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Using a Tag as a Stimulus Prompt to Increase Correct Dressing Orientation

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Title: Using a Tag as a Stimulus Prompt to Increase Correct Dressing Orientation
Language: English
Authors: Foster, Hannah G., Elliott, Tyler-Curtis C. (ORCID 0000-0001-6826-4449), Ayres, Kevin M.
Source: Research and Practice for Persons with Severe Disabilities. 2023 48(4):203-214.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 12
Publication Date: 2023
Document Type: Journal Articles
Reports - Research
Education Level: Elementary Education
Descriptors: Daily Living Skills, Clothing, Students with Disabilities, Autism Spectrum Disorders, Skill Development, Stimuli, Cues, Program Effectiveness, Accuracy, Preschool Children, Elementary School Students
DOI: 10.1177/15407969231205849
ISSN: 1540-7969
2169-2408
Abstract: Dressing is an important skill for students with developmental disabilities, so they rely less on caregivers and build independence. Research evaluating dressing skills instruction commonly uses some type of graduated guidance to teach the skill. In this study, three students receiving special education services under autism eligibility had already received instruction on dressing skills using graduated guidance. Although this procedure was enough to teach the dressing steps (including putting on the clothing), it was not sufficient in teaching the student to put on the clothing with the correct orientation. Thus, these students walked out of the bathroom wearing clothes that were inside out and/or backward. We placed a 12-cm red stimulus prompt on the target clothing item and evaluated the effects on correct dressing orientation for these three students using a multiple probe design. For all three students, the stimulus prompt increased accuracy, and for two participants, accuracy was maintained. For the two students who maintained the skill, we systematically faded the tag, and they maintained perfect dressing orientation.
Abstractor: As Provided
Entry Date: 2023
Accession Number: EJ1400369
Database: ERIC
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  Value: <anid>AN0173550858;myx01dec.23;2023Nov14.04:08;v2.2.500</anid> <title id="AN0173550858-1">Using a Tag as a Stimulus Prompt to Increase Correct Dressing Orientation </title> <p>Dressing is an important skill for students with developmental disabilities, so they rely less on caregivers and build independence. Research evaluating dressing skills instruction commonly uses some type of graduated guidance to teach the skill. In this study, three students receiving special education services under autism eligibility had already received instruction on dressing skills using graduated guidance. Although this procedure was enough to teach the dressing steps (including putting on the clothing), it was not sufficient in teaching the student to put on the clothing with the correct orientation. Thus, these students walked out of the bathroom wearing clothes that were inside out and/or backward. We placed a 12-cm red stimulus prompt on the target clothing item and evaluated the effects on correct dressing orientation for these three students using a multiple probe design. For all three students, the stimulus prompt increased accuracy, and for two participants, accuracy was maintained. For the two students who maintained the skill, we systematically faded the tag, and they maintained perfect dressing orientation.</p> <p>Keywords: dressing; stimulus prompt; instructional technology; personal care</p> <p>Independent dressing can be a complex skill to learn because it requires mastery of several component skills, including fine motor movements, balance, awareness of the body, and discrimination skills ([<reflink idref="bib1" id="ref1">1</reflink>]). In addition, the mastery of dressing skills requires a series of multiple discrete behaviors, chained into a complex sequence ([<reflink idref="bib31" id="ref2">31</reflink>]). Even with these challenges, teaching dressing is still important for people with developmental disabilities because learning proper dressing skills has many positive outcomes, such as alleviating a burden on caretakers ([<reflink idref="bib30" id="ref3">30</reflink>]) and positive outcomes for the learners themselves in that they learn a daily independence skill ([<reflink idref="bib4" id="ref4">4</reflink>]).</p> <p>Typically developing children often learn how to dress independently through trial-and-error shaping, but children with developmental disabilities might require a more systematic teaching procedure to learn the skill ([<reflink idref="bib29" id="ref5">29</reflink>]). There are various studies that highlight different prompting strategies used to teach dressing skills including most-to-least prompting ([<reflink idref="bib7" id="ref6">7</reflink>]), simultaneous prompting ([<reflink idref="bib29" id="ref7">29</reflink>]), constant time delay ([<reflink idref="bib15" id="ref8">15</reflink>]), picture prompting ([<reflink idref="bib25" id="ref9">25</reflink>]), training of component motor skills ([<reflink idref="bib32" id="ref10">32</reflink>]), and video modeling ([<reflink idref="bib2" id="ref11">2</reflink>]). Of the various prompting methods, graduated guidance (or some variation) is one frequently used method used to teach dressing skills ([<reflink idref="bib5" id="ref12">5</reflink>]; [<reflink idref="bib21" id="ref13">21</reflink>]; [<reflink idref="bib23" id="ref14">23</reflink>]; [<reflink idref="bib28" id="ref15">28</reflink>]; [<reflink idref="bib30" id="ref16">30</reflink>]; [<reflink idref="bib35" id="ref17">35</reflink>]). Graduated guidance is ideal for a task such as dressing because it has strong research support for use with chained motor behaviors, especially those that require physical assistance ([<reflink idref="bib8" id="ref18">8</reflink>]; [<reflink idref="bib16" id="ref19">16</reflink>]).