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Teaching self-feeding skills to profound retardates using reinforcement and fading procedures
B~ltAVXOrtTrmRAPY (1971) 2, 62-67
Teaching Self-Feeding Skills to Profound Retardates Using Reinforcement and Fading Procedures1 SAMUEL BERKOWlTZ,z PATRICK J. SHERRY, AND BARBARA.ALPHIN DAVIS Crownsville State Hospital, Essex Community College, and Rosewood State Hospital Fourteen institutionalized profoundly retarded boys who had never spoon-fed themselves were selected for a behavior modification program focusing on self-feeding. The boys ranged in chronological age from 9 to 17 years and possessed Vineland Social Ages from 1.3 to 1.7 years. The seLf-feeding task was divided into seven discrete steps, with each succeeding step requiring the child to perform more of the self-feeding process. On the first step the aide, while holding the child's hand with his spoon in his hand, made the entire feeding cycle for the child. With each of the sueceeding six steps the aide faded out a portion of her help, until the child was making the entire self-feeding movement without any help from the aide. All 14 boys learned to perform the self-feeding task within periods ranging from 2 to 60 days and 10 of the 14 boys were still feeding themselves 41 months later. Implications for treatment of retardates are discussed.
Spradlin and Girardeau (1966) and Watson (1967) have reviewed a broad range of studies dealing with the application of behavior modification procedures to the behavioral problems of retarded persons. A number of studies have dealt with self-feeding within the context of broader programs for the retardate (Blackwood, 1962; Gorton & Hollis, 1965; Hundziak & Maurer, 1963; Kimbrell, Luekey, Barbuto, & Love, 1966; Pursley & Hamilton, 1965; Spradlin, 1964; Whitney & Barnard, 1966). A film (National Library of Medicine, 1967) intended for use in the training of institutional staff working with the severely retarded contains a brief sequence depicting general procedures for developing self-feeding skills. But an explicit step-by-step outline of procedures to be followed is lacking. 1Portions of this paper appeared in the Maryland Mental Hygiene Newsletter, March, 1967, and were also presented at the annual meeting of the Maryland Psychological Association, Baltimore, May, 1968. 2Requests for reprints should be sent to Samuel Berkowitz, Psychology Department, CrownsviUe State Hospital, Crownsville, 21032. 62
TEACHING SELF-FEEDING
TO RETARDATES
63
The present study describes a practical program that deals with a most time-consuming problem in institutions for the retarded that of spoon-feeding profoundly retarded children. The study was carried out at a cottage for profoundly retarded boys in Rosewood State Hospital, a large state institution for retardates. The cottage housed 85 profoundly retarded boys ranging in age from 9 to 17. Each boy had been placed in one of four groups according to his level of self-help skills. There were 35 boys in the lowest group, of which 16 were customarily spoon-fed by nursing aides. It is these 16 boys that were the subjects of the present study. Of these 16 spoon-fed boys, 7 were selected for working with in the first instance. Though all 16 were ambulatory and physically capable of feeding themselves, the staff chose these 7 because they were younger, less hyperactive, and emitted fewer disturbing behaviors than the remaining 9. Of the remaining 9 boys, one had to be totally rejected since he exercised too much aversive control over the staff, and another died before he could be brought into the self-feeding program. This left 7 rather more di~cult boys to work with once experience had been obtained with the first group. The two groups did not differ significantly with respect either to chronological age, range 9-17 years, or Vineland Social Age, range 1.3-1.7 years with a mean Social Quotient of 12. At the time of their selection, all 14 boys had been spoon-fed for their entire lives. All previous efforts to teach them self-feeding with a spoon had been terminated without success. To win the essential interest and support of the nursing aides directly concerned with the care of these boys, meetings with both the morning and evening staffs were held weekly in order first to introduce and then to discuss and refine the new feeding techniques. Apart from a sincere interest in helping these boys attain a higher level of self-help skills, support