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By: Lindsey Goggin and Kathleen MacDonald

2 CENTRAL THEORIES FOR POTTY TRAINING CHILDREN USED IN THE USGradual Child-Oriented Training (BRAZELTON METHOD)

• Child-oriented gradual training was designed in 1962 based on the recommendations of T. Berry Brazelton, who conducted the largest toilet training survey in the United States. Promotes readiness on the part of the child as well as the parents. Parents must respond to signs of a child’s readiness to train which include: physiologic attainment of bladder and bowel control and sufficient neurologic maturity for the child to voluntarily accept the responsibility to participate in toilet training. Parent’s must also be willing to participate in the training and be aware of obstacles to the training process such as daycare. 1,2

Structure, Endpoint-Oriented Training (AZRIN and FOX METHOD)

• Approach that emerged in the 1960s and 70s. The Azrin-Foxx method comes from from an applied behavior analysis of toilet training in which they identified a number of component skills that could be taught to a toddler. The child would be toilet trained once all of the components were learned. This methodology allows for small deviations and failures as the child is learning.1 Azrin and Fox Method is considered to be the more successful of the two2

1. Brazelton et. al., “Instruction, Timeliness, and Medical Influences Affecting Toilet Training,” Journal of the American Academy of Pediatrics, 103 (1999); 1353-1358

2. Kalsson, et. al. “The Effectiveness of Different Methods of Toilet Training for Bowel and Bladder Control.” Agency for Healthcare Research and Quality. 147 (2006): Accessed September 25, 2011. http://www.ahrq.gov/clinic/tp/toilettrtp.htm

CURRENT EXISTING SOLUTIONS (BASED ON BRAZELTON AND AZRIN-FOX’S METHOD)

1. The Readiness Approach: A method of toilet training based on Brazelton’s theory. The method is a relaxed, positive method that respects the child's ability to learn, while watching for signs that the child is physically, intellectually, and psychologically "ready" to be potty trained. A child will show interest in potty training might include: talking about going to the potty, being interested in other’s going to the toilet. The age that a child begins to potty train is based on the emergence of these signs rather then the actual age of a child.1

2. Dr. Phil’s One-Day Method: Children are taught toilet training by using a doll that wets. The child learns to use the potty themselves by ‘teaching’ the doll to go to the potty. ‘Big kid underwear’ is put on the doll. The doll is taken to the potty after it drinks something and uses the potty. When the doll has success, it is thrown a “potty party” to celebrate. The child is told that they will also have a party when they learn to use the bathroom. The entire potty training process learned via demonstration with the doll.2 This method is based on the Azrin-Fox method.

 

1. “The Readiness Method.” Nick Jr.com. Date of access September 25, 2011. http://www.nickjr.com/preschool/potty-training/advice/potty_training_readiness_ap.html

2. “Potty Train Your Child in Less Then One Day.” Dr. Phil.com. Accessed September 26, 2011. http://drphil.com/articles/article/264/

CURRENT EXISTING SOLUTIONS CONTINUED

3. Practicing Safety Module for Toilet Training: Toilet training is a period with a high incidence of abuse. This method aims to teach toilet training to children while eliminating stress on the child and frustration on the part of the parent-therefore making abuse less likely using various strategies. Examples of these strategies include: noticing signs that a child is ready to toilet train and not pushing them to do so unless they are ready and not trying to train a child to toilet change during other dramatic family changes that will cause stress on both the child and the parent (i.e. moving).1

1. “Practicing Safety Module in Toilet Training.” The American Academy of Pediatrics. Accessed September 26, 2011. http://www.aap.org/sections/scan/practicingsafety/Modules/ToiletTraining/ToiletTraining.pdf

CURRENT EXISTING SOLUTIONS THAT DEVIATE FROM BRAZELTON AND AZRIN-FOX

4. Montessori Approach: Based on the idea that toilet training begins at birth. Cloth diapers are used so children understand the discomfort from wetting themselves and begin to associate their urinary function with the feeling of wetness. Children are also shown the dirty diapers when it is changed as well the clean ones and can assist in getting the new nappies so they feel a part of the process and are aware of it. Scolding and over-congratulating are avoided.1

5. Elimination Communication: Mothers or caregivers learn through observation (baby goes when he/she wakes up, after) to understand cues and body language of a baby. Babies do not wear diapers. When they have to go to the bathroom they bring the baby to a pot or wrap a cloth over them. As children get older they begin to go to the pot themselves.

