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The use of picture cues to establish self-control in the preparation of complex meals by mentally retarded adults
Applied Research in MentalRetardation, Vol, 3, pp. 105-1 |9, 1 9 8 2 Printed in the USA. All rights reserved.
0270-3092182/020105-15503.0@0 Copyright© 1982PergamonPress Ltd
The Use of Picture Cues to Establish SelfControl in the Preparation of Complex Meals by Mentally Retarded Adults James F. Martin and Frank R. Rusch University of Illinois at Urbana-Champaign
and Vicki L. lames, Paul I. Decker, and Karen A. Trtol Developmental Services Center of Champaign County
This investigation examined the effectiveness of picture cues in establishing selfcontrol in the completion of complex meals by mildly and moderately retarded adults. Three participants, who lived in nonsheltered residential settings, were trained to prepare five complex meals. Following a training baseline comprised of pre-instruction, instructional feedback, and trainers" presence, picture recipe cards were introduced in a multiple-baseline fashion. Rapid improvement in the ability of each participant to independently complete each meal when the picture recipe cards were used occurred. A return to baseline for one of the participants demonstrated further selfdirected antecedent stimulus control of the picture recipe cards as an effective treatment procedure. A discussion of future areas of research is included.
Mentally retarded adults must acquire a variety of complex, community survival skills to live successfully in community environments (Martin, Rusch, & Heal, in press; Schalock, Harper, & Carver, 1981); for those who have been unsuccessful often fail due to inappropriate behavior or lack of needed skills (Sigelman, Nova.k, Heal, & Switzky, 1980). With the current emphasis upon integrating mentally retarded adults into community environments from sheltered residential settings, competence in completing everyday tasks, such as meal preparation, Requests for reprints may be addressed to James E. Martin, University of Illinois, Bureau of Educational Research, 188 Education, 1310 S. 6th Street, Champaign, IL 61820.
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is required. Schalock and Harper (1978), for instance, determined through a two-year follow-up of independent living placements that, along with other specific skill deficits, 80% of the individuals who failed experienced problems with meal preparation. In a five year follow-up of the same individuals living independently, Schalock et al. (1981) found the ability to prepare meals was an essential variable for success. The development of meal preparation skills with mentally retarded individuals has received increasingly complex examination. Robinson-Wilson (1977) trained three severely mentally retarded adults in a sheltered workshop to prepare simple food items (hot chocolate, Jello, and hot dogs) through the use of hand-drawn, picture recipes that included color-coded stove dials and a timer. The three recipes were introduced in a different sequence to each individual, and each subsequent recipe required fewer trails indicating across task stimulus generalization. Matson (1979) trained 24 moderately to severely retarded adults in an institutional setting to prepare a simple breakfast (coffee, instant cereal, juice, and toast), a simple lunch (sandwich, canned soup), an intermediate breakfast (bacon/sausage, canned biscuits, and fried/scrambled eggs), and an intermediate lunch (hot dogs and Kool-Aid). Trainer modeling, followed by one person demonstrating the preparation of a meal with questioning of the remaining individuals about the procedures used, enabled them to improve their cooking skills. Johnson and Cuvo (1981) utilized a training package comprised of graduated prompting, praise, graphic feedback, and hand-drawn picture-recipes with written directions to train cooking of single food items, Two moderately and two mildly mentally retarded adults were trained in a sheltered workshop kitchen to boil an egg, boil vegetables, bake one biscuit, broil one hot dog, and broil an english muffin. Additionally, Schleien, Ash, Kiernan, and Wehman (1981) developed independent cooking skills in a profoundly mentally retarded woman in a sheltered workshop. Through instructional feedback and material modification she acquired and maintained the ability to boil an egg, broil a muffin, and bake a T.V. dinner, plus generalize her skills to boil a food packet and bake a pizza. The research literature indicates that mentally retarded individuals can learn select meal preparation skills, however, self-control in preparing complex meals in vivo has yet to be demonstrated. Self-control refers to when an individual implements procedures to control his or her own behavior (Kazdin, 1980), and to all processes related to changing or maintaining one's own behavior (Shapiro, 1981). The important aspect of self-control is that the person plays a major role in arranging the stimulus condition (Krasner & Ullmann, 1973). More specifically, self-control is a means to facilitate the occurrence of desired behavior through self-exposure to certain stimuli that will increase its likelihood (Skinner, 1953). Self-control responses are dependent upon mediating variables, which have traditionally been language based, such as self-instruction (Bandura & Waiters 1963; Goldfried & Merbaum, 1973; Kanfer & Karoly, 1972). Recently, self-control mediation had been based
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upon self-reinforcement, self-contract, biofeedback, and upon self-control manuals, to name a few (Goetz & Etzel, 1978; Kazdin, 1980). One of the most common procedures is to have a person initiate a shift in stimulus control from one aspect of the environment to another (Kanfer & Phillips, 1972). To date, much of applied self-control research is based upon identification of the procedures people can use to control their own behavior (O'Leary & Dubey, 1979). Thus, self-control strategies are beginning to be used with mentally retarded individuals (Shapiro, 1981), who would seem to be excellent candidates since they are often abnormally dependent upon others (Mahoney & Mahoney, 1976). A developing area of research that has application to facilitating self-control with the mentally retarded is the use of picture cues as the mediating variable (Connis, 1979; Johnson & Cuvo, 1981; Robinson-Wilson, 1977; Sowers, Rusch, Connis, & Cummings, 1980; Spellman, DeBriere, Jarboe, Campbell, & Harris, 1978); especially since many mentally retarded individuals have difficulty in selecting relevant stimuli from a stimulus field (Zeaman & House, 1963). Three recent studies (Connis, 1979; Johnson & Cuvo, 1981; Sowers et al., 1980) examined the effects of picture cues in combination with pre-instruction, instructional feedback, and repeated practice in vocational training programs. Connis (1979) incorporated the use of photographs to sequence the completion of work tasks by three moderately mentally retarded adults. The intervention combined self-recording with pre-instruction in how to use picture cues. Pre-instruction included modeling, role playing, and a rationale for training. Independent movement from one task to the next throughout the workday was praised; failure to change independently resulted in the error being corrected. Picture cue training enabled three of the four subjects in this study to change tasks independently. Sowers et al. (1980) trained three moderately mentally retarded adults to manage their break times. Sowers et al. (1980) introduced pre-instruction in how to utilize a picture cue that depicted clock faces with the time configurations illustrating when to leave and return from lunches and breaks. Correct time management was praised and errors were corrected through instructional feedback consisting of repeated practice in identifying correct clock faces. Each of the three subjects in this study learned to manage their own time. Johnson et al. (1981), as mentioned above, trained four mentally retarded individuals to cook single food items with a training package that contained picture cues. Collectively, it is not apparent from these studies, however, which component of the training package was most responsible for the results. It is possible that any one component could have obtained similar results. For example, in the Sowers et al. (1980) study, perhaps the picture cues alone would have enabled the subjects to learn to manage their own time. Since efforts to integrate mentally retarded adults into the community and costs associated with training are being examined (Heal & Laidlaw, 1980; Neenan, 1974), approaches should be investigated that initially rely upon trainers but ultimately upon self-management. Attention needs to be paid to the benefits
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of the self-control techniques introduced by Connis (1979), Johnson et al., (1981), and Sowers et al. (1980). These efforts are unique since they initially relied upon trainer assistance but ultimately upon self-directed stimulus control. Isolating the effects of picture cues may aid in the further development of selfcontrol components, which may lead to more efficient training methods. Connis (1979), Sowers et al. (1980), and Johnson et al. (1981) compared their instructional training packages to non-treatment baselines. Their designs did not permit the determination of which component contributed the most to change. Although component analyses have decreased in the literature (Hayes, Rincover, & Solnick, 1980), their value is apparent for isolating effective selfcontrol components (Goldfried & Merbaum, 1973; Kendall, 1977; Shapiro, 1981). The purpose of this study was to undertake a component analysis to examine the effects of picture cues as a means to establish self-control to complete complex tasks, and to train a skill heretofore not empirically validated.
