SKILL TRAINING IN THE MENTALLY RETARDED PERSONS

DOLft

National Institutefor the

Mentally Handicapped

Towards Independence Series - 3

SKILL TRAINING IN THE MENTALLY RETARDED PERSONS

A PACKAGE FOR TRAINERS

MEAL TIME SKILLS

National Institute for the Mentally Handicapped(Ministry of Social Justice & Empowerment, Govt. of India)

Manovikasnagar P.O., Secunderabad 500 009. A.P. INDIA.Phones: 040-7751741 - 745, Fax: 040-77501 98

Copyright National Institute for the Mentally Handicapped, 1990All rights reserved.

Reprint - 2002

Contributors:

Jayanthi Narayan A.T. Thressia KuttyM.S. (Sp. Ed.) Ph. D., D.S.Ed. MA. BEd D,S Ed

Project Coordinator Research Officer

Other titles in the series:

* Gross Motor Skills* Fine Motor Skills* Toilet Training

Tooth Brushing* Bathing* Dressing* Grooming* Social Skills

Printed at: Sree Ramana Process, Secunderabad-3. Ph: 040-7811750

ACKNOWLEDGEMENTS

The project team expresses sincere thanks to UNICEF forfunding thisproject. Theadvice and guidance provided bythe following project advisory committee membersperiodically during the course of the project is gratefully acknowledged.

Project Advisory Committee Institute members

Dr. V. Kumaraiah Dr. D.K. MenonAssociate Professor (CI. Psy) DirectorNIMHANS, Bangalore

Ms. V. Vimala, Dr. T. MadhavanVice Principal Asst. Prof. of PsychiatryBalavihar Training SchoolMadras

Prof. K.C. Panda, Mr. T.A. Subba RaoPrincipal Lect. in Speech PathologyRegional College of Education & AudiologyBhu bane swar

Dr. N.K. Jangira Mrs. Reeta PeshawariaProfessor (Special Education) Lect. in CI. PsychologyNCERT, New Delhi

Ms. Girija DeviAsst. Communication Devt. OfficerUNICEF, Hyderabad

The guidance and suggestions of Dr. D.K. Menon, Director, NIMH are especiallyacknowledged with special reference. The efficient secretarial assistance in typingout the drafts throughout the project by Sri A. Venkateswara Rao requires a specialmention and grateful acknowledgement. The administrative support bySri T. Pitchaiah, Sri V. Ram Mohan Rao and Mr. K.S.R.C. Murthy are sincerelyappreciated. Last, but not the least, we are grateful to the parents of the mentallyretarded children who cooperated with us for the field trial of the skill trainingpackages and for having given suggestions for modification which are suitablyincorporated.

CONTENTS PAGE

Introduction1

Where to start? 2

Find the delay 3

Find the level 4

When to train? 5

General problems 8

Possible solutions 1 0

Howtotrajn? 12

INTRODUCTION

Thirst and hunger are basic physiological needs of humanbeing. Oral reflexes are present in an infant during the time ofbirth. These reflexes help the child to suck and swallow.Gradually, he learns to eat semi-solid and solid food. As hegrows, appropriate meal time skills are needed to become anacceptable person in the society. So independence in eatingis a self care as well as asocial skill. In course of time, a normalperson is able to achieve this skill as a result of the opportunitiesgiven to him in the family and in the society.

There is a tendency among parents to feed instead oftraining the mentally retarded child to eat by himself.

It prevents him from achieving eating skills. Most of thetime he is restricted from participating in social functionswhere he has to exhibit the acceptable mealtime manners.

This booklet explains how to train a mentally retardedperson step by step so that he can independently take hismeals and participate in various functions where he has toobserve the manners in the company of his friends, relativesand family members.

Where to start ?

Depending on the level of functioning of the child, use

checklist 1 or 2 from the following pages.

Eating meals together is a part of family and community

life. Teach the mentally retarded childrennecessary meal time

skills by giving him opportunities to eat with the family, relatives

and friends. He is a part of the family and the society.

The key to success is

* Proper observation and training during meal time* Provision of more opportunities, appreciation and

proper rewards for the child's cooperation andachievements.

2

FIND THE DELAY - CHECK LIST-i

DEVELOPMENTAL SEQUENCE IN EATING SKILLS

Eating skills Not achieved AchievOral reflexes - Sucking

to Begins to hold bottle with littleassistanceBegins to swallow from cupsMay eats some solidsSucks from spoonMay bring objects to mouth ifplaced in handsBasic chewing begins to appear

to Holds bottle by himself and bringsbottle to mouthHolds and eat a small biscuitindependentlyBegins chewing .