was engendered also by the recognition that the eliminated time spent on the spoon-feeding routine would now become available for other duties. PROCEDURE A table in the corner of the patient's dining hall, formerly utilized as a serving table, was used for the training program. The dining hall accommodated all 85 ehildren in the cottage. The first seven target boys were assigned to the aides who were to be responsible for their feeding training. Each child was brought into the dining hall just prior to the opening of the dining hall for the daily meals. Since there were three meals a day, this occurred 21 times per week. The second seven boys continued to be spoon-fed in the traditional manner until it was time for them, too, to be introduced to the self-feeding program. Tho aides were told to give no food whatsoever to any of the first seven boys
64
BERKOWITZ, SHERRY, AND DAVIS
between meals and that meal-time food was to be made available only in accordance with procedures to be outlined. The aides were further advised that it might be necessary physically to restrain any boy's nonspoon hand should he attempt to use it to grab food. Despite these precautions, it still occasionally became necessary to remove children from the table before the completion of their meal either because they had managed to grab food, or because they resisted using their spoon. These children were then pernfitted to return to the dining table after all the others had finished their meals. If they again grabbed food, they were removed from the dining area and missed the remainder of their meal. In practice, while portions of meals were missed or delayed on a number of occasions, on only four occasions was a returned child removed. Some boys consistently tried to grab food, others not at all. The technique involved basic operant procedures in which the self-feeding process was divided in to seven discrete steps. These seven steps were also depicted on posters placed on the wall above the feeding table for the aides to see. Each successive step required more unaided behavior by the child--a larger segment of the self-feeding cycle, and less help from the aide--thereby successively approximating the final response of the total self-feeding cycle. At the same time as she was shown how to fade out her assistance, the aide was also shown how to prompt any child observed hesitating on any particular step of the cycle by such devices as elbow and wrist nudging or spoon pushing. In addition to such prompting the aide also presented verbal praise, pats on the back, and so forth when a child successfully executed the particular step he was on. The sequence of the seven self-feeding steps was as follows: 1. Aide, holding child's hand with spoon in child's hand, makes entire feeding cycle, from plate (scooping food) to mouth and back to plate. 2. Aide makes entire feeding cycle, but partially releases child's hand (still holding spoon with food on it) 2-3 in. below child's mouth. Child lifts spoon these last few inches himself. 3. Aide releases child's hand approximately six inches from child's mouth, Child lifts spoon about six inches. 4. Aide scoops food, releases child's hand at plate level. Child lifts spoon from plate to mouth. 5. Aide brings child's hand to plate, releasing hand. Child scoops food, and lifts spoon to mouth. 6. Aide releases hand after child has emptied spoon. Child brings spoon clown to plate, scoops food, and lifts to mouth. 7. Child executes entire self-feeding cycle by himself. On the 1st day of the training program, the aide stood behind the child, holding the spoon tightly in his hand and feeding him as he sat facing the plate of food on the table (step 1). This procedure was followed for all three meals of this 1st day. On the first meal of the 2nd day, after repeating the above procedure several times, the aide introduced the first variation (step 2) in the fading proeedure. Now the aide let go of the child's hand about 2-3 in. from the child's mouth. The child was now required to move the spoon these few inches to get his reinforcement. Upon the successful completion of step 2 for at least one entire meal, the aide advanced to step 3, terminating her grip and movement at a distance still further from the child's mouth and closer to the plate of food, thus requiring the child
TEACI-//NG SELF-FEEDING TO RETARDATES
65
