A Telehealth Delivered Toilet Training Intervention for Children with Autism

Abstract

Background:

Independence in toileting is a vital skill, yet toilet-training interventions for children with autism are limited.

Objectives:

We investigated the acceptability and preliminary efficacy of a hybrid telehealth intervention that used synchronous individualized coaching sessions and asynchronous online educational materials to support parents in toilet training their children with autism.

Method:

Participants included 34 families of children with autism ages 2 to 8 years. Measures were administered at pre- and postintervention (10–12 weeks) and included the Toileting Behavior Questionnaire, Goal Attainment Scaling, and Canadian Occupational Performance Measure.

Results:

Twenty-five families completed all intervention procedures. Parents found the intervention highly acceptable and reported significant improvements in child toileting behaviors; however, families accessed the asynchronous intervention materials at a low rate.

Conclusion:

A parent coaching model delivered through telehealth may be a promising method to increase toileting independence among families of young children with autism.

Introduction

Independence in toileting is an essential skill. Children’s toileting independence leads to more community, social, and educational opportunities that positively influence longitudinal developmental trajectories (Cicero & Pfadt, 2002; Richardson, 2016). Many children with autism show significant delays in toileting independence (Dalrymple & Ruble, 1992; Richardson, 2016). While typically developing children gain independence in toileting by 3 to 4 years (Blum et al., 2003; Schum et al., 2002), studies suggest that the majority of children with autism do not reach this milestone by 3.5 years (Dalrymple & Ruble, 1992; Niemczyk et al., 2018). However, interventions to address toilet training among young children with autism are limited.

Given the limited access to intervention services for families of children with autism (e.g., Boyd et al., 2010), the efficacy of telehealth delivered interventions are becoming increasingly investigated. The COVID-19 pandemic, however, unveiled the limited evidence from which providers have to draw on to deliver efficacious interventions during the rapid shift to telehealth, particularly related to children’s adaptive behavior (Ramos et al., 2020). Therefore, more research is warranted to understand intervention strategies that successfully promote adaptive behavior skills via telehealth for young children with autism.

While evidence is limited, studies show that typically developing children take 6.9 to 14.6 months to achieve complete toileting independence for urination and bowel movements (Schum et al., 2002). In comparison, children with autism have been reported to take 18 to 25 months to demonstrate gains in toileting skills, though the majority of children continue to urinate in places other than the toilet after the time of toilet training (Dalrymple & Ruble, 1992). A recent review (Niemczyk et al., 2018) of 19 studies of incontinence rates of children with autism showed that up to 57% of samples demonstrated urinary continence, while fecal incontinence ranged from 2% to 70.6%. While the aforementioned prevalence rates of incontinence and toilet training time are quite variable, it remains clear that many children with autism demonstrate difficulties and extended training needs for toileting independence.

Delayed toilet training is associated with difficulties with peer interactions, personal hygiene, skin irritation, increased cost in diapers, and can have a negative impact on school and community inclusion (Leader et al., 2018; Vermandel et al., 2008). Toileting independence allows for increased access to after school programs, day camps, and other extracurricular activities. Adaptive behavior difficulties, like toileting, contribute to parent stress (Hall & Graff, 2011; Rivard et al., 2014) and may influence engagement in interventions designed to target core features of the disorder. While we have a myriad of parent-implemented, evidence-based interventions to address core symptoms of autism spectrum disorder (i.e., social communication, restricted and repetitive behaviors; for a review, see Steinbrenner et al., 2020), there remains limited evidence on parent-mediated intervention approaches to address adaptive behavior.

Existing toilet training interventions for young children with autism are limited in their use of holistic, family-focused approaches. For example, the most commonly used intervention approaches to address toilet training for children with autism include behavior-based strategies outlined in the Azrin & Foxx Rapid Toilet Training (RTT) protocol (Azrin & Foxx, 1971). However, such methods are time-intensive and research suggests that a rapid method of toilet training may not have long-lasting effects (for review, see Kroeger & Sorensen-Burnworth, 2009). In addition, one review of measurement issues in toilet training interventions showed that the majority of toilet training studies reported dichotomous findings (either children were toilet trained or not) (Francis et al., 2017). The combination of rapid toilet training procedures with measures that are not sensitive to children’s incremental changes in toileting independence does not set up children or families for long-term success (de Carvalho et al., 2021; Klassen et al., 2006).

