Azrin and Foxx Article Summary
Hannah Worley After reading the article, “A Rapid Method of Toilet Training the Institutionalized Retarded”, by N. H. Azrin and R. M. Foxx, I will present in this summary the main points of the problem of incontinence and the procedures used to train toileting. I will also present the results as well as the discussion of potential issues and conclusion from the study.
The main issue that the authors were dealing with in this experiment was the incontinence of, at the time considered, profoundly retarded people who were institutionalized. This subject had been tackled before but with no success or lasting effects. The authors not only attempted to teach independent toileting to these patients but approached the subject in a way that was different than the average approach. They viewed independent toileting instead of as a response to their internal body, as “a complex operant and social learning process that has been hindered by a reduced learning capacity and by institutionalization” (Azrin and Foxx, 1971, p. 89). This view of the target behavior allowed them to create a procedure with positive reinforcement that would effectively teach the institutionalized retardates to toilet independently.
The procedure was implemented with nine male patients from the hospital ward who were profoundly retarded and incontinent. Their IQ levels, physical, and mental abilities were varied, but all were maintained on a routine of regular toileting. There was an experiment group and a control group in order to keep the influence of outside or unaccounted variables low to none. For eight hours during the day, the patients were seated in a designated toileting area and were monitored as to whether they had wet their pants of soiled themselves. There was a strict schedule of events throughout the day of monitoring the patients which included feeding the patient fluids every half hour and also a scheduled toileting every half hour. During this time, if after every 5 minutes the patient is dry, they would receive an edible as a reinforcer plus social praise. During this scheduled toileting times, shaping was used to address the issues of dressing and undressing in order for that to not be a behavior that hinders independent toileting learning. And if the patient was able to toilet on his own, he received another edible and social reinforcer. In order for the trainers to know if the patients had appropriately toileted, the used an apparatus which was the toilet bowl insert that informed the trainers if there was proper toileting
In order for the trainers to know if the patients had wet or soiled themselves they used electronic moisture sensing apparatuses to let them know. This apparatus “consisted of a moisture-sensitive pair of shorts that sounded a signal when the resident urinated or defecated in the shorts” (Azrin and Foxx, 1971, p. 91). If the patients inappropriately wet or defecated on themselves, the procedure then required a number of steps as a consequence. The patients would have to go get new clothes, get undressed and take a shower, clean up the mess and handwash dirty clothes, then be removed from the toileting area and placed on a 1-hour timeout from edibles, social reinforcement, fluids, and a chair. But they would continue to have a scheduled toileting routine every 30 minutes. These apparatuses were essential to the procedure as they let the trainers know immediately when a patient properly toileted in order to receive reinforcement, or when they had an accident and would immediately be placed on a timeout.
As stated previously, this procedure attempted to do something different other than teach patients the feeling of having to go to the bathroom. It attempted to teach patients to be under a specific stimulus control, that of which was sitting on the toilet and eliminating. Sometimes prompts were needed but were then faded. After the training phase, the patients moved into a lesser monitored post-training maintenance procedure where they would only be checked six times daily for accidents with no apparatuses. If there was an accident though, the same procedure as during training would be implemented plus a delay of their meal and/or no snack would be given. This reduction of checking continued on to minimal maintenance and finally a termination of maintenance procedures when the patient does not have an accident for one month.
The simple fact is that this experiment proved to reduce incontinence after the training procedure about 90%. “Before training, the residents averaged about two accidents per 8-hr day per patient. After training, the number of accidents decreased to about one accident every fourth day per resident,” (Azrin and Foxx, 1971, p. 95). These results were drastically more successful compared to previously attempted experiments. The actual training had an average of six days for the patients and voluntary control over toileting was accomplished in three days. Successful toileting wasn’t the only result from this experiment, a sense of satisfaction also resulted in the hospital staff and the supervisors, as well as the patients interpreted through their behavior signs. After all the nine patients went through the maintenance procedure and finally once no longer having the maintenance procedure utilized, some degree of generalization was measured through the patients being able to go to the bathroom during the middle of the night.
This study proved to be a successful and cost-effective way to treat incontinence in institutionalized profoundly retarded patients. The procedure applied was a fairly quick and pleasant experience for the patients and staff included. By implementing this training procedure with a control group, the authors were able to perform a within-subject and between-groups comparison that showed virtually no other factors involved in influencing the decrease of incontinence. This study had a few key parts that made it so successful. The set up of understanding that toileting was a chain of behaviors that could be reinforced and punished with operant conditioning, instead of looking at proper toileting as a reflexive response made all the difference. The fact that the authors considered steps in the behavior chain to be taught and shaped throughout the procedure also improved the success. This procedure has proved to be successful in this class of patients and has also been applied to other various classes of people and proved time and time again successful.