1. “A Montessori Approach to Toileting.” The Montessori Method. Accessed September 22, 2011. http://www.michaelolaf.net/08%20toileting1.htm

2.Elimination Communication Simplified. Accessed September 22, 2011. http://ecsimplified.com/

TARGET AUDIENCE

Moms of children 24 to 36 months currently engaging or beginning to start potty training their children

- Program will target both boy and girl toddlers with targeted messages for each gender

HEALTH GOAL

By the completion of the Tots on Pots program, participants will decrease their risk of emotional scaring (i.e. stress) as a result of poor toilet training by 10%

COMMUNICATION OBJECTIVES

• By October 18th and the completion of the program, participants will increase their knowledge of healthy, evidence based potty training tips by 20% such as mentoring, modeling, reinforcements, and appropriate goal setting (Behavior Capability)

• By October 18th , and the completion of the program, participants will be able to identify 3 barriers for success such as poor goal setting, inconsistent charting and reinforcements, and a negative training environment (Expectancies and Environment)

• By October 18th, and the completion of the program, participants will be able to identify successful reinforcement factors for aiding their toddler towards successful toilet training such as providing treats, play time, or a special treat (Expectatancies and Reinforcement).

• By October 18th, and the completion of the program, participants will have an increase confidence in their ability to successfully potty train their tot than at the start of the program (Self Efficacy).

• By October 18th, and the completion of the program, parents will have a decreased sense of isolation and increased feelings of support as a result of the interactive “DIAPER” support component. (Emotional Coping Response)

BEHAVIOR OBJECTIVES

• By October 11th, participants will increase their use of the toilet by 30 %

• By October 11th, parents of toddler participants will increase their ability to achieve potty training success by 30%

• By October 11th, participants will have a decrease in the number of non-toilet voids by 15%

• By October 11th, participants will have an increase in accident free nights by 10%

SOCIAL COGNITIVE THEORY Albert Bandura’s Social Cognitive Theory will be the

basis for the development of our messaging program:

Environment: Factors physically external to the person; Provides opportunities and social support

Our program will encourage parents to create a safe/healthy environment for their children to embrace potty training. Messages focused on identify safe spaces, feeling comfortable in their surroundings, and providing a pressure free environment will be developed

Situation: Perception of the environment; correct misperceptions and promote healthful forms

Messages focused on creating a stress-free, comfortable environment will encourage parents to help toddlers feel safe during unknown situations

SOCIAL COGNITIVE THEORY CONTINUED

Behavioral Capability: Knowledge and skill to perform a given behavior; promote mastery learning through skills training

Messages will focus on skills to motivate their child to begin potty training, as well as tips and suggestions for moving their progress forward will be sent

Expectations: Anticipatory outcomes of a behavior; Model positive outcomes of healthful behavior

Messages on creating and establish attainable and achievable goals an expectations will be set early on in the program

SOCIAL COGNITIVE THEORY CONTINUED

Expectancies: The values that the person places on a given outcome, incentives; Present outcomes of change that have functional meaning

Parents will be encouraged to establish desirable incentives for good behavior, such as time with a specific toy, candy, or stickers on a reward chart

Self-Control: Personal regulation of goal-directed behavior or performance; Provide opportunities for self-monitoring, goal setting, problem solving, and self-reward

Parents will be encouraged to establish a visible progress chart within the home that both the child and parent can look upon daily. Messages will be sent to remind parents to track their child's progress on this chart

SOCIAL COGNITIVE THEORY CONTINUED

Observational learning: Behavioral acquisition that occurs by watching the actions and outcomes of others’ behavior; Include credible role models of the targeted behavior

In certain circumstances, some children may respond more by mimicking their parents behavior, if so, messages on how best to incorporate this into their training will be distributed

SOCIAL COGNITIVE CONTINUEDReinforcements: Responses to a

person’s behavior that increase or decrease the likelihood of reoccurrence; Promote self-initiated rewards and incentives

Messages reminding parents to reward their child or to deliver negative reinforcements will be sent throughout the day. In addition, when parents respond using the “Pee” “Poo” and “Diaper” interaction messages, Congratulatory or “Encouragement” messages will be sent.

SOCIAL COGNITIVE THEORYSelf-efficacy: The person’s confidence in performing a particular

behavior; Approach behavioral change in small steps to ensure success

Tips and suggestions for sustaining and increasing their confidence will be sent sporadically, more frequently if some parents are struggling to make progress.

Emotional coping responses: Strategies or tactics that are used by a person to deal with emotional stimuli; provide training in problem solving and stress management

For parents with toddlers struggling emotionally with potty training, messages focused on these responses will be sent along with tips and suggestions on how best to overcome these obstacles.