</p> <p>The previously evaluated methods for teaching dressing skills all use response prompts (also called extra-stimulus prompts). These prompting strategies focus on using external stimuli, delivered by an instructor, to assist learners engage in the correct response ([<reflink idref="bib20" id="ref20">20</reflink>]). Another type of prompt, yet to be evaluated with dressing, is the stimulus prompt (also called stimulus manipulation and within-stimulus prompts). Stimulus prompts manipulate the materials of the target stimulus to ensure correct responding ([<reflink idref="bib20" id="ref21">20</reflink>]; [<reflink idref="bib34" id="ref22">34</reflink>]). There are three types of stimulus prompt fading procedures commonly used to teach discriminations: Stimulus fading, stimulus prompting, and superimposition. Because there are slight definition variations for these stimulus-prompting procedures seen in the literature (see [<reflink idref="bib9" id="ref23">9</reflink>]; [<reflink idref="bib20" id="ref24">20</reflink>]; [<reflink idref="bib24" id="ref25">24</reflink>]; [<reflink idref="bib34" id="ref26">34</reflink>]), we will not attempt to delineate or define them here. The important part of these procedures to note is that the antecedent stimuli are manipulated to occasion correct responding, rather than an external stimulus providing a guide for correct responding.</p> <p>Stimulus prompts have been used to teach a variety of skills including letter-sound correspondence ([<reflink idref="bib10" id="ref27">10</reflink>]), number identification ([<reflink idref="bib11" id="ref28">11</reflink>]), and color naming ([<reflink idref="bib19" id="ref29">19</reflink>]). In our review of the literature, we did not find any studies using stimulus prompts to teach functional skills (i.e., dressing, eating, cleaning). [<reflink idref="bib34" id="ref30">34</reflink>] noted one important difference in procedures that use stimulus prompts: some use the critical stimulus feature and some utilize an arbitrary feature when establishing stimulus control. For example, when teaching the identification of pictures of wet animals, enhancing the critical stimulus feature would be to make the water droplet large in size; a non-critical feature would be putting a large red arrow pointing to the wet animal. This distinction has functional value because previous research using arbitrary features found it more difficult to fade the prompts than those that highlighted the critical stimuli ([<reflink idref="bib34" id="ref31">34</reflink>]).</p> <p>The majority of the research for teaching dressing skills uses response prompting techniques to teach each individual step of the dressing chain. However, one specific step of the chain (putting the clothing item on with the correct orientation) may require explicit discrimination training. In this study, we worked with three students whose teacher had used graduated guidance (prior to the study) to teach all steps of dressing, except the students did not master the step of ensuring the correct orientation of the clothing item. Thus, for these students, the current best practices (response prompting techniques) were insufficient to teach this discrimination. In addition, no studies have currently evaluated methods for teaching this clothing orientation discrimination. One logical solution would be to increase the salience of the clothing orientation using a stimulus prompt. Thus, the purpose of the current study was to examine if a stimulus prompt (a red visible tag on the clothing item) could assist learners struggling to discriminate the correct orientation of clothing while dressing (i.e., putting on a shirt that is not inside out or backward).</p> <hd id="AN0173550858-2">Research Question</hd> <p>What are the effects of the addition of a stimulus prompt (red tag) following ineffective response prompting on the correct orientation of clothing for students with autism spectrum disorder when implemented by researchers in a school context?</p> <hd id="AN0173550858-3">Method</hd> <p></p> <hd id="AN0173550858-4">Participants</hd> <p>Three students with autism spectrum disorder (ASD) participated in the study. All students attended public school in a large southeastern town, either in a preschool (Jerry, Keith) or third through fifth grade (Joel) adapted curriculum special education classroom. As a part of the classroom instruction, all students had practiced dressing using graduated guidance. We included these students in the study because, even with classroom instruction of graduate guidance, they were able to go through the motor tasks of putting on their clothes, but the clothing was often oriented incorrectly (inside out and/or backward). All students had an Individualized Education Program (IEP) eligibility for ASD as well as a Speech/Language Impairment. On the assessment of the Developmental Profile, Fourth Edition ([<reflink idref="bib3" id="ref32">3</reflink>]), all three students scored in the first or second percentile when compared with same-aged peers.