JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2004, 37, 97–100 NUMBER 1(SPRING 2004)

EXTENDED DIAPER WEARING: EFFECTS ON CONTINENCE IN AND OUT OF THE DIAPER

RACHEL S. F. TARBOX,W.LARRY WILLIAMS, AND PATRICK C. FRIMAN UNIVERSITY OF NEVADA, RENO

Diaper use is widespread and possibly even increasing across diverse populations in the United States, ranging from to very old adults. We found no reports of an ex- perimental analysis of the effect of wearing diapers on the frequency of urinary accidents and the attainment of continence skills (e.g., urinating in the ). In this study, we used a withdrawal design to evaluate the effect of wearing diapers on daily urinary ac- cidents and successful voids for an adult who had been diagnosed with mental retardation. Results indicated that wearing diapers increased the rate of accidents and decreased the rate of successful voids. Clinical implications of these results are discussed. DESCRIPTORS: caregiver training, incontinence,

Urinary incontinence causes an array of able benefit, as are any increases in confi- problems ranging from personal embarrass- dence, mobility, or social participation the ment to imperiled public health. As just one use of diapers may provide for those who example, incontinence at day-care centers wear them. But whether extended diaper use can promote the spread of infectious diseases produces unwanted behavioral effects has yet (Berk & Friman, 1990). Yet, abundant ex- to be experimentally investigated. For ex- perimental evidence indicates that with skills ample, does wearing diapers merely capture training urinary continence can be estab- urinary accidents or does it also set the oc- lished and maintained effectively in diverse casion for their occurrence? More important, populations, including infants (Smeets, Lan- does wearing diapers promote or impede the cioni, Paul, & Oliva, 1985), emotionally dis- attainment of out-of-diaper continence turbed adolescents (e.g., Friman & Vollmer, skills? We address these questions in this ex- 1995), severely handicapped individuals perimental case study. (Azrin & Foxx, 1971), and very old adults (Burgio et al., 1990). A popular cultural and METHOD commercial trend toward increased diaper Participant. Ralph, a 29-year-old man usage, however, appears to promote conve- with mental retardation, lived in a commu- nience over continence by forestalling (e.g., nity residential setting for individuals with in the young) or even forgoing (e.g., in the developmental disabilities and attended a vo- handicapped or very old) skills training (e.g., cational workshop from 9:30 a.m. to 2:30 Goode, 1999; Lancaster, 1990). The con- p.m. weekdays. Prior to the investigation, venience for caregivers created through use Ralph was regularly placed in diapers (De- of diapers with those in care is an indisput- pends௡ adult diapers) at home by residential staff and was intermittently placed in diapers We thank Deborah Grinager for her assistance with the preparation of this article and Jay Summers and while at the workshop, depending on staff the staff at the Prevocational Assessment, Training and vigilance and inclination. Ralph arrived at Habilitation Center at the University of Nevada, the workshop in a diaper. This study was Reno, for their assistance with data collection. conducted to determine the effects of diaper Address correspondence to Larry Williams, Psy- chology Department/296, University of Nevada, use on Ralph’s continence and attainment of Reno, Reno, Nevada 89557. continence skills.

97 98 RACHEL S. F. TARBOX et al.