METHOD Subjects
Mark was a 23-year-old Downs Syndrome male with a severe speech impairment. Past IQ scores have varied from a 33 to a 40 on the Stanford-Binet, to a 50 on the WAIS. These data and his adaptive behavior ratings placed him in the moderate level of mental retardation. Prior to this investigation, Mark worked at a sheltered workshop and lived in a large intermediate care facility for the mentally retarded (ICF/MR). Adaptive behavior assessments and past records indicated that Mark did not always pay attention to instructions, became upset when criticized, and had been known to steal the belongings of others. Jane was a 40-year-old woman who obtained an IQ of 33 on the StanfordBinet and a 47 on the WAIS. These data and her adaptive behavior ratings also placed her in the moderate level of mental retardation. She lived in a large state institution for 20 years, from age 13 to 32. Since leaving the institution she had resided in various nursing homes. Like Mark she lived in a large ICF/MR and worked at a community sheltered workshop before inclusion in this study. Past records and adaptive behavior assessments indicated Jane had been verbally abusive to staff, had poorly developed community social skills, and had limited functional academic skills. Judy was a 28-year-old woman who had an estimated IQ of 49 and 68 as measured on the Stanford-Binet, and a 58 as determined on the WAIS. These data and her adaptive behavior ratings place her in the mild to moderate range of mental retardation. Until she was 19 years old she had lived with her parents and attended special education classes in a public school. In 1972, upon referral from her school, she enrolled full time at a sheltered workshop. Two years later
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she left her family's home and moved into the same ICF/MR as Mark and Jane. Besides being obese, her records and behavioral assessments indicated she had been verbally abusive and non-compliant, especially when involved in a training situation. Mark, Jane, and Judy were employed for two years, one year, and one year, respectively, as kitchen laborers in the food service division at the Urbana Campus of the University of Illinois (Rusch & Schutz, 1979). This employment provided the income they needed to move from the ICF/MR into their own separate community apartments and to become financially independent. Each person was a member of an apartment training program. Setting This investigation took place in the kitchens of Mark, Jane, and Judy's apartments. They each lived with one other mentally retarded roommate. The apartments were located in different neighborhoods in the Champaign-Urbana community. Two of the apartments were in large complexes where approximately 200-300 people lived while the third was a duplex where four people lived. The kitchens were equipped with similar appliances and utensils. The only exception was that Jane's apartment had a gas stove while Mark and Judy's apartments had electric ranges. Observation and Recording Procedures Apartment training program staff collected data in each of the participants' kitchens. The participants prepared meals on their days off except for Mark who also prepared breakfast when scheduled to work evening shifts. Trainers were responsible for observing, recording, and training throughout the study. Staff trainers. Four trainers collected data and implemented the experimental procedures. Three of these trainers were graduates of undergraduate programs specializing in either social work, psychology, or special education; the fourth had a Master's degree in psychology. Each had a minimum of one year experience using behavioral procedures with mentally retarded adults in nonsheltered settings. Three of the trainers were employed full-time by the apartment training program and the fourth was the first author. Before data collection began each trainer reviewed the training, observation, and recording procedures. After observing Mark, Jane, and Judy prepare one meal, a final observation and recording system was established. During the first six weeks of this study trainers met weekly to discuss inter-observer agreements/disagreements, and review the observation, recording, and experimental procedures, including the schedule for observer agreement. These sessions were discontinued after agreement scores exceeded 80% for five weeks.
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Independent and dependent variables. O ' L e a r y and Dubey (1979) stress that an individual's use o f self-controlling behavior be classified as the independent measure, while the dependent variable constitute measures of other individual behavior. In this study, the percent o f picture recipe pages turned independent o f trainer assistance constituted the independent variable. This measure represented the self-directed use of picture recipe cards. The percent of meal steps completed independent o f trainer assistance served as the dependent variable. Experimental Tasks. Five nutritionally balanced meals were selected by the apartment training staff based upon input from Mark, Judy, and Jane. These meals were then presented for final approval. For example, Jane requested that hamburgers be supplanted by spaghetti and meat sauce, a change agreed upon by Mark and Judy. Ultimately the five meals included: (a) baked chicken, corn, and apple pie; (b) roast beef, carrots, potatoes, and Jello; (c) broiled fish fillets, green beans, and pudding; (d) spaghetti with meat sauce, tossed salad, and broiled garlic bread; and (e) fried eggs, bacon, orange juice, and coffee. Each meal was then task analyzed by the apartment training staff, resulting in a range o f 4 8 - 7 6 steps or sub-tasks, depending upon the complexity of the meal. Table 1 depicts the task analysis for preparing fish fillets, green beans, and pudding. 1 These meals required using most o f the basic cooking skills such as frying, baking, broiling, boiling, defrosting, peeling, measuring, and slicing. TABLE 1 Task Analysis For Meal Three: Broiled Fish Fillets, Green Beans, and Pudding
1. Remove fish fillets from freezer 2. Place package of fillets on plate 3. Place fillets on plate and place into refrigerator to thaw 4.-12. LOCATE: milk, small pan, bowl, spatula, pot, holder, measuring cup, spoon, box of pudding, plate 13. Set pan on small burner 14. Pour i cup of milk 15. Pour milk into the pan 16. Pour 1 cup of milk 17. Pour milk into pan 18. Open box of pudding 19. Pour pudding into milk 20. Stir until pudding is mixed with milk 21. Turn burner to medium 22. Stir until large bubbles appear (boil) 23. Turn burner off
24. By using spatula, pour pudding into bowl 25. Put pudding into refrigerator 26.-32. LOCATE: Broiler pan, fish fillets, small pan, large spoon, margarine, salt and pepper, brush 33. Turn oven control to broil 34. Rub broiler pan with light coating of butter 35. Open package of fish fillets 36. Rinse fillets with rurming water 37. Throw package away 38. Season fillets with salt and pepper 39. Place large spoon full of butter into sauce pan 40. Turn burner to medium 41. Place pan on burner and stir butter until melted 42. Turn burner off 43. Place brush into melted butter (continued) JTask analyses for each meal are available upon request.
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TABLE 1 (Continued) 44. Brush butter onto both sides of the fish fillets 45. Place fillets into oven, near the broiler unit 46. Set timer for 5 minutes 47.-49. LOCATE: frozen green beans, pan, measuring cup 50. Hold measuring cup under running water 51. Measure I/2 cup of water 52. Place pan on burner 53. Pour 1/2cup of water into pan 54. Season with salt 55. Pour beans from bag into measuring cup 56. Measure 1 cup of beans 57. Put bag of beans back into the freezer 58. Pour beans into pan
59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73.
