Vicarious learning from toilet training through animated film: case study of behavioral play

therapy.

Author: Laura dos Santos Gomes Coelho

e-mail: lauragcoelho@mac.com

homepage: http://www.homepage.mac.com/lauragcoelho

Abstract

A report of the treatment of Lara (4 years and 5 months old) who was experiencing secondary retentive

encopresis, with an interval of over 72 hours between bowel movements. The evaluation was conducted

through interviews with the parents and nannies, observation in school, individual play sessions and

family play sessions; the interventions focused on the use of animated films, play activities and toys to

develop behavioral habits and to toilet train. After the intervention using animated film, Lara had bowel

movements in the office and had daily bowel movements during the 12 months of treatment; she had

three serious accidents in this period. Most likely, after watching the characters toilet train and earn

stickers in the animated film, Lara was vicariously reinforced and learned the relationship between the

behavior of the characters (toilet training) and the consequent reward (sticker). The game with the dolls

used in the film is considered a type of play mediation.

Key words: behavioral play therapy; encopresis; habituation; vicarious learning.

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1. Introduction

Being autonomous in the activities of daily life during childhood (getting dressed, taking a

shower, choosing and showing preference for clothes, toys, etc.) involves carrying out tasks with

varying degrees of difficulty, in various contexts (school, social and family gatherings); carrying out

toilet training correctly (i.e. with approximately 17 steps, beginning when the child expresses the desire

to go to the toilet, and finishing with washing hands) is part of the development of an individual’s

autonomy. The ideal situation, According to Brazelton (1962), is to begin toilet training at the age of

two, and it should be based on the child's readiness for training (at about 18 months), rather than

coercion; at 24 months, step-by-step training should begin; at 36 months, through positive

reinforcement (praising the child’s performance), encouragement (inducing the child to accomplish the

task) and showing understanding towards the child, it is possible to achieve fecal continence; finally, at

48 months, toilet training is complete (Stadler, Gorski, and Brazelton, 1999). However, pediatricians are

often asked about the child’s refusal to undergo training and “there is a lack of empirical data on this

phenomenon in the literature. There is no mention of either stool withholding or stool toileting refusal in

Brazelton's 1962 study” (Taubman, 1997, pag. 56).

Some studies suggest that the child’s refusal to toilet train is associated with past experience,

i.e., constipation, where the child found it difficult to defecate and defecation was painful. (Issenman,

Filmer and Gorski 1999; Blum, Taubman and Nemeth, 2004). According to Fleisher (2004), “although

constipation is an important element in the pathogenesis of stool toilet refusal, not every young child

with painful defecation becomes averse to the toilet; and not every child who is averse to the toilet has

experienced painful defecation. Other factors such as anxiety may interfere with toilet learning”

(Fleisher, 2004, page 1809). Fleisher’s (2004) criticism to the idea that constipation is not enough to

explain toileting refusal implies that changes need to be made in the retention cycle proposed by

Issenman, Filmer and Gorski (1999), in which constipation initially causes fecal impaction; then,

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defecating becomes painful; and the child refuses to use the toilet, and the whole cycle starts over again.

The retention cycle proposed by Issenman, Filmer and Gorski (1999) does not take into account

significant changes in the family dynamics (separation of parents, birth of siblings), and in the activities

of daily life (transition from breast milk to new types of food, transition from diapers to toilet during

toilet training, or changing schools) which may cause aversion to the toilet. For instance, during toilet

training, the parent’s task, through instruction and examples, is to gradually establish the use of the

toilet, replacing the previous habit of using diapers - which are easier and simpler - to defecate or urinate

at any time. During this period, an aversive event (e.g., sudden withdraw of diapers, painful defecation,

or fear of falling into the toilet) or a positive one (birth of a sibling or travel) may cause an intense

reaction in the child, particularly crying and avoiding toilet training. The more parents try to establish

the transition from diaper to toilet, the more the child’s reaction of refusal intensifies, and a situation of

aversion to toilet is established. From a psychological perspective, reactions such as increased crying or

refusal to use the toilet are called sensitization, which is defined as a reaction, of long or short duration,

to abrupt changes in the environment, the function of which is to regulate and organize the vast amount

of information in this new environment, for instance by distinguishing between harmful and positive

stimuli (Domjan, 1996).

