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Simulation procedures for teaching independent menstrual care to mentally retarded persons
Applied Researchin Mental Retardation, Vol. 7. pp. 21-35. 1986 Printed in the USA. All rights reserved.
0270-3092/86 $3.00+ .00 Copyright © 1986 Pergamon Press Ltd.
Simulation Procedures for Teaching Independent Menstrual Care to Mentally Retarded Persons Gina S. Richman 1, Yula Ponticas 1, Terry I. Page, and Susan Epps 2 John F. Kennedy Institute and Johns Hopkins University School of Medicine
Four mentally retarded adolescent females participated in a program f o r assessment and training o f independent menstrual care skills. Three task analyses served as the basis f o r instruction: (a) menstrual stain on underwear, (b) menstrual stain on a sanitary pad, and (c) menstrual stain on both sanitary p a d and underwear. During individual training sessions, subjects were taught to perform correct sequences via simulation training with a small doll, in which a trainer utilized instructions, praise, modeling, and corrective feedback. Three types o f assessment probes were conducted prior to training, upon completion o f specified mastery criteria, and during post-training follow-up sessions. Doll probes assessed performance with the toy doll, self-probes assessed naturalistic performance but under conditions o f simulated menstruation, and in vivo probes assessed performance during actual menstruation. Results o f a multiple baseline analysis indicated that subjects emitted f e w correct responses during baseline probes, but showed consistent improvements that corresponded to the introduction o f training. Generalization to untrained skills was noted with all subjects. Follow-up assessments indicated maintenance o f skills f o r periods up to 30 weeks following termination o f training.
Although mentally retarded females reach menarche at an older age than developmentally normal females (Culley, 1974; Rundle & Sylvester, 1965; Salerno, Park, & Giannini, 1975), eventually caretakers must either attempt to teach functional menstrual-care skills or provide custodial care of these needs themselves. It has been reported that even mentally retarded young A d d r e s s r e p r i n t r e q u e s t s to: T e r r y J. P a g e , J o h n F. K e n n e d y I n s t i t u t e , 707 N o r t h B r o a d w a y , B a l t i m o r e , M D 21205. ' N o w at F l o r i d a S t a t e U n i v e r s i t y . 2Now at U n i v e r s i t y o f O r e g o n .
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women functioning as high as the trainable range rarely provide their own menstrual care (Alcorn, 1974; H a m m a r & Barnard, 1966). To address the problems associated with the menstrual-care needs of the mentally retarded, medical procedures rather than educational approaches have often been the recommended treatment. Several studies have reported parental approval of surgical hysterectomy for their mentally retarded daughters as a means of eliminating menstrual care problems ("Sexual Development," 1976; Turchin, 1974). Others have cited specific cases in which hysterectomies were performed at least in part due to menstrual hygiene concerns (Alcorn, 1974; Bass, 1978; Crain, 1980; McNamara, Scoggin, & Raskin, 1974; Perrin, Sands, Tinker, Dominquez, Dingle, & Thomas, 1976). However, the use of nontherapeutic hysterectomies has raised numerous ethical and legal concerns (Crain, 1980; West, 1977). Since 1974 there has been a moratorium on the use of federal funds for involuntary sterilization or for sterilization of persons under the age of 21 (Dowben & Heartwell, 1979). The central issue related to sterilization of mentally retarded persons concerns consent ("DHEW Proposes," 1978), and the question of the individual's capacity to give informed consent. Another medical intervention sometimes recommended is the use of drugs such as norethisterone or norethynodrel with mestranol to induce amenorrhea (Roxburgh & West, 1973; Shropshire, Morris, & Foote, 1967). Although the prescription of such medication circumvents legal problems associated with surgical procedures, their use is not without side effects, and long-term studies have yet to be done. Moreover, drug therapy should not be considered the treatment of choice if less intrusive interventions are available. Research in the area of training functional skills to the mentally retarded has resulted in numerous programs for teaching a variety of self-help repertoires. A technology based on behavioral instructional methods has emerged over the past 15 years and been shown to be successful in teaching skills such as toileting (Azrin & Foxx, 1971), dressing (Minge & Ball, 1967), toothbrushing ( H o r n e r & Keilitz, 1975), and feeding (Barton, Guess, Garcia, & Baer, 1970). Despite the development of this well-defined technology, the problem of menstrual care in mentally retarded individuals remains an area in which no widely accepted programs are available. Only a few studies have addressed the problem, and none have provided a documented, replicable program. For example, Girardeau and Spradlin (1964) reported on the initial stages of a token economy for mentally retarded women. Although correct use of sanitary napkins was included as one of several self-care training goals, specific procedures were not described and results were not discussed. Moudgil (1970) briefly outlined a program to teach menstrual care to the mentally retarded, but training was limited to only one subject and objective data were not provided. Hamilton, Allen, Stephens, and Davall (1969) employed a 5-step pro-
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cedure in training mentally retarded institutionalized females to use sanitary napkins. However, specific training procedures were not described, and no baseline data were reported. The present study was designed to identify methods for the assessment and training of menstrual-care skills to moderately and severely mentally retarded young women. Thus, one goal was to develop procedures for assessing menstrual care skills without having to rely on the presence of menstruation. A second goal was to develop and evaluate training procedures for teaching independent menstrual skills. A training program was designed based on previous research (Neef, Iwata, & Page, 1978; Page, Iwata, & Neef, 1976) that had suggested advantages of simulation training with mentally retarded individuals. METHOD
Subjects Four mentally retarded females participated as subjects. Each subject had experienced menarche at least 4 years prior to the study and menstruated regularly. All of the subjects lived at home, and had been referred because of dependence upon family a n d / o r school staff for menstrual care. Arlene was 21 years old, had Down syndrome and was reported to be functioning in the severe to profound range of mental retardation. Her expressive speech was largely unintelligible due to severe articulation problems, although she complied with simple l and 2-step requests. Debbie was 18 years old and had been diagnosed as severely retarded (IQ = 35 on Stanford-Binet). She had functional expressive language and followed 2-step requests. Karen was 17 years old and moderately mentally retarded (IQ = 47 on Stanford-Binet). She readily complied with 1-step requests with prompting, but had difficulty with expressive language due to stuttering. Bonnie was 17 years old and moderately mentally retarded (IQ = 43 on Stanford-Binet). She demonstrated basic expressive language and complied with multiple-step requests.
