A Stepwise Animated Video Modeling App With Token-Based Reinforcement for Toilet Training in Children With Autism Spectrum Disorder: Pilot Study Using Multiple-Baseline and Single-Case Designs.

Abstract

Background: Toilet training is a major challenge for children with autism spectrum disorder. While mobile health offers accessible support, few apps specifically address the complex chaining required for independent toileting routines.

Objective: This pilot study evaluated the feasibility and preliminary effectiveness of a caregiver-mediated mobile app using stepwise animated video modeling with token-based reinforcement support for toilet training in young children with autism spectrum disorder.

Methods: A multiple-baseline design across participants (urination training) and a single-case AB design (defecation training) were used. Ten children (aged 3-6 years) were enrolled, and 4 (40%) were included in the final analyses. The tablet-based intervention guided a 16-step toileting routine using animation and token reinforcement. Primary outcomes were caregiver-recorded in-toilet elimination success (percentage) and routine completion (percentage). Secondary outcomes included standardized adaptive behavior scores (Korean Scales of Independent Behavior-Revised) and social validity.

Results: Four children completed the study, whereas 6 were not included in the final analyses for heterogeneous reasons, including child engagement, caregiver implementation burden, and postenrollment ineligibility. Among completers, in-toilet elimination success improved substantially from baseline, reaching 100% for all participants at the limited 3-day follow-up observation window conducted 3 months after the intervention. Notably, one participant showed marked improvement from a stable 0% at baseline to 93.8% (30/32) of elimination events during the intervention. Routine completion also increased across all participants, suggesting improvements in independence. Caregivers reported favorable treatment adherence and social validity.

Conclusions: The app showed preliminary feasibility and was associated with improvements in toileting outcomes among families who maintained engagement. However, the high attrition rate suggests that successful implementation may depend on child engagement readiness and caregiver resources. Future research should prioritize defining readiness criteria to identify families most likely to benefit from digital toileting interventions.