Effectiveness of response restriction with prompting combined with overlearning in children and adolescents with day-time urinary incontinence/non-retentive faecal incontinence.

Children and adolescents with neurodevelopmental disabilities seldom attain continence for urine and faeces through maturation. One-to-one training is often needed to establish continence. There is international consensus about the use of least-to-most intrusive treatment procedures for children with Elimination Disorders (ED) with Standard Urotherapy (SU) being considered a first-line treatment. However, specific guidelines pertaining to additional low intrusive procedures, while still producing the desired effect of attaining continence, are lacking in the literature. Furthermore, few studies describe the content of SU interventions and the effectiveness of SU specifically pertaining to children and adolescents with neurodevelopmental disabilities (ND). This PhD study focusses on adhering to the least-to-most intrusive guidelines for treatment and determining the effectiveness of standard urotherapy, behavioural training procedures based on response restriction with prompting and overlearning for self-initiated toileting.

Research question

Is RR with prompting effective in attaining self-initiated toileting in children and adolescents with DUI/NFI? Does the addition of an overlearning component contribute to better maintenance of the new skills over time?

Participant characteristics and setting

Twelve participants (5-18 y) will participate in this study. Intervention sessions will be conducted in a therapy room, 3 x 3m, at SeysCentra. Adjacent to the therapy room is a toilet room, 1,5 x 1,5m. In the therapy room is a table, two chairs, and a cupboard.

Study design

A non-concurrent multiple probe design across participants (Kazdin, 2011) will be used to investigate the effectiveness of RR with prompting and overlearning on DUI/NFI in participants.

Procedures

Participants will visit the training centre for ten workdays (no weekends) from 9:00 AM to 3:00 PM for RR training with prompting. Protocolized RR will be using prompting and ABA procedures will be utilized during training. Participants who attain mastery based on a predetermined criterion, will receive protocolled overlearning for the remainder of the training. During post-intervention, parents will foster generalization in the natural environment (e.g., at home) of the participant. Parents will receive protocolled feedback and instruction. Post-intervention will end after a pre-set criterion will be reached or after ten weeks. Eight weeks following post-intervention, maintenance will be measured in the follow-up phase for three days. Parents will not receive any feedback or instructions during follow-up measurements.

Measures and materials

Parents will be asked to measure urinary and faecal accidents, self-initiated toileting habits at home for at least five probes during the baselines, post-intervention, and follow-up. Event recording during a morning session (9:00 AM-12:00PM) and afternoon session (12:00 PM – 3:00 PM) of urinary accidents and self-initiated toileting habits (rate per three hours) will be conducted.

Strategy of analyses

Visual analyses using the guidelines of Lane and Gast (2014) for trend, level and stability of time series data within and between conditions will be assessed. Effect sizes will be calculated by using the Tau-U (Parker & Vannest, 2012) or by using another statistical analysis for single case research. Tau-U examines nonoverlap of data between phases and controls for a positive baseline trend (Parker, Vannest, & Davis, 2011; Parker, Vannest, Davis, & Sauber, 2011).

Power calculation

In this study, a single case design (SCD) will be used.

RR with prompting results in a higher rate of self-initiated toileting and a decrease in urinary/faecal accidents. The addition of overlearning will result in better maintenance of the acquired skills over time.

Rate of self-initiated toileting and urinary/faecal accidents at the end of:
- Baseline 1
- SU
- Baseline 2
- Intervention
- Post-intervention
- Follow-up

Response Restriction (RR) with prompting
Standard Urotherapy (SU)
Overlearning