Setting Sessions with Debbie, Karen, and Bonnie were conducted in their school setting, a prevocational program for mentally retarded adolescents and adults. For Arlene, who was not enrolled in an educational program, sessions were conducted in a pediatric hospital outpatient clinic. In both facilities, assessment and training sessions were held in bathrooms and adjoining lounge areas. During assessment and training sessions, use of these areas by other persons
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was prevented in order to protect the privacy of subjects. Furniture included tables, chairs, and couches. Materials Underwear and self-adhesive sanitary pads were stained with non-toxic red tempera paint to allow for assessment and training of menstrual-care skills in the absence of menstruation. Other supplies included small paper bags for disposal of soiled pads, small clear plastic bags for storage of soiled underwear, clean underwear, and clean sanitary pads. A 12 in female doll with underwear was used in assessment and training. Self-adhesive sanitary pads scaled to the appropriate size were cut from full-size pads. Data Collection Response definitions and scoring. Table 1 shows task analyses identified for three different sequences of menstrual care. Each task analysis describes correct responses in the presence of a particular discriminative stimulus, which would presumably become salient when an individual sat on a toilet to urinate or defecate. The discriminative stimuli consisted of: (a) stained underwear, indicating recent onset of menses; (b) stained sanitary pad, indicating menstrual discharge since previous placement of a clean pad; and (c) stained sanitary pad and underwear, indicating excessive menstrual flow sufficient to stain underwear as well as pad. The behaviors described in Table 1 served as the basis for response definitions. A response was scored as correct if it was independently emitted within 5 s of the preceding response or trainer instruction. In some cases, the sequence of response could deviate from that shown in Table 1 and still be scored as correct. Assessment probes. Three different types of probes were conducted. Selfprobes, doll probes, and in vivo probes were scheduled under the following conditions: (a) during baseline, (b) upon mastery of one of the skill sequences, and (c) during follow-up. Reinforcement was not provided for correct responses, nor was there any feedback for incorrect responses. Length of probes varied between 1-5 minutes. Self-probes were designed to assess: (a) generalization of learned skills from doll training sessions to naturalistic conditions, (b) performance in the absence of reinforcement and corrective feedback, and (c) the occurrence of generalization to untrained skills. To allow for assessment in the absence of menstruation, menstrual flow was simulated by using pads and underwear stained with red tempera paint. In a self-probe for stained underwear, the subject was asked to put on previously stained underwear and then to go to the bathroom and sit on the toilet. When seated, the subject was asked to identify what she
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T A B L E 1. Task Analyses of Menstrual Care for Each of Three Stimulus Conditions: Stained Pad, Stained Underwear, and Stained Pad and Underwear
Stained Underwear
Stained Pad
Stained Pad and Underwear
1. Identify stained underwear. 2. Obtain clean pad. 3. Obtain clean underwear. 4. Obtain plastic bag.
1. Identify stained pad. 2. Obtain clean pad. 3. Obtain paper bag.
1. Identify stained pad. 2. Identify stained underwear. 3. Obtain clean pad. 4. Obtain clean underwear. 5. Obtain paper bag. 6. Obtain plastic bag.
5. Return to bathroom and close door. 6. Wash hands. 7. Pull underwear below knees and sit on toilet,
4. Return to bathroom and close door. 5. Wash hands. 6. Pull underwear below knees and sit on toilet,
7. Return to bathroom and close door. 8. Wash hands. 9. Pull underwear below knees and sit on toilet.
8. Remove soiled underwear 9. Place soiled underwear in plastic bag.
7. Remove soiled pad from underwear. 8. Place soiled pad in paper bag.
10. Remove soiled pad from underwear. 11. Place soiled pad in paper bag. 12. Removed soiled underwear. 13. Place soiled underwear in plastic bag.
10. Wipe vaginal area. I I. Dispose of paper in toilet, 12. Flush toilet once. 13. Put on clean underwear. 14. Pull tab off clean pad. 15. Properly dispose of tab. 16. Press clean pad into uuderwear,
9. Wipe vaginal area. 10. Dispose of paper in toilet, I 1. Flush toilet once. 12. Pull tab off clean pad. 13. Properly dispose of tab. 14. Press clean pad into underwear,
14. Wipe vaginal area. 15. Dispose of paper in toilet. 16. Flush toilet once. 17. Put on clean underwear. 18. Pull tab off clean pad. 19. Properly dispose of tab. 20. Press clean pad into underwear.
17. Pull up underwear and outer clothes, 18. Wash hands after above sequence, 19. Remove plastic bag from bathroom,
15. Pull up underwear and outer clothes, 16. Wash hands after above sequence, 17. Properly dispose of paper bag.
21. Pull up underwear and outer clothes. 22. Wash hands after above sequence. 23. Properly dispose of paper bag. 24. Remove plastic bag from bathroom.
s a w in h e r u n d e r w e a r . F o l l o w i n g e i t h e r a c o r r e c t v e r b a l r e s p o n s e , o r n o c o r rect r e s p o n s e after the q u e s t i o n was r e p e a t e d , the subject was a s k e d to dress and was taken to the lounge area outside the bathroom where the menstrual care supplies were kept. H e r e she was asked w h a t materials were n e e d e d to t a k e care o f t h e stain, a n d given t h o s e she i d e n t i f i e d . A f t e r t h e s u b j e c t s t o p p e d requesting materials, or 5 s following a repetition o f the q u e s t i o n with no further responding, the subject was instructed to do what she was supposed to
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do when she saw a stain. She was then allowed to respond until she made no further responses or verbally indicated she was finished. Probes were terminated when all of the steps had been completed or when no responding occurred for a period of 5 s following the repeated question. Similar sequences were followed during the probes for stained pad and the combined stainedpad-and-underwear conditions. Dollprobes were designed to assess (a) generalization of learned skills to conditions under which reinforcement and corrective feedback were not provided, and (b) generalization to untrained skills. Doll probes were conducted to provide more information in the event of poor generalization to naturalistic probes. Specifically, incorrect performance on a self probe or in vivo probe (described in the following paragraph) would be attributed to (a) incomplete acquisition of skills if performance was also incorrect on the doll probe, or (b) poor stimulus generalization from doll training if the doll probe performance was correct. Conditions were identical to self-probes with the exception that the doll rather than the subject herself was the locus of discriminative stimuli and a scaled-down toilet and sanitary pads were used. Doll probes were conducted for all three task analyses shown in Table 1. In vivo probes were designed to assess: (a) subjects' skills under conditions of actual menstrual flow on pads a n d / o r underwear, (b) performance in the absence of reinforcement and corrective feedback, and (c) generalization to untrained skills. They were conducted whenever actual menstruation was present during a scheduled probe session. Initially, the presence of menstruation was checked by the trainer when a subject was asked to replace her own underwear for the purposes of conducting a self-probe. Subsequently, attempts were made to schedule clinic visits to coincide with subjects' menstrual cycles. In vivo probes were conducted in the same setting as self-probes and doll probes, and were identical in format with the exception that menstrual flow was not simulated. Observer training and agreement. Three female experimenters served as observers. Training consisted of reading response definitions, discussing potential ambiguities, and practicing data collection during probe a n d / o r training sessions. A second observer was present during 50°7o of all probe sessions to assess interobserver agreement. Agreement was assessed on a step-by-step basis for all subjects on the three task analyses. Indices of occurrence agreement were obtained by dividing the number of agreements on occurrence by agreements on occurrence plus disagreements and multiplying by 100. Combined or overall agreement indices were obtained by dividing the total number of agreements by agreements plus disagreements and multiplying by 100. Interobserver agreement indices were 100°70 for both occurrence and combined indices across all probes.
