A Manualized Wireless Moisture Alarm Intervention for Teaching Toileting in Children with Autism

Background:  For many children with autism, development of toileting skills is delayed relative to the general population, resulting in increased demands on the family and decreased independence for the child. Because of this, a toilet training method that is user-friendly, relatively rapid and effective is needed. In this study, we developed a methodology that entails a novel enuresis alarm and a corresponding parent training manual and are currently comparing the effectiveness of this toilet training method with a standard intervention. 

Objectives:  Objectives of this study are: (1) to develop the technology and corresponding manualized treatment; (2) obtain preliminary data on the feasibility, acceptability, and perceived helpfulness of the enuresis alarm intervention compared to a standard behavioral intervention in children with autism.

Methods: The enuresis alarm (or "pager") consists of an Ipod-based app that interfaces with a transmitter and disposable moisture sensor positioned in the child's underwear that activates upon contact with small amounts of urine. The device has the following features: (1) auditory and/or vibratory page of parent and/or child at the onset of a toileting accident; (2) maintenance of a time-stamped record of accidents; (3) instant Bluetooth electronic data transmission for timely clinician review of data and feedback; (4) picture-based reinforcement menu for child; (5) “reminder” page for parent and child for prompting "dry pants checks" and independent initiation of toileting. The treatment program consists of a manualized parent-training program divided into distinct modules from introduction to fading and generalization. This experimental toilet training technology and corresponding training manual are currently being compared with a standard behavioral intervention (i.e., ATN Toilet Training Tool Kit) in a pilot randomized trial with 30 children with autism (aged 3 - 5) at three diverse sites in the US. 

Results: Field-testing of the device indicates a high degree of durability and sensitivity to the onset of urination, as well as a minimum of false positives or negatives. Parent-training and implementation of device for toilet training progressing successfully with data suggesting effectiveness in at least some instances.

Conclusions: The iPod-based enuresis alarm and corresponding treatment manual may offer a viable alternative to lengthy and difficult standard behavioral intervention for parents of children with autism. Opportunity for near-immediate clinician feedback, time-stamped accident data and relative ease of training procedure may present advantages that aid families and their clinicians overcome training difficulties. Our preliminary data support conducting a larger trial to test efficacy of the alarm and manualized parent training program.