the item or activity, you could then re-visit the toileting problem. By having this student learn to ask for things when they are not in the immediate vicinity, requesting the toilet when the bladder or bowel needs to be relieved would be much easier to acquire. The extension to teaching the child to signal that he needs to go to the bathroom could be more viable.

Ennio Cipani, Ph.D.


1 The material defining the four major operant functions is contained in chapter 1 of my FBA text, which is available free online at publisher’s website or Amazon (but I would certainly encourage/insist that BCBA’s read all the first four chapters to gain a conceptually comprehensive view of my model). As a side note, the major functions are NOT attention, tangible, escape and sensory. These individual category functions are more appropriately classified under one of the four functions. In addition, “escape” as a function is ambiguous and vague; escape from what? If you read my text, you will gain an understanding of how functions are derived via a specification of their antecedent and consequent variables.

2 One would also want to experimentally manipulate the times of instructional or non-instructional conditions for a few days, so that one can rule out this factor, since it currently is confounded with the time of day being the same each day. The student may go every day around 9:30 AM because he has to urinate, it just so happens to always coincide with the same instructional activity being presented.

3 I would define urinating in one’s pants as an accident once the student has demonstrated that s/he is capable of independent toileting. The reliable occurrence of a direct chain of behaviors involving going to the toilet seat, pulling down one’s pants or dress, and voiding, or requesting the toilet when the bladder or bowel is full would constitute such criteria. If the toilet seat has not obtained some reasonable level of stimulus control over elimination, there exists a skill deficit.

I recommend Mary Barbera’s book, Verbal Behavior Approach, as well as Mark Sundberg’s VB-MAPP, both on Amazon. Additionally, an advertiser with this newsletter has a product that provides audio and video rich training on the VB-MAPP for those needing BACB CEU credits (www.vbmappapp.com).
References

Azrin, N.H. & Foxx, R. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied Behavior Analysis, 4, 89-99.

Cipani, E. (1990). The communicative function hypothesis: An operant behavior perspective. Journal of Behavior Therapy and Experimental Psychiatry, 21, 239-247.

Cipani, E. (1994). Treating children’s severe behavior disorders: A behavioral diagnostic system. Journal of Behavior Therapy and Experimental Psychiatry, 25, 293-300.

Cipani, E. (2018). Functional behavioral assessment, diagnosis, and treatment: A complete system for education and mental health settings. (Third Edition) New York: Springer Publishing.

Cipani, E. & Schock, K. (2011). Functional behavioral assessment, diagnosis, and treatment: A complete system for education and mental health settings. (Second Edition) New York: Springer Publishing. (1st edition-2007)

Mace, F.C., M.L., Lalli, J.S.,, West, B.J., Belfiore, P., Pinter,E., & Brown, D.K.. (1988). Behavioral momentum in the treatment of non-compliance. Journal of Applied Behavior Analysis, 21,123-141. doi: 10.1901/jaba.1988.21-123

Taylor, S., Cipani, E., & Clardy, A. (1994). A stimulus control technique for improving the efficacy of an established toilet training program. Journal of Behavior Therapy and Experimental Psychiatry, 25, 155-160.

Stay tuned  for Dr. Cipani's recommendations -- and for the next case submission!
Here is a sneak peak of the upcoming case:

October Sneak Peak: "Hurting oneself"
Many of the readers of this column have probably had clinical contact with children with autism and/or intellectual disabilities who engage in severe and intense forms of physical self-injury. From the viewpoint of the casual observer, such self-destructive acts seem to defy any reasonable explanation. Common naïve explanations for a client who engages in self-injury belie an environmental analysis. “It comes out of nowhere,” or “s/he does it because they have autism/intellectual disabilities,” are often touted as suitable explanations. Even professionals in the field of developmental disorders as recent as the late 1970s contended that such behaviors defied a social learning model. How could someone “learn” how to inflict such damage to oneself? It was not until the groundbreaking research conducted at Johns Hopkins under Dr. Brian Iwata and colleagues (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982) that an environmental explanation became verified through an experimental analysis in the clinical laboratory. The primary role of environmental contextual conditions was exposed as the causal factor in an individual’s self-injury (see multitude number of research studies in research journals such as the Journal of Applied Behavior Analysis ).

Can a functional operant model explain even cases where self-injury has reached dangerous proportions (involving tissue damage )? How do such dangerous forms develop? Stay tuned for the October column of Ask Cipani! where these questions will be explored, and answered, in exquisite detail.


About: Ask Cipani! is a periodic column that addresses a submitted case presentation from a BCBA who wants some suggestions/advice on identifying the function of a particular challenging behavior(s). Dr. Ennio Cipani's response addresses the presenting case in terms of possible motivative conditions (EO) and subsequent environmental functions to consider, and possible tests/validation strategies to conduct to verify the putative function. The advice provided in the Ask Cipani! column is provided with the caveat that its use is considered carefully by a certified or licensed behavior analyst. Since Dr. Cipani is only aware of the information presented to him, each reader must make a determination of whether such advice fits any particular case. It also is incumbent on any reader to determine if additional consultation should be sought for either program design and/or logistical implementation.

Ennio Cipani, Ph.D., is the author of the popular text, Functional Behavioral Assessment, Diagnosis and Treatment (2018, 3rd edition), which features a unique function-based classification system, the Cipani Behavioral Classification System or Cipani BCS. He co-authored a diagnostic manual for school settings on the Cipani BCS with his daughter, Alessandra Cipani, titled, Behavioral Classification System for Problem Behaviors in Schools. He also authored an e-book called "A Clinical Treatment Guide to 10 Common Behavioral Pediatric Problems" which can be downloaded for free here. Dr. Cipani partnered with BDS to bring you a companion CE course for his free e-book called, "10 Common Pediatric Problems & Solutions," available here.

Please direct all comments, inquiries about the column, or correspondence for Ennio Cipani to joel@behaviordevelopmentsolutions.com 

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