</p> <p>Jerry was a 5-year-old male whose family spoke Spanish in the home. He primarily communicated in English through both Picture Exchange Communication System (PECS; [<reflink idref="bib12" id="ref33">12</reflink>]) and vocal communication. During the regular school day, Jerry worked on the functional skills of dressing and washing his hands. Joel was a nine-year-old Black male who primarily spoke English in the home and preferred to communicate vocally. In addition to the aforementioned IEP eligibility, Joel had a mild intellectual disability. During the regular school day, Joel worked on the functional skills of dressing and washing his hands. Keith was a 5-year-old Black male whose home spoke English. Keith primarily communicated with PECS ([<reflink idref="bib12" id="ref34">12</reflink>]), and during the regular school day, Keith worked on the functional skills of dressing and washing his hands. Keith had a behavior intervention plan that targeted various topographies of aggression maintained by access to attention, tangibles, and escape/avoidance. All parents provided signed informed consent, and the study was approved by the local university's Institutional Review Board.</p> <hd id="AN0173550858-5">Setting</hd> <p>Students attended a Pre-K through fifth grade, Title I school with 309 students. The student population contained 45.6% Black students and 21.7% Hispanic students. Due to the level of need, the entire district received free lunch. The students in this study attended a demonstration classroom run by the local university as a practicum and training site for preservice special education teachers and behavior analysts. Thus, the classrooms were led by behavior analysts and staffed by practicum students in behavior analysis.</p> <p>Because the regular school day did not provide naturalistic opportunities to practice functional goals (e.g., dressing, tying shoes, and brushing teeth), and these skills are of critical importance for students with developmental disabilities, the classroom teachers set aside a specific time of day where the students could practice functional goals. For example, at least two teachers (so they were not alone) would take the students to the restroom located down the hall from the classroom and (with the privacy of the restroom stall or door) remove the students' shirt to create a learning opportunity for dressing. The teachers would then use this opportunity to teach the students how to put on the shirt. All students had a learning history of going into the bathroom to complete functional goals such as dressing and washing hands. We elected to contrive the opportunity to teach dressing because the students did not receive any other opportunities to practice the skill (e.g., did not work on it at home, did not attend gym class). The limitations of creating a non-natural opportunity to practice dressing were necessary because, without it, the student would never have an opportunity to practice and thus never learn the skill. To protect the students and take into account their assent, if the student began engaging in challenging behaviors (e.g., aggression and elopement) prior to removing the clothes, we did not conduct the trial. We interpreted these instances as removal of assent: This only happened twice during the entire study. Both instances were with Keith on the day he was sent home sick (only one trial was conducted that day).</p> <hd id="AN0173550858-6">Materials</hd> <p>In all trials, we used the clothes the participants wore to school. The clothing item changed each day and they practiced using the same clothing for which they would use outside of sessions. For intervention sessions, we used a 12 cm × 4.75 cm piece of red duct tape (referred to as a "tag"). For pants and shorts, we placed the tag on the back of the pants (where the pants tag is often placed). For the shirt, we placed the tag on the inside of the shirt, specifically on the bottom front of the shirt. We selected to place the tags here rather than the location of the clothing tag first because tags on clothes are often inconsistent (i.e., sometimes on the back, sometimes on the side, sometimes non-existent). Thus, there was no possible way to highlight the "critical" feature that directs the student to know if the clothing item is facing the correct direction because there is no consistent critical feature. Second, with this placement, the student would only need to learn one discrimination (the student can place their hands in relation to the tag the same for pants, shirt, and underwear). Thus, we strategically chose this location such that the student could learn to put on one item of clothing (pants) and then use the exact same hand placement on the other clothing items (shirt and underwear). Although this location was arbitrary in relation to the normally occurring tag placement, we selected it to be more functional for the student once they acquired the skill (to be able to dress the same way for every clothing item). See Figure 1 for an example of where we placed the tag.</p> <p>Graph: Figure 1. Visual Depiction of the Stimulus Tag Placement.</p> <hd id="AN0173550858-7">Response Definitions and Measurement</hd> <p>Because the students only struggled with dressing orientation, we did not collect data on the entire dressing chain, but rather just the discrete step of dressing orientation. With Jerry, we focused on pants; with Joel, underwear; and with Keith, shirt. We selected these targets because when we probed all three clothing items, these were the items with which the students made the most orientation errors. We used event recording to measure the percentage of trials with correct clothing orientation. We defined a <emph>correct response</emph> as any response that ended with the student putting their clothing on with the correct orientation (i.e., not inside out and facing the front). We defined an <emph>error</emph> as any response in which the student put on the clothing item inside out, backward, put two legs in one hole (pants/underwear), and/or put their head through the arm holes (shirt). We determined if the response was a correct response or an error prior to intervening with graduated guidance. We calculated the percentage of correct trials by dividing the correct trials by the total number of trials for that school day and multiplying by 100%. We used paper and pencil to collect all data (primary, interobserver, procedural fidelity).