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Experimental Conditions Baseline. Prior to initiation of training, individual subjects' skills on each of the three task sequences were measured by way of assessment probes. Each subject participated in self-probes, doll probes, and when possible, in vivo probes. Skill training. Individual subjects were taught to perform the correct sequences of responses via training with the toy doll. Subjects were taught to manipulate the doll so as to emit correct response sequences in the presence of each of the three relevant discriminative stimuli, as shown in Table 1. Training consisted of utilizing a forward-chaining procedure. Subjects proceeded through the task analysis until a response was performed incorrectly or omitted. At this point, the trainer required the subject to perform the step correctly, and then start the chain over. The trainer used verbal prompts, modeling, or, if necessary, physical guidance to prompt the correct response. Praise was delivered contingent upon correct responding; with one subject (Arlene) edible reinforcement (e.g., cookie or cracker) was used. Only one task analysis was trained at a given time, beginning with the stained-pad sequence. Mastery criterion was the completion of an entire task sequence with no errors for a minimum of two trials. Session length was approximately 30 minutes. Upon reaching mastery criterion on a sequence, a short review session was conducted. The purpose of these sessions was to provide a brief review of previously learned skills. Each review session consisted of having a subject demonstrate correct performance of all previously trained response sequences. Reinforcement and corrective feedback were provided as during training. Following a review session, assessment probes were conducted as previously described. First a doll probe was conducted, followed by a self-probe or, when possible, an in vivo probe. During assessment probes, correct response sequences were not reinforced and no feedback was provided contingent upon incorrect responses. If one or more skills were performed incorrectly during the probe, the next training session consisted of additional training on the incorrect responses. When mastery criterion was again met, another probe session was held. Once a subject achieved 80°7o or better on the post-training self-probe for stained-pad skills, similar training began for the stained-underwear sequence. Once criterion was attained for stained-underwear skills, training began on the final task analysis, combined-pad-and-underwear skills. Follow-up. After the completion of training, assessment probes were scheduled to monitor maintenance of skills across time. Doll probes were not conducted. Whenever possible, sessions were scheduled to coincide with menstruation to allow for the collection of data under in vivo conditions. Follow-up
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assessment probes were identical to probes conducted during baseline and upon achievement of mastery criterion. E x p e r i m e n t a l Design
Training procedures were implemented within the framework of multiplebaseline designs across both subjects and behaviors (Baer, Wolf, & Risley, 1968). First, with respect to subjects, training was begun with Debbie and Arlene after three baseline assessment probes. With Karen and Bonnie, initiation of training was lagged and begun following six baseline assessment probes. Second, with respect to behaviors, baseline assessment probes on all three task sequences was followed by training only on the stained-pad skills; the other two sequences continued to be assessed under baseline conditions. Implementation of training was then lagged across the two remaining sequences. RESULTS Figure 1 shows assessment data for all subjects on self-, doll, and in vivo probes. Results of baseline, post-training, and follow-up probes are presented with data collapsed across all three skill sequences to show the multiple baseline analysis across subjects. During baseline assessment, the range of correct responding on self-probes was 38-41% for Debbie, 0% for Arlene, 33-45°70 for Bonnie, and 10-19% for Karen. Following the initiation of skills training, scores on self-probes increased to 79-100% for Debbie, 43-95% for Arlene, 97-100% for Bonnie, and 46-100% for Karen. Corresponding performance increments were observed on doll probes with all three subjects. Although a limited number of in vivo probes were possible, improved performance on this measure was observed subsequent to the initiation of training. Moreover, increases for in vivo scores covaried with improvements on self and doll probes. Figure 2 shows assessment data for all subjects, plotted across the three different skill sequences to show the multiple-baseline analysis across responses. During self-probe baseline assessments with Debbie, correct responding ranged from 7 to 17 on pad skills to 9 of 19 on both underwear skills and 9 of 24 on the combined sequence, After training on the stained-pad sequence, correct responding increased to the m a x i m u m 17 steps on both doll and selfprobes; in addition, generalization to the remaining baselines can be noted. Training on the stained-underwear sequence also resulted in further increases in correct responding for that skill, to the m a x i m u m 19 steps on both doll and self-probes. Generalization to the combined-underwear-and-pad sequence made training on that component unnecessary with Debbie. Maximum correct responding continued to be observed for all three sequences during subse-
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29
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FIGURE 2. Number of correct responses on each of the task analyses by all subjecls on selfprobes (open circles), doll probes (closed circles), and in vivo probes (Iriangles).
30
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31
quent assessment probes, and was maintained at follow-up conducted 30 weeks after the termination of training. Data collected on Debbie during in vivo probes showed similar increases as training was introduced across the three skill sequences. The first possible in vivo probe occurred while all three skill sequences were being assessed under baseline conditions and resulted in only 6 correct of 24 possible responses on the combined sequence. During the second in vivo assessment, separate probes on both the pad and the combined sequence were conducted. This was possible because of the occurrence of additional menstruation following an initial probe on the combined sequence. Correct responding on the pad sequence, which had been trained, was the m a x i m u m 17. On the combined sequence, which was untrained, 16 of 24 steps were correct. All steps were performed correctly on the final two in vivo probes; one on the combined sequence at the conclusion of training and one on the pad sequence at the 30-week follow-up. Similar results were obtained with the remaining three subjects. Arlene made no correct responses on the initial three baseline probes. As training was introduced, substantial improvements were noted on both self-probes and doll probes, and generalization to untrained skills was observed. All skills were maintained across subsequent probes with the m a x i m u m 17, 19, and 24 correct responses, respectively, for pad, underwear, and the combined sequence on all three follow-up probes 12 weeks after discontinuation of training. The one in vivo probe conducted with Arlene was on stained-pad skills after that sequence had been trained, and resulted in correct performance on all 17 steps. As a result of structural variations in the bathroom where Karen was trained, Step 3 (closing b a t h r o o m door) was deleted from the task analysis; thus, the total possible correct responses was reduced by one. As with Debbie, correct responding was infrequent during initial baseline probes with Karen. As training was sequentially introduced, performance on target skills approached maximum correct, and generalization to untrained sequences was observed. Two in vivo probes were possible with Karen, both on the stainedunderwear sequence. On the first, under baseline conditions, she performed only 1 of the 18 steps correctly; the second, after training on that sequence, resulted in 14 steps correct. No follow-up probes were possible with Karen. Bonnie also exhibited a small number of correct responses during initial baseline assessments. Training on the stained-pad and stained-underwear sequences resulted in m a x i m u m performance of 17 to 19 correct responses, respectively, on those skill sequences. Generalization to the combined-padand-underwear sequence following training on the first two sequences made training on that component unnecessary. Follow-up probes conducted 30 weeks after training reflected continued maintenance of skills. Two in vivo probes were possible with Bonnie, both on the stained-pad sequence. The initial in vivo probe was during baseline, resulted in zero correct responses; the second was at the 30-week follow-up and resulted in the m a x i m u m 17 correct responses.