Parent-implemented interventions are considered an evidence-based practice to promote developmental outcomes in young children (Steinbrenner et al., 2020). Many studies on toilet training interventions for young children with autism use a parent-implemented model (Francis et al., 2017) to support parents’ use of behavior-based strategies for gaining urination independence (e.g., Kroeger & Sorensen, 2010) and decreasing encopresis (Mevers et al., 2020). However, many of the existing toilet training intervention studies do not consider how young children learn best through everyday experiences and interactions with familiar people in familiar contexts. In addition, practitioners that support toilet training must consider the family’s environment to provide support in the authentic context, during routines and activities to promote the child’s participation in learning experiences (Division for Early Childhood [DEC], 2014). Parents may need support in understanding the toilet training process holistically and how children’s individual characteristics (e.g., sensory processing, communication level, preferred interests) may be relevant during different parts of the toilet training process.

Taken together, the evidence points to the need for investigations of family-centered interventions that target toilet training among young children with autism. Alternate service delivery models such as telehealth and self-directed technology-based applications have emerged as evidence-based methods to provide intervention services (AOTA, 2018; Cason et al., 2012). Currently, the available hybrid (i.e., self-directed modules coupled with coaching) telehealth intervention models are largely focused on social-communication skills for children with autism (Ingersoll et al., 2016; Pickard et al., 2016), while telehealth delivered parent coaching interventions focused on specific areas of adaptive behavior, such as toileting, remain limited. Evidence exists for synchronous telehealth sessions, but we have little understanding of utilization asynchronous materials as well as how outcomes may be related to such utilization (for review, see Simacek et al., 2021). In addition, few studies have used a hybrid model with a mix of both synchronous and asynchronous material. Given that much of our evidence for telehealth is based on synchronous models, it is critical to examine hybrid models of delivery.

Therefore, the purpose of this study was to investigate the acceptability and preliminary efficacy of a hybrid telehealth delivered toilet training intervention with synchronous and asynchronous components among families of young children with autism ages 2.5 to 8 years. Drawing from Division of Childhood Recommended Practices (DEC, 2014) and Occupation-Based Coaching (OBC; Dunn et al., 2018; Little, Pope, et al., 2018), we implemented a 10- to 12-week telehealth intervention that used both synchronous coaching sessions with an occupational therapist and access to asynchronous educational materials about toileting development. Our research questions included the following:

• Research Question 1 (RQ1): How did caregivers rate the acceptability of the toilet training intervention?

• Research Question 2 (RQ2): How often did caregivers report they accessed asynchronous materials?

• Research Question 3 (RQ3): To what extent did the toilet training intervention influence child toileting skills?

Method

This study used a quasi-experimental, pre- to posttest design to evaluate the feasibility and preliminary efficacy of a synchronous coaching with asynchronous education intervention program for achieving toileting skills. All parents completed a consent form and this study was approved by the university’s institutional review board.

Intervention

Synchronous Coaching Sessions

The intervention consisted of five live, video conferencing sessions that occurred via the Zoom™ platform every other week for 10 to 12 weeks with each session lasting approximately 30 to 45 min. Parents were the primary attendee of the sessions, and children attended depending on parent preference. Interventionists consisted of three licensed occupational therapists with approximately 1 to 3 years of experience using OBC to deliver services to families. During the weeks in which the interventionist did not videoconference with the parent, the interventionist emailed the parent to check in about strategy use and problem solve any difficulties. The content and structure of the live, video conferencing sessions was rooted in OBC (Dunn et al., 2018; Little, Pope, et al., 2018), which is drawn from Early Childhood Coaching (Rush & Shelden, 2020) and incorporates elements of positive psychology (Biswas-Diener, 2020). All OBC sessions follow a similar procedure which include (a) greeting and discussing a positive event related to the child, (b) discussing the joint plan from the previous session, (c) reflective questioning to determine next steps and problem solve new strategies to support the family and child in toilet training, and (d) creating a joint plan of strategies to support the child’s toilet training for the family to try until the next session.

