Advancing continence in typically developing children: Adapting the procedures of Foxx and Azrin for primary care

Objective: To (1) identify and summarize procedures of Foxx and Azrin's classic toilet training protocol that continue to be used in training typically developing children and (2) adapt recent findings with the original Foxx and Azrin procedures to inform practical suggestions for the rapid toilet training of typically developing children in the primary care setting. Method: Literature searches of PsychINFO and MEDLINE databases used the search terms "(toilet∗ OR potty∗ AND train∗)." Selection criteria were only peer-reviewed experimental articles that evaluated intensive toilet training with typically developing children. Exclusion criteria were (1) nonpeer reviewed research, (2) studies addressing encopresis and/or enuresis, (3) studies excluding typically developing children, and (4) studies evaluating toilet training during infancy. Results: In addition to the study of Foxx and Azrin, only 4 publications met the above criteria. Toilet training procedures from each article were reviewed to determine which toilet training methods were similar to components described by Foxx and Azrin. Common training elements include increasing the frequency of learning opportunities through fluid loading and having differential consequences for being dry versus being wet and for voiding in the toilet versus elsewhere. Conclusion: There is little research on intensive toilet training of typically developing children. Practice sits and positive reinforcement for voids in the toilet are commonplace, consistent with the Foxx and Azrin protocol, whereas positive practice as a corrective procedure for wetting accidents often is omitted. Fluid loading and differential consequences for being dry versus being wet and for voiding in the toilet also are suggested procedures, consistent with the Foxx and Azrin protocol.