to lift the spoon a greater distance. With each step, the child succeeded in performing more of the self-feeding cycle by himself and required less assistance from the aide. The aim was to ensure success by making the steps small and by not trying to advance the child too quickly. When a child regressed to a lower step, there was an increase in the aide's prompting. Several boys were recycled, returning to step 1 when their behavior regressed more than two or three steps. As the child's behavior was shaped into its final form, the aide's help was gradually faded out. The aides were provided with charts for each child which pictured the seven steps. It was thus easy for the aides to check off at the end of each meal the step a particular child was working on. This enabled the aide on the next shift to follow the child's progress and to know where to begin with the child. RESULTS All seven boys in the first group learned to feed themselves in periods ranging from 2 to 21 days. The second group of seven boys took between 13 and 60 days and proved to be more difficult to work with (see Discussion below). After each child reached step 7 he remained under supervision for approximately 2 weeks before being returned to eat at his regular table. Individual differences were observed in terms of the length of time the child took to learn the entire cycle as well as in the stability of each step in the cycle. In observing the aides during the training sessions, several spontaneous innovations on the part of the aides were noted, such as making the food more manageable for the children to scoop with their spoons, using their own fading and prompting procedures when a child stopped or slowed down his eating, and so forth. These additions and modifications were discussed at the weekly meetings and immediately programmed into the procedure if, as was generally the case, they met with general approval. This policy served two purposes: the innovations contributed directly to the success of the program and the aides--rightly e n o u g h - felt that they played an active and valued creative role in the overall project. All children were returned to the regular cottage eating schedule after successful completion of the individual training. They were seated at long family-style tables with the other boys in the cottage and maintained their self-feeding with no additional supervision other than that given to the other children in the cottage. Ten of the 14 boys still maintained their self-feeding some 41 months later. The other four maintained their skills for 23--35 months. Of these four, two regressed only recently when there was a drastic cut in the number of employees in the cottage, and the other two have been bedridden for 6 and 18 months, respectively, where the policy is to spoon-feed these children.
66
BERKOWITZ, StlEI~qY, AND DAVIS
DISCUSSION This study demonstrates the feasibility of initiating and successfully implimenting a self-feeding program based on behavior modification procedures with profound retardates in an institutional setting. While no extra funds or supplies were allotted, the program did have the complete support of the cottage director. Without this cooperation and encouragement, it is unlikely that the program could have been suecessful. While the program was designated as "research" and "experimental," the benefits to the children and the staff were constantly emphasized. To modify the behavior of the children and to maintain this modification, it was concomitantly necessary to modify the behavior of the staff and then to maintain this modified behavior. Weekly meetings, and continual "on-the-spot" discussions of procedures, problems, progress, and other pertinent matters as they arose were critical in this regard. The nursing staff was the necessary "apparatus" in the study and constant social reinforcement to shape their behavior became an integral aspect of the program. An equally important factor was the powerful reinforcing effect on the staff of the changes observed in seemingly intractable children. For example, one aide offered the following spontaneous comment: "You know, Dr. B., I feel so proud. I've never felt so proud in my whole life. I've worked for 22 years in hospitals, but I've never been able to help anyone as I am howl" The encouraging presence of the experimenters at almost all meals probably enhanced both the consistency and accuracy with which the aides applied the procedures and recorded progress. In this respect it is important to note that, when the second group of seven boys were