Overall, OBC is a structured method of intervention that uses families’ naturally occurring routines and everyday interests as a basis for achieving child goals. By ensuring that all intervention opportunities occur in families’ authentic contexts, the interventionist can support the caregivers’ ideas for how to structure the daily routine to provide the child opportunities for skill development. In addition, OBC uses elements of positive psychology coaching to consistently support the caregiver to use the child’s strengths as a basis for intervention to promote parent responsiveness and warmth toward the child. Using OBC as a method to address toilet training skills is a natural fit; interventions to promote independence in toilet training must draw on families’ everyday environments and routines. Thus, OBC uses reflective questions to collaboratively problem solve with parents to derive solutions that match the authentic routine of the family and child.

Asynchronous Educational Materials

We drew from the literature to conceptualize eight domains related to toilet training, as we intended for the intervention to be accessible to families of children at any level of toileting independence and cover a range of topics that may influence toilet training success (e.g., dressing and sensory processing; see Online Supplemental Table 1). Parents had access to online materials, which included eight 20- to 30-min podcasts and associated tip sheets about specific domains related to children’s toilet training. The first two authors created and recorded the podcasts, all of which capitalized on research related to children’s toilet training, common myths related to toilet training, and many of which featured interviews from experts in their respective fields (e.g., sensory processing and communication strategies). See Table 1 for content of podcasts. All podcast and tip sheet materials were based on empirical evidence for toilet training (e.g., for review, see Kroeger & Sorensen-Burnworth, 2009), and used family friendly language to educate parents about discrete strategies for facilitating children’s independence in toileting. The podcasts and tip sheets were made available to parents on a website, and during the synchronous sessions, parents were instructed on the podcasts that may be most relevant to their child’s toilet training process (e.g., communication or sensory processing).

Table 1.

Participant Characteristics.

Group	Completed all sessions (n = 25)	Did not complete all sessions (n = 5)	Dropped out of study (n = 4)X
Mean (SD) range
Child CA	66.88 mos	56.00 mos	71.25 mos
	(21.4 mos)	(22.90 mos)	(13.52 mos)
	32–104 mos	33–94 mos	62–91 mos
SRS t-score a	76.4 (9.02)	75.6 (10.78)	85.25 (6.95)
	53–90	57–84	75–90
% male	88%	60%	100%
Baseline Child Toileting Behavior Questionnaire Score b	115.36 (16.23)	110.40 (19.80)	100.75 (12.97)
	89–161	87–131	91–119
n (%)
Child race/ethnicity
White	21 (84.0)	4 (80.0)	2 (50.0)
Black	2 (8.0)	1 (20.0)	2 (50.0)
Asian	1 (4.0)	0	0
Hispanic	1 (4.0)	0	0
Mother education
Some High School	1 (4.0)	0	0
High School	4 (16.0)	1 (20.0)	1 (25.0)
Associates	5 (20.0)	0	1 (25.0)
Bachelors	7 (28.0)	3 (60.0)	1 (25.0)
Masters	8 (32.0)	1 (20.0)	0
Prefer not to answer	0	0	1 (25.0)
Family income
<20k	3 (12.0)	0	1 (25.0)
20–39k	7 (28.0)	3 (60.0)	0
40–59k	2 (8.0)	0	0
60–79k	3 (12.0)	0	2 (50.0)
80–99k	4 (16.0)	1 (20.0)	0
>100k	4 (16.0)	1 (20.0)	1 (25.0)

Note. CA = chronological age; SRS = social responsiveness scale.

