FACTORS AFFECTING DAYTIME DRYNESS IN PRESCHOOLERS WITH AUTISM SPECTRUM DISORDER: THE CONTRIBUTIONS OF CHILD-SPECIFIC CHARACTERISTICS AND TREATMENT HISTORY
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Successful toilet training is a key developmental milestone typically accomplished during the preschool-age range. Preschool-age children are developing the necessary components (e.g., social skills, communication, transitioning and generalizing behaviors) needed for the toilet training process during this time. One indicator of a child’s toilet training success is the achievement of daytime dryness, defined as a period of at least 12 months since the last daytime bladder accident (Rutter et al., 2008). By age 5 years, 95% of typically-developing children have achieved daytime dryness (Oppel, Harper, & Rider, 1968). Failure to achieve daytime dryness by age 5 is outside of normative development and it may affect a child’s level of independence, inclusion in school and childcare activities, and overall quality of life (Azrin & Foxx, 1974; Kroeger & Sorensen, 2010; Schonwald, 2009; Thomson et al., 2011). Failure to achieve daytime dryness by age 5 years may also warrant a diagnosis of enuresis (American Psychiatric Association, 2013). Children with Autism Spectrum Disorder (ASD) may have difficulty achieving daytime dryness within the normative age range (Ando, Yoshimura, & Wakabayashi, 1980; Dalrymple & Ruble, 1992). Individuals with ASD demonstrate unique diagnostic core symptoms (i.e., deficits in social communication and interactions, and restricted, repetitive behaviors, interests, or activities) and often have associated features (i.e., significant deficits in intellectual functioning and adaptive behavior) that may make toilet training more difficult (Azrin & Foxx, 1974; Dalrymple & Ruble, 1992; Lane et al., 2009; Luiselli, 1997; Schonwald, 2009; Wheeler, 2007). Despite the difficulty and stress associated with toilet training in the ASD population, limited research exists on factors that may affect toilet training success for these children (Dalrymple & Ruble, 1992; Keen, Brannigan, & Cuskelly, 2007; Macias et al., 2006). Specifically, there is a lack of data-based research investigating the relation between ASD core symptoms, as well as associated features and daytime dryness in preschool-age children with ASD. After diagnosis or when functioning deficits are recognized, children with ASD may receive various treatments, which most commonly include behavioral, speech/language therapy, and occupational therapy (Bowker, D’Angelo, Hicks, & Wells, 2011; Goin-Kochel, Mackintosh, & Myers, 2009; Green et al., 2006; Pringle et al., 2012). While none of these treatments, by definition, specifically target toilet training, each treatment does target the necessary precursor skills (e.g., compliance, social, communication, motor, and daily living skills). Further research is needed to determine how participation in these treatments may affect achievement of daytime dryness, particularly for children with differing ASD core symptoms and associated features. The current study aimed to contribute to the understanding of predictive factors that may affect achievement of daytime dryness in preschool-age children with ASD. To enhance identification of children who may have difficulty toilet training and, ultimately, to inform early interventions to increase the likelihood of toileting success, this study investigated the specific characteristics of preschoolers with ASD (e.g., ASD core symptoms and associated features of intellectual functioning and adaptive behavior), as well as their participation in various treatments, to determine whether these factors affect the achievement of daytime dryness by age 5 years. Extant data from a subset of the national, multisite Simons Simplex Collection (SSC; n=637) were analyzed in the current study to investigate the following research questions: 1) what are the adaptive behavior relative and normative strengths and weaknesses and intellectual functioning characteristics for preschool children with ASD?; 2) what factors predict whether a preschool-age child achieves daytime dryness by age 5 years?; 3) what is the predictive validity of the factors that are significant in determining whether a preschool-age child achieves daytime dryness by age 5 years?; and 4) does adding the reported history of treatment type, intensity, and/or duration to the model as a moderator affect the direction or strength of the relation between the ASD core symptoms/associated features and the achievement of daytime dryness by age 5 years? Descriptive analyses and standardized difference equations were conducted to determine the adaptive behavior relative strengths and weakness and intellectual functioning characteristics. The intellectual functioning for this sample fell into the below average range, and 32% of the children had FSIQ scores in the intellectual disability (ID) range. The adaptive behavior profile for this sample indicated significant impairments in adaptive behavior functioning and a relative weakness in socialization, which were consistent with previous research (Gillham et al., 2000; Kanne et al., 2011; Sparrow et al., 2005). Logistic regression analyses were conducted to investigate the impact of certain factors that predict whether a preschool-age child achieves daytime dryness by age 5 years. Of the possible factors that were considered, three were significant predictors (i.e., the Vineland-II ABC, Vineland-II Communication, and the Vineland-II Daily Living Skills) of the achievement of daytime dryness by age 5 years. An increase in these adaptive behavior skills increased the likelihood of achieving daytime dryness within the normative age range. Receiver operating characteristic (ROC curve) analyses were conducted to determine predictive validity and descriptive utility of the significant factors. “Cut scores” were established and diagnostic test evaluations indicated positive predictive values ranging from 71% to 73% and negative predictive values ranging from 68% to 74%. Lastly, logistic regression analyses were conducted to investigate whether adding the reported treatment type to the regression model as a moderator would affect the direction or strength of the relation between the significant factors and the achievement of daytime dryness by age 5 years. The logistic regression results, with treatment as a moderator variable, indicated that having had intensive behavioral (i.e., ABA-based) or speech therapy treatment did impact the likelihood of achieving daytime dryness by age 5 years. Limitations of the current study and future directions are discussed.