Described in more detail, the cycle of fecal retention begins with sensitization (Figure 1A), i.e.,

the child’s reaction to some significant change in the environment (for instance, a reaction of crying

when defecation is painful; resistance to a new nanny; refusing a new school or home; irritation and

obstinacy faced with separation of parents; crying and anxiety on the birth of a sibling…). Sensitization

causes aversion and fear of defecating in the toilet; aversion to the toilet causes the child ignore the

physiological signs and retain feces; fecal retention over several days leads to fecal impaction, pain,

abdominal distention, and behavioral changes which precede pain (irritability, refusal to eat meals,

increase in the number of toys when playing, decrease in the duration of play activities with increased

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Figura 1 – (A) Cycle of retention is initiated with the sensitization that begins aversion, fear and fecal

retention (B) behavioral habituation to the toilet reduces fear, the abdominal behavior of fecal retention

and pains eliminating the cycle of fecal retention.

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running, and apathy towards play). In the last stage of the retention cycle, following the administration

of laxatives, medication and a fiber-rich diet, the child may expel dry feces, owing to the retention

pattern, reporting pain, which leads to a restarting of the long-term sensitization cycle.

From this perspective, the retention cycle can be altered through the habituation process (Figure

1B). From a psychological point of view, habituation is defined as a reaction, of long or short duration,

characterized by a progressive reduction in the intensity of the behavior (e.g., crying, fecal retention and

refusal to use the toilet) as the individual is exposed to the stimulus that sparks off the behavior (e.g.

the toilet, foods which facilitate defecation). The habituation process is the opposite process to

sensitization, and is characterized as a reaction to a specific stimulus. Like sensitization, it has a self-

regulatory function, enabling the child to organize the information from the environment (Domjan,

1996).

According to Taubman (1997), toileting refusal can cause severe constipation, and if not

resolved, can lead to primary encopresis. The most commonly recommended procedure for treating

encopresis is cognitive and behavioral approaches, associated with medication. More recently, play

therapy has been used as an alternative way of treating children with encopresis, as it allows behavioral

and/or cognitive strategies to be integrated in play activities, seeking to evaluate and interfere in

situations which cause suffering to children and parents (Knell, 1995). This case study refers to the

medical care given to a child (named Lara) with retentive secondary encopresis. The objective of this

study is to investigate the factors related to the start and maintenance of the defecation pattern, to

analyze and clarify the process of habituation and sensitization during toilet training, and to carry out

behavioral intervention through an animated film.

2. Method

2.1. Participant

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Lara, aged 4 years and five months, was attended between September and October 2005. She

lived with her parents, one brother, and two nannies. Lara began school at the age of 1 year and 8

months. In the second half of 2004, her family moved to another house and, in this given period, Lara

moved to a different school. She has adapted well in both of the schools she has attended. Lara is

introverted, shy, jealous and loving with her parents, and shows difficulty in adapting to new

environments.

2.2. Assessment

The assessment lasted 11 days (from 19th Sept 05 to 30th Sept 05), and consisted of the

following stages: an interview with parents, a questionnaire on Lara’s daily activities, two play sessions

with Lara, two family play sessions in the presence of the parents and brother, contact with the two

nannies, a visit to Lara’s schools, a session with the parents to hand over the results. The use of

laxatives was suspended during the assessment, and mineral oil was used for 10 days. Given the

parent’s concern and request as to what attitude they should take, the therapist recommended that they

do not force their daughter to use the toilet, that they reduce the time on the toilet to 3 or 5 minutes,

and that they mark on a calendar the days when she defecated.

