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Self-Help Skills
It is not uncommon for individuals with developmental delays to be behind in their acquisition of basic self-help skills. Nor is it unusual for them to require considerable assistance and effort from their parents and other adults to accomplish even basic tasks such as dressing and toileting. Nonetheless, with patient, systematic instruction, many students with developmental delays learn quite intricate self-help skills. Once the student becomes more self-sufficient, she will be happier with herself and easier to care for. Also by learning to become self-sufficient, the student will be more likely to enter a less restrictive placement in school and the community. For instance, students who are toilet trained are more likely to be accepted for enrolment in mainstream classes than students who do not know how to use the toilet.
This chapter presents programs for teaching the student to eat with a spoon, expand her diet, eat when requested, dress and undress, brush hair, brush teeth, wash hands, and use the toilet. Obviously, the skills discussed in this chapter do not encompass all those the student needs to know; however, a sufficient number of teaching principles are illustrated to allow for adequate generalization of these principles when constructing additional programs. The programs presented in this chapter are examples of programs presented in more detail by other investigators. Research into the area of helping individuals with developmental delays acquire self-help skills has been active over the past 30 years. Relevant materials are included among the References at the end of this manual.
Other programs presented in this manual should not be taught at the expense of teaching self-help skills. In one's attempt to comprehensively normalize the student's behaviours, the teaching of self-help skills is critical. Plan on completing most or all of the programs presented in this chapter in approximately 2 years. However, do not attempt to teach too many skills at one time; select a single skill and, before going on to the next skill, work regularly with the student until she makes significant progress with the target skill. Such a procedure helps to maintain the teacher's motivation and build the student's self-esteem.
Teaching many of the skills described in this chapter requires use of the shaping and chaining procedures described in Chapter 10. That is, several self-help skills are taught by reinforcing approximations of the target response, breaking down various complex behaviours into smaller elements, or both. As the individual elements of a particular self-help skill are learned, the teacher gradually combines these elements into a chain of behaviours occasioned by a general verbal instruction.
Most of the skills or skill elements are prompted physically (i.e., by manually guiding the student through the desired motions) or by modelling (i.e., demonstrating the behaviours). If the student is able to imitate the adult, modelling prompts rather than more intrusive physical prompts should be used. If the student needs prompting so as to follow a particular verbal instruction, the student gives evidence that she does not understand the teacher's instruction. Over time, however, the student will acquire some receptive language simultaneously with self-help skills through the combination of verbal instructions and prompts.
The program to teach feeding may be started after the student masters the first steps in nonverbal imitation using objects. Other more complex skills, such as brushing hair, dressing, hand washing, tooth brushing, and toileting, are best begun after the student masters the Nonverbal Imitation Program (Chapter 13) and are able to follow several verbal instructions.
Eating with a Spoon
Eating with a spoon is typically taught first because spoons are easier to manipulate than other eating utensils. Because eating is a complex behaviour, it should be broken down into several small discrete steps. A backward chaining technique is recommended to teach eating with a spoon.
To begin, select a spoon the student can easily manipulate. If the student's hands are too little for a typical adult spoon, try a child-sized spoon. The student will learn to independently feed himself more quickly if he does not have to struggle with holding a spoon that is awkward for him to manipulate. Use soft foods, such as applesauce, oatmeal, mashed potatoes, or yogurt. Soft foods are easier to put on a spoon and tend to be more reinforcing than dry cereal or small bites of meat or vegetables. The foods used should be ones the student prefers and should be placed in a bowl, making it easier for the student to secure the food onto the spoon.
Backward Chaining the Steps Together
The target behaviour is for the student to pick up a spoon placed next to a bowl of food, put the spoon in the food, move the spoon with food on it to his mouth, eat the food, and place the spoon back on the table. To teach the target behaviour using backward chaining, break down the behaviour into the following discrete steps:
► Steps 1-2
Place the spoon with food on it in the student's mouth after giving the general instruction 'Eat.' Using a manual prompt, help the student take the spoon out of his mouth and place it on the table. Provide the student with verbal reinforcement. By placing the spoon on the table, each trial is kept discrete from other trials. In addition, placing the spoon on the table helps the student learn to pause between bites. Gradually fade the physical prompt over subsequent trials. After the physical prompt is faded, give the general instruction 'Eat' again and hand the student the spoon (with food on it). Manually prompt the student to grip the spoon and place it in his mouth. Reinforce the student by letting him eat the food on the spoon. Have the student complete the chain by placing the spoon back on the table. After the student successfully places the spoon in his mouth and then removes it and puts it on the table with assistance in four to five trials, fade the prompts and reinforcement for placing the spoon in his mouth. Provide reinforcement contingent on the completion of both responses. Once Steps 1 and 2 are mastered (5 out of 5 or 9 out of 10 unprompted correct responses), go on to Step 3.
Step 3
Hand the student the spoon (with food on it), give the general instruction 'Eat,' and manually prompt the student to lift the spoon from an empty bowl. Reinforce the response. If fading of prompts was successful in Steps 1 and 2, the student should complete the chain of behaviours. Verbally reinforce the student after he places the spoon on the table. After the student successfully completes the entire sequence of behaviours, fade the prompts and reinforcement for the behaviour of lifting the spoon from the bowl. Continue to fade the prompts and reinforcement from this behaviour until the student completes the entire chain following presentation of the general instruction 'Eat.' Once Step 3 is mastered (5 out of 5 or 9 out of 10 unprompted correct responses), go on to Step 4.
Step 4
Place the spoon under a portion of food in the bowl and give the general instruction 'Eat.' Manually prompt the student to lift the spoon from the bowl, keeping only a small portion of the food on it. (Soft, sticky foods such as pudding or yogurt are much easier than other foods for the student to keep on the spoon.) Reward the student for picking up the spoonful of food and placing it into his mouth by letting him eat the food and by providing verbal reinforcement. If the fading of prompts was successful in previous steps, the student should place the spoon in his mouth and then remove it and place it on the table. Verbally reinforce the student after he places the spoon on the table. Provide any necessary prompts to complete this chain of behaviours. After the student successfully lifts the spoon from the bowl, eats the food, and places the spoon on the table for a few trials, fade the prompts and verbal reinforcement for lifting the spoon. Continue to fade the prompts and verbal reinforcement for this behaviour until the student completes the entire chain following presentation of the general instruction 'Eat.' Once Step 4 is mastered (5 out of 5 or 9 out of 10 unprompted correct responses), go on to Step 5.
► Step 5
Hand the student the spoon and give the general instruction, 'Eat.' Manually prompt the student to move the spoon to the bowl. Provide social reinforcement for moving the spoon toward the bowl. The student should then complete the remainder of the chain without assistance. If the student does not complete the chain, provide the least amount of prompt necessary to reinstate correct responding. Verbally reinforce the student after he places the spoon on the table. After the student successfully completes the sequence of behaviours, starting with moving the spoon to the bowl, fade the prompts and verbal reinforcement for the behaviour of moving the spoon to the bowl. Continue to fade the prompts and verbal reinforcement provided for this behaviour until the student completes the entire chain following presentation of the general instruction 'Eat.' Once the student reaches criterion, go on to Step 6.