Reciprocal determinism: The dynamic interaction of the person, the behavior, and the environment in which the behavior is performed; consider multiple avenues to behavioral change, including environmental, skill, and personal change.

At the beginning of the program, parents will be encouraged to create and sustain a comfortable training environment to encourage behavior change in their environment and social interactions, such as purchasing a potty chair and introducing the child to the chair slowly in a pressure free environment.

INITIAL CONCEPT…• Establish pre-test evaluation criteria to assess where each

participant stands in their training (not yet ready, contemplating, ready to act, already training, struggling with training)

• Once assessed, participants will begin to receive targeted messages based upon their pre-test responses

• For those not yet ready to act, messages about how to prepare their toddler will be sent

• For those who are ready to act, messages focused on tips for introducing the toilet to their toddler will be sent

• For those struggling with training, messages focused on how to remain calm and suggestions for softly encouraging their child will be sent

• As a way to personalize the message, we will incorporate messages based on their status as well as the gender of their baby. Potty training boys is different than potty training girls, therefore the messages will be targeted for these audiences.

INITIAL CONCEPT…

• In addition to messages sent to parents, we will foster interaction with two way messaging. When a child successfully uses the toilet, parents will text “Pee” or “Poo” to our number. This number will be tracked and the daily total will be sent at the end of the day.

• At the end of each day, Participants who submitted successful attempts will receive a text message containing the number of “potties” they earned for the day with an option to submit a “Potty goal” for the next day

• If the parents are struggling, they can text “Diaper” to our number to receive encouraging messages and suggestions on how to alter their behavior

• Parents will continue to receive encouraging and informative messages throughout the entire week to build confidence and capabilities

• Parents can submit pictures of their child’s reward chart for additional support messaging to show to their toddlers

• At the completion of the program, participants will be evaluated on their progress and the effectiveness of the timing and content of the messages sent

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By: Lindsey Goggin and Kathleen MacDonald

SUMMARY OF CONCEPT• Established pre-test evaluation criteria to assess where each

participant stands in their training (not yet ready, contemplating, ready to act, already training, struggling with training)

• Once assessed, participants received targeted messages based upon their pre-test responses

• For those not yet ready to act, messages about how to prepare their toddler were sent

• For those who are ready to act, messages focused on tips for introducing the toilet to their toddler were sent

• For those struggling with training, messages focused on how to remain calm and suggestions for softly encouraging their child were sent

• As a way to personalize the message, we incorporated messages based on their status as well as the gender of their baby. Potty training boys is different than potty training girls, therefore the messages were targeted for these audiences.

SUMMARY OF CONCEPT…

• In addition to messages sent to parents, we fostered interaction with two way messaging. When a child successfully uses the toilet, parents texted “POTTY” to our number. This number was tracked and the daily total was sent at the end of the day.

• At the end of each day, Participants who submitted successful attempts were sent a text message containing the number of “potties” they earned for the day with an option to submit a “Potty goal” for the next day

• If the parents were struggling, they texted “Diaper” to our number and received encouraging messages and suggestions on how to alter their behavior

• Parents continued to receive encouraging and informative messages throughout the entire week to build confidence and capabilities

• Parents could submit pictures of their child’s reward chart for additional support messaging to show to their toddlers

• At the completion of the program, participants were evaluated on their progress and the effectiveness of the timing and content of the messages sent

TARGET AUDIENCE

Moms of children 24 to 36 months currently engaging or beginning to start potty training their children

- Program will target both boy and girl toddlers with targeted messages for each gender

HEALTH GOAL

By the completion of the Tots on Pots program, participants will decrease their risk of emotional scaring (i.e. stress) as a result of poor toilet training by 10%

COMMUNICATION OBJECTIVES

• By October 18th and the completion of the program, participants will increase their knowledge of healthy, evidence based potty training tips by 20% such as mentoring, modeling, reinforcements, and appropriate goal setting (Behavior Capability)

• By October 18th , and the completion of the program, participants will be able to identify 3 barriers for success such as poor goal setting, inconsistent charting and reinforcements, and a negative training environment (Expectancies and Environment)

• By October 18th, and the completion of the program, participants will be able to identify successful reinforcement factors for aiding their toddler towards successful toilet training such as providing treats, play time, or a special treat (Expectancies and Reinforcement).

• By October 18th, and the completion of the program, participants will have an increase confidence in their ability to successfully potty train their tot than at the start of the program (Self Efficacy).