</p> <hd id="AN0173550858-8">Interobserver Agreement</hd> <p>A second observer independently but simultaneously collected data for each student throughout all conditions. We calculated interobserver agreement using trial-by-trial agreement ([<reflink idref="bib18" id="ref35">18</reflink>]). Specifically, we took the number of trials with agreement and divided it by the total number of trials with agreement plus trials with disagreement and multiplied by 100%. For Jerry, the secondary observer collected data for 29.2% of baseline trials with 100% agreement, 39.7% of intervention trials with 100% agreement, and 33.3% of retention and fading trials with 100% agreement. With Joel, the secondary observer collected data for 43.3% of baseline trials with 92.3% agreement, 42.9% of intervention trials with 100% agreement, and 22.2% of retention and fading trials with 100% agreement. Finally, for Keith, the secondary observer collected data for 63% of baseline trials with 100% agreement, 69% of intervention trials with 85% agreement, and 11.1% of retention trials with 100% agreement. Raw interobserver agreement data for all students can be found in Supplemental Materials.</p> <hd id="AN0173550858-9">Research Design and Data Analysis</hd> <p>We used a multiple probe across participants design ([<reflink idref="bib17" id="ref36">17</reflink>]) to evaluate the effectiveness of the stimulus prompt. We randomized the order in which students first received intervention. Before introducing intervention on Tier 1, all three tiers had to be stable. Once Jerry responded with 100% accuracy for 2 days and the other remaining tiers were stable, we began intervention for Joel. Once Joel reached 100% accuracy for 2 days and Tier 3 was stable, we began intervention for Keith. We made decisions using visual analysis; specifically changes in trend, level, and variability following condition changes ([<reflink idref="bib14" id="ref37">14</reflink>]).</p> <p>We also conducted an effect size evaluation using the between-case standardized means difference metric (BC-SMD; [<reflink idref="bib13" id="ref38">13</reflink>]; [<reflink idref="bib27" id="ref39">27</reflink>]). This effect size reports the magnitude and direction of the intervention effect compared with baseline. This effect size measure is considered design comparable because it allows for comparison between single-case designs and between-group experimental designs ([<reflink idref="bib33" id="ref40">33</reflink>]). We used the free online calculator single-case design hierarchical linear model (<emph>scdhlm</emph>; [<reflink idref="bib26" id="ref41">26</reflink>]) to compute the effect size estimates. We selected the Restricted Maximum Likelihood (REML) model because it is flexible to violations of assumptions (i.e., the effect is homogeneous across cases, stable baseline, etc.). We included fixed and random effects for baseline level as well as fixed and random effects for change in linear trend and change in level for treatment. For the initial treatment time, we selected 7 (the shortest baseline length was 7 days), and for the follow-up time, we selected 14 (because the shortest intervention period was 7 days).</p> <hd id="AN0173550858-10">Procedures</hd> <p></p> <hd id="AN0173550858-11">Graduated Guidance</hd> <p>In each session we attempted to embed five trials into each student's day; however, most days we completed 3 to 5 trials. For Jerry, we conducted an average of 4.7 trials a day (range = 2–5), for Joel an average of 4.1 trials a day (range = 1–5), and for Keith an average of 4.4 trials a day (range = 1–5). The only day we conducted one trial was session 22 because illness caused the students to go home early. For each session, the instructor took the student to the restroom stall three to five times throughout the school day and assisted the student in taking off the target clothing item. The instructor balled up the clothing, to not influence the way the clothing was positioned, and placed the clothing item in front of the student. They always ensured the clothing was not inside out. The instructor then provided a general attentional cue and the task direction, "Put your [insert clothing item] on." If the student did not start picking up the clothing item, the instructor continued to repeat the task direction about every 10 s. If the student began putting the item on incorrectly, the instructor intervened by saying "That is the wrong way" and used graduated guidance to help the student fix the orientation. Graduated guidance consisted of the instructor delivering physical prompts, based on their current, moment-to-moment judgment (what level of physical prompt they need to use to get the response at that moment) and fading it as soon as possible ([<reflink idref="bib8" id="ref42">8</reflink>]; [<reflink idref="bib16" id="ref43">16</reflink>]). To ensure we could collect data on if the student emitted a correct response or not, we used graduated guidance as an error correction if the student made a mistake. For example, if the student put their legs into the pants such that they were backward, the trial counted as an error and the instructor began implementing graduated guidance. With graduated guidance, the instructor used only the level of physical prompt (i.e., none, partial physical, full physical) that was needed at that moment. For example, if the instructor began with a full physical (hand-over-hand) and felt the student begin engaging in the correct psychomotor response, they would release from a full physical to a partial physical (guiding the student's hand), to give the student the opportunity to respond correctly. If the student then begins making an error (i.e., putting legs back in the wrong hole), the instructor increases the level of the physical prompt (i.e., go back to a full physical). When the student put the clothing item on with correct orientation (with or without graduated guidance) the instructor said "Yes, that is the right way to put your [clothing item] on, excellent job!" and the trial ended.