► Step 6
Place the spoon next to the bowl and give the general instruction 'Eat.' Manually prompt the student to pick up the spoon and then provide social reinforcement for his performance of the behaviour. The student should then complete the remainder of the chain without assistance. When the student successfully completes the sequence of behaviours, fade the prompts and verbal reinforcement for the behaviour of picking up the spoon. Remember to provide verbal reinforcement contingent on completion of the entire chain, starting with picking up the spoon following presentation of the general instruction 'Eat.'
After the student masters Steps 1 through 6, you may want to prompt and reinforce him for pausing between bites without having to put the spoon on table each time he finishes a bite. However, if the student tends to eat quickly, continue to have him put the spoon on the table after each bite to slow down his eating.
Note that this chain of behaviours is not illustrated with an adult model of appropriate spoon use. Instead, the student is manually prompted through each step. It is better, however, to teach these behaviours by providing assistance through the use of both modelling and physical prompting. If the student is able to imitate all of the individual behaviours that make up the skill, teach by using modelling exclusively to save time and energy.
Areas of Difficulty
Rather than postponing gratification (which is what the student must learn to do in order to eat appropriately with utensils and in small portions), the student might revert to earlier ways of eating when faced with a bowl of one of his favourite foods. Or, the student might use the spoon to self-stimulate (e.g., by flipping the spoon while gazing at the light reflecting off of it). If the student engages in self-stimulatory behaviour with either his hands or the spoon, or if he frequently attempts to place his hands in either the food or the bowl, instruct him by saying, 'Hands quiet,' if he acquired this skill earlier in treatment (e.g., during the first hours of establishing cooperation and tantrum reduction). When given this instruction, the student should keep his hands in his lap between trials. If he does not, brush up on the instruction 'Hands quiet' by prompting and reinforcing the student for placing both hands in his lap until the next instruction to eat is given. Remember to provide the student with reinforcement for keeping his hands in his lap between bites and for using the spoon appropriately.
If the student experiences difficulty manipulating the spoon, first teach him to use the spoon without feeding himself. Begin by teaching the student to correctly pick up a large spoon using the handle. When he masters this skill, teach the student to use the spoon to make a scooping motion inside an empty bowl and then to scoop a small amount of sticky food such as pudding or yogurt out of the bowl. Use an undesired food if you are not going to allow the student to eat the food at this point. After the student masters this skill, generalize to a smaller spoon and then return to the sequence of steps outlined earlier to teach the student to feed him with the spoon.
If the student masters feeding himself with a spoon when sticky foods are used but experiences difficulty generalizing to bite-size pieces of solid food, teach the student to scoop small objects out of a bowl using a large spoon. Place small objects such as little plastic beads into a bowl. Teach the student the motions involved in scooping up some of the objects and dropping them back into the bowl. When the student masters the scooping motion, teach him to balance the objects on the spoon long enough to transfer them to an adjacent bowl. After this skill is mastered, generalize to a smaller spoon and then to scooping up bite-size pieces of solid food.
Finally, if the student experiences serious difficulty in mastering eating with a spoon when taught through the use of backward chaining procedures, try forward chaining procedures as described in the next section.
Forward Chaining the Steps Together
The steps in forward chaining are virtually identical to those in backward chaining except they are presented in the reverse order. To aid the teacher, the steps are presented in detail. Note that these steps are illustrated with the use of both verbal instructions and manual prompts. This is done with the intent of helping to teach receptive language. If the combination of both manual and verbal prompts does not facilitate mastery of the receptive instructions used in this program, delete the verbal component.
► Step 1
Place the spoon next to the bowl and give the general instruction 'Eat.' Manually prompt the student to pick up the spoon and then reinforce either by verbally praising the student or by giving him a small portion of the food from the bowl (use a separate spoon). Fade all prompts. When the student picks up the spoon unprompted in 5 out of 5 or 9 out of 10 trials, go on to Step 2.
► Step 2
Place the spoon next to the bowl of food and give the general instruction 'Eat.' After the student successfully picks up the spoon, give the instruction for the next response in the chain ('Spoon in bowl'), manually prompt the student to move the spoon to the bowl, and reinforce the student's response. Repeat trials while fading the manual prompt. When the student successfully places the spoon in the bowl without manual prompting, fade the instruction 'Spoon in bowl' (e.g., by deleting it one word at a time or by gradually lowering its volume). After this step is mastered (5 out of 5 or 9 out of 10 unprompted correct responses), go on to Step 3.
► Step 3
Place the spoon next to the bowl of food and give the general instruction 'Eat.' After the student picks up the spoon and moves it to the bowl, give the instruction 'Get food' while physically prompting him to place the spoon under a portion of food by turning his wrist to make the spoon dip inward. Reinforce and fade the prompts over subsequent trials. After the student successfully moves his spoon under a portion of food without assistance, fade the specific instruction 'Get food.' When the student masters this step (i.e., he responds correctly in 5 out of 5 or 9 out of 10 unprompted trials), go on to Step 4.
► Step 4
Place the spoon next to the bowl of food and give the general instruction 'Eat.' After the student independently picks up the spoon, moves it to the bowl, and places it under a portion of food, give the instruction 'Lift spoon' and guide his hand so that he lifts the spoon upward toward his mouth. When the student successfully lifts the spoon toward his mouth without prompting, fade the specific instruction 'Lift spoon.' After Step 4 is mastered (5 out of 5 or 9 out of 10 unprompted correct responses), go on to Step 5.
► Step 5
Place the spoon next to the bowl of food and give the general instruction 'Eat.' After the student successfully picks up the spoon, moves it to the bowl, places it under a portion of food, and lifts it toward his mouth, give the instruction 'Put in mouth' and guide his hand to place the spoon in his mouth. The student may open his mouth to accept the spoon without additional prompting. The student is reinforced by eating the food on the spoon and by your verbal reinforcement. Fade prompts and then fade the specific instruction 'Put in mouth.' After the student masters Step 5, go on to Step 6.
► Step 6
Place the spoon next to the bowl of food and give the general instruction 'Eat.' After the student independently picks up the spoon and moves it to the bowl, places it under a portion of food, lifts it toward and places it and the food in his mouth, give the instruction 'Spoon on table,' prompting him to take the spoon out of his mouth and place it on the table. Provide verbal reinforcement, and fade the prompts over subsequent trials. Finally, fade the specific instruction 'Spoon on table.'
Note that in these steps, you rely upon manual prompting to teach the student to eat with a spoon. If the student you work with is proficient in nonverbal imitation, it is better to teach by using a combination of modelling and physical assistance or, if possible, modelling alone.
Generalizing the Use of Eating Utensils
Once the student successfully feeds himself soft foods using a spoon, switch to small quantities of solid foods. This should only require a prompt to help the student to spoon the food and perhaps to hold the spoon steady before placing it into his mouth; the student should be capable of performing the remaining steps on his own.
After the student is able to use a spoon to eat different kinds of food, teach the student to eat with a fork and a knife. Use pieces of food small enough for the student to eat in one bite but large enough that they can be easily cut with a knife and then picked up with a fork. As done when teaching the student the behaviours needed to eat with a spoon, reduce the task into separate steps. Following backward or forward chaining procedures, begin teaching by using prompting, specific instructions (if using forward chaining procedures), and reinforcement for each step, and then slowly fade out the prompting, specific instructions, and reinforcement until the student can perform the chain of behaviours when given a general instruction.