^at-score 75 to 90 = severe; 66 to 74 = moderate; 59 to 65 = mild. ^bHigher scores indicate more toileting difficulties.

Recruitment Procedures

We recruited families of children ages 2 to 8 years through a flyer sent to local autism specific agencies and posted on social media (e.g., Facebook). We included a wide age range of children consistent with the literature reporting ages of toileting independence for children with autism, regardless of severity (Leader et al., 2018). We excluded families if they were not fluent in English or if the child had a co-existing genetic condition (e.g., Fragile X Syndrome and Down Syndrome). All families reported that they were receiving simultaneous services through early intervention, school, and/or clinics.

Participants

We enrolled 34 families in the intervention study; 25 families completed all intervention activities. Five families did not complete all intervention sessions but did provide follow-up data, and four families dropped out of the study completely. All autism diagnoses were parent-reported, and parents provided information about the diagnostic clinic, clinician, and date of the child’s diagnosis. Participant characteristics are shown in Table 1.

Measures

To characterize the sample, we used a Demographic Form (unpublished questionnaire), which included questions about families’ race/ethnicity, parent education, socioeconomic status, and family composition. We also used the Social Responsiveness Scale–Second Edition (SRS-2; Constantino & Gruber, 2007), a caregiver report quantitative measure of the core features of autism, as a measure of autism severity (see Table 1).

We administered the Telehealth Acceptability Questionnaire (Little, Wallisch, et al., 2018) postintervention, which has two subscales: telehealth acceptability (i.e., parents’ satisfaction with the use of telehealth to communicate and work with the interventionist) and OBC satisfaction (i.e., parents’ perceptions of the effectiveness of the content and process of the OBC intervention). The measure used a Likert-type scale (1 = strongly agree to 6 = strongly disagree), and we added two questions about the asynchronous components of the intervention (i.e., I like the email check-ins with my interventionist and I like the online materials of the intervention).

We collected data pre- and postintervention, and used the following assessments as outcome measures.

Toileting Behavior Questionnaire (Little et al., under review)

The measure consists of 36 items which were designed to span a continuum of specific behaviors associated with toilet training, based in the nine domains of toilet training as shown in Table 2. Each of the items was rated on a 5-point scale, which measured the frequency of behaviors associated with toileting (5 = Always/Almost Always, 4 = Frequently, 3 = Sometimes, 2 = Once in a While, 1 = Never/Almost Never). Higher scores indicate increased independence in toilet training, and possible scores range from 36 to 180. Rasch analysis results show that the measure is a valid and reliable measure of the developmental sequence of toileting skills among children with (n = 139) and without developmental conditions (n = 160) (BLINDED FOR MASKED REVIEW). Rasch analysis of difficulty of items on the measure showed a progression of skills that ranged from easy, or beginning of toilet training independence (e.g., “My child will stay bowel-movement free overnight,” “My child will enter the bathroom at home”) to difficult, or gaining independence in toilet training (e.g., “My child is able to tear off the right number of sheets of toilet paper,” “My child can independently wipe after pooping”).

Table 2.

Telehealth Acceptability Questionnaire Item and Subscale Results.

Scale/Item	Completed intervention (n = 25) Mean (SD) a Range	Did not complete intervention (n = 5) Mean (SD) a Range
Telehealth Acceptability Subscale	1.56 (0.74)	2.13 (1.13)
	1.00–4.50	1.00–3.63
Occupation-based Coaching Satisfaction Subscale	1.84 (1.01)	2.23 (0.79)
	1.00–5.57	1.43–3.57
I liked the email check-ins with my interventionist.	1.40 (0.65)	1.80 (0.84)
	1.00–3.00	1.00–6.00
I liked the online materials used in the intervention.	2.16 (1.55)	2.80 (1.79)
	1.00–3.00	1.00–5.00

^a1 = highly agree to 6 = highly disagree.