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DISCUSSION Results obtained with the four subjects in this study suggest that the menstrual care program is appropriate for the assessment and training of functional skills in trainable and severely mentally retarded females. The two multiple baseline analyses suggest that the forward chaining procedure was responsible for large increases in correct performance. With all four subjects, performance on assessment probes improved only after skill training had been initiated. Furthermore, with individual subjects, initial training of stainedpad skills resulted in improved performance on that sequence. With three subjects, generalization to untrained sequences was observed. Subsequent implementation of training across the remaining skill sequences resulted in further improvement with all four subjects. Despite the many documented programs to teach functional self-help skills to the mentally retarded, this program is one of the few available to teach menstrual-care skills. Moreover, this program can be seen to offer a more thorough description and evaluation than previous menstrual care programs in which either baseline data were not available (Hamilton et al., 1969), or no outcome data were reported (Girardeau & Spradlin, 1964; Moudgil, 1970). Although evaluated only with trainable and severely mentally retarded persons in this study, the program appears applicable to other broad groups of individuals with skill deficits in menstrual care. The generalization to untrained skill sequences that was noted with all four subjects was not totally unexpected in light of the number of responses that are c o m m o n to all three skill sequences. Although the degree of generalization observed here confounds somewhat a multiple-baseline analysis across responses, it can be seen as a clinically desired outcome. In fact, with two of the four subjects, training on the final sequence, combined-pad-and-underwear skills, was not necessary because of the improvement attributable to generalization. One noteworthy aspect of the results is the maintenance of appropriate performance observed with the three subjects for whom follow-up data were collected. Correct responding was observed 12 weeks after training was terminated with Arlene and 30 weeks after training with Debbie and Bonnie. O f particular importance are those follow-up probes that were conducted under in vivo conditions. Both Debbie and Bonnie showed 100% maintenance of stained-pad skills during in vivo assessment probes 30 weeks after training. Although the doll-training component of the program was not directly evaluated here, it does appear to have advantages over a more direct, in vivo intervention. First, with doll training the location of sessions is not restricted to a bathroom or other private areas, but can be carried out in most classroom and home settings. Second, presentation of repeated instructional trials is facilitated by using a doll rather than the individual herself (e.g., menstrua-
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tion is more easily simulated with the doll). Third, the use of a doll avoids repeatedly exposing an individual to potentially embarrassing situations (e.g., having to wear stained pads and underwear). Despite the positive results obtained with the subjects in this study, it is important to note two possible drawbacks. First, the majority of data were collected under conditions of simulated menstruation. However, conducting assessment and training sessions only during times of real menstruation would not have been practical. Sessions would have been difficult to schedule and the long delays between sessions might be expected to increase the number of sessions necessary to meet mastery criterion. As a result of the concern for naturalistic assessment, in vivo probes were conducted whenever actual menstrual flow was present. However, because it was not possible to conduct in vivo probes under conditions of covert observation, sessions were similar to those during self-probes. Second, subjects' inability to obtain necessary materials may have affected subsequent steps in each of the skill sequences. It is possible that merely providing materials such as clean pads, underwear, and bags may have resulted in improved baseline scores. Considering the necessity of appropriate menstrual hygiene and the legal and ethical problems associated with elective hysterectomies, the present training program provides a useful methodology for assessing and teaching menstrual self-care with trainable and severely mentally retarded persons. Educational procedures such as those described here should be attempted before considering more intrusive techniques, such as surgical or other medical (e.g., drug) interventions. Future research in the area of menstrual-care training with the mentally retarded will need to explore additional methods for conducting training. In light of the demonstrated effectiveness of doll training, it might be possible to provide instruction within a group training format. Or, higher functioning individuals may be successfully trained via alternative procedures, such as using picture cues to teach correct skill sequences. In addition, it will be important in future research to examine methods of programming generalization of menstrual care skills to more naturalistic conditions, and to document independent performance o f proper hygiene. Acknowledgements-This research was supported in part by Grant # 00917-15-0 from Mater-
nal and Child Health of the Department of Health and Human Services. Appreciation is extended to Brian lwata and Nancy Neef for their helpful comments regarding the preparation of this manuscript. REFERENCES AIcorn, D. A. (1974). Parental viewson sexual developmentand education of the trainable mentally retarded. The Journal of Special Education, 8, 119-130. Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet training the institutionalized
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retarded. Journal o f Applied Behavior Analysis, 4, 89-99. Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal o f Applied Behavior Analysis, 1, 91-97. Barton, E. S., Guess, D., Garcia, E., & Baer, D. M. (1970). Improvement of retardates' mealtime behaviors by timeout procedures using multiple-baseline techniques. Journal o f Applied Behavior Analysis, 3, 77-84. Bass, M. S. (1978). Surgical contraception: A key to normalization and prevention. Mental Retardation, 16, 399-404. Crain, L. S. (1980). Sterilization and the retarded female: Another perspective. Pediatrics, 66, 650-651. Culley, W. J. (1974). Age and body size of mentally retarded girls at menarche. Developmental Medicine and Child Neurology, 16, 209-213. DHEW proposes 30-day waiting period for sterilizations; No funds for under 2/5, contraceptive hysterectomies. (1978). Family Planning Perspectives, 10, 39. Dowben, C., & Heartwell, S. F. (1979). Legal implications of sterilization of the mentally retarded. American Journal o f Disease o f Children, 133, 697-699. Girardeau, F. L., & Spradlin, J. E. (1964). Token rewards in a cottage program. Mental Retardation, 61, 345-351. Hamilton, J., Allen, P., Stephens, L., & Davall, E. (1969). Training mentally retarded females to use sanitary napkins. Mental Retardation, 7, 40-43. Hammar, S. L., Barnard, K. E. (1966). The mentally retarded adolescent: A review of the characteristics and problems of 44 non-institutionalized adolescent retardates. Pediatrics, 38, 845-857. Homer, R. D., & Keilitz, 1. (1975). Training mentally retarded adolescents to brush their teeth. Journal o f Applied Behavior Analysis, 8, 301-309. McNamara, V. P., Scoggin, W. A., & Raskin, F. (1974). Sterilization of the mentally retarded at the Medical College of Georgia, under law no. 1288. Journal o f the Medical Association o f Georgia, 63, 327-331. Minge, M. R., & Ball, T. S. (1967). Teaching of self-help skills to profoundly retarded patients. American Journal o f Mental Deficiency, 71, 864-868. Moudgil, A. C. (1970). Teaching menstrual hygiene to a mentally retarded. Indian Journal o f Mental Retardation, 3, 50-54. Neef, N. A., lwata, B. A., & Page, T. J. (1978). Public transportation training: In vivo versus classroom instruction. Journal o f Applied Behavior Analysis, 11, 331-344. Page, T. J., lwata, B. A., & Neef, N. A. (1976). Teaching pedestrian skills to retarded persons: Generalization from the classroom to the natural environment. Journal o f Applied Behavior Analysis, 9, 433-444. Perrin, J. C., Sands, C. R., Tinker, D. E., Dominquez, B. C., Dingle, J. T., & Thomas, M. J. (1976). A considered approach to sterilization of mentally retarded youth. American Journal o f Diseases o f Children, 130, 288-290. Roxburgh, D. R., & West, M. J. (1973). The use of the norethisterone to suppress menstruation in the intellectually severely retarded woman. The Medical Journal o f Australia, 2, 310-313. Rundle, A. T., & Sylvester, P. E. (1965). Endocrinological aspects of mental deficiency. Growth and development of young females. American Journal o f Mental Deficiency, 69, 635. Salerno, L. J., Park, J. K., & Giannini, M. J. (1975). Reproductive capacity of the mentally retarded. The Journal o f Reproductive Medicine, 14, 123-129. Sexual development in mentally handicapped children. (1976). British Medical Journal, 2, 71-72. Shropshire, L., Morris, W. M., & Foote, E. L. (1967). Suppression of menstruation: A hygiene measure in the care of mentally retarded patients. Journal o f the American Medical Association, 200, 144-145.
