Teaching Personal Care Skills and Independent Adaptive Functioning

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Teaching Personal Care Skills and Independent
Adaptive Functioning

• Linda A. LeBlanc
• Western Michigan University
• linda.leblanc_at_wmich.edu

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Successful Acquisition of Self Care Skills

• Enhance progress on long-term goals of functional
  independence and effective community living
• Remove barriers to future placements
• Enhance long term quality of life for students
  and their families
• Allow greater privacy
• Decreases risk of victimization (toileting
  skills)

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Barriers to targeting these in schools

• Each problem crosses home/school settings
• Intervention in just one setting probably wont
  solve the problem
• Need coordination between home and school
• These problems dont fall under the specific
  domain of any school professional
• No one has specific ownership of these targets
• Requires knowledge, willingness, preparation and
  persistence and no one may have the expertise
• Other issues are plentiful and fall more easily
  into the traditional academic model

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Todays Structure

• Background information
• Empirical support for intervention strategies
• Specific how-to for each strategy with examples
• Brainstorming and problem-solving with anonymous
  individual cases

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Teaching Strategies

• Intensive Toilet Training
• Chaining
• Picture Activity Schedules
• Video Modeling

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Toilet Training An Important Developmental
Milestone

• Typically developing children are usually toilet
  trained between 24 and 36 months.
• Individuals with autism may remain incontinent
  through adulthood.
• Negative impact of incontinence
• Reduced social interactions, limited academic
  opportunities, and less opportunities in the
  community for the child.
• For parents, incontinence often results in
  financial burden, social stigma, and
  embarrassment.

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Azrin and Foxx (1971, 1973)

• Targeted daytime and nighttime urinary
  incontinence in adults with developmental
  disabilities
• 80 reduction in accidents by all participants
  within 12 days
• Implemented the intensive behavioral program to
  34 typically-developing children
• 100 of participants became continent
• Mean length of training trials 4 hours
• Results maintained through 4 month follow-up

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Research Support

• Five studies have used a version of the Azrin
  Foxx procedure with children with disabilities
• Luiselli, Reisman, Helfen, Pemberton (1979)
• Smith (1979)
• Hagopian, Fisher, Piazza, Wierzbicki (1993)
• Taylor, Cipani, Clardy (1994)
• Didden, Sikkema, Bosman, Duker, Curfs (2001)
• All demonstrated success but none use
  parent/teachers as primary agents of change
• Only 2 participants with autism across all five
  studies

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WMU Center for AutismToilet Training Protocol

• Over the last 5 years at WMU we have worked with
  over 25 families on toilet training using an
  intensive outpatient model
• Target daytime urine incontinence
• Generally had tried lots of interventions with
  little success
• Hourly sits, positive reinforcement
• Common problem is that the interventions are
• not intensive enough with few and spread out
  learning opportunities
• do not target both parts of the problem where
  to go and where not to go

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Treatment Components Sitting Schedule

• Intensive sitting schedule
• Consequences for successful urination
• Fluid loading
• Drink as much as possible early in day until
  about 1-2 p.m.
• Communication training (child-specific)
• Urine alarm and underwear (no diapers)
• Positive practice

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Treatment ComponentsSitting Schedule

• Increased chance of success
• Probability of success early on is or less than
  probability of being on toilet
• Minimize aversiveness and boredom of being on
  toilet
• Can reinforce sitting quietly on toilet
• Do not allow escape
• Video or music access
• Make sure comfortable while sitting

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Treatment ComponentsSitting Schedule

• Day 1
• 10 min on, 5 min off
• 10 min on, 10 min off
• 5 min on, 15 min off
• 5 min on, 25 min off
• 5 min on, 35 min off
• 5 min on, 45 min off

• Day 2 to end
• 5 min on, 1 hour off
• 5 min on, 1 ½ hrs off
• 5 min on, 2 hrs off
• 5 min on, 2 ½ hrs off
• 5 min on, 3 hrs off
• 5 min on, 4 hrs off
• Sitting schedule removed

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Treatment Components Powerful Consequences

• Positive Reinforcement for Success
• Food, Drink, Tangibles/Activities
• Provide most powerful potential reinforcers
  immediately for success
• Preference Assessment
• Negative Reinforcement for Success
• Get off the toilet as soon as you urinate
• Critical for some children we minimize it early
  in the protocol and then it becomes more
  important

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Treatment Components Communication Training

• Select Mode based on child and listener community
• Speech, PECS, sign
• Must always have access to communication response
• Conduct a training trial every time you do a
  scheduled sit
• Praise for communication
• Eventually this is the only way the child will
  get to go to the bathroom because all scheduled
  sits will be eliminated
• ABSOLUTELY CRITICAL FOR SUCCESS