Canadian Occupational Performance Measure (COPM; Law et al., 1998)

The COPM is an outcome-based assessment in which persons/caregivers identify goals in self-care, productivity, and leisure. Parents rate performance and satisfaction on a scale from 1 to 10 (not satisfied to extremely satisfied). We adapted this measure to specifically align with a parent’s report of the child’s performance in toilet training, asking parents about their satisfaction with their child’s current level of performance in toilet training as well as asking how, given the parent’s perceptions of the child’s level of functioning, the child is currently performing in toilet training.

Goal Attainment Scaling (GAS)

GAS is a method to document, quantify and chart progress on goals in everyday life. In this method, a parent identified the child’s current behavior, and then scaled behavior descriptions that illustrate progressive behavioral improvements. The 4-point scale was used for this study, which includes: 0 = what does the child behavior look like now? −1 = what would the child behavior look like if it got worse?; 1 = what would the behavior look like if it got slightly better?; 2 = what would the behavior look like if it were perfect?. Across pediatric studies, the GAS method demonstrates sound psychometric properties (for review, see Steenbeek et al., 2007). During the first online session, parents set goals related to their child’s toilet training behaviors that they believed would be achievable within 10 weeks.

Data Analysis

First, we used Mann–Whitney U tests to examine the potential of systematic differences in autism severity, chronological age, and toileting behavior questionnaire baseline scores between families that completed the intervention (n = 25) versus those that did not (n = 9). To address Research Question 1 (i.e., How did caregivers rate the acceptability of the toilet training intervention?), we used descriptive statistics derived from the Telehealth Acceptability Questionnaire (Little, Wallisch, et al., 2018). To address Research Question 2 (i.e., How often did caregivers report they accessed asynchronous materials?), we used descriptive analyses to determine which asynchronous materials (i.e., podcasts and tip sheets) were accessed the most by parents. To address Research Question 3 (i.e., To what extent did the toilet training intervention influence child toileting skills?), we used paired sample t-tests to examine changes in child toileting skills, child performance in toilet training (i.e., GAS, COPM) and parent satisfaction (i.e., COPM). Finally, as an exploratory analysis, and due to the small sample size, we used Wilcoxon Signed Rank tests to examine changes in Toileting Behavior Questionnaire scores among the n = 5 families that did not complete all synchronous coaching sessions.

Results

Children enrolled in the intervention were aged 32 to 104 months, and approximately 83% of the sample was male (see Table 2). There were no baseline differences between families that completed and those that did not complete intervention sessions based on the Mann–Whitney U test results for SRS-2 severity (p = .676), chronological age (p = .303), and toileting behavior questionnaire baseline score (p = .645). While not significant, participants that dropped out of the study completely (n = 4) had the lowest baseline Toileting Behavior Questionnaire scores.

How Did Caregivers Rate the Acceptability of the Toilet Training Intervention?

Using a Likert-type scale of 1 = highly agree to 6 = highly disagree, results showed that parents that completed all intervention found the use of telehealth (M = 1.56) and OBC highly acceptable (M = 1.84), while parents that did not complete all intervention sessions rated the acceptability of telehealth (M = 2.13) and OBC (M = 2.23) slightly lower (see Table 2). Parents rated the online materials lower than other components of the intervention overall, and parents that did not complete all intervention sessions rated the asynchronous components somewhat lower than those that completed all sessions.

How Often Did Caregivers Report They Accessed Asynchronous Materials?

Descriptive analyses showed that overall parents did not have high frequencies of accessing the asynchronous materials (M = 1.64 podcasts accessed, SD = 2.40; M = .96 tip sheets accessed, SD = 2.23). Twelve parents (48%) reported that they accessed podcasts and eight parents (32%) of the sample reported that they reviewed or downloaded tip sheets. The “Sensory Processing and Potty Training” (n = 10), as well as the “Communication and Potty Training” (n = 8) podcasts were most frequently accessed (see Table 3).

Table 3.

Acceptability and Asynchronous Material Utilization.