</p> <hd id="AN0173550858-12">Intervention</hd> <p>Intervention ran just like graduated guidance sessions with two exceptions: First, the instructor placed a red tag on the clothing item to help orient the clothing direction when the student put it on themself. In addition, when the student put on their clothing with incorrect orientation, the instructor oriented the student to the tag while conducting graduated guidance by saying "That is the wrong way. Put your hands on either side of this tag, like this, and you will put it on the right way."</p> <hd id="AN0173550858-13">Retention</hd> <p>Due to class illnesses and two school breaks, we had 20 calendar days without intervention practice. Thus, we used this opportunity to evaluate the retention of the skill for each participant. We conducted retention sessions the same as intervention sessions (stimulus tag and graduate guidance in place).</p> <hd id="AN0173550858-14">Tag Fading</hd> <p>Originally, we planned to fade the stimulus prompt immediately following mastery, however, due to the illness and school breaks previously mentioned, we took the opportunity to evaluate retention. We then faded the tag after re-establishing correct responding. To fade the stimulus prompt, we systematically reduced the size of the tag until the student could no longer see the tag. We followed a fading schedule of lengths of 12 cm, 6 cm, 4 cm, 2 cm, and then 0 in (no tag). To expedite the tag fading, we made trial-by-trial decisions on tag fading (rather than based on responding across a whole session). Following an independent trial, we moved to the next fading criteria. If the student made an error on a trial, we went backward in the fading criteria. Once we removed the tag completely, we continued until the student emitted a correct response for three consecutive trials.</p> <hd id="AN0173550858-15">Procedural Fidelity</hd> <p>A second observer also watched a portion of the trials to collect procedural fidelity data. For each trial, the additional observer answered "yes" or "no" on a checklist of critical intervention steps. The control variables present across all conditions were (a) if the instructor had all the materials ready at the start of the trial, (b) if the instructor waited until the student made an error to intervene with graduated guidance, (c) if the clothing was placed in a ball in front of the child, (d) if the instructor provided the task direction, (e) if the instructor provided verbal praise to the student if they put on their clothes correctly, (f) if the instructor provide feedback about the direction when the student put on their clothing item with incorrect orientation, and (g) if the instructor provided graduate guidance following the student putting on their clothes with incorrect orientation. During the intervention, retention, and fading sessions, we also collected data on (h) if the instructor added the red tag to the clothing.</p> <p>During Jerry's sessions, we collected procedural fidelity data for 45.8% of baseline trials with 99.1% of steps followed, 37.9% of intervention trials with 100% of steps followed, and 33.3% of retention and fading trials with 100% steps followed. With Joel, we collected procedural fidelity data for 63.3% of baseline trials with 97.1% steps correctly followed, 57.1% of intervention trials with 100% steps correctly followed, and 22.2% of retention and fading trials with 100% steps correctly followed. Finally, for Keith we collected procedural fidelity data for 66.7% of baseline trials with 100% steps followed correctly, 55.2% of intervention trials with 100% steps followed correctly, and 11.1% of retention trials with 100% steps followed correctly.</p> <hd id="AN0173550858-16">Results</hd> <p>During the graduated guidance baseline condition, none of the students responded at the desired 100% accuracy. Across Jerry's sessions, he responded correctly only an average of 17% of the time with moderate variability (range = 0–25%) and no trend. During Joel's baseline sessions, he averaged only 68.3% correct responding with moderate variability (range = 50–80%) and no trend. Finally, during Keith's baseline sessions, he averaged 17.5% correct responding with moderate variability (range = 0–40%) and a decreasing trend.</p> <p>Once we began intervention for the first student, Jerry, we saw an increasing trend until his dressing accuracy reached and continued at ceiling levels (100%). During this time, we saw no corresponding increase for Joel or Keith. Once we introduced intervention for Joel, we saw an immediate effect through an increase in level to ceiling level responding (100%) that continued through intervention. During this time, we continued to see no change in accuracy for Keith. Once we introduced the intervention for the final participant, Keith, we saw his responding begin to increase in trend until it reached a level of 80–100% correct responding (See Figure 2). This immediate increase following the introduction of intervention across three different participants at three different points in time suggests a functional relation between the implementation of the stimulus tag and increases in the percentage of dressing opportunities with correct clothing orientation.</p> <p>Graph: Figure 2. Results of Using a Stimulus Tag to Increase Correct Dressing Orientation. Note. GG = graduated guidance; Tag = stimulus prompt tag.