Increasing Variety in the Student's Diet
Many individuals with developmental delays eat a very limited number of foods. A restricted diet is often of great concern for parents who fear their child may suffer from malnutrition. If you have such concerns, it is a good idea to consult a paediatrician to examine the student's physical health. At the same time, you may want to create a list of the foods the student eats and those she prefers not to eat to help ascertain whether certain nutrients are missing from the student's diet. In addition, if you notice that certain foods have detrimental effects on the student's behaviour, include this information when consulting the paediatrician. For example, food allergies (e.g., allergies to milk or wheat products) and large amounts of sugar can cause major behavioural disturbances in some individuals.
There are times when food preferences seem incorporated into an individual's ritualistic behaviours. When such rituals are interrupted, the individual may tantrum. We mentioned earlier in this manual that a certain student would eat only perfectly shaped Cheerios and would throw major tantrums when he encountered ones that were not perfectly shaped. This behaviour required that the student's parents go through every box of Cheerios they bought and carefully scrutinize the contents for imperfectly shaped Cheerios. While typical individuals sometimes show similar idiosyncrasies, more often than not such persons outgrow them over time. Whether individuals with autism follow a similar pattern is not known. In any case, for those parents who risk exposing their child to a restricted diet or forever seem to have to prepare special meals separate from those served to other family members, it may be helpful to increase the variety in the child's diet.
The present program describes steps whereby the student is helped to eat a larger variety of foods. Once the student eats novel foods in special teaching sessions, the student is taught to eat specific foods when you so request. Finally, to facilitate generalization, introduce these foods into regular mealtimes with family members.
In preparation for this program, create a list of foods the student already eats and note those that are highly preferred. Then create a list of foods that the student does not eat but that may be of benefit to the student. The general rule is to use favourite or highly preferred foods as reinforcers for eating non-preferred foods. For example, if the student has a strong preference for a particular cracker, find a cracker slightly different from the preferred one in terms of appearance, taste, or shape, and then use the preferred cracker as the reinforcer for taking a small bite of the new cracker. Similarly, if the student eats only a certain brand of chicken nuggets, select a second brand that is similar in appearance and taste and use small bites of the preferred brand of nugget as a reinforcer for taking a small bite of the novel one. It is also helpful to have access to powerful food reinforcers, such as chocolate frosting or ice cream, and to provide small tastes of those treats as reinforcers for exploring new and non-preferred foods. This is not all that different from what parents do with typical children, such as when a child is served dessert only after she finishes her vegetables. The teaching program for students with developmental delays, however, proceeds in relatively small steps (which help ensure success). Based on findings in empirical research, there are reasons to believe that one can change food preferences by following such procedures.
Using Modelling To Teach Eating a Non-preferred Food
The student and the adult should sit in chairs across the table from each other. Place two very small portions (about the size of a quarter) of a non-preferred food in the middle of the table. Place a favourite food reinforcer (e.g., chocolate frosting or ice cream) on the table next to you.
► Step 1
Present the instruction ('Do this') and use a finger to touch the small piece of non-preferred food on the table in front of you. If necessary, physically prompt the student to do the same. Reinforce the student with a small bite of her favourite food for having touched the non-preferred food. (Small bites are used to avoid early satiation). Fade the prompt and place the criterion for mastery at 5 out of 5 unprompted correct responses.
► Step 2
Present the instruction ('Do this') and pick up the food from the table, then place it back. Physically prompt the student to perform the same behaviour if necessary. Reinforce, fade the prompt, and bring to mastery.
► Steps 3-5
Present the instruction ('Do this') and pick up the food, touch it to your nose, and then put it back down. Continue until mastery is reached. In Step 4, repeat the instruction, pick up the food, touch it to your lips, and then place it back on the table. In successive steps, increase the level of exposure to the food by holding the food to your lips for 1 second, gradually increasing to 5 seconds, before placing it back down on the table. Then proceed to Step 5, teaching the student to pick up the food and touch it to her tongue.
If the student becomes upset during any step presented above, immediately go back to an earlier step and reinforce her for completing the imitation of your action with the food. Then gradually increase the student's exposure to the non-preferred food until she masters Step 5.
► Steps 67
Present the instruction ('Do this'), place a very small piece of the food in your mouth, and prompt the student to imitate your action. Should the student swallow the food, immediately reinforce with a small bite of her favourite food (e.g., a teaspoon of ice cream or a small sip of a favourite beverage). If the student does not swallow the food, help remove the food from her mouth and then, over several trials, increase the time interval the student must hold the food in her mouth from 1 to 5 seconds. In Step 7, you should model chewing and swallowing the food after the student places the food in her mouth. Try prompting the student to swallow the food by giving her a sip of her favourite beverage to swallow or a bite of a favourite food to eat. This immediate reward not only serves to reinforce the chewing or swallowing but also serves to remove the taste of the non-preferred food. (In the technical literature, if a mildly aversive stimulus is systematically paired with a highly preferred stimulus, the first stimulus loses its aversive properties and begins to resemble the preferred one).
As the student advances through this program, introduce foods that are progressively more dissimilar to those the student presently eats. For example, introduce foods that differ in texture and colour from the student's usual foods. Each new dimension may have to be introduced separately and in a stepwise fashion. Use very gradual steps when introducing multicoloured and multi-textured foods, such as pizza or spaghetti with tomato sauce, because such foods may look very different from those on the student's original food list. When introducing pizza, for example, begin with a small piece of crust only, then add a small amount of sauce, then cheese, and then gradually increase the portion to a regular-size piece of pizza. Keep in mind that some items (e.g., mushrooms, green pepper) may be more aversive than other items. If the student has a strong aversion to particular accessory foods, remove these food items for the time being.
Teaching the Student to Eat When Requested To Do So
Typical individuals learn to eat certain foods at certain times when requested or expected to do so. There are several reasons for teaching the student with developmental delays to do the same, one of which is to help the student eat some or all of the foods presented at mealtime. Another reason is to teach the student to restrict his food intake between meals. As it may be difficult to teach the student to eat a non-preferred food when so requested, you may want to begin by teaching him to eat a favourite food or a neutral food upon your request. At the same time, you may want to teach the student not to eat a favourite food when it is available (e.g., when it is on the table or in the refrigerator).
The student may have already been taught to eat certain foods as part of the Early Receptive Language Program (Chapter 15). For example, the student may have been taught to respond appropriately to such requests as 'Drink juice' and 'Eat cookie.' Follow the same steps described in Chapter 15 to teach the student to eat a particular food upon your request. If possible, begin by using a neutral or not strongly preferred food item. For illustrative purposes, we use cheese.
► Step 1
Place two small pieces of cheese on the table, one in front of the student and one in front of yourself. Present the instruction 'Eat cheese,' prompt by modelling the behaviour, and reinforce the student's imitation with a favourite food. Gradually fade the model prompt until the student eats the small portion of the food without prompting and without becoming upset. Note that many students become upset at the prospect of eating a food when requested to do so even if they accepted the food when the teacher modelled the behaviour. In our experience, with practice and with the preferred food reinforcer in view, most students overcome their emotional response to this situation.