2.3. Case Conceptualization

Based on the data collected during the play sessions, an interview with the parents, an interview

with the nannies, analysis of questionnaires concerning her daily activities, observation at school, and an

interview with the school psychologist, the hypothesis was proposed that Lara was probably

consuming food which was hard to digest, which was making intervals between defecations longer than

24 hours, the feces were becoming dry, and when she defecated, she probably was probably straining

too much, with bleeding and pain. Successive events of painful defecation, along with the other effects

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of sensitization (crying, irritation, refusal to eat) probably led to the toileting refusal. From this

perspective, the refusal pattern was a way of avoiding pain. However, prolonged retention caused the

feces to become drier, requiring the use of medication (laxatives and suppositories), and making

defecation even more painful. Lara presented fecal retention with the following effects: mood changes

(during fecal retention, Lara was nervous or quiet, hiding behind the furniture), anatomic and

physiological changes (her abdomen was distended, and only reduced in size after defecation), social

behavior changes (after each critical accident, she was ashamed to show her dirty underwear to the

nanny), changes in eating behavior (Lara avoided eating fruits and other foods which contributed to fecal

elimination), and cognitive changes (Lara asked the nanny whether she felt pain when defecating, said

she found it painful, and that she did not want to pass a stool). This cognitive change suggests that Lara

was still seeking information in order to form a judgment or belief about her change in defecation pattern

and her ability to carry out toilet training on her own.

2.4 Course of Treatment

To achieve the goal of facilitating defecation and establishing toilet training, the parents were

advised to implement the following measures: 1) to change the family diet (introducing, for instance,

Japanese food: soy sauce, Japanese risotto prepared with “Gohan”, salads, and olive oil); 2) to observe

the behavioral indications of bowel functioning, and record the times of defecations; 3) to give Lara

personalized stickers with different designs (hello kitty, Ariel and Sponge Bob, ballet shoes, hearts and

flowers) after toilet training, according to the following rule: if Lara tried to defecate, she would be given

a little sticker; if she managed to do it, she would be given a big one. The aim was to maximize the

number of stickers she earned, to encourage her toilet train. During the first week, toilet training should

begin with 3 or 4 minutes on the toilet, teaching her the right sitting posture; 4) if she did not manage to

defecate in the toilet, she should be told by the family members that it was ok, that it was only an

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attempt, and that she was learning to use the toilet; 5) in the second week, they should take her to the

toilet at the most favorable time to defecate, and keep marking the frog-shaped calendar on the days she

defecated in the toilet. A play intervention session was proposed, to the parents, to take place at the

clinic, using and animated film produced especially for Lara. The hypothesis was that the use of the

animated film would establish: 1) vicarious learning of information on toilet training, and encouragement

to carry out toilet training on a daily basis; 2) behavioral habituation to daily toilet training, as watching

animated films was a regular habit for Lara, and generally not associated with contexts of emotional

tension.

The use of films in psychotherapy contexts is based on Bandura’s study of observational or

vicarious learning through role models (Thellen, Fry, Fehrenbach and Frautschi, 1979). Within this

perspective, vicarious learning is a result of three processes: 1) observation of a role model, whether live

or through some other media (film, TV, comics, hypermedia resources on the Internet…), 2) vicarious

reinforcement or punishment; and 3) cognitive mediation (mental representation). After vicarious

learning, the learner may, immediately or after some time, perform the action that he or she observed.

Thus, after Lara has watched the characters in the animated film carry out toilet training and receive

stickers, it is expected that Lara would be vicariously reinforced, and a link established between the

behavior of the characters in the film (toilet training) and the reinforcement obtained (stickers).

After an attempt at toilet training encouraged by the parents, a play session took place, during

which the animated film “A doll’s day” was shown (Figure 2). The intervention session took place on

October 5th 2005, and lasted 1 hour and 20 minutes. The animated film was used to present, within a

context of play, both daily activities belonging to the children's world (playing house, using dolls, and

daily activities) and toilet training, which Lara’s parents tried to implement with her (focusing on the

attempt to defecate, use of stickers, and the suggest diet for Lara). With live narration from the

therapist, the film presented the daily routine of two dolls (Kelly® and Amanda) performing the

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Figura 2 – Frames of the animation Film "doll`s day"

following activities: one character wakes up, walks towards Amanda’s bed, and wakes her up; then

they both have breakfast, and use the toilet, where Kelly® teaches Amanda which toilet to use, and

how to mark the sticker on the calendar. next, the two dolls play hide and seek, and finally, they watch

TV. The session was filmed with a Sony DCR TRV-140 digital camera. After explaining to Lara that

she would watch a film with dolls that she knew, the 4’02’’ minute film was played, on a 12-inch

screen of an Apple notebook (http://www.homepage.mac.com/lauragcoelho/filme). The computer was

placed on a table adjusted to Lara’s height, with the dolls and furniture and setting used in the film

placed next to it.

