Teaching intermittent self-catheterization skills to mentally retarded children

Research in Developmental Duabihrres, Vol. Prmred in the USA. All rights reserved.

Teaching

8, pp.

521-529.

1987 Copynghl

Intermittent

Skills to Mentally

0891-4222/87 $3.00 + .CKl il-I 1987 Pergamon Journals Inc.

Self-Catheterization Retarded Children

Kenneth J. Tarnowski Ohio State University and

Columbus Children’s Hospital

Ronald S. Drabman Unrversity oi Mississippi

Medical Center

In an A-B design with replication, the efficacy of a behavioral training program for teaching two mildly retarded children intermittent se&catheterization skills was assessed. Component skills were task-analyzed and trained via a graduated prompting procedure. Results indicated that both children rapidly acquired the component skills necessary to perform self-catheterization in an accurate and nearly independent manner. Benefits of children engaging in their own healthcare maintenance are discussed.

Children with spinal cord damage (e.g., trauma, myelomeningocele) often exhibit urologic dysfunction (Drago,Wellner, Sanford, & Rohner, 1977; Rossier, 1974). Surgical diversion methods (e.g., ileal conduit diversion) have been widely used in such cases (Lorber, 1971; Middleton & Hendren, 1976). However, the long-term outcome of diversion has been disappointing due to the incidence of upper urinary tract infections and damage associated with the use of this procedure (Belman, 1972; Glenn, Small, & Boyarsky, 1968; Scott, 1973). These complications have prompted the search for alternative methods of treatment. One alternative to diversion is intermittent catheterization. Intermittent

Requests for reprints should be sent to Dr. Kenneth .I. Tarnowski, Department of Pediatrics, Ohio State University, 700 Children’s Drive, Columbus, OH 43205 or Dr. Ronald S. Drabman, Department of Psychiatry, University of Mississippi Medical Center, 2500 North State Street, Jackson. MS 39216. 521

522

K. JOTarnowski and R. S. Drabman

catheterization involves the removal of urine from the bladder by periodic insertion of a catheter into the urethral opening. Clean intermittent catheterization (Lapides, Diokno, Silber, & Lowe, 1972) has been employed with increasing frequency over the last decade. The catheterization method proposed by Lapides et al. (1972) does not require the sterile conditions of other methods of catheterization (e.g., Guttman, Riches, Whitteridge, & Jonason, 1947) and thus allows the possibility of teaching self-catheterization skills to affected patients. Children who have been managed with catheterization methods have been found to have decreased infections and increased dryness (Lapides, Diokno, Gould, & Lowe, 1976; Mulcahy, James, & McRoberts, 1977). Several studies have reported the successful training of self-catheterization skills in school-aged children (Hannigan, 1979; Hardy, Melnick, Gregory, & Schoenberg, 1975; Lyon, Scott, & Marshall, 1975). In the Hannigan (1979) study, four five-year-old children with myelodysplasia were taught selfcatheterization through the use of instructions and prepractice on anatomically correct dolls. Although the results of efforts to teach children catheterization have been encouraging, it remains equivocal whether these skills may be successfully taught to children with compromised cognitive functioning (e.g., mild mental retardation). Indeed, practitioners may be hesitant to institute such training with children unless they evince normal levels of cognitive functioning (Hannigan, 1979). However, if mentally retarded individuals could be taught to actively participate in their catheterization, this might be a great help to them and their caretakers. We examined the efficacy of behavioral training procedures in the context of a program designed to teach self-catheterization skills to two children with mild mental retardation. An A-B design with replication was used to evaluate the training procedures.

METHOD

Subjects

and Setting

Participants were two children who were undergoing physical reevalnation and rehabilitation services in an acute inpatient pediatric care facility. Both children were in the mild range of mental retardation according to American Association on Mental Deficiency criteria (Grossmarl, 1977) (WISC-R Full Scale IQ = 61 and 63 for Tony and Josh, respectively). Tony was a six-year-old male who presented with myelomeningocele. Josh was a six-year-old male who recently had surgery for spinal cord neoplastic disease. Both children exhibited intact upper extremity motor skills. Both children were being

Intermittent Self-Catheterization

523

catheterized by staff or parents before the initiation of the study; Tony for a period of approximately two and one-half years, and Josh for about two months. Sessions were conducted three times daily in the child’s room which contained two beds, chairs, a wheelchair, assorted toys, and a private bathroom. Task Analysis A task analysis was conducted in order to determine the component steps and performance sequence integral to proper self-catheterization. The basis for the task analysis was direct observation of nursing personnel conducting the procedure with several patients. Molar responses were specified since both children had previous experience with catheterization and it was known that they were capable of performing subcomponents contained within each step. The resulting 22-step task analysis was reviewed and approved by medical staff. The task analysis is presented in Table 1.