► Step 2
Slowly increase, in an incremental and stepwise fashion, the portion of food the student is expected to eat. For example, introduce a piece of food cut into half the size of a sugar cube, then increase the portion to the size of a full sugar cube, then to a cube and one half, and so forth. It is important that you show the student the special food item to be used as a reinforcer for his eating the food when requested. If the student becomes too upset at the sight of a larger portion of food, go back to earlier steps by having the student touch the larger portion of food in imitation of your action, then move it toward his nose, then move it to his mouth, and then touch it to his tongue. Should the student continue to be upset, reinstate the student's cooperation by interspersing a few nonverbal imitation or receptive instruction trials unrelated to eating the food item? Remain at any given portion size for several trials (10 to 20 or more) before increasing size. Take your time and proceed in small steps until the student can eat a regular portion of the food.
Should the student's progress be very slow when using a neutral food item, switch to a highly preferred food and establish instructional control using that food. Place the preferred food item on the table and teach the student to eat the food when you request him to do so. This setting is also helpful for teaching the student not to eat the food on the table until asked to do so. The steps for teaching this skill may involve placing a preferred food on the table and instructing the student, 'Do not eat.' Prompt the student to withhold reaching for the food until he is given the instruction 'Eat (food)' (or some similar instruction). Note that all individuals must learn when to eat and when not to eat and to comply with others' requests in this regard.
Introducing Foods into the Student's Mealtime
After the student masters eating a regular portion of food in a structured setting, gradually introduce that food into the student's mealtime. Proceed in a stepwise fashion as follows: At mealtime, place on the student's plate a small portion (e.g., bite-size) of the non-preferred food the student just mastered eating. The special reinforcer the student will receive contingent on eating the new food item should be in full view. Follow your regular mealtime rules about leaving the table if the student eats most or all of the meal. In other words, if the student must eat a certain amount of her regular meal before being excused from the table, continue to follow these guidelines. Remember that the student should not receive the special reinforcer unless she at least tries the new food item. If the student refuses the new food item as part of her regular meal, return to earlier steps to establish the new food as more appetizing and reintroduce the item to the table during her regular mealtime at a later date. In gradual steps, slowly increase the size of the portion the student must eat before receiving her special reinforcement. Once a student eats what her parents consider to be a reasonable amount of the new food, slowly remove the special reinforcer and continue to supply this new food as part of the student's regular meal.
A program like the one outlined in this section may take several months to accomplish. Remember, however, there are large individual differences among students in their rates of progress in this and every other program. Keep in mind that for students who have gained skills in receptive language, you may verbalize certain contingencies (e.g., if the student eats a certain food, she will receive a reinforcer; conversely, if she does not eat the food, she will not receive a reinforcer). In any case, maintain an appropriate perspective by considering the length of time it takes for typical children to learn to eat the kinds of foods their parents want them to eat. Also keep in mind that some typical individuals go for days hardly eating anything at all, seeming to live on oxygen alone. Despite parents' fears, it is unusual for such children to suffer from malnutrition.
Undressing and Dressing
A. Undressing
The skills required to undress one are taught more easily than those required to dress; consequently, undressing is targeted first. The goal of this program is for the student to remove certain pieces of clothing after being asked to do so. The steps for removing a pair of pants are outlined first, as this undressing skill is often the easiest for the student to learn and for the teacher to instruct. Backward chaining procedures are used in teaching this skill and can be applied to the steps involved in teaching the student to take off his shirt, socks, shoes, and jacket. Prior to learning to undress independently, the student should have achieved some mastery in imitation of object manipulation, gross motor imitation, and receptive language.
Removing Pants
When first teaching the student to remove pants, choose a pair of pants that do not fit too snugly on the student. The pants should have an elastic waistband that does not require unbuttoning or unzipping and should fit easily over the student's hips and legs. A loose-fitting pair of shorts is also a suitable choice when teaching this program. The target behaviour of removing pants can be broken down into the following discrete steps presented in the order in which they should be taught:
► Step 1
Seat the student on the floor or on a chair and position the waistband of his pants around his feet. Give the general instruction 'Pants off' and physically prompt the student to grip the waistband of his pants by hooking his thumbs inside the waistband, pulling them off from around his feet, and placing them on the floor. Reinforce and fade the prompt over successive trials. Set mastery at 5 out of 5 or 9 out of 10 unprompted correct responses.
► Step 2
Seat the student on the floor or on a chair and position the waistband of his pants around his ankles. Proceed as described in Step 1.
► Steps 3-4
Steps 3 and 4 are analogous to Steps 1 and 2 except the waistband of the student's pants is placed around his shins in Step 3 and around his knees in Step 4.
► Steps 5-7
In Steps 5 through 7, the response requirements are gradually increased in succinct steps from placing the waistband around the student's thighs to around his hips and then to around his waist. Beginning with Step 5, the student should stand to facilitate removing his pants. Prompt the student to remove the pants from around his thighs and then reinforce as done in earlier steps. Once Step 5 is mastered, go on to Step 6, which is equivalent to Step 5 except that the students pants are positioned around his hips? Once Step 6 is mastered, go on to Step 7, having the student remove the pants from around his waist.
Removing a Shirt
When teaching the student to remove his shirt, use a loose-fitting short-sleeved shirt without buttons or zippers. The shirt should have a large opening at the top so it easily fits over the student's head. Using the same procedures described above for teaching the student to remove his pants, teach the student to remove his shirt. Removing a shirt can be broken down into the following steps:
Removing Socks
When beginning to teach the child to remove socks, use an older child's or adult's sock and gradually decrease the size of the sock as the student becomes proficient at removing socks. Removing socks can be broken down into the following steps and taught by following the backward chaining procedures described above:
Removing Shoes
Shoes of a larger size than the student's own shoe size should be used when first teaching this portion of the program. As with removing socks, start by using an older child's or adult's shoe (ideally without laces) and gradually decrease the shoe size as the student becomes proficient at removing shoes. This skill can be broken down into the following steps and then combined using backward chaining procedures:
Removing a Jacket
A loose-fitting jacket should be used when beginning to teach the child to remove a jacket. Removing a jacket can be broken down into the following steps and then chained in the corresponding order:
B. Dressing
In this program, the target response is for the student to dress himself when the teacher requests for him to do so. Except for the instruction (e.g., 'Dress') given to the student, teaching a student to dress should be done in the same manner as undressing. In other words, the final step in the chain of behaviours is taught first and the preceding steps are added in descending order until the first step in the chain is reached. The distinct steps for putting on pants, a shirt, socks, shoes, and a jacket are presented below, in the order in which they should be taught. Follow the backward chaining procedures outlined earlier to combine the steps listed for each dressing behaviour.
Putting on Pants
A loose pair of pants or shorts with an elastic waistband that fits easily over the student's legs and hips should be used. Putting on pants can be broken down into the following steps:
Putting on a Shirt
A loose-fitting short-sleeved shirt with a large opening at the top should be chosen when first teaching this portion of the program. Putting on a shirt may be broken down into the following steps:
Putting on Socks
A loose-fitting pair of socks should be used in the initial stages of this portion of the program. Putting on socks can be broken down into the following steps:
Putting on Shoes
Shoes of a size larger than the student's own shoe size should be used when beginning to teach this program. Putting on shoes can be broken down into the following steps:
Putting on a Jacket
Use a loose-fitting jacket when teaching this skill. Putting on a jacket can be broken down into the following steps:
Wait until a later time to target fastening skills, such as zipping, buttoning, and snapping, given that these tasks require finger dexterity and are often difficult for students to learn. When you do teach fastening skills, you may want to begin with fasteners that are attached to a board or large piece of fabric. These skills can later be generalized to the student's own clothing.