When timer rings Remove fillets from oven Turn fillets over by using turner Place fillets back into oven Set timer for five minutes Turn burner to high for the green beans When timer rings Remove fillets from oven Turn broiler off Place fillets onto serving platter Turn burner off for the green beans Put green beans into serving bowl Take pudding from refrigerator Spoon pudding into serving bowls Set food on table and then enjoy the meal
Observer agreement. Inter-observer agreement was assessed 49 times (37% o f the meals) across all experimental conditions and participants for the steps completed independent of trainer assistance, and 26 times (27% of the trials) for the pages turned independent o f trainer assistance. The four trainers described above and three others who were not associated with the direct training, but who were trained observers, served as raters of agreement. They recorded observations simultaneously and independently o f trainers during all agreement sessions. An agreement occurred when the trainer and agreement observer recorded for the same meal step or page an identical response; a disagreement occurred when the response for the same step or page was marked differently. Agreement percentage was determined by dividing the number of steps or pages in agreement by the number o f agreements plus disagreements (multipled by 100). The range of interobserver agreement scores for both the percent of steps completed independently and the percent of picture pages turned independently, ranged from 82% to 100% with a mean o f 95% and 87%, respectively.
Experimental Design, Conditions, and Procedures A multiple-baseline design across subjects (Cuvo, 1979) was utilized. Two experimental phases were introduced to all three subjects. In addition, a reversal was tried with Jane. The purpose of this reversal was to evaluate practice (Kazdin & Kopel, 1975). The two experimental phases were (a) pre-instruction and instructional feedback and (b) pre-instruction, instructional feedback, and picture
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recipe cards. A training baseline was used so that (a) the individuals would obtain instructional feedback that would enable them to successfully complete an entire meal, which could not happen in a non-treatment baseline and, (b) to establish the foundation for the component analysis that would permit the effects of the addition of picture-recipe cards to be determined. Pre-instruction and instructional feedback. During this phase the trainer sat with the participant at the kitchen table before the preparation of each meal. Prior to the first meal a rationale for preparing the meal was given and later repeated if the participant questioned the procedures. The rationale introduced the importance of being able to cook independent of trainer help. Before every meal, preinstruction in how to sequentially complete each step was provided. For example, Mark was told, "This morning you are going to prepare fried eggs, bacon, orange juice, and coffee. Listen to what I say. When I ' m finished, fix the meal. First, locate the can of orange juice, a container..." Instruction continued until all steps were reviewed, at which time the participant was told to prepare the meal. Instructional feedback consisted of verbal praise or error correction when steps were completed correctly or incorrectly, respectively. Independent responses were intermittently praised, while verbal and/or physical cues and prompts were utilized to complete a step performed incorrectly or a step that was begun out of sequence. Mark, Judy, and Jane received two meals a day, usually lunch and dinner, five days a week as a result of their being employed as kitchen laborers; thus, they prepared meals in their apartments only on their days off. These days were not always consecutive nor the same from week to week. As a result, baseline measurement did not begin or end on the same day for all the subjects. This study extended over three and a half months (111 days). The schedule of meals was based in part on the time available for cooking, avoidance of meal repetition, and conflicts with other events, such as visiting out of town or being called back to work. Pre-instruction, instructional feedback, and picture recipe cards. Black and white, 35 mm photographs of each step of the five meals, except for the stove controls that were hand drawn, were placed on laminated 15.5 m m x 12.5 mm cards. These cards were then bound by metal rings. Below each picture was a number that indicated the card's position in the sequenced recipe and a typed statement that described the step, e.g., "25. dump fruit cocktail into strainer held over sink." The steps that required preparation the evening before, such as "defrosting the fish" and "making the pudding," were denoted by small (1 mm × ~2 mm) yellow stickers placed on the lower fight hand comer of the picture cards. Pre-instruction in the use of the recipe cards was provided immediately prior to preparation. For instance, Mark was told, "Tonight you are going to get part
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of tomorrow's meal ready. You are going to get the chuck roast out of the freezer and make the Jello, Remember, look at the cards, do what you see, then turn the page. Place the chuck roast on the plate, then turn the page. N o w . . . " This was continued until all steps were reviewed, at which time the participant was told, "Prepare the meal by using the picture recipe cards." A rationale was given when Mark, Jane, and Judy first used each of the picture recipe cards for the five different meals, and was repeated whenever they questioned a step or procedure, just as it had been done during baseline. All other components of the baseline training package remained the same, along with the addition of instructional feedback directed at the use of the picture recipe cards. For example, verbal and/or physical cues were provided when a page was not turned or if a page was turned out of sequence. Reversal. A return to baseline training conditions was instituted for Jane on Meal
30 and remained until all five meals were prepared. During this phase the meals were prepared without the use of the picture recipe cards. Following the completion of each of the five meals, the picture recipe cards were re-introduced (Meal 36). RESULTS The percent of steps for each meal completed independent of trainer assistance and the percent of pages in the picture recipe book that were turned independently are shown in Figure 1. During the initial pre-instruction and instructional feedback phase, Mark's scores ranged from a low of 20% to a high of 50%, with a mean of 35%; Jane's 12 scores ranged from a low of 12% to a high of 49% with a mean of 31%; and Judy's 15 baseline scores were generally higher and more stable than Mark's or Jane's, except for the third meal where she completed only 12% (of the steps independently). Judy's scores ranged from 12% to 68% with a mean of 53%. A slight upward trend was also evident in Jane and Judy's data. When the picture recipes were introduced Mark, Jane, and Judy immediately improved their ability to independently complete assigned meal steps. Mark and Judy improved from a 28% last baseline score to a 69% first intervention score and from a 48% last baseline score to a 94% first intervention score, respectively. Jane also improved her performance on steps completed independently. Her last baseline score was 45% and when the picture recipe cards were introduced, she obtained a score of 60%. Following introduction of the picture recipe cards, Mark and Jane continued to perform more steps independently as demonstrated by increasing trends. Within five meals Mark's level of independence increased from 68% to 90% and, after nine more trials, the data stabilized near the 90% level or above throughout the remainder of this investigation. Jane's improvement was more gradual, but each repetition of the meals resulted in a higher mean score. The
JUDy
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CONSECUTIVE MEALS
REVERSAL
FIGURE 1. The percent of steps for each meal completed and the percent of picture recipe book pages turned independent of trainer assistance for all three subjects across all experimental phases.