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Treatment Component Urine Alarm

• Palco Wet Stop
• We have had best success with this model
• Sew pouch into underwear
• Pin Velcro holder to shirt
• 6-10 pairs of underwear needed

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Treatment Components Positive Practice

• Practice appropriate behavior 5 times
• Run to toilet
• Pull down pants
• Sit on toilet
• allow 1 min to finish on first sit
• if completed in toilet, practice is over
• Stand up
• Pull up pants
• Run back to site of accident
• Repeat series four more times
• No smiles, joking, or fun

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TreatmentDay 1 at Clinic

• Friday 9am to 4pm
• Toilet training and parent training
• All components in place
• Procedures implemented by staff in the morning
  and by parents in the afternoon
• Sitting schedule thinned throughout day
• Child moved up one level each hour
• No diapers during waking hours

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Days 2 3 (weekend)at Home

• Conducted by parents in the home
• Phone consultation and 2 hour visit by staff if
  needed
• No fluid loading
• Schedule progression based on ½ day success

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Treatment Day 4 through Follow-up

• Conducted in the home and school by parents and
  trained school staff
• Urine alarm removed after two days at 100
  continence with at least one initiation
• Sitting schedule progressed based on ½ day with
  success
• Final step in progression is no scheduled sits
• Can lose progress and initiations if you put a
  schedule back in place

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Outcomes of a recent study

• Average percent success during baseline 12.6
• Average percent success during treatment 89.2
• Average percent success during one month
  follow-up 97.3
• Average length of treatment 16 days
• Average instances of positive practices 10

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Outcomes contd

• Nighttime continence often occurs spontaneously
  within 4-6 months of achieving daytime dryness
• Reinforce it if it occurs
• Target it using
• alarm at night
• fluid restriction after 6 pm
• scheduled sit immediately prior to nighttime
• night waking if necessary
• Bowel continence often occurs spontaneously as
  well

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Bowel Training

• Constipation is a common problem for children
  with autism due to
• Food selectivity
• Limited fluid intake
• Sensory issues and holding
• Constipation accounts for 80 of cases of
  encopresis
• Work with physician to manage regimen and
  increase dietary compliance
• Stool softeners may decrease sensory issues
• Treat until child is defecating every day or
  every other day DO NOT OVER TREAT

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Bowel Training

• Track time of defecation
• Most show a pattern
• Schedule a sit 30 minutes prior to average time
  of defecation
• Make sure feet reach flat surface for better
  pushing
• Prompt to go to toilet at physical signs of
  defecation
• Reinforce success with special rewards and praise
• Clean pants check every hour reward clean pants
• Responsibility Training child helps to clean up
  any created mess

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A Special Case

• Urine continent but requests diaper and will only
  defecate in the diaper
• Attempt to determine if the child prefers
• Standing to defecate
• The feel of the diaper
• Stimulus Fading
• Fade stand to sit
• Fade away the diaper

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Independence in Other Self Care and Adaptive
Skills

• Wiping
• Brushing Teeth
• Brushing Hair
• Showering
• Dressing

• Making a snack
• Doing the laundry
• Washing dishes
• Setting the table
• Getting bag ready for school

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Chaining

• Chaining is a very useful basic teaching
  procedure that you can use for these kinds of
  skills
• Chain
• Multi-step actions where all steps have to occur
  in right sequence to get it right

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Importance of a chain

• Each completed step serves as a cue for the next
  relevant action
• If the chain is interrupted you may lose some
  steps in the sequence
• Examples of Chains
• tying shoes, making a sandwich, starting a car
• long division, playing a musical scale
• Before a chain is taught you have to identify
  every step using a TASK ANALYSIS

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Task Analysis

• Task Analysis list of all behaviors, natural
  cues, and instructions in the chain
• Observer someone perform the task well
• Consult an expert
• Perform the task yourself
• 3 Chaining Methods
• Backward Chaining
• Forward Chaining
• Total Task Presentation

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Teaching a step in the chain

• Present initial instruction (e.g., Put on your
  gloves.)
• Present the steps instruction (e.g., Insert
  hands.)
• Use prompts if needed
• Use reinforcement for correct responses as needed
• Fade prompts
• When behavior occurs without prompts, move to the
  next step

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Linking Steps Together Backward Chaining

