Compliance with daily living routines: A case study.

The outcome of an intervention grounded in operant conditioning for a child with multiple medical diagnoses and mild mental retardation was examined. "David," an 8-year-old African American male, showed resistance to performing routine self-help activities that he was able to perform independently. An improvement was noted between baseline and intervention data. Such anecdotal data may have implications for the generalization of compliance to other medical settings for children. Key words: operant conditioning, compliance, medical settings, self-help, mental retardation ********** "David" was an 8-year-old African-American male who was admitted to a residential home for children with medical complications at age 2 years and 11 months with a medical diagnosis of a gastrostomy, tracheotomy cranial nerve dysfunction, post encephalitis, and brain stem and cord dysfunction with central hypoventilation. His mother reported that her pregnancy and the delivery were normal. At approximately 7 months of age, David was hospitalized for episodes of nausea and vomiting. He was diagnosed with myocarditis and viral myoencephalitis and he required ventilator support. Subsequently, David received a tracheostomy and efforts to wean him from vent support were unsuccessful. Therefore, he was unable to return home due to extensive medical needs. At the time of this intervention, David's medical diagnosis included: History of encephalitis meningitis, Status post viral myocarditis/myoencephalitis, Paralyzed diaphragm bilaterally, Sleep apnea secondary to brain stem injury, Tracheostomy, Gastrostomy, Bilateral typanostomy with tubes, Questionable seizure, Significant esophageal stricture with dilatation. David also had a diagnosis of mild mental retardation and psychological testing indicated that he functioned at a 4 to 5 year age level, regarding cognitive, social and emotional functioning. David was ambulatory and verbalized his wants and needs. Due to his tracheostomy, he was often difficult for unfamiliar listeners to understand. He had no functional swallowing skills, and received all his nourishment via a gastrostomy. David also had a tracheostomy and was ventilator dependent during sleep due to episodes of central sleep apnea. His fine and gross motor skills were adequately developed for participation in activities of daily living. He was able to follow complex directions. David loved action figures, superheroes (especially Batman), and Power Rangers. He enjoyed drawing these characters and had many of his pictures taped to his closet door. David was also gaining an understanding of money and he enjoyed shopping. The primary presenting problem reported by the staff included David's noncompliance when asked to perform simple daily routines such as making his bed and independently doing his g-tube and trach care. Although he was capable of doing many of the activities independently, he either refused to complete the activity or insisted on needing assistance from staff the majority of the time. Since David was eight years old at that time, increasing his independence would not only benefit the staff but also David. ASSESSMENT Following the initial concern filed by the staff, staff interviews and observations were conducted. From this, twelve main requests frequently asked of David were discovered. These main requests included making his bed, brushing his teeth, getting dressed, picking out clothes, tying shoes, picking up toys, using saline bullets, washing his hands, wearing a nosey, bathing himself, and his trach and g-tube care. Observations indicated that when David did not comply he typically got out of doing the task or received assistance. When David complied or performed the activity independently he occasionally received unenthusiastic verbal praise. Baseline data was collected to gain a current percentage of compliance and an idea about tasks that were more difficult for David. …