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Vicarious learning from toilet training through animated film: case study of behavioral play
therapy.
Author: Laura dos Santos Gomes Coelho
e-mail: [email protected]
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.
15
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
16
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).
REFERENCES
Bandura, A. (1971) Psychological Modeling: Conflicting Theories. Chicago: Aldine-Atherton.
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