Toilet training skill domain topic	No. of times podcasts accessed (n = 25)	No. of times tip sheets accessed (n = 25)
Advanced Planner	2	2
Readiness: How do I know if my child is ready?	5	2
The Routine: Strategies to get you started	6	4
Communication and Potty Training	8	4
Sensory Processing and Potty Training	10	3
Dressing and Potty Training	3	3
Wiping: Strategies to teach wiping	3	3
Pooping in the potty	4	3
Trouble-shooting: When the going gets tough	5	3

To what extent did the toilet training intervention influence child toileting skills?

Paired sample t-tests showed significant improvements in child gains related to toileting skills as well as parent satisfaction with child performance in toilet training (all p < .01; see Table 4). Cohen’s d values showed a medium effect size for the Toileting Behavior Questionnaire and a large effect size for all other measures. GAS scores showed the largest effect size (d = 2.39), followed by COPM parent satisfaction (d = 1.07), and COPM child performance (d = 0.82). In the exploratory analysis, which examined changes in Toileting Behavior Questionnaire scores among the 5 families that did not complete all synchronous coaching sessions, the sample did not show significant changes based on the Wilcoxon Signed Rank tests (X = −.674, p = .600). Overall, parents that completed all synchronous sessions reported a mean 9.72 point increase (SD = 13.28) in their child’s toilet training skills, whereas families that did not complete all intervention sessions reported a 5.0 mean point increase (SD = 7.52) on the Toileting Behavior Questionnaire.

Table 4.

Child and Caregiver Results.

Measure	t	df	p	Cohen’s d
Toileting Behavior Questionnaire	3.321	24	<.01	0.49
Goal Attainment Scaling	−8.269	20	<.001	2.39
COPM child performance	−4.788	20	<.001	0.82
COPM parent satisfaction	−5.475	20	<.001	1.07

Note. COPM = Canadian occupational performance measure.

Discussion

Novel findings from this study suggest that parents found a telehealth delivered intervention to be effective in supporting development of toileting behaviors in their children with autism. In this study, we used an individualized intervention that provided coaching and education to parents of children with autism. We provided 5 synchronous videoconferencing sessions as well as 9 online, asynchronous educational modules to support self-guided learning about toilet training over 10 to 12 weeks. Parents set goals related to their child’s toileting independence, and individualized coaching sessions focused on family-identified priorities and goals related to the child’s toilet training.

This approach to support children’s toilet training development expands previous interventions by not only including parents throughout the entire intervention process, but making them the key driver of the intervention. Furthermore, this approach adds to the body of evidence supporting parent-implemented interventions (Steinbrenner et al., 2020). Given it may take up to or beyond 25 months to reach full toileting independence (e.g., Dalrymple & Ruble, 1992), this intervention offers a way to build parent capacity to continue working on children’s toileting independence when the formal intervention time discontinues.

Many toilet training approaches use short duration, intensive procedures that are often too burdensome for families and heavily rooted in reinforcement and punishment behavioral techniques. In this study, the intervention utilized a hybrid (synchronous and asynchronous) model that was longer in duration than other toilet training protocols (i.e., 10–12 weeks) and focused on both increasing parent capacity, and supporting parent knowledge related to toilet training. In addition, the intervention is less structured than other toilet training protocols due to its’ reliance on parent-implementation of strategies that are driven by family priorities and authentic routines and contexts. Our findings suggested that children made progress on toileting skills even with less intervention intensity. Research suggests interventions that are less burdensome to families, and are based on the family’s context and routines, may result in better maintenance of skills (e.g., Pellecchia et al., 2019). Since the toilet training intervention in our study was guided by parents, and more easily embedded into a family’s daily life, it may have the potential to create longer-lasting effects on toileting skills, or provide parents the skills to continue to support their child’s developmental progression through toilet training.