Brushing Hair
The ultimate goal of this program is for the student to brush her hair when you say, 'Brush hair.' A combination of imitation, shaping, and chaining should be used to teach the student to brush her hair. You may want to teach the student to brush her hair while seated at a mirror as this may facilitate acquisition of the target behaviour.
► Step 1
Place one hairbrush in front of the student and one in front of yourself. Give the instruction 'Brush hair' while picking up your brush. If the student does not pick up the brush after you model the response, consequate the non-response and verbally prompt her on the next trial by saying, 'Do this,' again picking up the brush. If the student does not respond correctly, physically prompt her to pick up the brush in the next trial immediately after you model the behaviour. Reinforce the response and fade the physical prompt until the student independently imitates picking up the brush in 5 out of 5 or 9 out of 10 trials. If you cannot fade the physical prompt, wait to introduce this program until you are sure that the student has mastered imitation involving object manipulation. Once Step 1 is mastered, go on to Step 2.
Step 2
Again model the behaviour of picking up the brush. Once the student imitates the action, move your brush up until it touches the top of your head and prompt the student to imitate the action if necessary. Reinforce the correct response. Once Step 2 is mastered (5 out of 5 or 9 out of 10 correct responses), go on to Step 3.
Step 3
Model the behaviours taught in Steps 1 and 2. After the student places the brush on top of her head, move your brush in a downward stoke to the base of your head. Repeat the entire sequence (i.e., pick up the brush, move it to the top of your head, and then stroke the brush through your hair to the base of your head) several times until the student imitates the sequence in a continuous and flowing manner so that there is little to no pause between each individual movement. Once Step 3 is mastered (5 out of 5 or 9 out of 10 correct responses), go on to Step 4.
Step 4
The goal of Steps 4 and 5 is to teach the student to imitate multiple strokes following the instruction 'Brush hair.' Begin by giving the instruction, moving your brush to the top of your head, and performing two downward strokes. Prompt the student to imitate the complete response if necessary. Provide reinforcement only after the student imitates two strokes with the brush. Once Step 4 is mastered, go on to Step 5.
Step 5
Step 5 is analogous to Step 4 except that in this step you gradually increase the number of strokes the student is required to make before receiving reinforcement. Present the instruction 'Brush hair' and complete three downward strokes. After the student masters completing three strokes, increase the number of strokes to four. Continue adding strokes one at a time until the student completes enough strokes to brush her entire head of hair. Once Step 5 is mastered, go on to Step 6.
► Step 6
The goal of Step 6 is to fade all the modelling prompts so the student can independently brush her hair when given the instruction 'Brush hair.' Gradually decrease the amount of prompting by providing less and less of your model. Begin by fading the last downward stroke first, then the second to last stroke, and so forth until you only model picking up the brush. Continue to fade your prompt until the student no longer requires a prompt to pick up the brush and brush her hair when given the instruction 'Brush hair.'
The steps described for brushing hair may be modified depending on the student's particular haircut. The teaching steps may include grasping the brush with the dominant hand, brushing the hair beginning at the part and moving downward on both sides, and grooming the hair at the back of the head. Further steps might address brushing the hair from underneath in order to groom long hair.
Brushing Teeth
Brushing teeth is a complex skill and should not be attempted until well into the second year of the Self-Help Skills Programs. Note that a typical individual may not acquire this skill until 5 to 6 years of age.
For this program you need the following materials: a toothbrush, toothpaste, a toothbrush holder, a cup, and a towel (have a duplicate of each of these items if modelling is to be used as a prompt). Similar to eating and dressing, the target behaviour of brushing teeth is composed of several discrete elements. A forward chaining procedure is used to teach and combine each of the elements in a forward chronological order. By the end of this program, the student should be able to brush his teeth after given the instruction 'Brush teeth.'
As with the teaching of any behaviour, modelling is the preferred prompt provided the student has mastered modelling. Some students advance relatively quickly in learning to imitate a model; others, however, advance at a slower pace and need more physical prompts. Also, some behaviours such as brushing teeth and washing hands are quite complex, consisting of several steps. More complex behaviours are likely to need a larger proportion of manual prompting. On the other hand, complex behaviours such as brushing teeth are likely to be introduced later in a student's program, after the student has made additional advances in the Nonverbal Imitation Program. We recommend that the teacher probe with modelling prompts before using manual prompts when introducing this program. Remember that a complex behaviour such as brushing teeth could, and perhaps should, be used to extend the nonverbal imitation skills acquired in Chapter 13.
This program may be begun at the table or some other convenient place. When the first five steps are mastered, move the program to the bathroom and have the student stand in front of the sink. The following chain of steps is suggested as a guide for instructing the student to brush teeth. This is an abbreviated list and does not encompass all possible steps or additional steps the student may need later as he grows older and more accomplished with his self-help skills. The behaviours to be taught can be broken down as follows:
As mentioned earlier, forward chaining is used to teach the student to brush his teeth. Modelling, as opposed to manual prompting, should be used as a prompt whenever possible
► Step 1
Until the student masters Steps 1 through 5, you may want to use a toothbrush without toothpaste. Present the instruction 'Brush teeth,' immediately prompt the student (using nonverbal imitation or manual guidance) to pick up his toothbrush, and reinforce the correct response. When the student correctly imitates your behaviour in 5 out of 5 or 9 out of 10 trials, go on to Step 2.
► Steps 2-5
Steps 2 through 5 involve teaching the student to brush his front teeth and the teeth on the left and right sides of his mouth. In Step 2, the student should imitate your picking up the toothbrush after presentation of the instruction 'Brush teeth.' Next, give the instruction 'Brush in' and prompt the student to put the brush in the left side of his mouth and then to brush the teeth on that side. Reinforce. After the student masters Step 2, teach Step 3 by following the completed sequence with the instruction 'Other side' and prompt the student to brush the teeth on the right side of his mouth. Reinforce. When the student masters Step 3, teach Step 4 by following the completed sequence with the instruction 'Front.' Prompt the student to brush his front teeth and follow this action with reinforcement. After the student masters Step 4, teach Step 5 by following the completed sequence with the instruction 'Brush down' and prompt the student to lay down the toothbrush. Follow this behaviour with reinforcement.
When the student masters Steps 1 through 5, fade the individual instructions, beginning with the instruction 'Brush in.' Fade this instruction one word at a time until the student picks up the toothbrush and brushes the teeth on the left side of his mouth (Steps 1 to 2) after presentation of the instruction 'Brush teeth.' After this goal is met, gradually fade the instruction 'Other side' one word at a time until the student complete Steps 1 through 3 following presentation of the instruction 'Brush teeth.' Finally, fade the instruction 'Front' and then 'Brush down' in a similar manner until the student completes Steps 1 through 5 following presentation of the instruction 'Brush teeth.' Continue practicing Steps 1 through 5 for approximately 1 to 2 weeks before moving on to Step 6.