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Turchin, G. (1974). Sexual attitudes of mothers of retarded children. The Journal of School Health, 44, 490-492. West, R. R. (1977). Sterilization of mentally retarded women. The Medical Journal of Australia, 1,830.
0270-3092/86 $3.00+ .00 Copyright © 1986 Pergamon Press Ltd.
Simulation Procedures for Teaching Independent Menstrual Care to Mentally Retarded Persons Gina S. Richman 1, Yula Ponticas 1, Terry I. Page, and Susan Epps 2 John F. Kennedy Institute and Johns Hopkins University School of Medicine
Four mentally retarded adolescent females participated in a program f o r assessment and training o f independent menstrual care skills. Three task analyses served as the basis f o r instruction: (a) menstrual stain on underwear, (b) menstrual stain on a sanitary pad, and (c) menstrual stain on both sanitary p a d and underwear. During individual training sessions, subjects were taught to perform correct sequences via simulation training with a small doll, in which a trainer utilized instructions, praise, modeling, and corrective feedback. Three types o f assessment probes were conducted prior to training, upon completion o f specified mastery criteria, and during post-training follow-up sessions. Doll probes assessed performance with the toy doll, self-probes assessed naturalistic performance but under conditions o f simulated menstruation, and in vivo probes assessed performance during actual menstruation. Results o f a multiple baseline analysis indicated that subjects emitted f e w correct responses during baseline probes, but showed consistent improvements that corresponded to the introduction o f training. Generalization to untrained skills was noted with all subjects. Follow-up assessments indicated maintenance o f skills f o r periods up to 30 weeks following termination o f training.
Although mentally retarded females reach menarche at an older age than developmentally normal females (Culley, 1974; Rundle & Sylvester, 1965; Salerno, Park, & Giannini, 1975), eventually caretakers must either attempt to teach functional menstrual-care skills or provide custodial care of these needs themselves. It has been reported that even mentally retarded young A d d r e s s r e p r i n t r e q u e s t s to: T e r r y J. P a g e , J o h n F. K e n n e d y I n s t i t u t e , 707 N o r t h B r o a d w a y , B a l t i m o r e , M D 21205. ' N o w at F l o r i d a S t a t e U n i v e r s i t y . 2Now at U n i v e r s i t y o f O r e g o n .
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women functioning as high as the trainable range rarely provide their own menstrual care (Alcorn, 1974; H a m m a r & Barnard, 1966). To address the problems associated with the menstrual-care needs of the mentally retarded, medical procedures rather than educational approaches have often been the recommended treatment. Several studies have reported parental approval of surgical hysterectomy for their mentally retarded daughters as a means of eliminating menstrual care problems ("Sexual Development," 1976; Turchin, 1974). Others have cited specific cases in which hysterectomies were performed at least in part due to menstrual hygiene concerns (Alcorn, 1974; Bass, 1978; Crain, 1980; McNamara, Scoggin, & Raskin, 1974; Perrin, Sands, Tinker, Dominquez, Dingle, & Thomas, 1976). However, the use of nontherapeutic hysterectomies has raised numerous ethical and legal concerns (Crain, 1980; West, 1977). Since 1974 there has been a moratorium on the use of federal funds for involuntary sterilization or for sterilization of persons under the age of 21 (Dowben & Heartwell, 1979). The central issue related to sterilization of mentally retarded persons concerns consent ("DHEW Proposes," 1978), and the question of the individual's capacity to give informed consent. Another medical intervention sometimes recommended is the use of drugs such as norethisterone or norethynodrel with mestranol to induce amenorrhea (Roxburgh & West, 1973; Shropshire, Morris, & Foote, 1967). Although the prescription of such medication circumvents legal problems associated with surgical procedures, their use is not without side effects, and long-term studies have yet to be done. Moreover, drug therapy should not be considered the treatment of choice if less intrusive interventions are available. Research in the area of training functional skills to the mentally retarded has resulted in numerous programs for teaching a variety of self-help repertoires. A technology based on behavioral instructional methods has emerged over the past 15 years and been shown to be successful in teaching skills such as toileting (Azrin & Foxx, 1971), dressing (Minge & Ball, 1967), toothbrushing ( H o r n e r & Keilitz, 1975), and feeding (Barton, Guess, Garcia, & Baer, 1970). Despite the development of this well-defined technology, the problem of menstrual care in mentally retarded individuals remains an area in which no widely accepted programs are available. Only a few studies have addressed the problem, and none have provided a documented, replicable program. For example, Girardeau and Spradlin (1964) reported on the initial stages of a token economy for mentally retarded women. Although correct use of sanitary napkins was included as one of several self-care training goals, specific procedures were not described and results were not discussed. Moudgil (1970) briefly outlined a program to teach menstrual care to the mentally retarded, but training was limited to only one subject and objective data were not provided. Hamilton, Allen, Stephens, and Davall (1969) employed a 5-step pro-
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cedure in training mentally retarded institutionalized females to use sanitary napkins. However, specific training procedures were not described, and no baseline data were reported. The present study was designed to identify methods for the assessment and training of menstrual-care skills to moderately and severely mentally retarded young women. Thus, one goal was to develop procedures for assessing menstrual care skills without having to rely on the presence of menstruation. A second goal was to develop and evaluate training procedures for teaching independent menstrual skills. A training program was designed based on previous research (Neef, Iwata, & Page, 1978; Page, Iwata, & Neef, 1976) that had suggested advantages of simulation training with mentally retarded individuals. METHOD
Subjects Four mentally retarded females participated as subjects. Each subject had experienced menarche at least 4 years prior to the study and menstruated regularly. All of the subjects lived at home, and had been referred because of dependence upon family a n d / o r school staff for menstrual care. Arlene was 21 years old, had Down syndrome and was reported to be functioning in the severe to profound range of mental retardation. Her expressive speech was largely unintelligible due to severe articulation problems, although she complied with simple l and 2-step requests. Debbie was 18 years old and had been diagnosed as severely retarded (IQ = 35 on Stanford-Binet). She had functional expressive language and followed 2-step requests. Karen was 17 years old and moderately mentally retarded (IQ = 47 on Stanford-Binet). She readily complied with 1-step requests with prompting, but had difficulty with expressive language due to stuttering. Bonnie was 17 years old and moderately mentally retarded (IQ = 43 on Stanford-Binet). She demonstrated basic expressive language and complied with multiple-step requests.
