Families of children and adults with severe and profound intellectual and developmental disabilities know something the system keeps ignoring: it costs a lot of money not to teach toileting. And yet, across the country, Medicaid and state disability agencies continue to pay for diapers, pull‑ups, gloves, wipes, laundry, and the staffing required to change individuals — often for decades — instead of investing in the evidence‑based teaching that actually works.
This isn’t just inefficient. It’s irrational.
The economics are simple
When toileting is not taught, Medicaid pays for continence supplies year after year. Group homes and day programs need additional staffing to manage frequent changes. Laundry loads multiply. Behavioral incidents increase. Infection risks rise. Every diaper change requires time, labor, and supervision.
Multiply that by 365 days a year. Multiply again by 30–50 years of life. Multiply again by thousands of individuals.
The cost is staggering.
The solution is not new
The Azrin & Foxx method — Rapid Toilet Training — has existed for decades. It is structured, behavioral, and highly effective, even for individuals with severe and profound IDD. It requires trained staff, consistency, and a few days of focused work. When implemented correctly, it dramatically reduces long‑term dependence on diapers and the staffing required to manage them.
It is also worth remembering where the method began. Azrin and Foxx’s original 1971 study was not designed for typically developing toddlers; it focused on nine profoundly disabled adults living in an institutional ward, where incontinence was treated as a routine condition of care rather than a skill that could be taught. With intensive, structured training over a median of four days, they reported an immediate reduction in incontinence of about 90 percent, eventually approaching near-zero levels. That history matters: the method now used with both disabled and neurotypical children was first demonstrated with adults who had already been written off by the system.
In other words: a short‑term investment produces lifelong savings.
So why isn’t it being taught?
Because the system seems to have quietly abandoned functional skill‑building.
Schools no longer appear to teach toileting. ABA providers rarely teach ADLs. DDS group homes lack training, staffing, and clinical oversight. Medicaid reimburses for supplies and supervision — but not outcomes. And providers are financially rewarded for dependence, not independence.
The result is predictable: individuals reach adulthood without basic self‑care skills, even though the methods to teach those skills have existed for half a century.
Families see the truth
Teaching toileting is humane. Teaching toileting is dignifying. Teaching toileting is cost‑effective. Teaching toileting is evidence‑based. Teaching toileting is possible.
The real question is why our systems refuse to do it.
Until Medicaid and state disability agencies stop paying for lifelong dependence and start requiring functional skill‑building, we will continue spending enormous sums of money on diapers and staffing — while denying individuals the independence they could have achieved.
It’s time to bring back what works.
Sources:
[1] A RAPID METHOD OF TOILET TRAINING THE INSTITUTIONALIZED RETARDED
[1] OF (SUMMER 1971) – ResearchGate
[1] 1D£R 2 (SUMMER 1971) A RAPID METHOD OF TOILET TRAINING – Nathan Azrin