► Steps 6-9
After the student masters Steps 1 through 5, teach Steps 6 through 9, which involve teaching the student to rinse his mouth with water. Present the instruction 'Brush teeth' and, after the student completes Steps 1 through 5, present the instruction 'Get cup' and prompt the student to pick up the cup. Reinforce the response. Continue to practice Steps 1 through 6 until Step 6 is mastered. Next, teach Step 7 by following the completed sequence with the instruction 'Take a sip.' Prompt the student to take a sip of water and follow this action with reinforcement. When the student masters Step 7, teach Step 8 by following the completed sequence with the instruction 'Rinse.' Prompt the student to rinse out his mouth and spit out the water. Teach Step 9 by following the completed sequence with the instruction 'Cup down.' Prompt the student to put down the cup and then reinforce the behaviour.
After the student masters Steps 1 through 9, fade the individual instructions given in Steps 6 through 9 by following the fading procedures outlined above for Steps 2 through 5; that is, fade the instruction for Step 6 ('Get cup') first and continue to fade the instructions in forward chronological order until the student completes Steps 1 through 9 following presentation of the instruction 'Brush teeth.' Continue practicing Steps 1 through 9 for approximately 1 to 2 weeks before moving on to Step 10.
► Steps 10-15
When the student masters Steps 1 through 9, proceed with Steps 10 through 15, which involve teaching the student to rinse his toothbrush and then dry his hands and mouth. Present the instruction 'Brush teeth.' After the student completes Step 9, present the instruction 'Water on' and prompt the student to turn on the cold water. Follow this action with reinforcement and continue to practice Steps 1 through 10 until Step 10 is mastered. Next, teach Step 11 by following the completed sequence with the instruction 'Wash brush,' prompting the student to rinse his brush under the water. Follow this action with reinforcement. When Step 11 is mastered, teach Step 12 by following the completed sequence with the instruction 'Put away' and prompt the student to put the brush in a holder. Follow this action with reinforcement. When Step 12 is mastered, teach Step 13 by following the completed sequence with the instruction 'Water off' and prompt the student to turn off the water. Reinforce the correct response. After the student masters Step 13, teach Step 14 by following the completed sequence with the instruction 'Dry hands,' prompt the student to dry his hands with a towel, and follow this action with reinforcement. When Step 14 is mastered, teach Step 15 by following the completed sequence with the instruction 'Dry mouth.' Prompt the student to dry his mouth with the towel and follow this action with reinforcement.
When the student masters Steps 1 through 15, begin to fade the individual instructions given for Steps 10 through 15 by following the fading procedures outlined above for Steps 2 through 5. Fade the instruction for Step 10 ('Water on') first and continue to fade in forward chronological order until the student completes Steps 1 through 15 following presentation of the instruction 'Brush teeth.' Finally, gradually fade out the use of prompts, transferring control to the general instruction.
Areas of Difficulty
If the sequence of 15 steps for brushing teeth appears too complex for the student's current level of functioning, it may be taught in a more gradual or simplified manner first and then shaped into the entire sequence at a later time. As recommended earlier, the motions involved in brushing teeth may be taught first in the student's teaching room with you and the student seated across from each other. Without toothpaste, you may teach the student to imitate brushing motions in this controlled environment. Similarly, you may teach imitation of drying motions with a towel for both the hands and mouth in a controlled environment before teaching the previously outlined sequence of steps in the bathroom.
If you encounter difficulties fading out the individual verbal instructions for each step, you may want to use a picture sequence to help the student achieve independence with his brushing routine. Using symbols or photographs of the student engaging in each of the steps, create a chart that depicts each step in a left-to-right or top-to-bottom fashion. Teach the student to follow this chart by prompting him to complete a step for each picture, then gradually fade yourself out as the student masters following the steps depicted on the chart. Consult the Reading and Writing Program and the Picture Exchange Communication System Program (Chapters 29 and 30, respectively) for more ideas about teaching the student to follow visual sequences.
Washing Hands
For this program, you need a bar of soap and a towel (have duplicates of these items available if modelling is tobe used as a prompt). The target response is for the student to wash her hands when you say, 'Wash hands.' Similar to brushing teeth, the target behaviour of hand washing is composed of several discrete steps that may be combined in forward chronological order. This program may be taught with the student standing in front of the sink in the bathroom or kitchen.
The following sequence of steps is recommended as a guideline for teaching the student to wash her hands:
As mentioned earlier, forward chaining is used to teach and combine the individual steps. Modelling as opposed to manual prompting should be used whenever possible.
► Step 1
Give the general instruction 'Wash hands' and immediately prompt the student to turn on the water. Provide reinforcement for this action. When the student masters Step 1 by independently performing the target action in 5 out of 5 or 9 out of 10 trials, go on to Step 2.
► Steps 2-7
Steps 2 through 7 involve teaching the student to put her hands under the water, wash them with soap, and then rinse them. Begin by presenting the instruction 'Wash hands.' After the student turns on the water, present the instruction 'Hands wet.' Prompt the student to put her hands under the water and then reinforce the behaviour. When the student masters Step 2, add Step 3 to the sequence by presenting the instruction 'Get soap' following the completed sequence (turning on the water and putting her hands under it). Prompt the student to pick up the soap, and provide reinforcement for this action. When the student masters Step 3, teach Step 4 by following the completed sequence of steps with the instruction 'Rub the soap' and prompt the student to rub the bar of soap between her hands. Follow this action with reinforcement. Once the student masters Step 4, teach Step 5. Following the completed sequence of steps, present the instruction 'Put soap away' and prompt the student to put the soap back in its proper location. Reinforce the response. When the student masters Step 5, teach Step 6 by presenting the instruction 'Rub hands,' prompting the student to rub her hands together. Follow this action with reinforcement. Next, teach Step 7 by following the completed sequence of steps with the instruction 'Hands wet.' Prompt the student to put her hands under the water and rinse them. Reinforce.
When the student masters Steps 1 through 7, begin fading the individual instructions by following the fading procedures outlined for Steps 2 through 5 in the Brushing Teeth section. That is, fade the instruction for Step 2 ('Hands wet') first and continue to fade in forward chronological order until the student completes Steps 1 through 7 following presentation of the instruction 'Wash hands.' Continue to practice Steps 1 through 7 for approximately 1 to 2 weeks before moving on to Step 8.
► Steps 8-11
When the student masters Steps 1 through 7, teach Steps 8 through 11, which involve teaching the student to turn off the water and dry her hands. Following the same teaching procedures outlined previously, use the instructions 'Water off' and 'Get towel' to complete the chain. Prompt as necessary. When the student masters Step 9, teach Step 10, which involves the instruction 'Dry hands' and prompting the student to dry her hands. When Step 10 is mastered, teach Step 11 by presenting the instruction 'Towel away' after the student completes the above sequence of steps. Prompt the student to put the towel away and then provide reinforcement.
After the student masters Steps 1 through 11, begin fading the individual instructions given in Steps 8 to 11 by following the fading procedures outlined in Steps 2 through 7; that is, fade the instruction for Step 8 ('Water off') first and continue to fade instructions in forward chronological order until the student completes Steps 1
through 11 following presentation of the instruction 'Wash hands.' Finally, gradually fade out the use of your prompts, transferring control to the general instruction.