brought into the program, the three authors became involved, coincidentally, in other professional activities and were unable to observe the procedures upon every occasion. During this period of time the children made very little progress. The failure to provide consistent social reinforcement may well have contributed to the longer period of time needed for the second group to learn self-feeding. The presence of the experimenters, their praise, encouragement, and attention in general seemed to be necessary ingredients in maintaining the aides' behavior. Considering the extremely low level of functioning of these boys, it would seem that, regardless of IQ, any child physically capable of holding a spoon and raising it from a plate to his mouth is also capable of learning to feed himself. The subiects of the present study were functioning at the 1-2-year-old level, and only the rates of competing behaviors and the experimental procedures (including the motivating
TEACHING SELF-FEEDING TO RETARDATES
67
and reinforcing of the aides) seemed to determine the amount of time necessary to acquire the self-feeding repertoires. The self-feeding program described above can be incorporated into virtually any total cottage p r o g r a m for severely retarded residents. The benefits to both the children and the staff are totally consistent with the goals of any such institution. E v e n if periodic "booster" sessions should be required, such a program would seem to be a worthy alternative to the dehumanizing custodial procedures that characterize so m a n y institutions for the retardate. REFERENCES BLACKWOOO, R. D. Operant conditioning as a method of training the mentally retarded. Unpublished Ph. D. dissertation, Department of Psychology, Ohio State University, 1962. GORTON, C. E., & HoLIeS, J. H. Redesigning a cottage for better programming and research for the severely retarded. Mental Retardation, 1965, 3, 16--21. HtrNnz~r, M., & MAtraEXa, R. A. A comparison of nursing care for profoundly mentally retarded boys in large and small groups. Unpublished manuseript, Columbus State School, Ohio, 1963. KIMBRELL,D. L., LUCKEY~R. E., BARBUTO,P. F. P., AND LOVE, J. C. Operation dry pants: an intensive habit-training program for severely and profoundly retarded. Unpublished manuscript, Abilene State School, Abilene, Texas, 1966. NATIONAL LmP~nY OF MEDICINE, Teaching the mentally retarded---a positive approach. (No. M-1453-X). Chamblee, Georgia, 1967. PtmSLF.Y, N. B., & HAMII.TON,J. W. The development of a comprehensive cottagelife program. Mental Retardation, 1965, 3, 26-29. SPaADLL'~, J. E. The Premack hypothesis and self-feeding by profoundly retarded children: a ease report. Parsons Research Center, Working paper No. 79, 1964. SI'I~,DL~, J. E., & Gm.~aDEAU, F. L. The behavior of moderately and severely retarded persons. In N. R. Ellis (Ed.), International review of research in mental retardation, Vol. I. New York: Academic Press, 1966. Pp. 257-298. WATSON, L. S. Application of operant conditioning techniques to institutionalized severely and profoundly retarded children. Mental Retardation Abstracts, 1967, 4, 1-18. WmTNEY, L. B., & BARN~mD, K. B. Implications of operant learning theory for nursing care of the retarded child. Mental Retardation, 1966, 4, 26-29.
Teaching Self-Feeding Skills to Profound Retardates Using Reinforcement and Fading Procedures1 SAMUEL BERKOWlTZ,z PATRICK J. SHERRY, AND BARBARA.ALPHIN DAVIS Crownsville State Hospital, Essex Community College, and Rosewood State Hospital Fourteen institutionalized profoundly retarded boys who had never spoon-fed themselves were selected for a behavior modification program focusing on self-feeding. The boys ranged in chronological age from 9 to 17 years and possessed Vineland Social Ages from 1.3 to 1.7 years. The seLf-feeding task was divided into seven discrete steps, with each succeeding step requiring the child to perform more of the self-feeding process. On the first step the aide, while holding the child's hand with his spoon in his hand, made the entire feeding cycle for the child. With each of the sueceeding six steps the aide faded out a portion of her help, until the child was making the entire self-feeding movement without any help from the aide. All 14 boys learned to perform the self-feeding task within periods ranging from 2 to 60 days and 10 of the 14 boys were still feeding themselves 41 months later. Implications for treatment of retardates are discussed.
