Toileting Accidents

We have a 29-year-old woman with Down Syndrome in our center that has recently begun having toileting accidents. As far as anyone here knows she has never had this problem as an adult. Her doctor said there was nothing medically wrong with her and it was probably for attention. We have a referral in to the staff psychologist but for now, it’s hard not to give her attention when we’re having to change her when she wets.

You were right to have her see a doctor. In our experience, incontinence in a person after years of independent toileting is almost always indicative of a medical problem. Because her doctor could not find a medical reason does not mean that there isn’t one. Unfortunately, doctors familiar and comfortable with providing care for persons with developmental disabilities are relatively hard to find. It is not uncommon for many physicians to attribute all behavior in persons with mental retardation to attention seeking, if there is no obvious medical condition. If these accidents don’t resolve soon we recommend seeking another medical opinion.

Another line of inquiry important to pursue is the possibility of physical, psychological, or sexual trauma. The sudden appearance of toileting problems with no history may be suggestive of abuse. Could this person have been victimized? We encourage you to investigate this carefully.

Did the onset of these toileting accidents follow a time when someone provided an inordinate amount of attention for a single occurrence? Is there an increase in other behaviors that appear “attention seeking?” If not, we would further doubt this is happening solely for the attention it receives.

We recommend conducting a functional assessment of the behavior in order to better understand the environmental variables that may be influencing this woman’s toileting accidents. Your psychologist will probably begin this process. If he or she doesn’t, you may want to suggest it. It is possible the behavior is related to a medical condition but not caused by that condition, which would suggest a number of possible reasons for it. For instance, she may feel bodily discomfort that is relieved by spontaneous urination. She may have a physical or emotional condition (i.e. anxiety or depression) that masks or causes her to misread the bodily signals that cue the need to urinate. Her toileting may have been dependent on specific people or other features of the environment that have recently changed. The toileting accidents may have been initially caused by a physical problem and then come under the influence or control of environmental events. Toileting “accidents” may also provide an escape from odious tasks and anxiety producing events. There are any number of possible explanations for the behavior. A thorough functional assessment will point you in the proper direction.

The functional assessment will answer questions you must ask in order to support this person in a meaningful and effective way.

• Where does the incontinence occur? Where does it never occur?
• When does it occur? When does it never occur?
• Who is present when it occurs? Who is never present when it occurs?
• Are there any recent dietary changes that could be affecting her toileting?
• What is happening in the environment immediately before the incontinence?
• What happens after the incontinence? What are the consequences? Not just consequences mediated by the staff, but other consequences that occur without the staff’s knowledge or control.
• Does the behavior occur despite your prompting her to use the toilet at appropriate intervals?
A global review of this woman’s circumstances should also be undertaken. Do the activities in her life provide meaning? Is there opportunity for friendship and enjoyable activity? Does she find her work rewarding? Does she have the opportunity to exercise power and make choices? These are critical lines of inquiry when deciding how best to support someone.

Let’s say you conduct a thorough investigation of the behavior and, against all odds, the physician is correct and the toileting accidents are maintained primarily by attention. What does this suggest? First, remember that a reinforcer like attention functions most powerfully when the person is relatively deprived of it. That should prompt you to examine your service setting closely. Why would this person have to resort to such behavior in order to gain attention? Ensuring adequate attention and relationship throughout her day will not only encourage the behaviors you wish to see but will reduce the power of attention to reinforce the behavior of concern.