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Before playing the film, the therapist established verbal interaction, telling Lara that a film

would be played, praising her performance in the drawing task that she was doing, and investigating

characteristics of the drawing (“is this blue here the sky?”). During the verbal interaction, Lara told the

therapist about what she was doing (“I wrote my name here”) and asked about the material used in that

task (“where’s the paintbrush?”). Lara agreed to watch the film. The therapist played the film and gave

the following live narration:

_ (Kelly®): oh, I’m waking up… the clock… I’m so lazy… but I have to get up. Oh, I’d like to stay in

bed longer, I have to have breakfast, I have lots things to do… I think… I think Amanda is still asleep.

Look, her feet are sticking up, it’s very dark in there, I can hardly see a thing. Ah I’ll turn around, ah

now I’m awake! (I’ll have a look at Amanda). AMANDA! AMANDA! ...hello, I’ll turn you around!

Let me see here from my window... Ha! You are already up ? Ah let’s have breakfast! Do you need any

help?

_ (Amanda): it’s not necessary…

_(Kelly®): look at our table, let’s eat breakfast. I’d like… there’s cake, pie, look… there’s risotto (Lara

looks at the paintbrush and the paper and looks at the screen again; dips the paintbrush into the paint),

- now I’ll go there, I’ll wash my hands, no, I’ll go to the toilet now, you can’t use the big one, you must

use this little one here. (large toilet, small toilet).

_(Amanda): But I need to go!

_(Kelly®): Now I’m going...

_ (Amanda): I want to clean myself too!

_(Kelly®): Look, I’ll put a little star here because you tried and me too. Let’s wash our hands, you

too; look! Great! What shall we do now?

Lara interrupted the narration when the two dolls began playing hide and seek. She said they

used calendars, and when they passed a stool they were given stickers. The therapist asked (Do you

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have three stickers?), and interpreted Lara’s action (“Good idea! I’ll give this idea to Kelly® too!”), and

tried to persuade her (“so, when you poo, do a big one! You’ll see, now you’ll do it every day! It’s

easy now!”) as in the following extract of the conversation:

- (Lara): I have (stickers)… when I do it, I have three stickers

_ (therapist): really?! Do you have three?!

_ (Lara): Yeap!

_ (therapist): so, you’ve got lots of stickers too!

_ (Lara): yeah, when I do a poo, they give me a big one.

_ (therapist): That’s great, Lara! she too! good Idea! I’ll give this Idea to Kelly® too… so, when you do

a poo, do a big one! You’ll see, now you’ll do it every day! It’ll be easy! Lara, do you want to put your

voice in this story? (Lara nods), So, I’ll play the story from the beginning, here’s the microphone, you

can start when you like!

Lara asked to watch the film twice. The film was played again without narration, and Lara

watched it while she was drawing. After watching the film, Lara decided, spontaneously, that the

following activity would be to play toilet training with the dolls and the setting used in the film. Three

toilet training play activities were carried out totaling 13 minutes. The first toilet training game lasted 5

minutes. The play began when Lara said that it was time for one of the dolls to pee or poo, and finished

when the doll used the toilet and placed the sticker on the calendar. During the game, Lara said that she

had various stickers, and that her mother placed a big sticker on the calendar each time she used the

toilet. Lara recognized that the doll’s calendar, with the picture of a frog on it, was similar to hers. The

therapist and Lara played with the dolls, offering them feeding-bottles and putting them on the toilet.

The therapist encouraged the doll, emphasizing that she should try. Lara encouraged the doll to make an

effort, as in the following extract of the conversation:

_ (Lara): it’s time for the little doll to pee.

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_ (therapist): Is it time? So, can I take her? I didn’t remember it was time. I’ll get the feeding-bottle, I

guess she really wants to go!

_ (Lara): Why?

_ (therapist): Because her panties are already down, she was already taking them off.