Spradlin and Girardeau (1966) and Watson (1967) have reviewed a broad range of studies dealing with the application of behavior modification procedures to the behavioral problems of retarded persons. A number of studies have dealt with self-feeding within the context of broader programs for the retardate (Blackwood, 1962; Gorton & Hollis, 1965; Hundziak & Maurer, 1963; Kimbrell, Luekey, Barbuto, & Love, 1966; Pursley & Hamilton, 1965; Spradlin, 1964; Whitney & Barnard, 1966). A film (National Library of Medicine, 1967) intended for use in the training of institutional staff working with the severely retarded contains a brief sequence depicting general procedures for developing self-feeding skills. But an explicit step-by-step outline of procedures to be followed is lacking. 1Portions of this paper appeared in the Maryland Mental Hygiene Newsletter, March, 1967, and were also presented at the annual meeting of the Maryland Psychological Association, Baltimore, May, 1968. 2Requests for reprints should be sent to Samuel Berkowitz, Psychology Department, CrownsviUe State Hospital, Crownsville, 21032. 62
TEACHING SELF-FEEDING
TO RETARDATES
63
The present study describes a practical program that deals with a most time-consuming problem in institutions for the retarded that of spoon-feeding profoundly retarded children. The study was carried out at a cottage for profoundly retarded boys in Rosewood State Hospital, a large state institution for retardates. The cottage housed 85 profoundly retarded boys ranging in age from 9 to 17. Each boy had been placed in one of four groups according to his level of self-help skills. There were 35 boys in the lowest group, of which 16 were customarily spoon-fed by nursing aides. It is these 16 boys that were the subjects of the present study. Of these 16 spoon-fed boys, 7 were selected for working with in the first instance. Though all 16 were ambulatory and physically capable of feeding themselves, the staff chose these 7 because they were younger, less hyperactive, and emitted fewer disturbing behaviors than the remaining 9. Of the remaining 9 boys, one had to be totally rejected since he exercised too much aversive control over the staff, and another died before he could be brought into the self-feeding program. This left 7 rather more di~cult boys to work with once experience had been obtained with the first group. The two groups did not differ significantly with respect either to chronological age, range 9-17 years, or Vineland Social Age, range 1.3-1.7 years with a mean Social Quotient of 12. At the time of their selection, all 14 boys had been spoon-fed for their entire lives. All previous efforts to teach them self-feeding with a spoon had been terminated without success. To win the essential interest and support of the nursing aides directly concerned with the care of these boys, meetings with both the morning and evening staffs were held weekly in order first to introduce and then to discuss and refine the new feeding techniques. Apart from a sincere interest in helping these boys attain a higher level of self-help skills, support was engendered also by the recognition that the eliminated time spent on the spoon-feeding routine would now become available for other duties. PROCEDURE A table in the corner of the patient's dining hall, formerly utilized as a serving table, was used for the training program. The dining hall accommodated all 85 ehildren in the cottage. The first seven target boys were assigned to the aides who were to be responsible for their feeding training. Each child was brought into the dining hall just prior to the opening of the dining hall for the daily meals. Since there were three meals a day, this occurred 21 times per week. The second seven boys continued to be spoon-fed in the traditional manner until it was time for them, too, to be introduced to the self-feeding program. Tho aides were told to give no food whatsoever to any of the first seven boys
64
BERKOWITZ, SHERRY, AND DAVIS
between meals and that meal-time food was to be made available only in accordance with procedures to be outlined. The aides were further advised that it might be necessary physically to restrain any boy's nonspoon hand should he attempt to use it to grab food. Despite these precautions, it still occasionally became necessary to remove children from the table before the completion of their meal either because they had managed to grab food, or because they resisted using their spoon. These children were then pernfitted to return to the dining table after all the others had finished their meals. If they again grabbed food, they were removed from the dining area and missed the remainder of their meal. In practice, while portions of meals were missed or delayed on a number of occasions, on only four occasions was a returned child removed. Some boys consistently tried to grab food, others not at all. The technique involved basic operant procedures in which the self-feeding process was divided in to seven discrete steps. These seven steps were also depicted on posters placed on the wall above the feeding table for the aides to see. Each successive