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MARK
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9-
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first five days average meal preparation score was 64%; the second was 69%, and the next eight meals averaged 76%. Judy's scores suggested that after the picture recipe cards were introduced she was able to complete 90% of the steps or more for the remainder of the study, except for the second trial after intervention which resulted in a score of 85%. Since the dramatic level effect that occurred with Mark and Judy did not occur with Jane, the picture recipe cards were removed on Meal 30 from Jane to examine the effects of practice separate from the picture cues. Her percent of steps completed independently decreased to below intervention level, but remained slightly higher than the baseline scores. The mean number of steps completed independently for the five meals was 52% and ranged from 45% to 56%. By contrast, the mean for the five prior meals was 77% and the mean for the five meals following the reversal (with the picture recipe cards) was 74%, 77% for the next five meals, 81% for the third group of meals, and, finally, a mean of 83% for the remaining meals. The percent of pages that were turned independent of trainer assistance covaried with the percent of steps completed independently. During Mark's first trials using the picture recipes, the percent of pages turned independently was higher than the percent of steps completed independently for three of the five prior trials. After this, however, the percent of pages turned independently either was equal to or slightly below the percent of steps completed independently. A similar pattern existed for Jane and Judy. However, the differences between the two measures were usually greater for Jane. For Jane, the percent of pages turned independently exceeded the percent of steps completed independently on two occasions prior to and three occasions following the reversal. DISCUSSION The results of this investigation indicate that mildly to moderately mentally retarded adults living in nonsheltered residential settings can, when provided sequenced, picture recipe cues prepare complex meals. This study is the first to systematically examine and isolate the effects that self-directed, antecedent picture cues have upon acquisition of complex tasks with mentally retarded persons. This investigation clearly showed that pre-instruction and feedback combined with pictorial cues resulted in each subject completing more steps independently across the five meals. Further, examination of the extent to which each meal was affected by the training program indicates generalization of increased competence across all meals for each individual. These results extend the existing literature in several ways. First, this study utilized a baseline composed of preinstruction and instructional feedback, whereas, the Connis (1979), Johnson et al. (1981), and Sowers et al. (1980) studies used no treatment baselines. Our baseline enabled comparisons to be made between the results of baseline procedures and procedures that included the picture cues. The present study clearly
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demonstrated that the change in the dependent measure was due to picture recipe cards in combination with pre-instruction and instructional feedback versus preinstruction and instructional feedback, alone. Second, the target behaviors in the present study were complex and required a variety of different responses, completed in a sequential order. The five meals ranged from 48 to 76 steps; and in order to independently complete the meals all basic cooking skills had to be utilized. In contrast, Connis (1979) measured between 9 to 14 task changes that remained constant each day; Sowers et al. (1980) included a target behavior composed of four subcomponents, i.e., going to and returning from lunches and breaks. Robinson-Wilson (1977), Johnson et al. (1981), and Matson (1979), trained the skills to prepare only simple parts of a meal, or just simple meals, never complex balanced meals. Third, using sequenced picture cards to facilitate the preparation of balanced meals is a time-efficient, self-control package that helps insure correct nutritional intake. Since one of the major reasons mentally retarded individuals fail in independent living is due to a lack of adequate meal preparation skills (Schalock & Harper, 1978), and nutritional problems (Schalock et al., 1981) this approach appears to be a viable means of addressing a serious issue. It is a functional, in vivo alternative to training menu planning based upon the four food groups, followed by learning to prepare each food item separately. The picture recipes circumvented having to learn the many abstract details of correct menu planning and quickly facilitated preparation of balanced meals. In nonsheltered training programs, where the goal is to decrease dependence upon staff, this approach provides a means to further independent functioning. Fourth, the sequenced self-managed picture recipe cards were, as described by Goetz and Etzel (1978), a means for establishing self-control over environmental stimuli. This self-control strategy relied on the prearrangement of antecedent cues to increase the likelihood of particular responses. This type of strategy is believed to facilitate the establishment of a response chain more effectively than the strategies that deal with later portions of a behavioral chain (Mahoney & Thoresen, 1974). The self-manipulation of the picture recipe cards provided the mentally retarded individuals in this study logically ordered, discriminative stimuli that controlled the preparation of complex meals. Similar to the positive verbal correspondence established when an individual says that he will do a certain behavior and does it (Karlan & Rusch, in press), this study suggests positive nonverbal correspondence occurred between the looking response and the completion of the various steps. Specifically, sequenced picture cues were the mediating variables that enabled the individuals in this study to control their own performance of complex behavioral chains. Finally, the percent of picture recipe cards turned independent of trainer assistance was usually below the dependent measure. This suggests that Mark, Jane, and Judy did not always rely upon the pictures. Occasionally, they would begin the next step in the meal preparation process without turning the page to
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look at the next picture. Perhaps after the cards are used over an extended period of time they may not rely upon the constant use of the cards; but instead they may refer to the pictures only when at a difficult step. This use of the picture recipe cards appears similar to the general population's use of written recipes. In summary, this study demonstrates both an effective and a functional approach to training an important survival skill. Sequenced picture recipe cards, when combined with pre-instruction and instructional feedback, enabled mentally retarded adults to manage their own behaviors in the preparation of complex meals. The training package also provided a functional training alternative to circumvent the need to have a framework of detailed, abstract knowledge about how to plan and prepare balanced meals. This demonstration of a practical means to enable mentally retarded adults to self-manage a complex survival skill is a critical step that recommends further community integration efforts. Future research is needed to assess maintenance of the acquired skills when pre-instruction, instructional feedback, and the trainers have been withdrawn. Even though the training package achieved high levels of task completion, the effects of withdrawing its components are unknown. The ability of mentally retarded adults to live in nonsheltered settings ultimately depends upon their long-term independent performance and self-management of the various survival skills. Research is underway to investigate the pattern of component withdrawal that is necessary to achieve long-term maintenance based upon the recommendations of Rusch and Kazdin (1981). Perhaps the use of self-directed external cues will enable mentally retarded individuals to achieve higher levels of truly independent functioning.
Acknowledgement--Special thanks are extended to Rachel Baron for assisting in the photography; to Thomas J. Laidlaw for his coordinating support; and to Laird W. Heal, M. Stephen Lilly, and Pat Gaydos for their suggestions and guidance. This research was supported in part by grants from the Illinois Department of Rehabilitation Services and the Office of Special Education and Rehabilitation.
REFERENCES Bandura, A., & Waiters, R. H. Social learning and personality development. New York: Holt, Rinehart and Winston, 1963. Connis, R. T. The effects of sequential pictorial cues, self-recording, and praise on the job task sequencing of retarded adults. Journal of Applied Behavior Analysis, 1979, 12, 355-361. Cuvo, A. J. Multiple-baseline design in instructional research: Pitfalls of measurement and procedural advantages. American Journal of Mental Deficiency, 1979, 84, 219-228. Goetz, E. M., & Etzel, B. C. A brief review of self-control procedures: Problems and solutions. The Behavior Therapist, 1978, 1, 5-8. Goldfried, M. R., & Merbaum, M. A perspective on self-control. In M. R. Goldfried & M. Merbaum (Eds.), Behavior change through self-control. New York: Holt, Rinehart and Winston, 1973. Hayes, S. C., Rincover, A., & Solnick, J. V. The technical drift of applied behavior analysis. Journal of Appl&d Behavior Analysis, 1980, 13, 275-285.