Setting Sessions with Debbie, Karen, and Bonnie were conducted in their school setting, a prevocational program for mentally retarded adolescents and adults. For Arlene, who was not enrolled in an educational program, sessions were conducted in a pediatric hospital outpatient clinic. In both facilities, assessment and training sessions were held in bathrooms and adjoining lounge areas. During assessment and training sessions, use of these areas by other persons
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was prevented in order to protect the privacy of subjects. Furniture included tables, chairs, and couches. Materials Underwear and self-adhesive sanitary pads were stained with non-toxic red tempera paint to allow for assessment and training of menstrual-care skills in the absence of menstruation. Other supplies included small paper bags for disposal of soiled pads, small clear plastic bags for storage of soiled underwear, clean underwear, and clean sanitary pads. A 12 in female doll with underwear was used in assessment and training. Self-adhesive sanitary pads scaled to the appropriate size were cut from full-size pads. Data Collection Response definitions and scoring. Table 1 shows task analyses identified for three different sequences of menstrual care. Each task analysis describes correct responses in the presence of a particular discriminative stimulus, which would presumably become salient when an individual sat on a toilet to urinate or defecate. The discriminative stimuli consisted of: (a) stained underwear, indicating recent onset of menses; (b) stained sanitary pad, indicating menstrual discharge since previous placement of a clean pad; and (c) stained sanitary pad and underwear, indicating excessive menstrual flow sufficient to stain underwear as well as pad. The behaviors described in Table 1 served as the basis for response definitions. A response was scored as correct if it was independently emitted within 5 s of the preceding response or trainer instruction. In some cases, the sequence of response could deviate from that shown in Table 1 and still be scored as correct. Assessment probes. Three different types of probes were conducted. Selfprobes, doll probes, and in vivo probes were scheduled under the following conditions: (a) during baseline, (b) upon mastery of one of the skill sequences, and (c) during follow-up. Reinforcement was not provided for correct responses, nor was there any feedback for incorrect responses. Length of probes varied between 1-5 minutes. Self-probes were designed to assess: (a) generalization of learned skills from doll training sessions to naturalistic conditions, (b) performance in the absence of reinforcement and corrective feedback, and (c) the occurrence of generalization to untrained skills. To allow for assessment in the absence of menstruation, menstrual flow was simulated by using pads and underwear stained with red tempera paint. In a self-probe for stained underwear, the subject was asked to put on previously stained underwear and then to go to the bathroom and sit on the toilet. When seated, the subject was asked to identify what she
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T A B L E 1. Task Analyses of Menstrual Care for Each of Three Stimulus Conditions: Stained Pad, Stained Underwear, and Stained Pad and Underwear
Stained Underwear
Stained Pad
Stained Pad and Underwear
1. Identify stained underwear. 2. Obtain clean pad. 3. Obtain clean underwear. 4. Obtain plastic bag.
1. Identify stained pad. 2. Obtain clean pad. 3. Obtain paper bag.
1. Identify stained pad. 2. Identify stained underwear. 3. Obtain clean pad. 4. Obtain clean underwear. 5. Obtain paper bag. 6. Obtain plastic bag.
5. Return to bathroom and close door. 6. Wash hands. 7. Pull underwear below knees and sit on toilet,
4. Return to bathroom and close door. 5. Wash hands. 6. Pull underwear below knees and sit on toilet,
7. Return to bathroom and close door. 8. Wash hands. 9. Pull underwear below knees and sit on toilet.
8. Remove soiled underwear 9. Place soiled underwear in plastic bag.
7. Remove soiled pad from underwear. 8. Place soiled pad in paper bag.
10. Remove soiled pad from underwear. 11. Place soiled pad in paper bag. 12. Removed soiled underwear. 13. Place soiled underwear in plastic bag.
10. Wipe vaginal area. I I. Dispose of paper in toilet, 12. Flush toilet once. 13. Put on clean underwear. 14. Pull tab off clean pad. 15. Properly dispose of tab. 16. Press clean pad into uuderwear,
9. Wipe vaginal area. 10. Dispose of paper in toilet, I 1. Flush toilet once. 12. Pull tab off clean pad. 13. Properly dispose of tab. 14. Press clean pad into underwear,
14. Wipe vaginal area. 15. Dispose of paper in toilet. 16. Flush toilet once. 17. Put on clean underwear. 18. Pull tab off clean pad. 19. Properly dispose of tab. 20. Press clean pad into underwear.