step required more unaided behavior by the child--a larger segment of the self-feeding cycle, and less help from the aide--thereby successively approximating the final response of the total self-feeding cycle. At the same time as she was shown how to fade out her assistance, the aide was also shown how to prompt any child observed hesitating on any particular step of the cycle by such devices as elbow and wrist nudging or spoon pushing. In addition to such prompting the aide also presented verbal praise, pats on the back, and so forth when a child successfully executed the particular step he was on. The sequence of the seven self-feeding steps was as follows: 1. Aide, holding child's hand with spoon in child's hand, makes entire feeding cycle, from plate (scooping food) to mouth and back to plate. 2. Aide makes entire feeding cycle, but partially releases child's hand (still holding spoon with food on it) 2-3 in. below child's mouth. Child lifts spoon these last few inches himself. 3. Aide releases child's hand approximately six inches from child's mouth, Child lifts spoon about six inches. 4. Aide scoops food, releases child's hand at plate level. Child lifts spoon from plate to mouth. 5. Aide brings child's hand to plate, releasing hand. Child scoops food, and lifts spoon to mouth. 6. Aide releases hand after child has emptied spoon. Child brings spoon clown to plate, scoops food, and lifts to mouth. 7. Child executes entire self-feeding cycle by himself. On the 1st day of the training program, the aide stood behind the child, holding the spoon tightly in his hand and feeding him as he sat facing the plate of food on the table (step 1). This procedure was followed for all three meals of this 1st day. On the first meal of the 2nd day, after repeating the above procedure several times, the aide introduced the first variation (step 2) in the fading proeedure. Now the aide let go of the child's hand about 2-3 in. from the child's mouth. The child was now required to move the spoon these few inches to get his reinforcement. Upon the successful completion of step 2 for at least one entire meal, the aide advanced to step 3, terminating her grip and movement at a distance still further from the child's mouth and closer to the plate of food, thus requiring the child
TEACI-//NG SELF-FEEDING TO RETARDATES
65
to lift the spoon a greater distance. With each step, the child succeeded in performing more of the self-feeding cycle by himself and required less assistance from the aide. The aim was to ensure success by making the steps small and by not trying to advance the child too quickly. When a child regressed to a lower step, there was an increase in the aide's prompting. Several boys were recycled, returning to step 1 when their behavior regressed more than two or three steps. As the child's behavior was shaped into its final form, the aide's help was gradually faded out. The aides were provided with charts for each child which pictured the seven steps. It was thus easy for the aides to check off at the end of each meal the step a particular child was working on. This enabled the aide on the next shift to follow the child's progress and to know where to begin with the child. RESULTS All seven boys in the first group learned to feed themselves in periods ranging from 2 to 21 days. The second group of seven boys took between 13 and 60 days and proved to be more difficult to work with (see Discussion below). After each child reached step 7 he remained under supervision for approximately 2 weeks before being returned to eat at his regular table. Individual differences were observed in terms of the length of time the child took to learn the entire cycle as well as in the stability of each step in the cycle. In observing the aides during the training sessions, several spontaneous innovations on the part of the aides were noted, such as making the food more manageable for the children to scoop with their spoons, using their own fading and prompting procedures when a child stopped or slowed down his eating, and so forth. These additions and modifications were discussed at the weekly meetings and immediately programmed into the procedure if, as was generally the case, they met with general approval. This policy served two purposes: the innovations contributed directly to the success of the program and the aides--rightly e n o u g h - felt that they played an active and valued creative role in the overall project. All children were returned to the regular cottage eating schedule after successful completion of the individual training. They were seated at long family-style tables with the other boys in the cottage and maintained their self-feeding with no additional supervision other than that given to the other children in the cottage. Ten of the 14 boys still maintained their self-feeding some 41 months later. The other four maintained their skills for 23--35 months. Of these four, two regressed only recently when there was a drastic cut in the number of employees in the cottage, and the other two have been bedridden for 6 and 18 months, respectively, where the policy is to spoon-feed these children.