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Heal, L. W., & Laidlaw, T. J. Evaluation of residential alternatives. In A. R. Novak & L. W. Heal (Eds.), Integration of developmentally disabled individuals into the community. Baltimore: Paul Brookes, 1980. Johnson, B. F., & Cuvo, A. J. Teaching mentally retarded adults to cook. Behavior Modification, 1981, 5, 187-202. Kanfer, F. H., & Karoly, P. Self-controh A behavioristic excursion into the lion's den. Behavior Therapy, 1972, 3, 398-416. Kanfer, F. H., & Phillips, J. S. Contract psychology: An operational approach to the problem of conscience and self-control. In R. C. Johnson, P. R. Dokecki, & O. H. Mowrer (Eds.), Conscience, contract, and social reality. New York: Holt, Rinehart and Winston, 1972. Karlan, G. R., & Rusch, F. R. Correspondence between saying and doing: Some thoughts on defining correspondence and future directions for applications. Journal of Applied Behavior Analysis, in press. Kazdin, A. E. Behavior modification in applied settings (rev. ed.). Homewood, Illinois: The Dorsey Press, 1980. Kazdin, A. E., & Kopel, S. A. On resolving ambiguities of the multiple-baseline design: Problems and recommendations. Behavior Therapy, 1975, 6, 601-608. Kendall, P. C. On the efficacious use of verbal self-instructional procedures with children. Cognitive Therapy Research, 1977, 1,331-341. Krasner, L., & Ullmann, L. P. Behavior influence and personality. New York: Holt, Rinehart and Winston, 1973. Mahoney, M. J., & Mahoney, R. Self-control techniques with the mentally retarded. Exceptional Children, 1976, 42, 338-339. Mahoney, M. J., & Thoresen, C. E. Self-control: Power to the person. Monterey, California: Brooks/Cole Publishing Co., 1974. Martin, J. E., Rusch, F. R., & Heal, L. W. Training community survival skills to mentally retarded adults: A review and analysis. Journal of Special Education, in press. Matson, J. L. A field-tested system of training meal preparation skills to the retarded. British Journal of Mental Subnormality, 1979, 25, 14-18. Neenan, W. B. Benefit-cost analysis and the evaluation of mental retardation programs. In P.O. Davidson, F. W. Clark, & L. A. Hamerlynck (Eds.), Evaluation of behavioral programs in community, residential, and school settings. Champaign, Illinois: Research Press, 1974. O'Leary, S. G,, & Dubey, D. R. Applications of self-control procedures by children: A review. Journal of Applied Behavior Analysis, 1979, 12, 449-465. Robinson-Wilson, M. A. Picture recipe cards: An approach to teaching severely and profoundly retarded adults to cook. Education and Training of the Mentally Retarded, 1977, 12, 69-73. Rusch, F. R., & Kazdin, A. E. Toward a methodology of withdrawal designs for the assessment of response maintenance. Journal of Applied Behavior Analysis, 1981, 14, 131 - 140. Rusch, F. R., & Schutz, R. P. Non-sheltered competitive employment of the mentally retarded adult: Research to reality? Journal of Contemporary Business, 1979, 8, 85-98. Schalock, R. L., & Harper, R. S. Placement from community-based mental retardation programs: How well do clients do? American Journal of Mental Deficiency, 1978, 83, 240-247. Schaiock, R. L., Harper, R. S., & Carver, G. Independent Living Placements: Five years later. American Journal of Mental Deficiency, 1981, 86, 170-177. Schleien, S. J., Ash, T., Kiernan, J., & Wehman, P. Developing independent cooking skills in a profoundly retarded woman. The Journal of the Association for the Severely Handicapped, 1981, 6, 23-29. Shapiro, E. S. Self-control procedures with the mentally retarded. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 12). New York: Academic Press, 1981. Sigelman, C. K., Novak, A. R., Heal, L. W., & Switzky, H. N. Factors that affect the success of
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community placement. In A. R. Novak & L. W. Heal (Eds.), Integration of developmentally disabled individuals into the community. Baltimore: Paul Brookes Publisher, 1980. Skinner, B. F. Science and human behavior. New York: MacMillan, 1953. Sowers, J. A., Rusch, F. R., Cormis, R. T., & Cummings, L. E. Teaching mentally retarded adults to time manage in a vocational setting. Journal ofApplied BehaviorAnalysis, 1980,13, 119-128. Spellman, C., DeBriere, T., Jarboe, D., Campbell, S., & Harris, C. Pictorial instructions: Training daily living skills. In M. E. Snell (Ed.), Systematic instruction of the moderately and severely handicapped. Columbus, Ohio: Charles E. Merrill, 1978. Zeaman, D., & House, B. J. The role of attention in retardate discrimination learning. In N. R. Ellis (Ed.), Handbook of mental deficiency. New York: McGraw-Hill Book Company, 1963.
0270-3092182/020105-15503.0@0 Copyright© 1982PergamonPress Ltd
The Use of Picture Cues to Establish SelfControl in the Preparation of Complex Meals by Mentally Retarded Adults James F. Martin and Frank R. Rusch University of Illinois at Urbana-Champaign
and Vicki L. lames, Paul I. Decker, and Karen A. Trtol Developmental Services Center of Champaign County
This investigation examined the effectiveness of picture cues in establishing selfcontrol in the completion of complex meals by mildly and moderately retarded adults. Three participants, who lived in nonsheltered residential settings, were trained to prepare five complex meals. Following a training baseline comprised of pre-instruction, instructional feedback, and trainers" presence, picture recipe cards were introduced in a multiple-baseline fashion. Rapid improvement in the ability of each participant to independently complete each meal when the picture recipe cards were used occurred. A return to baseline for one of the participants demonstrated further selfdirected antecedent stimulus control of the picture recipe cards as an effective treatment procedure. A discussion of future areas of research is included.
Mentally retarded adults must acquire a variety of complex, community survival skills to live successfully in community environments (Martin, Rusch, & Heal, in press; Schalock, Harper, & Carver, 1981); for those who have been unsuccessful often fail due to inappropriate behavior or lack of needed skills (Sigelman, Nova.k, Heal, & Switzky, 1980). With the current emphasis upon integrating mentally retarded adults into community environments from sheltered residential settings, competence in completing everyday tasks, such as meal preparation, Requests for reprints may be addressed to James E. Martin, University of Illinois, Bureau of Educational Research, 188 Education, 1310 S. 6th Street, Champaign, IL 61820.
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is required. Schalock and Harper (1978), for instance, determined through a two-year follow-up of independent living placements that, along with other specific skill deficits, 80% of the individuals who failed experienced problems with meal preparation. In a five year follow-up of the same individuals living independently, Schalock et al. (1981) found the ability to prepare meals was an essential variable for success. The development of meal preparation skills with mentally retarded individuals has received increasingly complex examination. Robinson-Wilson (1977) trained three severely mentally retarded adults in a sheltered workshop to prepare simple food items (hot chocolate, Jello, and hot dogs) through the use of hand-drawn, picture recipes that included color-coded stove dials and a timer. The three recipes were introduced in a different sequence to each individual, and each subsequent recipe required fewer trails indicating across task stimulus generalization. Matson (1979) trained 24 moderately to severely retarded adults in an institutional setting to prepare a simple breakfast (coffee, instant cereal, juice, and toast), a simple lunch (sandwich, canned soup), an intermediate breakfast (bacon/sausage, canned biscuits, and fried/scrambled eggs), and an intermediate lunch (hot dogs and Kool-Aid). Trainer modeling, followed by one person demonstrating the preparation of a meal with questioning of the remaining individuals about the procedures used, enabled them to improve their cooking skills. Johnson and Cuvo (1981) utilized a training package comprised of graduated prompting, praise, graphic feedback, and hand-drawn picture-recipes with written directions to train cooking of single food items, Two moderately and two mildly mentally retarded adults were trained in a sheltered workshop kitchen to boil an egg, boil vegetables, bake one biscuit, broil one hot dog, and broil an english muffin. Additionally, Schleien, Ash, Kiernan, and Wehman (1981) developed independent cooking skills in a profoundly mentally retarded woman in a sheltered workshop. Through instructional feedback and material modification she acquired and maintained the ability to boil an egg, broil a muffin, and bake a T.V. dinner, plus generalize her skills to boil a food packet and bake a pizza. The research literature indicates that mentally retarded individuals can learn select meal preparation skills, however, self-control in preparing complex meals in vivo has yet to be demonstrated. Self-control refers to when an individual implements procedures to control his or her own behavior (Kazdin, 1980), and to all processes related to changing or maintaining one's own behavior (Shapiro, 1981). The important aspect of self-control is that the person plays a major role in arranging the stimulus condition (Krasner & Ullmann, 1973). More specifically, self-control is a means to facilitate the occurrence of desired behavior through self-exposure to certain stimuli that will increase its likelihood (Skinner, 1953). Self-control responses are dependent upon mediating variables, which have traditionally been language based, such as self-instruction (Bandura & Waiters 1963; Goldfried & Merbaum, 1973; Kanfer & Karoly, 1972). Recently, self-control mediation had been based