• All steps are completed for the client, except
  for the last, then second to last, etc.
• 1-2-3-4-5 (therapist) 6 (client) mastery
• 1-2-3-4 (therapist) 5-6 (client) mastery
• 1-2-3 (therapist) 4-5-6 (client) mastery, etc.
• Use when there is a natural reinforcer at the end
  of the chain
• Use when task termination is a reinforcer

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• Put on your coat ? XXX zips up his coat from ½
  way ? Good job! Go play outside
• Put on your coat ? XXX hooks the zipper. ? He
  zips up his coat ? Good job! Go play outside
• Put on your coat ? XXX puts arms through
  sleeves.? He hooks the zipper. ? He zips up his
  coat ? Good job! Go play outside

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Advantages of Backward Chaining

• Minimizes endurance and motivation problems
  associated with long chains
• Completing the chain may often produce a natural
  reinforcer (ex., going outside).
• Student will get to contact the reinforcers
  quickly

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Forward Chaining

• Teach the steps in a forward manner, 1 at a time
• 1 (reinforcer) mastery
• 1-2 (reinforcer) mastery
• 1-2-3 (reinforcer) mastery, etc.
• Use when the client can perform each of the steps
• Use when the initial steps are easiest

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Supplemental Strategies for Chaining

• Written Lists
• Useful for literate clients (even those who dont
  speak) if there are many steps to remember
• Picture prompts
• Useful for non-literate clients (event those who
  dont speak) if there are many steps to remember
• Self-instructions
• Useful for clients with extensive vocal
  repertoires
• Often want them to start a chain by presenting
  the relevant Sd to themselves

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Why use activity schedules?

• To increase behavior that has been learned but is
  not occurring independently
• To reduce problem behavior during transitions
• To teach new sequences of behavior

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Activity Schedules

• Popular in schools for transition issues
• Preset order of activities
• Visual stimulus cues each activity
• Child becomes progressively more independent in
  use of schedule
• Initially developed to sequence complex chains of
  behaviors
• Recipe use
• Steps in assembly tasks
• Clerical and laundry tasks

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Prerequisite Skills

• Ability to discriminate pictures from backgrounds
• Identity matching with 3D objects
• Identity matching with picture to object
• Tolerance of manual guidance
• Ability to manipulate materials

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Self-management with PAS(P S, 1994)

• 3 boys with autism
• 3 tasks for each child
• Setting Table, Laundry, Making Lunch, Making Bed,
  Making a Drink
• Baseline Told Child to Do task
• PAS
• 3 ring binder
• Picture on each page
• Picture of Reinforcer at the end

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Self-management with PAS(P S, 1994)

• Training
• 1- Pic Discrimination,
• 2- Select SR, turn pages, perform actions, self
  reinforce,
• 3- fading therapist (time of absence or
  proximity)
• Post-treatment No book
• 2-month Follow-up Book and no-book

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Self-management (P S, 1994)

• All children learned all 3 tasks, generally task
  learning time decreased across tasks
• Effects with no book were slightly mixed but
  performance was better for 2 of 3 tasks by
  follow up
• Advantages and Disadvantages to dependence on
  books?

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Incorporating Technology

• Rehfeldt et al (2004)
• Illustrates how to use powerpoint and videoclips
  to create electronic activity schedule
• Allows unique incorporation of video modeling
  with other PC technology
• Can be simple or complex
• Insert sound clips
• Insert video clips
• Insert pictures
• Insert timers with alarm

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Recommendations for Pictures

• Identify the critical element
• Objects
• Actions/interactions
• Create a picture that replicates what the student
  sees
• Eliminate distracting aspects of environment
• Zoom in close enough to clearly see element
• Consider clip art as an alternative
• Shoot close up and eliminate the background
• Take generic photos that could be used for
  multiple children when possible

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• Power point based
• Picture Activity Schedule

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Video-Modeling

• Presentation of a video segment of a person
  accurately performing the desired task
• Has been used to teach
• Self-help skills
• Language
• Social Skills (e.g., play, perspective taking)
• Academic skills

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Video-Modeling

• Potential advantages of video modeling (LeBlanc,
  et al, 2003 Sherer et al, 1999)
• Engaging medium means better attending
• Capitalizes on visual learning strengths
• Allows focus/highlight of relevant stimulus
  features
• Learning occurs without social demands
• Cost-efficiency videos can be repeated

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Recommendations for VM

• Make sure your video perspective is accurate
• Use a model that is competent and similar to your
  learner if possible
• Same age peer with great skills who is
  cooperative
• Try to film the video in the real context
• Show the video immediately prior to attempting
  the task
• As child gets better at the task you can increase
  time between watching the video and doing the task