17. Pull up underwear and outer clothes, 18. Wash hands after above sequence, 19. Remove plastic bag from bathroom,
15. Pull up underwear and outer clothes, 16. Wash hands after above sequence, 17. Properly dispose of paper bag.
21. Pull up underwear and outer clothes. 22. Wash hands after above sequence. 23. Properly dispose of paper bag. 24. Remove plastic bag from bathroom.
s a w in h e r u n d e r w e a r . F o l l o w i n g e i t h e r a c o r r e c t v e r b a l r e s p o n s e , o r n o c o r rect r e s p o n s e after the q u e s t i o n was r e p e a t e d , the subject was a s k e d to dress and was taken to the lounge area outside the bathroom where the menstrual care supplies were kept. H e r e she was asked w h a t materials were n e e d e d to t a k e care o f t h e stain, a n d given t h o s e she i d e n t i f i e d . A f t e r t h e s u b j e c t s t o p p e d requesting materials, or 5 s following a repetition o f the q u e s t i o n with no further responding, the subject was instructed to do what she was supposed to
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do when she saw a stain. She was then allowed to respond until she made no further responses or verbally indicated she was finished. Probes were terminated when all of the steps had been completed or when no responding occurred for a period of 5 s following the repeated question. Similar sequences were followed during the probes for stained pad and the combined stainedpad-and-underwear conditions. Dollprobes were designed to assess (a) generalization of learned skills to conditions under which reinforcement and corrective feedback were not provided, and (b) generalization to untrained skills. Doll probes were conducted to provide more information in the event of poor generalization to naturalistic probes. Specifically, incorrect performance on a self probe or in vivo probe (described in the following paragraph) would be attributed to (a) incomplete acquisition of skills if performance was also incorrect on the doll probe, or (b) poor stimulus generalization from doll training if the doll probe performance was correct. Conditions were identical to self-probes with the exception that the doll rather than the subject herself was the locus of discriminative stimuli and a scaled-down toilet and sanitary pads were used. Doll probes were conducted for all three task analyses shown in Table 1. In vivo probes were designed to assess: (a) subjects' skills under conditions of actual menstrual flow on pads a n d / o r underwear, (b) performance in the absence of reinforcement and corrective feedback, and (c) generalization to untrained skills. They were conducted whenever actual menstruation was present during a scheduled probe session. Initially, the presence of menstruation was checked by the trainer when a subject was asked to replace her own underwear for the purposes of conducting a self-probe. Subsequently, attempts were made to schedule clinic visits to coincide with subjects' menstrual cycles. In vivo probes were conducted in the same setting as self-probes and doll probes, and were identical in format with the exception that menstrual flow was not simulated. Observer training and agreement. Three female experimenters served as observers. Training consisted of reading response definitions, discussing potential ambiguities, and practicing data collection during probe a n d / o r training sessions. A second observer was present during 50°7o of all probe sessions to assess interobserver agreement. Agreement was assessed on a step-by-step basis for all subjects on the three task analyses. Indices of occurrence agreement were obtained by dividing the number of agreements on occurrence by agreements on occurrence plus disagreements and multiplying by 100. Combined or overall agreement indices were obtained by dividing the total number of agreements by agreements plus disagreements and multiplying by 100. Interobserver agreement indices were 100°70 for both occurrence and combined indices across all probes.
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Experimental Conditions Baseline. Prior to initiation of training, individual subjects' skills on each of the three task sequences were measured by way of assessment probes. Each subject participated in self-probes, doll probes, and when possible, in vivo probes. Skill training. Individual subjects were taught to perform the correct sequences of responses via training with the toy doll. Subjects were taught to manipulate the doll so as to emit correct response sequences in the presence of each of the three relevant discriminative stimuli, as shown in Table 1. Training consisted of utilizing a forward-chaining procedure. Subjects proceeded through the task analysis until a response was performed incorrectly or omitted. At this point, the trainer required the subject to perform the step correctly, and then start the chain over. The trainer used verbal prompts, modeling, or, if necessary, physical guidance to prompt the correct response. Praise was delivered contingent upon correct responding; with one subject (Arlene) edible reinforcement (e.g., cookie or cracker) was used. Only one task analysis was trained at a given time, beginning with the stained-pad sequence. Mastery criterion was the completion of an entire task sequence with no errors for a minimum of two trials. Session length was approximately 30 minutes. Upon reaching mastery criterion on a sequence, a short review session was conducted. The purpose of these sessions was to provide a brief review of previously learned skills. Each review session consisted of having a subject demonstrate correct performance of all previously trained response sequences. Reinforcement and corrective feedback were provided as during training. Following a review session, assessment probes were conducted as previously described. First a doll probe was conducted, followed by a self-probe or, when possible, an in vivo probe. During assessment probes, correct response sequences were not reinforced and no feedback was provided contingent upon incorrect responses. If one or more skills were performed incorrectly during the probe, the next training session consisted of additional training on the incorrect responses. When mastery criterion was again met, another probe session was held. Once a subject achieved 80°7o or better on the post-training self-probe for stained-pad skills, similar training began for the stained-underwear sequence. Once criterion was attained for stained-underwear skills, training began on the final task analysis, combined-pad-and-underwear skills. Follow-up. After the completion of training, assessment probes were scheduled to monitor maintenance of skills across time. Doll probes were not conducted. Whenever possible, sessions were scheduled to coincide with menstruation to allow for the collection of data under in vivo conditions. Follow-up
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G. S. Richman et al.
assessment probes were identical to probes conducted during baseline and upon achievement of mastery criterion. E x p e r i m e n t a l Design
Training procedures were implemented within the framework of multiplebaseline designs across both subjects and behaviors (Baer, Wolf, & Risley, 1968). First, with respect to subjects, training was begun with Debbie and Arlene after three baseline assessment probes. With Karen and Bonnie, initiation of training was lagged and begun following six baseline assessment probes. Second, with respect to behaviors, baseline assessment probes on all three task sequences was followed by training only on the stained-pad skills; the other two sequences continued to be assessed under baseline conditions. Implementation of training was then lagged across the two remaining sequences. RESULTS Figure 1 shows assessment data for all subjects on self-, doll, and in vivo probes. Results of baseline, post-training, and follow-up probes are presented with data collapsed across all three skill sequences to show the multiple baseline analysis across subjects. During baseline assessment, the range of correct responding on self-probes was 38-41% for Debbie, 0% for Arlene, 33-45°70 for Bonnie, and 10-19% for Karen. Following the initiation of skills training, scores on self-probes increased to 79-100% for Debbie, 43-95% for Arlene, 97-100% for Bonnie, and 46-100% for Karen. Corresponding performance increments were observed on doll probes with all three subjects. Although a limited number of in vivo probes were possible, improved performance on this measure was observed subsequent to the initiation of training. Moreover, increases for in vivo scores covaried with improvements on self and doll probes. Figure 2 shows assessment data for all subjects, plotted across the three different skill sequences to show the multiple-baseline analysis across responses. During self-probe baseline assessments with Debbie, correct responding ranged from 7 to 17 on pad skills to 9 of 19 on both underwear skills and 9 of 24 on the combined sequence, After training on the stained-pad sequence, correct responding increased to the m a x i m u m 17 steps on both doll and selfprobes; in addition, generalization to the remaining baselines can be noted. Training on the stained-underwear sequence also resulted in further increases in correct responding for that skill, to the m a x i m u m 19 steps on both doll and self-probes. Generalization to the combined-underwear-and-pad sequence made training on that component unnecessary with Debbie. Maximum correct responding continued to be observed for all three sequences during subse-