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upon self-reinforcement, self-contract, biofeedback, and upon self-control manuals, to name a few (Goetz & Etzel, 1978; Kazdin, 1980). One of the most common procedures is to have a person initiate a shift in stimulus control from one aspect of the environment to another (Kanfer & Phillips, 1972). To date, much of applied self-control research is based upon identification of the procedures people can use to control their own behavior (O'Leary & Dubey, 1979). Thus, self-control strategies are beginning to be used with mentally retarded individuals (Shapiro, 1981), who would seem to be excellent candidates since they are often abnormally dependent upon others (Mahoney & Mahoney, 1976). A developing area of research that has application to facilitating self-control with the mentally retarded is the use of picture cues as the mediating variable (Connis, 1979; Johnson & Cuvo, 1981; Robinson-Wilson, 1977; Sowers, Rusch, Connis, & Cummings, 1980; Spellman, DeBriere, Jarboe, Campbell, & Harris, 1978); especially since many mentally retarded individuals have difficulty in selecting relevant stimuli from a stimulus field (Zeaman & House, 1963). Three recent studies (Connis, 1979; Johnson & Cuvo, 1981; Sowers et al., 1980) examined the effects of picture cues in combination with pre-instruction, instructional feedback, and repeated practice in vocational training programs. Connis (1979) incorporated the use of photographs to sequence the completion of work tasks by three moderately mentally retarded adults. The intervention combined self-recording with pre-instruction in how to use picture cues. Pre-instruction included modeling, role playing, and a rationale for training. Independent movement from one task to the next throughout the workday was praised; failure to change independently resulted in the error being corrected. Picture cue training enabled three of the four subjects in this study to change tasks independently. Sowers et al. (1980) trained three moderately mentally retarded adults to manage their break times. Sowers et al. (1980) introduced pre-instruction in how to utilize a picture cue that depicted clock faces with the time configurations illustrating when to leave and return from lunches and breaks. Correct time management was praised and errors were corrected through instructional feedback consisting of repeated practice in identifying correct clock faces. Each of the three subjects in this study learned to manage their own time. Johnson et al. (1981), as mentioned above, trained four mentally retarded individuals to cook single food items with a training package that contained picture cues. Collectively, it is not apparent from these studies, however, which component of the training package was most responsible for the results. It is possible that any one component could have obtained similar results. For example, in the Sowers et al. (1980) study, perhaps the picture cues alone would have enabled the subjects to learn to manage their own time. Since efforts to integrate mentally retarded adults into the community and costs associated with training are being examined (Heal & Laidlaw, 1980; Neenan, 1974), approaches should be investigated that initially rely upon trainers but ultimately upon self-management. Attention needs to be paid to the benefits
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of the self-control techniques introduced by Connis (1979), Johnson et al., (1981), and Sowers et al. (1980). These efforts are unique since they initially relied upon trainer assistance but ultimately upon self-directed stimulus control. Isolating the effects of picture cues may aid in the further development of selfcontrol components, which may lead to more efficient training methods. Connis (1979), Sowers et al. (1980), and Johnson et al. (1981) compared their instructional training packages to non-treatment baselines. Their designs did not permit the determination of which component contributed the most to change. Although component analyses have decreased in the literature (Hayes, Rincover, & Solnick, 1980), their value is apparent for isolating effective selfcontrol components (Goldfried & Merbaum, 1973; Kendall, 1977; Shapiro, 1981). The purpose of this study was to undertake a component analysis to examine the effects of picture cues as a means to establish self-control to complete complex tasks, and to train a skill heretofore not empirically validated.
METHOD Subjects
Mark was a 23-year-old Downs Syndrome male with a severe speech impairment. Past IQ scores have varied from a 33 to a 40 on the Stanford-Binet, to a 50 on the WAIS. These data and his adaptive behavior ratings placed him in the moderate level of mental retardation. Prior to this investigation, Mark worked at a sheltered workshop and lived in a large intermediate care facility for the mentally retarded (ICF/MR). Adaptive behavior assessments and past records indicated that Mark did not always pay attention to instructions, became upset when criticized, and had been known to steal the belongings of others. Jane was a 40-year-old woman who obtained an IQ of 33 on the StanfordBinet and a 47 on the WAIS. These data and her adaptive behavior ratings also placed her in the moderate level of mental retardation. She lived in a large state institution for 20 years, from age 13 to 32. Since leaving the institution she had resided in various nursing homes. Like Mark she lived in a large ICF/MR and worked at a community sheltered workshop before inclusion in this study. Past records and adaptive behavior assessments indicated Jane had been verbally abusive to staff, had poorly developed community social skills, and had limited functional academic skills. Judy was a 28-year-old woman who had an estimated IQ of 49 and 68 as measured on the Stanford-Binet, and a 58 as determined on the WAIS. These data and her adaptive behavior ratings place her in the mild to moderate range of mental retardation. Until she was 19 years old she had lived with her parents and attended special education classes in a public school. In 1972, upon referral from her school, she enrolled full time at a sheltered workshop. Two years later
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she left her family's home and moved into the same ICF/MR as Mark and Jane. Besides being obese, her records and behavioral assessments indicated she had been verbally abusive and non-compliant, especially when involved in a training situation. Mark, Jane, and Judy were employed for two years, one year, and one year, respectively, as kitchen laborers in the food service division at the Urbana Campus of the University of Illinois (Rusch & Schutz, 1979). This employment provided the income they needed to move from the ICF/MR into their own separate community apartments and to become financially independent. Each person was a member of an apartment training program. Setting This investigation took place in the kitchens of Mark, Jane, and Judy's apartments. They each lived with one other mentally retarded roommate. The apartments were located in different neighborhoods in the Champaign-Urbana community. Two of the apartments were in large complexes where approximately 200-300 people lived while the third was a duplex where four people lived. The kitchens were equipped with similar appliances and utensils. The only exception was that Jane's apartment had a gas stove while Mark and Judy's apartments had electric ranges. Observation and Recording Procedures Apartment training program staff collected data in each of the participants' kitchens. The participants prepared meals on their days off except for Mark who also prepared breakfast when scheduled to work evening shifts. Trainers were responsible for observing, recording, and training throughout the study. Staff trainers. Four trainers collected data and implemented the experimental procedures. Three of these trainers were graduates of undergraduate programs specializing in either social work, psychology, or special education; the fourth had a Master's degree in psychology. Each had a minimum of one year experience using behavioral procedures with mentally retarded adults in nonsheltered settings. Three of the trainers were employed full-time by the apartment training program and the fourth was the first author. Before data collection began each trainer reviewed the training, observation, and recording procedures. After observing Mark, Jane, and Judy prepare one meal, a final observation and recording system was established. During the first six weeks of this study trainers met weekly to discuss inter-observer agreements/disagreements, and review the observation, recording, and experimental procedures, including the schedule for observer agreement. These sessions were discontinued after agreement scores exceeded 80% for five weeks.
