Using a Picture Activity Schedule Treatment Package to Teach Toothbrushing to Children with ASD

Moran, K., Reeve, S. A., Reeve, K. F., DeBar, R. M., & Somers, K. (2022). Using a picture activity schedule treatment package to teach toothbrushing to children with autism spectrum disorder. Education and Treatment of Children, 45, 145-156. https://doi.org/10.1007/s43494-022-00074-6

Reviewed by: Jeannine Ederer, BS, and Robert H. LaRue, PhD, BCBA-D
Graduate School of Applied and Professional Psychology, Rutgers University

Why research this topic?

Procedures to teach specific skills for individuals with autism Individuals with disabilities are often affected by oral hygiene issues. Oral hygiene is a topic of interest as failure to maintain oral health leads to serious negative outcomes such as acute and chronic pain, sleep and eating difficulties, and periodontal disease. While research suggests there is a need for increased oral care among children with Autism Spectrum Disorder (ASD) and related disorders, there are few evidence-based approaches targeting increasing toothbrushing skills and tolerance.

The existing literature on independent toothbrushing is relatively sparse. Prior researchers have used video modeling, task analyses, and picture activity schedules to teach independent toothbrushing. While these studies have produced encouraging results, none evaluated the effects of the removal of the associated prompts. This is a concern as children with ASD may become dependent upon caregivers, models, or schedules to complete toothbrushing independently. Prompt fading is an important and often overlooked step in behavioral programming. While prompt fading is commonly used with other skill-acquisition procedures, this void in the literature suggests that it may not been employed while teaching toothbrushing. Due to the gaps in the current literature, this study sought to analyze the effectiveness of an independent toothbrushing procedure, including a picture activity schedule, manual prompting, and progressive-prompt delay, and prompt fading on maintenance of independent toothbrushing.

What did the researchers do?

Three males with ASD participated in the study. Patrick (6 years old), Jonathan (8 years old), and Michael (9 years old) were selected for the study as they each needed to improve or acquire the skill of toothbrushing. At the start of the study, all participants were capable of following a picture activity schedule, holding and manipulating a manual toothbrush, putting toothpaste on a toothbrush, and expelling water from their mouths. Sessions were conducted in a classroom bathroom, a hallway bathroom, and a classroom sink area, and generalization probes were conducted in the participants’ home bathrooms. Prior to the start of the baseline sessions, multiple stimulus without replacement (MSWO) preference assessments were conducted for all participants. At the end of each toothbrushing session, independent of responding, participants were granted access to their top five tangible and top five edible items identified in the preference assessment.

The experimenters developed a task analysis outlining the steps for toothbrushing. Baseline sessions were conducted prior to teaching. The percentage of independently completed toothbrushing steps was monitored throughout the baseline and intervention phases. If the participant did not engage in toothbrushing within 3 minutes or stopped brushing for 3 minutes, the session was terminated. If any disruptive behavior occurred, the session was terminated. Intervention was comprised of a picture activity schedule, manual prompts, and a progressive prompt delay procedure. The picture activity schedule included pictures depicting each toothbrushing component on a magnetic strip on the wall at eye level. The manual prompts involved physically prompting the participants to point to the picture, obtain the materials, complete the toothbrushing component, and remove the completed step from the picture activity schedule. The progressive prompt delay procedure started with a 0-s delay for every step in the first two sessions, followed by a 2-s second delay, and after 90% of the steps were completed correctly, the final 4-s delay began. If an error occurred during the task, the experimenter corrected the error and in the next session, returned to a 0-s delay for the corresponding step. To fade the picture activity schedule, after a participant completed the entire task independently for two consecutive sessions, the schedule was removed in segments beginning with the pictures at the end. More pictures were removed following two consecutive sessions of 100% independence. If an error occurred after pictures had been removed, the errored step’s corresponding picture would be represented for a single session. Maintenance data were collected following 2-weeks and 1 month after mastery was reached. A multiple-probe-across participants design was utilized.

Preintervention and postintervention generalization probes were implemented in each participant’s home. These probes of toothbrushing skill were implemented using a tinting agent to make plaque on the teeth more visible (Listerine Agent Cool Blue). The experimenters used this tinting agent to measure the amount of plaque on participants’ teeth following brushing.

What did the researchers find?

In baseline, independent completion of toothbrushing was low and stable across participants. Following the introduction of the treatment package, responding increased to 100% for all participants. In addition, these gains were maintained after the removal of the picture activity schedule. Patrick met mastery criteria after 35 sessions, Jonathan after 57 sessions, and Michael after 93 sessions. All participants demonstrated a clinically significant increase in the generalization of toothbrushing skills in untaught environments. Maintenance data showed that all participants maintained independent toothbrushing after 2-weeks and 1-month. The pre- and post-intervention probes indicated a substantial decrease in visible plaque for all three participants.

What are the strengths and limitations of the study?

The primary strength of the study was that the researchers were able to develop an effective treatment package for independent toothbrushing and were then able to successfully use prompt fading procedures to further increase the independence of individuals with ASD. To increase the generalization of the skill acquired, experimenters conducted sessions in various locations and used generalization probes and maintenance data to ensure toothbrushing was generalized and maintained in the home setting.

While the study holds many strengths, it is not without limitations. From an external validity standpoint, the participants came to the study with some intact toothbrushing skills, so they do not necessarily represent the population of learners who need to acquire toothbrushing skills. In addition, the pre-intervention and post-intervention probes using Listerine Agent Cool Blue were only probed once before and after intervention. While there were practical reasons for restricting the number of probes (e.g., participants might enjoy seeing the blue on their teeth), fewer probes limit the confidence in the generality of the findings. Given the lifelong nature and importance of toothbrushing, longer maintenance probes would be needed. Another limitation was that participants were provided with access to preferred items at the end of each session noncontingent on performance. If reinforcement was used following the completion of correct toothbrushing steps, the rate of skill acquisition may have increased or varied.

What do the results mean?

The current investigation addresses an important gap in the literature in that it is the first of its kind to support an effective treatment package involving a picture activity schedule, manual prompting, and progressive prompt delay to teach independent toothbrushing. In addition, the study used effective prompt fading of pictures and manual prompts to increase independence with the skill. The study provides a template for clinicians, caregivers, and other stakeholders to utilize when teaching toothbrushing among the named population that results in maximum independence and a reduction in negative health outcomes.

Citations within the synopsis:

Ederer, J., & LaRue, R. H. (2023). Research Synopsis: Using a picture activity schedule treatment package to teach toothbrushing to children with autism spectrum disorder. Science in Autism Treatment, 20(7).

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