_ (Lara): I don’t want… if she tries she doesn’t want…

_ (therapist): she can try, I think she wants to, and she really feels like trying.

_ (Lara): I have one of these…

_ (therapist): Do you? Do you want to feed her, or shall I? You tell me.

_ (Lara): You.

_ (therapist): shall I!? ok then, our Kelly®! ....I’m thirsty. (the therapist prepares the toilet and the

feeding-bottle, and places the doll on the toilet) – it’s time to go to the toilet.

-(therapist, imitating Kelly®'s voice): - Ok.

_ (therapist): I guess she really needs to pee.

_ (therapist, imitating Kelly®'s voice): I do...

_ (Lara): every day she is holding it in, every day she…

_ (therapist): every day she tries, she can’t hold it, we should let the pee come out, and the poo as well.

_ (therapist, imitating Kelly®'s voice): ok, I’ll add a really big sticker to my calendar.

_ (therapist): That’s right! A really big sticker. Ah, Kelly®, I already know, it’s going to be Sponge

Bob.

_ (Lara): No, in my house my mother… the day when she “does”, its… my mother puts it on for me…

(smiling)

_ (therapist, putting Kelly® on the toilet): Ah! That’s great!

_ (Lara): Try hard…

_ (therapist): Thank you very much, Lara! See, Kelly®? Just a little effort.

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The second toilet training game lasted 3 minutes. The therapist and Lara played at choosing

stickers, and placed one of the dolls on the toilet. Lara smiled, encouraging the doll to make an effort

(“she’s going to do a poo so that I can put another sticker”). She explored the doll’s setting, wrote

down their names, and said that the doll would try again, humming a song. The game ended when the

therapist said that if the doll tried again, they would give her other kinds of stickers.

The third toilet training game lasted 5 minutes, and began when Lara said:

_ (Lara): She wants to try!

_ (therapist) : She wants to try again!

_ (Lara): I guess it’s time!

_ (therapist): It’s time to try… so, let’s put her there again.

Lara suggested that the dolls defecate while watching TV. While Lara was doing the toilet

training activities, she told the therapist about her activities at school and began drawing. Lara gave a

very detailed description of the activities, as in the following extract of the conversation:

_ (Lara): Open your legs (she opens the doll’s legs on the toilet).

_ (therapist): Open your legs… I guess that’s enough, I’ll take her panties off, ok?

_ (Lara): You do a poo there, and I’ll…

_ (therapist, humming): I’ll make my tree … Kelly®, all right?

_ (therapist, imitating Kelly®): All right…

_ (therapist): great, very good…

_ (Lara): Try hard, Kelly® ...

_ (therapist): Listen to what Lara tells you, she’s trying to help you, just a little effort…

_ (Lara): Just a little…

After this third toilet game, Lara went to the toilet and defecated without the therapist’s

assistance. Her mother came into the room, at Lara’s request, praised her daughter and watched the film.

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2.5 Follow-up

After defecating during the play session while watching the film (October 5th), Lara defecated on

a daily basis from October 2005 and September 2006, without any toileting refusal, using the school

toilet, and eating various types of foods, as suggested in the assessment, as well as plums in the

morning and evening. The use of mineral oil was suspended the day after the film session. In October

2005, Lara had three critical accidents with a pattern of diarrhea (she twice defecated in her underwear,

on October 13th, after using the school toilet, and once at home, on October 16th). These critical

accidents probably occurred because Lara was returning to the daily defecation pattern, as a

consequence of the diet change (eating plums, for instance), and the behavioral habituation. There were

no more critical accidents after reducing the consumption of plums. The use of calendars and stickers

was suspended in December 2005. From December/2006 to April/2007, despite having normal bowel

functioning and despite her parent’s encouragement to use the toilet and eat appropriately, Lara

sometimes presented 48-hour intervals between defecations.

2.6 Discussion

Lara’s pattern of fecal retention is described by the following retention cycle: beginning with

sensitization, i.e., painful defecation, in June and July 2005, generating aversion and fear of using the

toilet (Lara reported pain on defecation; her aversion to the toilet caused her to ignore the physiological

signs and retain the feces); she had fecal retention for several days, causing fecal impaction, pain,

abdominal distension and behavioral changes which precede pain (irritability, refusal to eat, and apathy

towards play). In the last phase of the retention cycle, after the use of laxatives, without a diet rich in

fibers, Lara expelled dry feces and reported pain.