Areas of Difficulty
As discussed in the section on brushing teeth, if the sequence of steps appears too complex for the student's current level of functioning, it may be taught in a more gradual or simplified manner. These behaviours may later be shaped into the sequence described. The motions involved in hand washing may be taught while the student is in the controlled environment of the teaching room. Here the student may be taught to imitate the motions of rubbing her hands together and drying her hands with a towel.
As mentioned earlier, you may also come across difficulties fading out the individual verbal instructions for each step. If this occurs, you may want to consider using a picture sequence to help the student become less prompt dependent. As with all self-help skills, remember that time is on your side; typical individuals also require a considerable amount of time before they master these skills.
Daytime Toilet Training
The following materials are needed to teach toileting skills: a potty seat or chair, a stool, cloth training pants, a watch or timer, a book to record toileting events, a large supply of the student's favourite drinks and salty snacks, and a variety of the student's favourite tabletop toys or activities. Before you teach this program to the student, the student should have mastered dressing and undressing with his pants. Toilet training the student initially requires a significant investment of time on your part; be prepared to devote several hours addressing this skill with the student. Remember, however, that after the student is toilet trained, both you and your student will be happier. The procedures described in this program are adapted and modified from Azrin and Foxx (1971). As they discussed, it is possible to successfully teach some students toileting skills in 1 day of intensive toilet training. After 1 day of 10 hours of training, the student should be able to hold his urine until instructed by the adult to use the bathroom. The procedures outlined in this section do not teach the student to initiate using the bathroom; initiating is taught separately in procedures described toward the end of this chapter. Initiation is taught after the student learns to control his bladder and is successful in that respect over several weeks.
In Preparation
A full day should be set aside to focus exclusively on toilet training (the intensive toilet training day). As a pre-training step, teach the student to go through the motions of going to the bathroom. Instruct the student, 'Let's potty.' If the student is verbal, prompt him to make a statement such as 'Potty' as you enter the bathroom. If the student is nonverbal, prompt him to give you a picture of a toilet or perform some other nonverbal gesture. Take the student into the bathroom and prompt him to pull down his pants (if the student already learned this skill from the previous section on undressing skills, merely ask him to take off his pants). Then prompt the student to sit on the toilet. If the student is big enough, it is preferable to use a regular toilet or a toilet with a potty seat rather than a potty chair. By doing so, toileting skills will not have to later be transferred from a potty chair to the toilet. When using a regular toilet, provide the student with a stool on which he can rest his feet as he sits on the toilet.
Once the student sits on the toilet, have him remain there for 3 to 5 minutes. While the student is sitting, reinforce him by allowing him to look through books, listen to music, do puzzles, or engage in some other favourite activity so he learns that sitting on the toilet is a pleasant activity. If the student happens to urinate while seated on the toilet, give him a very special treat and abundant verbal praise, and then let him leave the bathroom. The special treats should consist of items (e.g., ice cream or chocolate chips) the student especially enjoys but is not allowed access to on a regular basis.
The pre-training procedure described should be conducted for approximately 3 to 5 minutes every hour and should be continued for 2 or 3 weeks prior to the day set aside for intensive toilet training. Two or 3 days prior to the intensive training day, increase the frequency of these trips to the toilet to every 15 to 20 minutes. This provides the student with extra exposure to the bathroom.
The Intensive Training Day
Before beginning the intensive training day, keep in mind that most but not all students are successful on their first day. If the student is successful, it is likely that this success will be restricted to bladder training as bowel training takes much longer to teach and learn. Also, even if the student is taught to urinate into the toilet by the end of the first day, it is likely that accidents will still occur. It takes some extra time to teach a boy to stand up and urinate after he masters urinating while sitting down. On top of that, it also takes some extra effort to help a boy aim his urine inside the toilet rather than on the seat or floor. We provide suggestions on how to teach such accuracy. Keep in mind that typical persons also need help aiming, avoiding accidents, and the like. The reason for having one intensive toilet training day is to mass trial this skill in order to get off to a good strong start.
To maximize the student's success on his day of intensive training, adhere to the following guidelines. First, increase the student's intake of liquids so he urinates frequently. Doing so provides the student with many successes (i.e., reinforced trials) on the toilet. Second, decide in advance which correction procedure you will use in the event of an accident. For example, you may have the student wash his wet pants in a sink for 2 minutes or wipe the floor with a wet cloth for 3 to 4 minutes. Keep in mind that the correction procedure chosen should not be an activity the student will enjoy but rather one that will require some effort. Third, keep the student entertained and engaged in activities throughout the day in the bathroom to help make toilet training a positive experience.
Following are the major steps involved in toilet training the student. To make the day more tolerable for the adults, have as many team members present as possible to take turns helping the student and providing food, drinks, happy conversations, and the like.
► Step 1
Early in the morning, just after the student wakes up, seat the student on the toilet after prompting him to say, 'Potty,' or to nonverbally demonstrate the need to go to the bathroom (e.g., by handing the teacher a picture of a toilet). This step may serve as a pre-training step to help the student initiate toileting and should be performed before each trip to the bathroom. Provide the student with many liquids and salty foods that will make him thirsty. The large amount of liquids serves as a prompt to urinate. During this step, the student should sit on the toilet for approximately 30 minutes. The student should not wear any undergarments or pants at this point to avoid the possible confusion of having to remove such garments. Allow the student to look at books, do puzzles, and so forth, to keep himself occupied while sitting on the toilet. When the student urinates, provide abundant verbal praise and a special treat selected just for potty training. Also provide the student with ample liquids as a reinforcer, which will serve to prompt future urination.
Let the student off the toilet for a 5-minute play break (make this break shorter if the student is likely to urinate during the break).
When the break is over, place the student back on the toilet for another trial. Even if the student does not urinate, give praise approximately every 3 minutes for sitting nicely and provide more liquids to drink. If the 30-minute period elapses without the student urinating, give the student a 5-minute play break. Stay near the bathroom during this break and keep the student undressed from the waist down. If the student begins to urinate during the break, quickly place him back on the toilet and then reinforce him for urinating into the toilet. If the student does not urinate during the break, allow him to play for the full 5 minutes and then return to the toilet for the next 30-minute session.
Step 2
After the student successfully urinates into the toilet three or four times and is consistently accident free during his breaks, decrease the amount of time on the toilet to 25 minutes and increase the break time to 7 minutes. The student should still be undressed from the waist down and returned to the toilet if an accident occurs during the break. As the student consistently urinates in the toilet and is accident free during breaks (three to four times in a row), continue to increase the break time to 15 minutes and gradually shorten the interval the student must sit on the toilet to 5 minutes.
If the student is not successful during longer breaks (i.e., if breaks cannot be increased to any substantial interval without incurring accidents) by the late afternoon of the first day, this may not be the right time for the student to learn the toileting skills presented in this section. Consider postponing the training for another 2 to 4 months; it is less frustrating for all involved to wait until the student is ready to learn a particular skill before beginning or resuming training.
Step 3
Dress the student in a pair of training pants after mastery of Step 2. Remove the training pants when the student is placed back on the toilet.