• By October 18th, and the completion of the program, parents will have a decreased sense of isolation and increased feelings of support as a result of the interactive “DIAPER” support component. (Emotional Coping Response)

SAM SCORIN

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Content

a) Purpose is evident: 2

b) Content about behaviors: 2

c) Scope is limited: 2

d) Summary or review included: 2

Literary Demand

e) Reading grade level: 1

f) Writing style, active voice: 1

g) Vocab uses common words: 2

h) Context is given first: 2

i) Learning aids via “road” signs”: 2

Learning Simulation Motivation

a) Interaction used: 2

b) Behaviors are modeled and specific: 2

c) Motivation- self efficacy: 2

Cultural Appropriateness

d) Match in logic, language, and experience: 2

e) Cultural image and examples: 2

TOTAL SAM SCORE: 26

TOTAL POSSIBLE SCORE: 28

Percent Score: 93%

OUR PROGRAM’S READING LEVEL SCOREREADING LEVEL: 8TH GRADE

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• 100% of respondents changed their environment as a result of the program

• 100% of respondent were able to identify 3 barriers to success (communication objective met)

• 50% of respondents were able to recall 3 tips they learned from the program, 1 respondent could only mention 1 (communication objective met)

• 100% of respondents felt supported to incredibly supported throughout the program (communication objective met)

• 50% of respondents felt more confident after the program (communication objective met)

• 50% of respondents said their child was more able to potty train

• 50% of respondents said their child’s attitude toward potty training changed positively, other 50% did not see this change

• 100% of respondents strongly agreed that the program helped them identify appropriate incentives (communication objective met)

• 50% of respondents felt the program helped encourage their kids toward potty training, other 50% did not

• 100% of respondents loved the supportive nature of the program as well as the consistent reminders (communication objective met)

THE FOLLOW-UP EVALUATION DELIVERED MIXED REVIEWS…

SAMPLE EVALUATION RESPONSES

What was your favorite part about the program?

“Regular reminders throughout the day to help me remember to encourage her to use the potty. Also, the positive/encouraging tone was helpful since potty training is not my favorite :)”

What was your least favorite part about the program?

“It would have been helpful to select the times of day that worked best for me to receive the messages. My daughter goes to bed super early & naps at a weird time so I sometimes got the texts at times that were less useful than other times could have been. That's a very minor thing though! “

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PROGRAM STATISTICS

• Days of messaging: 7

• Number of participants: 7

• Number of messages per day: 3-5*

• Number of text messages sent: 30-35*

• Number of “Potty” interactions: 12

• Number of “Diaper” interactions: 2

*Depended on level of

interactivity for the user

• On a scale of 1 to 10, respondents gave our program a 9

• Respondents marked our information as Moderately Relevant

• Respondents read all of the messages

• Respondents said the frequency was adequate

• Respondents appreciated the interactive component of the program

• All of the respondents would recommend the program to their friends

THE PROGRAM EVALUATION YIELDED POSITIVE RESULTS

SAMPLE RECOMMENDATIONS:

What did you like most about the program?

“The most helpful aspect was just a reminder to be intentional about reminding & encouraging my daughter. “

What did you not like about the program?

“It seems helpful to have a way to differentiate between peeing and pooping on the potty for the "potty" texts that the user sends in since some children are so much more comfortable with doing one than the other. “

LESSONS LE

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CHANGES TO PROGRAM FROM INITIAL CONCEPTImproved Language of Texts

• Messages fun and readable

• Simple Language

• Shorter Messages

Changed the use of “PEE” and “POO” to “POTTY” to make it simpler

Gave people the option to track the total POTTY number at the end of each day or as they went along

Incorporated explanations to remind them of program features along

the way such as reminding them to text their goal for the next day.

LESSONS LEARNED

Provide a good explanation of the program before it begins (i.e. what to expect, examples of what they will be receiving, limitations of the program)

Improve Interactive features of program

• Remind people of the interactive features throughout the program

• Make people feel like there is a person on the end of the texts rather than it being an automated message

How to make language fit into a text message format

• Short and simple language

• Fun, readable messages

FUTURE RECOMMENDATIONS Add in a function for working moms. This would include a different message track that takes into account that the mom will only have mornings, evenings and weekends to reinforce these messages.

Program features that would allow moms to sign-up for program with other caregivers such as dads, nanny's, grandmas or anyone else that spends a significant amount of time with the child.

Allow the person receiving the messages to select the quantity of text messages to receive and the time of day that they would get it.

For moms that sign up for an additional week, a library of messages that would be geared towards people in week two of training.

Stick with initial concept of separating “potties” into “pee” and “poop”, some children are more comfortable with one over the other

Create the bank of support messages to be given when DIAPER is texted from a group of moms. Tell the participants that the support messages were created by mom’s like them

Pair with a website and a hotline where people can call with specific questions and be directed to more resources

QUESTIONS?