Lara had already learnt how to use the toilet, but only know a defecation situation without pain.

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She was beginning to learn something new: that defecation can sometimes be associated with pain and

discomfort. The interview with her nanny showed that, in Lara’s view, defecation took on a new

meaning. It had become associated with pain. It also showed that she had not yet formed a clearly

defined judgment or belief about this new learning, and she was still gathering information about it in

order to form a judgment (for example, the belief that she is not capable and/or that in her particular

case, defecation is difficult and painful). The self-efficacy belief or judgment would be a by-product or a

subsequent phase of this search for information from four main sources: relevant role models for Lara

(the nanny, friends at school), emotional and somatic conditions (such as pain and discomfort), success

or failure in the toilet training tasks, and information from the attempts at verbal persuasion by parents

and relatives. The use of animated films and live play with the dolls from the film might have generated

a context in which the four sources of information were present: role models (Lara’s favorite dolls),

hints on the somatic conditions of the role model (painless defecation), verbal persuasion in the

interaction between the dolls, and successful toilet training.

The hypothesis that explains the changes observed in Lara’s defecation pattern is that the

animated film produced habituation effects, i.e., progressively decreasing her toileting refusal as she was

exposed, with each repetition of the film, to the specific context of using the toilet. As the process of

habituation is the opposite to sensitization, the film may have enabled exposure to the context of using

the toilet, without intensifying the sensitization effects. The habituation effect proposed by the film

comes from the use of music, movement, the narrative, dolls, furniture, and the activities presented in

the film (hide and seek game, use of stickers and calendars), which were all familiar to Lara. These

components are incompatible with the emotional triggering of anxiety and apprehensiveness during real

toilet training, when there is the possibility of pain or failure to defecate. The habituation brought by

the film should reduce toileting refusal, fecal retention and subsequent behavioral reactions (irritability,

apathy and refusal to eat) which are part of the retention cycle.

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Besides bringing habituation effects, watching the film appears to have results in the learning of

certain relations. For example, the relation between using the toilet and filling in the calendar with

stickers, and between using the toilet and the hide and seek game, which may have been learnt through

watching the dolls in the animated film. This learning can be inferred by the three games played by Lara

soon afterwards, with the dolls, in which she simulated using the toilet, followed by marking the

calendar with stickers or by a leisure activity (e.g., watching TV, as shown in the film). While Lara’s

parents had done the toilet training at home, using big and small stickers after she tried to defecate, the

film presents two characters who are successful in the task and receive stickers for good performance.

Learning, through observation, about use of the toilet / filling in the calendar and using the toilet /

playing hide and seek, offered by the film, appears to have occurred the very first time she watched the

film, because in the two repetitions of the film, she paid attention to details which bore little relation to

using the toilet (e.g., Lara looked at the screen, in particular, when there was background music).

Vicarious learning was possible because: 1) the dolls in the film became role models for Lara (the

dolls were chosen as role models after observing Lara’s play activities and after an interview with the

nanny), 2) Lara received vicarious reinforcement by watching the role models being given stickers after

defecating and 3) the three play activities carried out after the film worked as mediators for the

defecation in the office toilet (play mediation) enabling manifest practice of the toilet training sequences.

In vicarious learning theory, role models are symbols (people or characters) whose actions the observer

considers important. According to Bandura (1971), when the observer is affected by the positive or

negative consequences of the actions of the role model, we say they have received vicarious

reinforcement. For example, the consequences of playing hide and seek and using stickers obtained by

the role models in the film, could have made Lara expect that both the she and the models would achieve

the same result in a game, and the next time the film was played, respectively. Besides encouraging her

to use the toilet, the vicarious reinforcement obtained by Lara when watching the role model’s behavior

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in the film may have given her information about the task (e.g., the notions that using the toilet is one of

the role model’s behaviors which should be followed by the observer, and that the model talks about

using the toilet with other people) and specified the behavior she should have in order to achieve

success (e.g., the observer must try and expel feces).

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