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Independent and dependent variables. O ' L e a r y and Dubey (1979) stress that an individual's use o f self-controlling behavior be classified as the independent measure, while the dependent variable constitute measures of other individual behavior. In this study, the percent o f picture recipe pages turned independent o f trainer assistance constituted the independent variable. This measure represented the self-directed use of picture recipe cards. The percent of meal steps completed independent o f trainer assistance served as the dependent variable. Experimental Tasks. Five nutritionally balanced meals were selected by the apartment training staff based upon input from Mark, Judy, and Jane. These meals were then presented for final approval. For example, Jane requested that hamburgers be supplanted by spaghetti and meat sauce, a change agreed upon by Mark and Judy. Ultimately the five meals included: (a) baked chicken, corn, and apple pie; (b) roast beef, carrots, potatoes, and Jello; (c) broiled fish fillets, green beans, and pudding; (d) spaghetti with meat sauce, tossed salad, and broiled garlic bread; and (e) fried eggs, bacon, orange juice, and coffee. Each meal was then task analyzed by the apartment training staff, resulting in a range o f 4 8 - 7 6 steps or sub-tasks, depending upon the complexity of the meal. Table 1 depicts the task analysis for preparing fish fillets, green beans, and pudding. 1 These meals required using most o f the basic cooking skills such as frying, baking, broiling, boiling, defrosting, peeling, measuring, and slicing. TABLE 1 Task Analysis For Meal Three: Broiled Fish Fillets, Green Beans, and Pudding
1. Remove fish fillets from freezer 2. Place package of fillets on plate 3. Place fillets on plate and place into refrigerator to thaw 4.-12. LOCATE: milk, small pan, bowl, spatula, pot, holder, measuring cup, spoon, box of pudding, plate 13. Set pan on small burner 14. Pour i cup of milk 15. Pour milk into the pan 16. Pour 1 cup of milk 17. Pour milk into pan 18. Open box of pudding 19. Pour pudding into milk 20. Stir until pudding is mixed with milk 21. Turn burner to medium 22. Stir until large bubbles appear (boil) 23. Turn burner off
24. By using spatula, pour pudding into bowl 25. Put pudding into refrigerator 26.-32. LOCATE: Broiler pan, fish fillets, small pan, large spoon, margarine, salt and pepper, brush 33. Turn oven control to broil 34. Rub broiler pan with light coating of butter 35. Open package of fish fillets 36. Rinse fillets with rurming water 37. Throw package away 38. Season fillets with salt and pepper 39. Place large spoon full of butter into sauce pan 40. Turn burner to medium 41. Place pan on burner and stir butter until melted 42. Turn burner off 43. Place brush into melted butter (continued) JTask analyses for each meal are available upon request.
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TABLE 1 (Continued) 44. Brush butter onto both sides of the fish fillets 45. Place fillets into oven, near the broiler unit 46. Set timer for 5 minutes 47.-49. LOCATE: frozen green beans, pan, measuring cup 50. Hold measuring cup under running water 51. Measure I/2 cup of water 52. Place pan on burner 53. Pour 1/2cup of water into pan 54. Season with salt 55. Pour beans from bag into measuring cup 56. Measure 1 cup of beans 57. Put bag of beans back into the freezer 58. Pour beans into pan
59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73.
When timer rings Remove fillets from oven Turn fillets over by using turner Place fillets back into oven Set timer for five minutes Turn burner to high for the green beans When timer rings Remove fillets from oven Turn broiler off Place fillets onto serving platter Turn burner off for the green beans Put green beans into serving bowl Take pudding from refrigerator Spoon pudding into serving bowls Set food on table and then enjoy the meal
Observer agreement. Inter-observer agreement was assessed 49 times (37% o f the meals) across all experimental conditions and participants for the steps completed independent of trainer assistance, and 26 times (27% of the trials) for the pages turned independent o f trainer assistance. The four trainers described above and three others who were not associated with the direct training, but who were trained observers, served as raters of agreement. They recorded observations simultaneously and independently o f trainers during all agreement sessions. An agreement occurred when the trainer and agreement observer recorded for the same meal step or page an identical response; a disagreement occurred when the response for the same step or page was marked differently. Agreement percentage was determined by dividing the number of steps or pages in agreement by the number o f agreements plus disagreements (multipled by 100). The range of interobserver agreement scores for both the percent of steps completed independently and the percent of picture pages turned independently, ranged from 82% to 100% with a mean o f 95% and 87%, respectively.
Experimental Design, Conditions, and Procedures A multiple-baseline design across subjects (Cuvo, 1979) was utilized. Two experimental phases were introduced to all three subjects. In addition, a reversal was tried with Jane. The purpose of this reversal was to evaluate practice (Kazdin & Kopel, 1975). The two experimental phases were (a) pre-instruction and instructional feedback and (b) pre-instruction, instructional feedback, and picture
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recipe cards. A training baseline was used so that (a) the individuals would obtain instructional feedback that would enable them to successfully complete an entire meal, which could not happen in a non-treatment baseline and, (b) to establish the foundation for the component analysis that would permit the effects of the addition of picture-recipe cards to be determined. Pre-instruction and instructional feedback. During this phase the trainer sat with the participant at the kitchen table before the preparation of each meal. Prior to the first meal a rationale for preparing the meal was given and later repeated if the participant questioned the procedures. The rationale introduced the importance of being able to cook independent of trainer help. Before every meal, preinstruction in how to sequentially complete each step was provided. For example, Mark was told, "This morning you are going to prepare fried eggs, bacon, orange juice, and coffee. Listen to what I say. When I ' m finished, fix the meal. First, locate the can of orange juice, a container..." Instruction continued until all steps were reviewed, at which time the participant was told to prepare the meal. Instructional feedback consisted of verbal praise or error correction when steps were completed correctly or incorrectly, respectively. Independent responses were intermittently praised, while verbal and/or physical cues and prompts were utilized to complete a step performed incorrectly or a step that was begun out of sequence. Mark, Judy, and Jane received two meals a day, usually lunch and dinner, five days a week as a result of their being employed as kitchen laborers; thus, they prepared meals in their apartments only on their days off. These days were not always consecutive nor the same from week to week. As a result, baseline measurement did not begin or end on the same day for all the subjects. This study extended over three and a half months (111 days). The schedule of meals was based in part on the time available for cooking, avoidance of meal repetition, and conflicts with other events, such as visiting out of town or being called back to work. Pre-instruction, instructional feedback, and picture recipe cards. Black and white, 35 mm photographs of each step of the five meals, except for the stove controls that were hand drawn, were placed on laminated 15.5 m m x 12.5 mm cards. These cards were then bound by metal rings. Below each picture was a number that indicated the card's position in the sequenced recipe and a typed statement that described the step, e.g., "25. dump fruit cocktail into strainer held over sink." The steps that required preparation the evening before, such as "defrosting the fish" and "making the pudding," were denoted by small (1 mm × ~2 mm) yellow stickers placed on the lower fight hand comer of the picture cards. Pre-instruction in the use of the recipe cards was provided immediately prior to preparation. For instance, Mark was told, "Tonight you are going to get part
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of tomorrow's meal ready. You are going to get the chuck roast out of the freezer and make the Jello, Remember, look at the cards, do what you see, then turn the page. Place the chuck roast on the plate, then turn the page. N o w . . . " This was continued until all steps were reviewed, at which time the participant was told, "Prepare the meal by using the picture recipe cards." A rationale was given when Mark, Jane, and Judy first used each of the picture recipe cards for the five different meals, and was repeated whenever they questioned a step or procedure, just as it had been done during baseline. All other components of the baseline training package remained the same, along with the addition of instructional feedback directed at the use of the picture recipe cards. For example, verbal and/or physical cues were provided when a page was not turned or if a page was turned out of sequence. Reversal. A return to baseline training conditions was instituted for Jane on Meal
30 and remained until all five meals were prepared. During this phase the meals were prepared without the use of the picture recipe cards. Following the completion of each of the five meals, the picture recipe cards were re-introduced (Meal 36). RESULTS The percent of steps for each meal completed independent of trainer assistance and the percent of pages in the picture recipe book that were turned independently are shown in Figure 1. During the initial pre-instruction and instructional feedback phase, Mark's scores ranged from a low of 20% to a high of 50%, with a mean of 35%; Jane's 12 scores ranged from a low of 12% to a high of 49% with a mean of 31%; and Judy's 15 baseline scores were generally higher and more stable than Mark's or Jane's, except for the third meal where she completed only 12% (of the steps independently). Judy's scores ranged from 12% to 68% with a mean of 53%. A slight upward trend was also evident in Jane and Judy's data. When the picture recipes were introduced Mark, Jane, and Judy immediately improved their ability to independently complete assigned meal steps. Mark and Judy improved from a 28% last baseline score to a 69% first intervention score and from a 48% last baseline score to a 94% first intervention score, respectively. Jane also improved her performance on steps completed independently. Her last baseline score was 45% and when the picture recipe cards were introduced, she obtained a score of 60%. Following introduction of the picture recipe cards, Mark and Jane continued to perform more steps independently as demonstrated by increasing trends. Within five meals Mark's level of independence increased from 68% to 90% and, after nine more trials, the data stabilized near the 90% level or above throughout the remainder of this investigation. Jane's improvement was more gradual, but each repetition of the meals resulted in a higher mean score. The
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FIGURE 1. The percent of steps for each meal completed and the percent of picture recipe book pages turned independent of trainer assistance for all three subjects across all experimental phases.