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29
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30
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31
quent assessment probes, and was maintained at follow-up conducted 30 weeks after the termination of training. Data collected on Debbie during in vivo probes showed similar increases as training was introduced across the three skill sequences. The first possible in vivo probe occurred while all three skill sequences were being assessed under baseline conditions and resulted in only 6 correct of 24 possible responses on the combined sequence. During the second in vivo assessment, separate probes on both the pad and the combined sequence were conducted. This was possible because of the occurrence of additional menstruation following an initial probe on the combined sequence. Correct responding on the pad sequence, which had been trained, was the m a x i m u m 17. On the combined sequence, which was untrained, 16 of 24 steps were correct. All steps were performed correctly on the final two in vivo probes; one on the combined sequence at the conclusion of training and one on the pad sequence at the 30-week follow-up. Similar results were obtained with the remaining three subjects. Arlene made no correct responses on the initial three baseline probes. As training was introduced, substantial improvements were noted on both self-probes and doll probes, and generalization to untrained skills was observed. All skills were maintained across subsequent probes with the m a x i m u m 17, 19, and 24 correct responses, respectively, for pad, underwear, and the combined sequence on all three follow-up probes 12 weeks after discontinuation of training. The one in vivo probe conducted with Arlene was on stained-pad skills after that sequence had been trained, and resulted in correct performance on all 17 steps. As a result of structural variations in the bathroom where Karen was trained, Step 3 (closing b a t h r o o m door) was deleted from the task analysis; thus, the total possible correct responses was reduced by one. As with Debbie, correct responding was infrequent during initial baseline probes with Karen. As training was sequentially introduced, performance on target skills approached maximum correct, and generalization to untrained sequences was observed. Two in vivo probes were possible with Karen, both on the stainedunderwear sequence. On the first, under baseline conditions, she performed only 1 of the 18 steps correctly; the second, after training on that sequence, resulted in 14 steps correct. No follow-up probes were possible with Karen. Bonnie also exhibited a small number of correct responses during initial baseline assessments. Training on the stained-pad and stained-underwear sequences resulted in m a x i m u m performance of 17 to 19 correct responses, respectively, on those skill sequences. Generalization to the combined-padand-underwear sequence following training on the first two sequences made training on that component unnecessary. Follow-up probes conducted 30 weeks after training reflected continued maintenance of skills. Two in vivo probes were possible with Bonnie, both on the stained-pad sequence. The initial in vivo probe was during baseline, resulted in zero correct responses; the second was at the 30-week follow-up and resulted in the m a x i m u m 17 correct responses.
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G. S. R i c h m a n et al.
DISCUSSION Results obtained with the four subjects in this study suggest that the menstrual care program is appropriate for the assessment and training of functional skills in trainable and severely mentally retarded females. The two multiple baseline analyses suggest that the forward chaining procedure was responsible for large increases in correct performance. With all four subjects, performance on assessment probes improved only after skill training had been initiated. Furthermore, with individual subjects, initial training of stainedpad skills resulted in improved performance on that sequence. With three subjects, generalization to untrained sequences was observed. Subsequent implementation of training across the remaining skill sequences resulted in further improvement with all four subjects. Despite the many documented programs to teach functional self-help skills to the mentally retarded, this program is one of the few available to teach menstrual-care skills. Moreover, this program can be seen to offer a more thorough description and evaluation than previous menstrual care programs in which either baseline data were not available (Hamilton et al., 1969), or no outcome data were reported (Girardeau & Spradlin, 1964; Moudgil, 1970). Although evaluated only with trainable and severely mentally retarded persons in this study, the program appears applicable to other broad groups of individuals with skill deficits in menstrual care. The generalization to untrained skill sequences that was noted with all four subjects was not totally unexpected in light of the number of responses that are c o m m o n to all three skill sequences. Although the degree of generalization observed here confounds somewhat a multiple-baseline analysis across responses, it can be seen as a clinically desired outcome. In fact, with two of the four subjects, training on the final sequence, combined-pad-and-underwear skills, was not necessary because of the improvement attributable to generalization. One noteworthy aspect of the results is the maintenance of appropriate performance observed with the three subjects for whom follow-up data were collected. Correct responding was observed 12 weeks after training was terminated with Arlene and 30 weeks after training with Debbie and Bonnie. O f particular importance are those follow-up probes that were conducted under in vivo conditions. Both Debbie and Bonnie showed 100% maintenance of stained-pad skills during in vivo assessment probes 30 weeks after training. Although the doll-training component of the program was not directly evaluated here, it does appear to have advantages over a more direct, in vivo intervention. First, with doll training the location of sessions is not restricted to a bathroom or other private areas, but can be carried out in most classroom and home settings. Second, presentation of repeated instructional trials is facilitated by using a doll rather than the individual herself (e.g., menstrua-
Menstrual Care
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tion is more easily simulated with the doll). Third, the use of a doll avoids repeatedly exposing an individual to potentially embarrassing situations (e.g., having to wear stained pads and underwear). Despite the positive results obtained with the subjects in this study, it is important to note two possible drawbacks. First, the majority of data were collected under conditions of simulated menstruation. However, conducting assessment and training sessions only during times of real menstruation would not have been practical. Sessions would have been difficult to schedule and the long delays between sessions might be expected to increase the number of sessions necessary to meet mastery criterion. As a result of the concern for naturalistic assessment, in vivo probes were conducted whenever actual menstrual flow was present. However, because it was not possible to conduct in vivo probes under conditions of covert observation, sessions were similar to those during self-probes. Second, subjects' inability to obtain necessary materials may have affected subsequent steps in each of the skill sequences. It is possible that merely providing materials such as clean pads, underwear, and bags may have resulted in improved baseline scores. Considering the necessity of appropriate menstrual hygiene and the legal and ethical problems associated with elective hysterectomies, the present training program provides a useful methodology for assessing and teaching menstrual self-care with trainable and severely mentally retarded persons. Educational procedures such as those described here should be attempted before considering more intrusive techniques, such as surgical or other medical (e.g., drug) interventions. Future research in the area of menstrual-care training with the mentally retarded will need to explore additional methods for conducting training. In light of the demonstrated effectiveness of doll training, it might be possible to provide instruction within a group training format. Or, higher functioning individuals may be successfully trained via alternative procedures, such as using picture cues to teach correct skill sequences. In addition, it will be important in future research to examine methods of programming generalization of menstrual care skills to more naturalistic conditions, and to document independent performance o f proper hygiene. Acknowledgements-This research was supported in part by Grant # 00917-15-0 from Mater-
nal and Child Health of the Department of Health and Human Services. Appreciation is extended to Brian lwata and Nancy Neef for their helpful comments regarding the preparation of this manuscript. REFERENCES AIcorn, D. A. (1974). Parental viewson sexual developmentand education of the trainable mentally retarded. The Journal of Special Education, 8, 119-130. Azrin, N. H., & Foxx, R. M. (1971). A rapid method of toilet training the institutionalized
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