Procedure Baseline. During baseline, nursing staff placed all catheterization materials next to the child and stated “Here is everything you need. 1 want you to do this by yourself. Do it just like 1 have been doing it. Make sure to do the best you can.” No consequences were provided for correct responding. If the child responded incorrectly or failed to initiate responding within 15 seconds following a verbal prompt (“Keep going” “What’s next?“), staff completed the step and instructed the child to proceed. The session terminated when the catheterization process had been completed. During catheterization, children were seated in their wheelchairs for all phases of the study. Given that both children were admitted for relatively brief inpatient stays, the daily costs associated with hospitalization, and the mandate to teach children selfcatheterization skills in a cost-effective manner, baseline data collection was rather brief for both subjects. For these reasons, only moderate stability in baseline data points was obtained prior to the initiation of training. Training. All training was conducted by nursing personnel. Training was conducted using a graduated prompting procedure (Horner & Keilitz, 1975; Poshe, McCubbrey, & Munn, 1982). Prompting procedures were (a) nonspecific prompting which involved asking the client “What do you have to do next?“, (b) verbal description of the step to be performed (e.g., “Wash your hands”), (c) verbal description accompanied by modeling of specific motor components, and (d) verbal description coupled with physical guidance. Prompts failing to produce initiation of correct responding within 10 sec-

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K. J Tarnowski and R. S. Drabman

TABLE 1. Self-Catheterization Task Analysis 1. 2. 3. 4. 5. 6. 7. 8.

Wash hands with soap and water. Wash penis with soap and water. Dry penis with towel. Open packer of lubricating jelly. Open packet of sterile gauze. Pur contents of lubricating jelly packer onto one side of sterile gauze. Put small end of catheter in lubricating jelly. Rotate small end of catheter in lubricating jelly so as to lubricate approximately three inches from tip of catheter. 9. Hold penis between thumb and index finger of non-preferred hand, palm up, in approximation to (within 1 inch) but below coronal ridge. 10. Hold penis away from body (perpendicular to torso). 11. While holding penis wirh non-preferred hand, hold catheter about l-2 inches from small end with preferred hand (index finger/thumb grasp-palm up). 12. Insert small end of catheter into penis about 1 inch. 13. Press catheter in slowly (about 1 inch per 10 seconds) until resistance is encountered (hard to push). 14. Take large breath and exhale while continuing to insert at same, slow rate. 15. Continue to insert until urine appears [staff position a bottle for child at opposite end of . .i catneterl[Staff/parent: Insert approximately I .5-2 inches more]* 16. Empty bladder as best possible by brief straining. 17. Two shifts in bodily position. 18. When no urine for 20-40 seconds, hold penis as in Steps 8 and 9. 19. Remove catheter with preferred hand while holding penis with non-preferred as specified above. Remove at same rate as specified above for insertion. 20. Empty urine that is in the catheter into the urine container. 21. Empty container in toilet. (Note: If urine samples needed for tests, staff remove needed amount to another container before patient empties into toilet.) 22. Wash hands with soap and water. *Staff/parenr

assistance

onds resulted in reprompting at a higher prompt level. Praise was delivered following each step which was performed correctly by the child. As the children became more proficient, the schedule was altered so that praise was delivered following the correct completion of several steps. A star chart was used in which a star was given for each of the component steps the child performed correctly. Stars were not redeemable for backup reinforcers. Maintenance

data. A criterion was established whereby training was terminated when subjects performed all component steps correctly on four consecutive sessions. Catheterization skills were reassessed two and three weeks following the completion of training for Tony and Josh, respectively. Children were provided with all materials and simply instructed to self-catheterize. Praise was delivered at the end of the session.

Intermittent Self-Catheterization

525

Observational Data On the basis of the task analysis, a behavioral checklist was constructed for use by raters. Observations involved noting whether each component step was performed independently or required prompting (verbal instruction, verbal instruction + modeling, and/or verbal instruction + physical guidance). In order to minimize risk of physical injury, staff inserted the catheter the final 1.5 to 2.0 inches. The dependent variable was the number of component steps performed correctly without prompting. Observers were two nurses aides and a psychology graduate student. Reliability was assessed on 20% of the baseline and training sessions. Interobserver agreement was defined as both observers agreeing a step had been performed correctly. Reliability was computed by dividing agreements by agreements plus disagreements and multiplying by 100. Reliability ranged from 73% to 95% with a mean of 87.3%.

Design An A-B design with replication evaluate the training procedures.