</p> <p>During the 20-day retention probe, both Jerry and Joel maintained correct responding at ceiling levels of 100%. During the retention sessions for Keith, we saw highly variable responding that ranged from 0% to 100% correct responding. Thus, we moved both Jerry and Joel to the tag-fading portion of the intervention. The tags were systematically faded with both Jerry and Joel without errors. The stimulus fading graphs, presented as a cumulative record, can be found in Figure 3.</p> <p>Graph: Figure 3. Cumulative Record of Stimulus Tag Fading.</p> <p>The between-case standardized mean difference estimator, using REML estimation with a random effect for treatment phase level and time trend yields a BC-SMD effect size estimate of 1.2358 with a standard error of 1.1843 and a 95% confidence interval of [-2.6827, 5.1544] and an autocorrelation of −0.0425.</p> <hd id="AN0173550858-17">Discussion</hd> <p>As dressing is such an important skill to the development of independence and less reliance on caregivers ([<reflink idref="bib4" id="ref44">4</reflink>]; [<reflink idref="bib30" id="ref45">30</reflink>]), it is important that researchers evaluate the best methods for teaching these skills. Although the current literature suggests using response prompting strategies such as graduated guidance ([<reflink idref="bib5" id="ref46">5</reflink>]; [<reflink idref="bib21" id="ref47">21</reflink>]; [<reflink idref="bib23" id="ref48">23</reflink>]; [<reflink idref="bib28" id="ref49">28</reflink>]; [<reflink idref="bib30" id="ref50">30</reflink>]; [<reflink idref="bib35" id="ref51">35</reflink>]), these methods may not be effective for all students. In addition, some students may need methods for teaching the discrimination required to ensure their clothing is facing the correct orientation. In this study, we demonstrated that for three students with ASD, graduated guidance alone was ineffective at increasing the percentage of trials in which the students put on their clothes with the correct orientation. However, once we combined graduated guidance with a stimulus prompt (a 12-cm red tag placed on the clothing item), all three students increased their percentage of correct clothing orientation. One possible explanation for this increase is that the stimulus prompt became a discriminative stimulus for orienting the clothing while dressing. Two of the three students maintained this skill following a 20-day retention period. In addition, both of the students for whom we tried to fade the tag with successfully maintained 100% correct responding once we faded and removed the tag.</p> <p>The tag that we used in this study was inherently arbitrary to the direction of the pants. We did not put the red tag over the natural tag of the pants/shirt, rather on a predetermined spot of the clothing item. Previous research suggests that fading a stimulus prompt is difficult when that stimulus highlights an arbitrary (non-critical) feature of the task. Thus, we assumed that fading the tag would prove to be unsuccessful and the tag would be used as an assistive technology (kept) rather than an instructional technology (eventually removed). However, we had success with fading the tag for both of the participants with which we attempted fading. One possible explanation for our success is that the student began attending to the critical features of the clothing at some point during the intervention; however, this explanation is hypothetical in nature. In addition, it is unlikely that at the beginning of the study, the students found dressing with the correct orientation automatically reinforcing. Thus, the reinforcer, in this case, was likely the socially mediated reinforcer of avoiding the graduated guidance prompt or being able to leave the bathroom. This reinforcer was present both in baseline and in intervention yet was insufficient to improve responding alone. As the reinforcer did not change, it is likely that a skill deficit was responsible for the lack of correct dressing orientation, rather than a motivation deficit.</p> <hd id="AN0173550858-18">Limitations</hd> <p>One concern with the methodology used in the study is the social and ecological validity of the procedures. Specifically, the instructor took the student into the restroom and created the opportunity for practicing the dressing skills rather than waiting for natural opportunities. Although there are many benefits to naturalistic teaching that cannot be overstated ([<reflink idref="bib22" id="ref52">22</reflink>]), practitioners may find it difficult to justify waiting for naturalistic opportunities that may or may not occur, when teaching dressing is of critical importance for students with developmental disabilities. For these students specifically, the school day did not contain any naturally occurring opportunities to change clothes. In addition, the opportunities to practice the skill provided outside of school (other therapies and home) were seemingly insufficient to teach the skill. This limitation of the procedures can be confounded by the many social and ecological benefits of the study (e.g., teaching in a context in which the students encounter, teaching with the clothing the students wore to school each day).