Before we introduce the alarm:
- Determine a schedule for trips to the bathroom for both school and home. If possible, schedule trips to the bathroom between activities (in other words, every day after lunch, or each morning on the way to breakfast). This will help Jonathon to learn to use the bathroom during these specific times and will, hopefully, build a habit. I’m thinking 1 trip at home in the morning, 2 trips at school in am, 1 at school in pm, 1 at home in afternoon, and 1 at night at home. Even though he is still in pull-ups, we want to practice the whole routine with the hopes of getting some successes.
- Develop a task analysis – or set of steps – for the toileting routine to assist the adults and Jonathon in doing the routine the same way each time. For example: steps may include: 1. walk into the bathroom, 2. pull down pants, 3. sit on toilet, 4. stay seated for 30 seconds, 5. stand up, 6. put on pants, 7. Flush, 8. wash hands, 9. reward.
- Choose a reward or rewards that you can use to reward Jonathon for cooperating with the routine. We will give him rewards for trying and even bigger ones for actually producing something into the toilet.
- Try to change his pull-ups in the bathroom if at all possible – or near to it. Every so often, when you have his attention, show him that the contents of the pull-up go in the toilet. (This is a hard thing to do hygienically and many times only the family does this part of the intervention – it is not essential, but does help to show the child what the toilet is for)
- Decide how to handle accidents. Usually, the best way is to firmly correct him “no Jonathon, bathroom!” and get him into the bathroom as soon as possible. After an accident (i.e., going in his pull-up), try to complete the entire toileting routine as described above.
- Before we get rid of the pull-ups or introduce the alarm – see if you can think of any behavioral signs that he needs to go or is currently going. Whenever possible, take him to the bathroom when it seems like he might need to go. Interrupting an accident with a quick trip to the bathroom can be remarkably effective.
Once the alarm arrives:
- Only put the alarm on Jonathon when adults are nearby who are working on this program, and when you will be walking distance from a bathroom. In other words, I wouldn’t suggest that he wear it on the school bus, but puts it on once he gets to the classroom.
- The alarm will come with directions for putting it on; basically, Jonathon can continue to wear pull-ups to prevent him from getting wet and the sensors can clip into his pull-ups. In time, we will fade the pull-ups, but not right away.
- If he tugs at it or seems uncomfortable, try to find ways to minimize his grabbing at the sensors or the cord, and of making him feel more comfortable with it on. Most kids get used to it fairly quickly, but sometimes we have to position the alarm in such a way that the student isn’t pulling at it.
- I recommend that you put the alarm on him in the bathroom and try to help him understand that the alarm is to help with the toileting.
- Any time moisture hits the sensors, the alarm will go off. As soon as you can, say “toilet” or “bathroom” (your choice, but try to be consistent by using just one word everywhere) and immediately escort Jonathon to the bathroom and help him to get on the toilet asap. It is actually best if the sound continues until he is sitting on the toilet and then it goes off. (Note: there are volume and sound controls on most alarms – feel free to adjust it to your comfort).
- Once Jonathon is on the toilet, try to keep him there for 30 seconds to a minute (longer if you can and if you have an instinct that he has more to produce). The idea of the alarm is that (hopefully), the sound startled him enough to stop the flow of urine and then he still needs to go. Hopefully, he will then pair the urge to go with being on the toilet.
- If he cooperates and completes the entire routine, even without producing anything in the toilet, give him a reward for effort. If he produces in the toilet, give him an even bigger reward.
- Consider using the attached data sheet – or develop something of your own that will help us to track what time he is urinating or having a bowel movement, whether he went in the pull-up or in the toilet, and whether or not the alarm was in use at the time.
- Alarm programs often take a 3 week commitment. If it doesn’t work in 3 weeks, we usually have to try something else.