Step 4
If the student remains accident free during breaks while wearing training pants and consistently urinates in the toilet, the break time should be further increased. The amount of time seated on the toilet should be proportionally decreased. Periodically check the student's training pants and verbally reward the student for having dry pants during break time. If an accident occurs, show the student the wet pants, state an informational 'No,' and have the student perform a correction procedure (e.g., have the student wash the pants for 2 minutes). The presence of wet pants may help the student discriminate (become aware of) accidents. After the student completes the correction procedure, return student to the toilet for 5 minutes.
► Step 5
For the remainder of the day, gradually increase the student's break time and proportionately decrease the amount of time required on the toilet. Continue to reinforce the student for urinating into the toilet and for having dry pants during break time. Implement the correction procedure if the student has an accident during a break. The student should continue to eat salty foods and drink plenty of liquids during the remainder of the day.
A realistic goal to strive for on this first day is 30-minute accident-free break periods interspersed with 2- to 3-minute intervals of being seated on the toilet with one or more successful urinations. The student should be allowed to leave the bathroom contingent on successful urination to enjoy the 30-minute break. It is crucial to continue this schedule until the student goes to bed. At that point, you may dress the student in a diaper to be worn overnight. If the student is placed in a diaper in the daytime, however, the diaper is likely to serve as a cue for urination. The diaper provides a stronger cue for urinating than the toilet in the early stages of training.
► Step 6
The day after intensive training, return to the student's regular routine (i.e., an intermingling of teaching time and play time) but take the student to sit on the toilet at specified time intervals (i.e., the longest interval mastered the previous day). In other words, continue with the student's teaching sessions during time off the toilet but take the student directly to the toilet as soon as the time interval passes even if this time falls during a formal teaching situation. The student should remain dressed only in training pants and a shirt for a few days to make the bathroom routine easier to complete. It is often helpful to use a timer to time the intervals so as to help reduce accidents. Intermittently check for dry pants during the intervals in which the student is not seated on the toilet. Reinforce the student if pants remain dry and use a correction procedure for accidents.
► Step 7
Over the next several weeks, gradually increase the break interval. For most students, the interval may be extended to a 1- or a 1/4-hour period between trips to the bathroom. For example, if at the end of the intense potty training day the student was successful with 30-minute breaks and sat on the toilet for 5 minutes or less, continue with this schedule for a couple of days, then increase the break interval to 35 minutes. Continue to increase in 5-minute intervals every couple of days. If at any time the student repeatedly has accidents, consequate the accidents with correction procedures and goes back to a shorter interval until the student is again successful. Remember that the correction procedure should not be enjoyable; if the procedure is enjoyable, it will inadvertently reinforce accidents.
Additional Toileting Skills
The toileting skills that follow may be addressed after the student masters the steps presented previously.
Aiming
Boys are notorious for missing the toilet. If this occurs with the student you work with, place Fruit loops (the cereal) inside the toilet as targets to improve the aim (Fruit loops are better than cereals such as Cheerios because Fruit loops are more discriminable given their bright colours). The prompt provided by the Fruit loops may be faded over trials by gradually reducing the number of cereal pieces placed in the toilet at a time. As always, reinforce correct behaviour.
Wiping
Instruct the student to get some toilet paper (e.g., by saying, 'Get paper'), helping him to take an appropriate amount. Reinforce the student, then help him to correctly grab the paper and prompt him through the motion of wiping himself after you give the instruction 'Wipe.' Provide the student with reinforcement for wiping, then instruct and prompt him to drop the paper into the toilet.
Flushing
After the student uses the toilet, instruct, 'Rush.' You may physically prompt this behaviour by guiding the student's hand to the handle and pushing down firmly or by modelling the behaviour if the student has mastered the imitation of gross motor movements. Praise the student for flushing the toilet and fade the prompt over successive trials. Many students enjoy flushing toilets; thus, this skill may eventually be used as reinforcement for eliminating in the toilet.
Teaching the Student to Initiate Using the Toilet
After a successful month or so with 1- to 2-hour periods between trips to the bathroom, slowly increase the interval in 5-minute increments. The purpose of increasing the time interval is to make the student aware of (discriminate) the need to urinate, which may help the student learn to initiate going to the bathroom by expressing, 'Potty,' or performing a nonverbal indication (e.g., gesturing or handing you a picture of a toilet). As the time interval grows increasingly long, help the student go into the bathroom by conducting treatment or playtime near an open bathroom door (especially as the end of the interval nears). You may further help the student by walking the student toward the bathroom door should you observe signs of his needing to urinate. You may also use a partial prompt by saying all or part of the word 'potty' or motioning the student to nonverbally indicate the need to go to the bathroom. Continue to increase the interval and fade prompts until the student independently initiates going to the bathroom when needing to urinate.
Defecating in the Toilet
Most students are successful at learning to urinate into the toilet but still have accidents with their bowel movemerits. Although controlling the bowels is often more difficult to acquire than controlling the bladder, the same basic procedures may be used to teach this skill as those used for teaching the student to urinate in the toilet. One of the major problems encountered when teaching the student to use the toilet for bowel movements centres on the infrequency of elimination and the virtual absence of prompts such as the liquids used to prompt urination. The fewer opportunities there are to prompt, the lower the frequency of the behaviour and opportunities to reinforce. Hence the slower rate of acquisition.
Perhaps the best way to go about teaching the student to defecate in the toilet is to anticipate when the student is likely to have a bowel movement. The student may defecate at a certain time of the day or go to a certain place in the house to defecate. If you can anticipate when the student is likely to have a bowel movement, prompt sitting on the toilet for 5 to 15 minutes to probe whether or not success follows. If the student is successful, provide abundant verbal praise and special edible treats. If the student is not successful, provide praise for sitting nicely on the toilet, remove the student from the toilet, and later place him back on the toilet for a short time. If you catch the student in the act of defecating in his pants, immediately place the student on the toilet in an attempt to provide him with a successful bowel movement in the toilet. If the student completes the bowel movement in the toilet, provide abundant verbal praise and a special edible treat. This phase will most likely take much more time and effort than training the student to urinate in the toilet. Try not to become discouraged with the student, however, as learning to defecate in the toilet is a difficult step and takes many students with developmental delays a long time to acquire.
Areas of Difficulty
As with the other programs in this manual, the toilet training program was developed to suit the learning characteristics of most students with developmental delays. Despite these procedures, a variety of unique problems may manifest themselves, and you will have to improvise solutions for these problems.
A common problem is the student's withholding defecation when on the toilet. Some students may refrain from defecating for 4 or more days, causing much anxiety in their parents and team members. Some typical individuals 'hold on' as well, especially if only unfamiliar bathrooms are nearby. One solution to this problem is to wait it out; another solution is to consult the student's paediatrician to obtain a fast-acting laxative, which should produce results within 1 to 2 hours. The latter solution serves as a prompt. If it is fear that causes the student to withhold defecation, use a student's potty chair and take steps unique to the student to reduce his fear (e.g., play music, have her hold a favourite toy).
Some students refuse to eliminate in the bathroom but may eliminate in other rooms of the house or outside in the yard. If this occurs, begin toilet training in the area where the student is comfortable eliminating and gradually move the potty chair inside in incremental steps.
Numerous teaching manuals are available for helping children with developmental delays acquire self-help skills. Such manuals include the guidebook by Baker et al. (1997) and the detailed program for toilet training by Azrin and Foxx (1971).
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