</p> <p>Most concerningly, the results of the tag prompt were not maintained for Keith. Although the acquisition of dressing is important, if the student cannot maintain the skill without continual practice, it is less functional for the student. One possible reason that the skill was maintained for the first two participants and not the third is that the first two participants received "overlearning" at 100% accuracy while the third participant only had one school day with 100% responding and several days with 80% responding. Previous research has demonstrated that overlearning results in shorter latency (more fluent) performance and more fluent performance results in better-maintained outcomes ([<reflink idref="bib6" id="ref53">6</reflink>]). [<reflink idref="bib35" id="ref54">35</reflink>] used overlearning to achieve fluency and maintenance with dressing. The results of this study support this notion in that the students who received overlearning maintained their performance at a higher accuracy. Unfortunately, it is unknown if Keith practiced further at 100% responding prior to beginning retention if he would have retained the skill.</p> <p>A second possible reason for Keith's lack of errors can be found in the type of errors he made. A post hoc analysis of the errors determined that Jerry and Joel each only made an "inside out" error once, while Keith made this specific error for 15 trials. This error pattern for Keith occurred although the instructor never turned the clothing inside out prior to placing it in front of the student. Thus, it is possible that the stimulus tag intervention is more effective at reducing front-to-back orientation errors rather than inside-out errors. We did not continue the evaluation with Keith once his performance dropped during the retention phase because he moved schools.</p> <p>Although the effects of this tag were positive, the small number of participants included in the study limits external validity. Future researchers should attempt to replicate our findings to determine if other students could benefit from the procedure. In addition, further replication could help determine under which conditions or for which students for which this procedure would be ineffective. In addition, researchers could systematically replicate these findings in a more natural setting by practicing dressing in a more contextually appropriate way for school (e.g., playing dress up during play and changing into gym clothes).</p> <p>In addition, for the two students who successfully dressed after fading the tag, it is currently unknown which part of the clothes signaled to the learner that the orientation was correct. It is possible that during teaching a certain part of the clothing became the signal for responding instead of the tag. It is also possible that the relevant parts of the clothes (i.e., tag) became the signal for responding once the instructor began fading the tag. One way to evaluate this would be to completely remove the tag prior to fading it to see if the students maintain correct responding. If future researchers were to remove the stimulus tag abruptly, rather than using fading, they could evaluate if systematically fading the tag is necessary (provided a critical aid for discrimination) or if the clothing itself became the stimulus for which the students attended.</p> <hd id="AN0173550858-19">Implications for Practice</hd> <p>The results of this study suggest that when response prompting strategies are ineffective at teaching the discrimination required for dressing orientation, including a stimulus prompt in the form of a simple tag on the clothing item can help increase dressing with correct clothing orientation. The addition of a tag is simple and thus can likely be used with teachers, parents, and direct service personnel without extensive training. The simplicity of this intervention makes it useful for teaching clothing orientation during dressing. In addition, because the stimulus tag procedure can be used <emph>with</emph> response prompting strategies (such as graduated guidance), rather than in place of them, teachers, parents, and direct service personnel would not need to change their current teaching method, only add the stimulus tag.</p> <hd id="AN0173550858-20">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-1-rps-10.1177_15407969231205849 for Using a Tag as a Stimulus Prompt to Increase Correct Dressing Orientation by Hannah G. Foster, Tyler-Curtis C. Elliott and Kevin M. Ayres in Research and Practice for Persons with Severe Disabilities</p> <p>We would like to thank Christina Novelli for her comments on a previous version of this manuscript. We would like to thank Nadya Logan, Chloe Wise, Leah Idichandy, Nestle Butler, Maddie Grosoff, Maddie Drives, Farin Allen, Jazmynn Flewellen, Sydney Miller, Natalie Morris, Krystin Abt, Sierra Stillwell, Amani Shukukani, Mackenzie Riley, Caity Schaefer, Olivia Burley, Renalie Labarda, Maddie Griffin, Kayla Mann, Sophie Schiff, Brianna Guess, Peyton Wolfe, Anna Helen McKelvey, Cristin Pharis, Ambani Lexy, Allie Bartlett, Lydia Johnson, Lane Baylard, Jordan Britt, Virginia Beth Butler, Ana Grullon, Mary Madison Brown, Audrey McNew, Marli Siciliano, and Sara Kathryn Snyder for their assistance with data collection.</p> <ref id="AN0173550858-21"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Abu-Dahab S. M. N., Skidmore E. R., Holm M. B., Rogers J. C., Minshew N. J. (2013). Motor and tactile-perceptual skill differences between individuals with high-functioning autism and typically developing individuals ages 5–21. 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Education & Treatment of Children, 9(1), 16–29. <ulink href="http://www.jstor.org/stable/42898943">http://www.jstor.org/stable/42898943</ulink></bibtext> </blist> </ref> <ref id="AN0173550858-22"> <title> Footnotes </title> <blist> <bibtext> The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> The author(s) received no financial support for the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> The methodology for this study was approved by the institutional review board of the university.</bibtext> </blist> <blist> <bibtext> Parents of all participants provided informed consent and permission for publication.