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first five days average meal preparation score was 64%; the second was 69%, and the next eight meals averaged 76%. Judy's scores suggested that after the picture recipe cards were introduced she was able to complete 90% of the steps or more for the remainder of the study, except for the second trial after intervention which resulted in a score of 85%. Since the dramatic level effect that occurred with Mark and Judy did not occur with Jane, the picture recipe cards were removed on Meal 30 from Jane to examine the effects of practice separate from the picture cues. Her percent of steps completed independently decreased to below intervention level, but remained slightly higher than the baseline scores. The mean number of steps completed independently for the five meals was 52% and ranged from 45% to 56%. By contrast, the mean for the five prior meals was 77% and the mean for the five meals following the reversal (with the picture recipe cards) was 74%, 77% for the next five meals, 81% for the third group of meals, and, finally, a mean of 83% for the remaining meals. The percent of pages that were turned independent of trainer assistance covaried with the percent of steps completed independently. During Mark's first trials using the picture recipes, the percent of pages turned independently was higher than the percent of steps completed independently for three of the five prior trials. After this, however, the percent of pages turned independently either was equal to or slightly below the percent of steps completed independently. A similar pattern existed for Jane and Judy. However, the differences between the two measures were usually greater for Jane. For Jane, the percent of pages turned independently exceeded the percent of steps completed independently on two occasions prior to and three occasions following the reversal. DISCUSSION The results of this investigation indicate that mildly to moderately mentally retarded adults living in nonsheltered residential settings can, when provided sequenced, picture recipe cues prepare complex meals. This study is the first to systematically examine and isolate the effects that self-directed, antecedent picture cues have upon acquisition of complex tasks with mentally retarded persons. This investigation clearly showed that pre-instruction and feedback combined with pictorial cues resulted in each subject completing more steps independently across the five meals. Further, examination of the extent to which each meal was affected by the training program indicates generalization of increased competence across all meals for each individual. These results extend the existing literature in several ways. First, this study utilized a baseline composed of preinstruction and instructional feedback, whereas, the Connis (1979), Johnson et al. (1981), and Sowers et al. (1980) studies used no treatment baselines. Our baseline enabled comparisons to be made between the results of baseline procedures and procedures that included the picture cues. The present study clearly
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demonstrated that the change in the dependent measure was due to picture recipe cards in combination with pre-instruction and instructional feedback versus preinstruction and instructional feedback, alone. Second, the target behaviors in the present study were complex and required a variety of different responses, completed in a sequential order. The five meals ranged from 48 to 76 steps; and in order to independently complete the meals all basic cooking skills had to be utilized. In contrast, Connis (1979) measured between 9 to 14 task changes that remained constant each day; Sowers et al. (1980) included a target behavior composed of four subcomponents, i.e., going to and returning from lunches and breaks. Robinson-Wilson (1977), Johnson et al. (1981), and Matson (1979), trained the skills to prepare only simple parts of a meal, or just simple meals, never complex balanced meals. Third, using sequenced picture cards to facilitate the preparation of balanced meals is a time-efficient, self-control package that helps insure correct nutritional intake. Since one of the major reasons mentally retarded individuals fail in independent living is due to a lack of adequate meal preparation skills (Schalock & Harper, 1978), and nutritional problems (Schalock et al., 1981) this approach appears to be a viable means of addressing a serious issue. It is a functional, in vivo alternative to training menu planning based upon the four food groups, followed by learning to prepare each food item separately. The picture recipes circumvented having to learn the many abstract details of correct menu planning and quickly facilitated preparation of balanced meals. In nonsheltered training programs, where the goal is to decrease dependence upon staff, this approach provides a means to further independent functioning. Fourth, the sequenced self-managed picture recipe cards were, as described by Goetz and Etzel (1978), a means for establishing self-control over environmental stimuli. This self-control strategy relied on the prearrangement of antecedent cues to increase the likelihood of particular responses. This type of strategy is believed to facilitate the establishment of a response chain more effectively than the strategies that deal with later portions of a behavioral chain (Mahoney & Thoresen, 1974). The self-manipulation of the picture recipe cards provided the mentally retarded individuals in this study logically ordered, discriminative stimuli that controlled the preparation of complex meals. Similar to the positive verbal correspondence established when an individual says that he will do a certain behavior and does it (Karlan & Rusch, in press), this study suggests positive nonverbal correspondence occurred between the looking response and the completion of the various steps. Specifically, sequenced picture cues were the mediating variables that enabled the individuals in this study to control their own performance of complex behavioral chains. Finally, the percent of picture recipe cards turned independent of trainer assistance was usually below the dependent measure. This suggests that Mark, Jane, and Judy did not always rely upon the pictures. Occasionally, they would begin the next step in the meal preparation process without turning the page to
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look at the next picture. Perhaps after the cards are used over an extended period of time they may not rely upon the constant use of the cards; but instead they may refer to the pictures only when at a difficult step. This use of the picture recipe cards appears similar to the general population's use of written recipes. In summary, this study demonstrates both an effective and a functional approach to training an important survival skill. Sequenced picture recipe cards, when combined with pre-instruction and instructional feedback, enabled mentally retarded adults to manage their own behaviors in the preparation of complex meals. The training package also provided a functional training alternative to circumvent the need to have a framework of detailed, abstract knowledge about how to plan and prepare balanced meals. This demonstration of a practical means to enable mentally retarded adults to self-manage a complex survival skill is a critical step that recommends further community integration efforts. Future research is needed to assess maintenance of the acquired skills when pre-instruction, instructional feedback, and the trainers have been withdrawn. Even though the training package achieved high levels of task completion, the effects of withdrawing its components are unknown. The ability of mentally retarded adults to live in nonsheltered settings ultimately depends upon their long-term independent performance and self-management of the various survival skills. Research is underway to investigate the pattern of component withdrawal that is necessary to achieve long-term maintenance based upon the recommendations of Rusch and Kazdin (1981). Perhaps the use of self-directed external cues will enable mentally retarded individuals to achieve higher levels of truly independent functioning.
Acknowledgement--Special thanks are extended to Rachel Baron for assisting in the photography; to Thomas J. Laidlaw for his coordinating support; and to Laird W. Heal, M. Stephen Lilly, and Pat Gaydos for their suggestions and guidance. This research was supported in part by grants from the Illinois Department of Rehabilitation Services and the Office of Special Education and Rehabilitation.
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