(Hersen & Barlow, 1976) was used to

RESULTS Figure 1 displays the number of catheterization steps performed correctly by both subjects during baseline, training, and maintenance phases. Children’s correct responding remained at low levels during baseline. The mean number of steps performed correctly by Tony and Josh during baseline were 8.3 (37.9%) and 5 (22.7%), respectively. Steps successfully completed during baseline consisted entirely of routine responses which subjects also performed in other contexts (e.g., washing hands, emptying container) as opposed to sophisticated catheterization-specific responses (e.g., catheter insertion). The number of steps that both children completed correctly was found to increase steadily during the course of training. A total of 29 and 40 training sessions were required to reach the training criterion for Tony and Josh respectively. Maintenance data indicated the children’s skills were maintained at a high level (~90%) when assessed posttraining. During maintenance, Tony was verbally prompted to strain briefly and make two bodily shifts after catheter insertion in order to maximize bladder drainage. Josh required a verbal prompt concerning appropriate breathing during catheter insertion. Dryness data were available for Tony. Staff checked the child for dryness each hour. Percent dryness increased from 63.6% to 81.3% from baseline to

526

K. J. Tarnowski and R. S. Drabman

BASELINE

TRAINING

MAINTENANCE

.

JOSH 0

5

10

15

20

25

30

35

40

45

SESSIONS FIGURE I. Number of catheterization steps performed baseline. training, and maintenance phases.

correctly

by the IWO subjects during

the termination of training. Dryness data were also collected for Josh but staffing changes resulted in an inordinate number of missing observations.

DISCUSSION The study demonstrated the effectiveness of using a graduated prompting sequence to teach mentally retarded children a complex health-related selfcare skill. Children rapidly learned to perform the catheterization procedure in an accurate manner. Maintenance of acquired skills was observed for both subjects after training was terminated. These results are consistent with earlier findings demonstrating that developmentally normal young children could be effectively taught self-catheterization skills (Hannigan, 1979; Hardy et al., 1975; Lyon et al., 1975). Additionally, they extend the use of behavioral teaching methods to the training of self-catheterization skills in children with mild mental retardation. Contrary to the belief of some health care practitioners, findings indicate that young mentally retarded children can be effectively taught this complex self-care skill in a cost-effective manner. Anecdotal data from staff indicated that by the completion of training, both children were able to selfcatheterize rapidly with minimal supervision. This finding is important given the numerous time-consuming demands placed on direct care staff. Because of sensation deficits, children may inadvertently injure themselves during the final phase of catheter insertion thus complete independence in

Intermittent

Self-Catheterization

527

self-catheterization may not be a realistic goal. Therefore, parents of both subjects were provided with instructions on how to supervise children’s catheterizations at the time of discharge. Specifically, parents were requested to observe several catheterization sessions and to conduct catheterization with their child under the supervision of a nurse upon termination of the child’s training. Baseline data for both children indicated that they profited little from prestudy catheterization experiences. The probable reason for this is found in the manner in which children are usually catheterized. Typically, only minimal child participation is required (e.g., straining, hold catheter once inserted, etc.). Although repeatedly exposed to catheterization, the child is inadvertently shaped to adopt a passive role in which almost all aspects of the procedure are “done to” him or her. Data suggest that Tony may have derived minor benefit from his prestudy catheterization experiences as reflected in the number of sessions required to reach criterion for termination of training. Although the baseline procedure contained some educational components, it is very unlikely that children would have acquired the necessary skills in the absence of other instructional strategies. Even if children can acquire component skills via the baseline procedure, it would have to be implemented over a large number of trials and thus represents an inefficient and cost-intensive teaching method. The goal of these training procedures was to increase the child’s active participation in conducting his own health-care maintenance. Such interventions are ultimately aimed at increasing the child’s ability to function independently. Anecdotal nursing reports indicated that both children were cared for with increased ease and were viewed more positively by staff following acquisition of self-catheterization skills. Data are needed on thegeneralization of self-catheterization skills from hospital to home settings. Possible consequences of children’s early acquisition of medical self-care skills include: (a) reduction of procedure-related stress which families of chronically ill children frequently experience (e.g., puts parent in supervisory role as opposed to constant direct care provider), (b) facilitation of children’s self-efficacy and self-concept, (c) reduction of risk for the development of a pattern of excessively dependent behavior, and (d)normalization of a child so that he or she might be better accepted by family, teachers, and peers. Specification of an invariant sequence with which training was conducted, repeated instruction/modeling/graduated physical guidance on each of the component steps, coupled with the use of praise and the star chart assisted in establishing a chained sequence of component responses. It is expected that these same procedures could be used to teach self-catheterization skills to nonretarded children. Although these procedures proved to be useful, other methods might be employed as well. For example, Hanni-

528

K. 1 Tarnowski

and R. S. Drabman

gan (1979) had children practice on anatomically correct dolls. Behavioral training procedures coupled with the use of dolls for practice and feedback might be an effective training strategy. Hannigan also suggested that the use of a mirror in conjunction with practice on dolls may be of benefit for females experiencing difficulty during catheter insertion. We focused on the acquisition of self-catheterization skills by children with compromised cognitive and adaptive behavior functioning. Unfortunately, patient aftercare occurred in other settings and precluded further follow-up. Although results indicated increased dryness and short-term maintenance of skills, follow-up for extended periods is needed. Results should also be replicated with individuals whose medical problems, degree of cognitive impairment, and history of prestudy experience with catheterization differ from those of the cases presented here.

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