</bibtext> </blist> <blist> <bibtext> Tyler-Curtis C. Elliott</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0001-6826-4449</bibtext> </blist> <blist> <bibtext> Editor-in-Charge: Craig H. Kennedy</bibtext> </blist> <blist> <bibtext> Supplemental material for this article is available online.</bibtext> </blist> </ref> <aug> <p>By Hannah G. Foster; Tyler-Curtis C. Elliott and Kevin M. Ayres</p> <p>Reported by Author; Author; Author</p> <p></p> <p>Hannah G. Foster is a behavior analyst at Hands of Hope ABA. Her current interests include early intervention services for children with autism.</p> <p>Tyler-Curtis C. Elliott is a doctoral student and behavior analyst at the University of Georgia. His current research interests focus on utilization of behavior analysis in schools with an emphasis on increasing teacher use of evidence-based practices.</p> <p>Kevin M. Ayres is a Professor of special education at the University of Georgia. His research interests focus on evaluation of school based interventiosn for improving learning outcomes for children with disabilities as well as response allocation within free operant contexts.</p> </aug> <nolink nlid="nl1" bibid="bib31" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib30" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib29" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib15" firstref="ref8"></nolink> <nolink nlid="nl5" bibid="bib25" firstref="ref9"></nolink> <nolink nlid="nl6" bibid="bib32" firstref="ref10"></nolink> <nolink nlid="nl7" bibid="bib21" firstref="ref13"></nolink> <nolink nlid="nl8" bibid="bib23" firstref="ref14"></nolink> <nolink nlid="nl9" bibid="bib28" firstref="ref15"></nolink> <nolink nlid="nl10" bibid="bib35" firstref="ref17"></nolink> <nolink nlid="nl11" bibid="bib16" firstref="ref19"></nolink> <nolink nlid="nl12" bibid="bib20" firstref="ref20"></nolink> <nolink nlid="nl13" bibid="bib34" firstref="ref22"></nolink> <nolink nlid="nl14" bibid="bib24" firstref="ref25"></nolink> <nolink nlid="nl15" bibid="bib10" firstref="ref27"></nolink> <nolink nlid="nl16" bibid="bib11" firstref="ref28"></nolink> <nolink nlid="nl17" bibid="bib19" firstref="ref29"></nolink> <nolink nlid="nl18" bibid="bib12" firstref="ref33"></nolink> <nolink nlid="nl19" bibid="bib18" firstref="ref35"></nolink> <nolink nlid="nl20" bibid="bib17" firstref="ref36"></nolink> <nolink nlid="nl21" bibid="bib14" firstref="ref37"></nolink> <nolink nlid="nl22" bibid="bib13" firstref="ref38"></nolink> <nolink nlid="nl23" bibid="bib27" firstref="ref39"></nolink> <nolink nlid="nl24" bibid="bib33" firstref="ref40"></nolink> <nolink nlid="nl25" bibid="bib26" firstref="ref41"></nolink> <nolink nlid="nl26" bibid="bib22" firstref="ref52"></nolink>
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  Data: Using a Tag as a Stimulus Prompt to Increase Correct Dressing Orientation
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  Data: <searchLink fieldCode="AR" term="%22Foster%2C+Hannah+G%2E%22">Foster, Hannah G.</searchLink><br /><searchLink fieldCode="AR" term="%22Elliott%2C+Tyler-Curtis+C%2E%22">Elliott, Tyler-Curtis C.</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-6826-4449">0000-0001-6826-4449</externalLink>)<br /><searchLink fieldCode="AR" term="%22Ayres%2C+Kevin+M%2E%22">Ayres, Kevin M.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Research+and+Practice+for+Persons+with+Severe+Disabilities%22"><i>Research and Practice for Persons with Severe Disabilities</i></searchLink>. 2023 48(4):203-214.
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  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
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  Data: <searchLink fieldCode="DE" term="%22Daily+Living+Skills%22">Daily Living Skills</searchLink><br /><searchLink fieldCode="DE" term="%22Clothing%22">Clothing</searchLink><br /><searchLink fieldCode="DE" term="%22Students+with+Disabilities%22">Students with Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Skill+Development%22">Skill Development</searchLink><br /><searchLink fieldCode="DE" term="%22Stimuli%22">Stimuli</searchLink><br /><searchLink fieldCode="DE" term="%22Cues%22">Cues</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Accuracy%22">Accuracy</searchLink><br /><searchLink fieldCode="DE" term="%22Preschool+Children%22">Preschool Children</searchLink><br /><searchLink fieldCode="DE" term="%22Elementary+School+Students%22">Elementary School Students</searchLink>
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  Data: 10.1177/15407969231205849
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  Data: 1540-7969<br />2169-2408
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  Data: Dressing is an important skill for students with developmental disabilities, so they rely less on caregivers and build independence. Research evaluating dressing skills instruction commonly uses some type of graduated guidance to teach the skill. In this study, three students receiving special education services under autism eligibility had already received instruction on dressing skills using graduated guidance. Although this procedure was enough to teach the dressing steps (including putting on the clothing), it was not sufficient in teaching the student to put on the clothing with the correct orientation. Thus, these students walked out of the bathroom wearing clothes that were inside out and/or backward. We placed a 12-cm red stimulus prompt on the target clothing item and evaluated the effects on correct dressing orientation for these three students using a multiple probe design. For all three students, the stimulus prompt increased accuracy, and for two participants, accuracy was maintained. For the two students who maintained the skill, we systematically faded the tag, and they maintained perfect dressing orientation.
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