66
BERKOWITZ, StlEI~qY, AND DAVIS
DISCUSSION This study demonstrates the feasibility of initiating and successfully implimenting a self-feeding program based on behavior modification procedures with profound retardates in an institutional setting. While no extra funds or supplies were allotted, the program did have the complete support of the cottage director. Without this cooperation and encouragement, it is unlikely that the program could have been suecessful. While the program was designated as "research" and "experimental," the benefits to the children and the staff were constantly emphasized. To modify the behavior of the children and to maintain this modification, it was concomitantly necessary to modify the behavior of the staff and then to maintain this modified behavior. Weekly meetings, and continual "on-the-spot" discussions of procedures, problems, progress, and other pertinent matters as they arose were critical in this regard. The nursing staff was the necessary "apparatus" in the study and constant social reinforcement to shape their behavior became an integral aspect of the program. An equally important factor was the powerful reinforcing effect on the staff of the changes observed in seemingly intractable children. For example, one aide offered the following spontaneous comment: "You know, Dr. B., I feel so proud. I've never felt so proud in my whole life. I've worked for 22 years in hospitals, but I've never been able to help anyone as I am howl" The encouraging presence of the experimenters at almost all meals probably enhanced both the consistency and accuracy with which the aides applied the procedures and recorded progress. In this respect it is important to note that, when the second group of seven boys were brought into the program, the three authors became involved, coincidentally, in other professional activities and were unable to observe the procedures upon every occasion. During this period of time the children made very little progress. The failure to provide consistent social reinforcement may well have contributed to the longer period of time needed for the second group to learn self-feeding. The presence of the experimenters, their praise, encouragement, and attention in general seemed to be necessary ingredients in maintaining the aides' behavior. Considering the extremely low level of functioning of these boys, it would seem that, regardless of IQ, any child physically capable of holding a spoon and raising it from a plate to his mouth is also capable of learning to feed himself. The subiects of the present study were functioning at the 1-2-year-old level, and only the rates of competing behaviors and the experimental procedures (including the motivating
TEACHING SELF-FEEDING TO RETARDATES
67
and reinforcing of the aides) seemed to determine the amount of time necessary to acquire the self-feeding repertoires. The self-feeding program described above can be incorporated into virtually any total cottage p r o g r a m for severely retarded residents. The benefits to both the children and the staff are totally consistent with the goals of any such institution. E v e n if periodic "booster" sessions should be required, such a program would seem to be a worthy alternative to the dehumanizing custodial procedures that characterize so m a n y institutions for the retardate. REFERENCES BLACKWOOO, R. D. Operant conditioning as a method of training the mentally retarded. Unpublished Ph. D. dissertation, Department of Psychology, Ohio State University, 1962. GORTON, C. E., & HoLIeS, J. H. Redesigning a cottage for better programming and research for the severely retarded. Mental Retardation, 1965, 3, 16--21. HtrNnz~r, M., & MAtraEXa, R. A. A comparison of nursing care for profoundly mentally retarded boys in large and small groups. Unpublished manuseript, Columbus State School, Ohio, 1963. KIMBRELL,D. L., LUCKEY~R. E., BARBUTO,P. F. P., AND LOVE, J. C. Operation dry pants: an intensive habit-training program for severely and profoundly retarded. Unpublished manuscript, Abilene State School, Abilene, Texas, 1966. NATIONAL LmP~nY OF MEDICINE, Teaching the mentally retarded---a positive approach. (No. M-1453-X). Chamblee, Georgia, 1967. PtmSLF.Y, N. B., & HAMII.TON,J. W. The development of a comprehensive cottagelife program. Mental Retardation, 1965, 3, 26-29. SPaADLL'~, J. E. The Premack hypothesis and self-feeding by profoundly retarded children: a ease report. Parsons Research Center, Working paper No. 79, 1964. SI'I~,DL~, J. E., & Gm.~aDEAU, F. L. The behavior of moderately and severely retarded persons. In N. R. Ellis (Ed.), International review of research in mental retardation, Vol. I. New York: Academic Press, 1966. Pp. 257-298. WATSON, L. S. Application of operant conditioning techniques to institutionalized severely and profoundly retarded children. Mental Retardation Abstracts, 1967, 4, 1-18. WmTNEY, L. B., & BARN~mD, K. B. Implications of operant learning theory for nursing care of the retarded child. Mental Retardation, 1966, 4, 26-29.