Procedure. The study was conducted at Experimental design. A withdrawal design Ralph’s workshop. During all conditions, was used to assess the effects of diaper use Ralph was prompted to use the toilet every on urinary accidents and successful voids. half hour. The prompt consisted of telling Ralph ‘‘it’s time to go to the bathroom,’’ and gently guiding him to the toilet. Once in the RESULTS AND DISCUSSION bathroom, Ralph independently pulled The results shown in Figure 1 suggest that down his pants and underwear (the staff wearing a diaper set the occasion for Ralph’s took off his diaper when he was wearing urinary accidents. In the diaper condition, one) and he sat on the toilet. During the Ralph had substantially more accidents (M diaper condition, Ralph remained in a dia- ϭ 1.5 per day) than in the no-diaper con- per throughout the day unless an accident dition (M ϭ 0.1 per day). The results also was detected, whereupon the diaper was suggest that wearing a diaper had a decre- changed. During the no-diaper condition, mental effect on his using the toilet because, Ralph’s diaper was removed when he arrived in the diaper condition, he used the toilet at the workshop and replaced when he left substantially less often (M ϭ 0.5 per day) for home. than in the no-diaper condition (M ϭ 1.8 Data collection. Trained staff collected per day). In addition, increased accidents on data at Ralph’s vocational workshop on the the 1st day of the second and third no-dia- daily occurrence of urinary accidents and per conditions suggest that when his diaper successful voids. An accident was recorded if was removed, it took Ralph at least a day to Ralph’s garments (i.e., diaper, , or recover his continence. pants) were seen or felt to be wet in any spot Although not addressed specifically by at the half-hour check. Successful voids were this study, the results suggest that the diaper defined as seeing or hearing urine contacting exerted discriminative control or was an es- the toilet during the scheduled toileting op- portunities. The time of day that Ralph was tablishing operation, or exerted a combina- taken to the toilet was also recorded for the tion of these functions. The reinforcers in- purposes of evaluating treatment integrity. volved cannot be identified with certainty, Treatment integrity data were collected for but the most plausible candidates appear to 100% of sessions. Treatment integrity was involve negative reinforcement (e.g., decreas- assessed by dividing the number of times es in the sensation of wetness, social detec- that Ralph was taken to the toilet within 5 tion of accidents, or the effort necessary to min of the scheduled time per day by the urinate). In addition to the function of the total number of scheduled toilet trips per diaper, it is possible that social reinforcement day, yielding a mean percentage of integrity played a role in the increase in toilet usage of 92% across all days (range, 72% to in the no-diaper condition. Future research 100%). Interobserver agreement was as- could extend these results by addressing sessed for at least 30% of the toilet trips dur- these issues. ing each day. Agreement was measured by A potential concern involves fluid intake dividing the number of agreements on each across conditions. Ralph drank two occurrence of an accident, a successful void, of milk a day throughout the study, but no and the time of day by the total number of record of his water intake was kept. Accord- agreements plus disagreements, yielding a ing to staff and observers, however, milk mean percentage of agreement of 100% comprised the major portion of his fluid in- across all days. take. A limitation involves the inclusion of DIAPERS AND 99

Figure 1. Number of toileting accidents per day are depicted in the panel. Number of successful voids per day are depicted in the bottom panel. only 1 participant, which limits the gener- Although the participant in this study was ality of the findings. an adult with developmental disabilities, the Concerns, limitations, and unanswered results have implications for other popula- questions notwithstanding, it seems prudent tions such as normally developing young to discuss some clinical implications of the children and very old adults. Market forces results. Incontinence is a problem across are promoting increased diaper use for both multiple normal and clinical populations, populations, and yet attaining and maintain- and an increasingly popular solution in- ing full continence is achievable for virtually volves the use of a diaper-like . all nonhandicapped children and many old- In some cases, use of the garments may be er, intermittently incontinent adults as well the only feasible solution, but in others, (Goode, 1999; Lancaster, 1990). The results their use, although convenient for caretakers, here suggest the importance of exploring may retard a wearer’s progress in the attain- whether diaper use instigates accidents or ment of continence skills. Wet diapers often forestalls appropriate toileting in these pop- provide a rationale for their own continued ulations. use (i.e., the fact that they are wet indicates the need for their use, as was the case in this study). The results here, however, suggest REFERENCES that the need for a diaper may be more ac- Azrin, N. H., & Foxx, R. M. (1971). A rapid method curately determined through use of out-of- of toilet training the institutionalized retarded. diaper tests. Journal of Applied Behavior Analysis, 4, 89–99. 100 RACHEL S. F. TARBOX et al.

Berk, L. B., & Friman, P. C. (1990). Epidemiologic http://www.nytimes.com/library/nationalscience/ aspects of toilet training. Clinical , 29, 011299sci-toilettraining.html 278–282. Lancaster, M. M. (1990). Urinary incontinence: Aids Burgio, L. D., Engel, B. T., Hawkins, A., McCormick, for management. In R. C. Hanby, J. M. Turnball, K., Scheve, A., & Jones, L. T. (1990). A staff L. D. Norman, & M. M. Lancaster (Eds.), Al- management system for maintaining improve- zheimer’s disease: A handbook for caregivers (pp. ments in continence with elderly nursing home 108–115). St. Louis: Mosby. residents. Journal of Applied Behavior Analysis, 23, Smeets, P. M., Lancioni, G. E., Ball, T. S., & Oliva, 111–118. D. S. (1985). Shaping self-initiated toileting in Friman, P. C., & Vollmer, D. (1995). Successful use infants. Journal of Applied Behavior Analysis, 18, of the nocturnal urine alarm for diurnal enuresis. 303–308. Journal of Applied Behavior Analysis, 28, 89–90. Received December 3, 2002 Goode, E. (1999). Pediatricians renew battle over toilet Final acceptance November 11, 2003 training. New York Times on the Web. Retrieved from Action Editor, Richard Smith