While the asynchronous online material was not accessed frequently overall, it appears information related to communication and sensory processing were accessed most often, and may be more relevant, or of interest, to families during the toilet training process. This means that the live video conferencing coaching sessions of the intervention may be the key ingredient to greater acceptability and possibly efficacy. Research suggests that both self-guided and therapist-led telehealth interventions for parents lead to child gains. Our findings align with research, however, which suggests that therapist-led groups reported greater gains (Ingersoll et al., 2016; Pickard et al., 2016) and parents may prefer synchronous coaching sessions versus listening to educational materials. In addition, qualitative interviews have found that parents in both conditions find the intervention highly acceptable, though, that parents in the therapist-led group discussed greater acceptability (Pickard et al., 2016). Given that parents in our study utilized the asynchronous materials infrequently, it may be that the individualized live videoconferencing coaching and between session check-in components of the intervention were the key ingredient to greater acceptability. In addition, parents were instructed which asynchronous material domain may be most related to their child; however, interventionists would provide education related to domain topics when parents did not listen to the asynchronous material. Providing an opportunity and more parent accountability to systematically review asynchronous educational materials would be a necessary future direction to understand overall parent acceptability and understanding of the asynchronous materials. Overall, these findings are especially important as telehealth services expand and more interventions use online materials to support asynchronous, or self-guided, parent training.

Our findings also revealed that families who did not complete all synchronous coaching sessions, but who did complete post-assessment data collection, were less likely to see gains in child toileting skills. Few studies have examined the outcome data of individuals who drop-out or do not complete the intervention. These findings may point to the efficacy of the live videoconferencing coaching sessions to influence parent behavior to then implement strategies that reinforce child toilet training skills. However, these findings could also mean that parents with incomplete intervention sessions may have dropped out of the study because of fewer gains in child toileting skills. The intervention may not have been the “right fit” for families with incomplete sessions, or the dosage and intensity of the intervention may not have best supported the family. Future studies should use Sequential Multiple Assignment Randomized Trial (SMART) designs to better tailor the intervention intensity to family needs, as well as continue to understand why certain families decided to stop the intervention.

Toilet training skills provide children more opportunities to participate in community activities, which are linked to better developmental outcomes for children with autism (Cicero & Pfadt, 2002; Richardson, 2016). Furthermore, when children lack toilet training skills they are more likely to experience decreased learning opportunities and isolation (Leader et al., 2018) from family and peers. Our study demonstrated an increase in child toileting skills, but also an increase in parent satisfaction with those skills. Interventions guided by parents and use of a reflective coaching model to support parents, may provide parents with a broader range of skills to use when confronted with difficult toileting behaviors and ultimately build family capacity.

Future Directions and Limitations

As a preliminary efficacy study, we used a small sample size with a wide age range, and while we analyzed the limited sample that did not complete all synchronous coaching sessions, this was not a true controlled condition. The lack of a control group is a threat to the study’s internal validity and future studies should examine this intervention with larger sample sizes and a control group. It is noteworthy that children increased their toilet training skills and parents reported significant changes in their child’s performance in toileting skills; however, all children began the intervention with different toileting training skill levels. In addition, future studies should examine the maintenance effects of this intervention and follow-up with families to determine if skills continued to increase or decrease over time. While most autism interventions have yet to determine the optimal intensity and duration (e.g., Pellecchia et al., 2019; Steinbrenner et al., 2020) of interventions, it is unclear if the dosage of the current toilet training intervention resulted in the best treatment response. Future studies should use pragmatic trials to tailor the intensity of the intervention based on child and parent response. This would provide insight into creating an intervention that is less burdensome to families, yet yields the greatest child progress. Our study reported on the usage of asynchronous materials; however, this was based on parent recall which may introduce bias. Since the number of materials parents reported accessing was rather low, it seems usage of asynchronous materials was not inflated. Future research should examine usage through website analytics to provide a more in-depth understanding of the amount of time parents spent accessing the materials, number of website visits, and obtain exact counts of podcast plays and “tip sheet” downloads.

Conclusion

Occupational therapy practitioners are increasingly using telehealth to serve children and families, and independence in activities of daily living is vital to practice. OBC delivered via telehealth, along with education activities, may be an effective intervention to promote independence in toileting training young children with autism.