Eats infant foods

to Sucks food from spoon

to Controls droolingHas more control over lips, tongueand'jawFeeds s& with fingers

Chews appropifeyGrasps spoonHolds cup by handle arid ttsto mouth for a sip

to Begins to suck using strawBegins to chew food with mouthclosedUses spoon with fewer accidentsUses cup with fewer accidentsHolds small cup in one hand

Chews and swallows before3peakingBegins to serve selfHolds spoon with fingerBegins to hold food With finger

Adapted from : Fallen, NH; Umansky, W. (1985) Young children with special needs..Columbus : Merrill Pub.

3

FIND THE LEVEL - CHECK LIST-2

LEVEL YES NO

Can suck

Can swallow

Can chew

4. Has proper tongue movements

5. Can hold milk bottle

6. Can drink from cup held by adult

7. Can pick up food and eat

8. Can hold a cup and drink from it

9. Can recognize edible and non-edible substances

0. Can drink from a tumbler

. Can drink through a straw

2. Can eat with a spoon

Can usea napkin

Can eat in a family setting

5. Can eat in a restaurantI -.

4

Train the child to drink whenhe is thirsty.

WHEN To TRAIN?

Train the child to eat when heis hungry.

In case the child is not able toindicate hunger and thirst,follow a time schedule.

5

As the child starts to indicatehis hunger use that signal.

Gradually encourage him toindicate his hunger and thirstthrough gestures/words,when he is hungry and thirstyand use thattime for training.

6

If the child is able to usegestures for food, use thisopportunity to train in eatingand drinking.

/

Let the child join the familymembers during meal time.Give him chances to observethe meal time manners.

Give him chances to eat withrelatives and friends and inrestaurants.

The child's physiological need toeat and drink is the first importantprerequisite for training.

7

I[

GENERAL PROBLEMS

Lack of finger coordination topick up food.

Inability to suck and swallow.

Inability to chew.

8

Lack of initiation andcooperation.

*Problems in digestion

*Constipation

*Does not know how much to eat

*Does not identify edible items

*Eating non-edible items - mud, paper, chalk

*Spilling, spitting, vomiting

9

POSSIBLE SOLUTIONS

Seek medical help for problemslike constipation andindigestion.

If needed, seek the guidance ofa physiotherapist for exercisesfor proper arm movements andfinger coordination.

Give activities forcoordination andmovements to pick upand put into mouth.

fingerarmfood

10

For proper sucking, andinitiation, after ruling out medicalproblems, observe theproblems and use theappropriate techniquesexplained in this booklet.

Observe and list out theproblems like eating non-edibleitems, spilling, spitting, andovereating. Discourage himfrom doing such things by givingrewards for appropriatebehaviours.

11

For developing proper mealtime habits, let the child havechances to eat with the familyand to observe the manners.

I

HOW TO TRAIN?

*Use the check list. Praise the child forthe items what hecan do.

*Find the level to know where, when and what to train.

*Understand the problems and have patience to train onestep at a time.

*Use appropriate rewards for the child's cooperation andattempts.

*Techniques in step-by-step training are explained in thefollowing pages. Follow the methods during training. Ifneeded, modify the methods depending on the need ofthe child.

12

1. Achildshouldbeabletosuckand swallow quite smoothly afew days after birth.

2. Sucking problems are oftenearly signs of neurologicalproblems. In such cases seekmedical help.

3. Proper jaw control isnecessary for appropriatesucking and swallowing.

If a child Jacks good jawcontrol assist him by usingyour thu.mb, index, andmiddle finger to give supportto the jaw.

Sucking and Swallowing

13

4. Positioning is important forproper sucking andswallowing. Keep the child insemi upright position in yourarms.

6. Use nipple with regular sizeholes. Large holes in a nipplemake a retarded child lazy tosuck. It also causes choking ifthe child has difficulty inswallowing.

14

5. Selection of proper liquids isalso important ior teachingsucking and swallowing.Pleasant tasting and mildlysweetened juices, warm orcool but not hot or very coldcan be given.

8. The lip and jaw control processshould begin before liquid foodis placed in the child's mouth.

7. A downward stroke on thechild's cheek stimulatessucking.

Hold the child's jaw closed andrub the chin.

swallowing.

It stimulates

15

Chewing and SwallowingA normal baby will be able to open his or her mouth while feeding. Inability todo so is a sign of problems and indicates the need for medical treatment.

2. Keep a small amount of babyfood in a spoon and place itonthe baby's tongue, touchingthe bottom gums. Wait to seewhether the child's jaws closetightly. This is called bite reflex.

3. The bite reflex normally fades, as the child begins to munch on foods. If thebite reflex is too strong use the following techniques.

16

RubthegumswithfingerprjorI

feeding.

Use foods that encouragemunching and chewing.

17

*Use a small spoon.

4. To train in chewing place foodin the baby's mouth andobserve.

5. If the child pushes it with thetongue, place the nextspoonful in the side of themouth.

((6. Help the child to start moving

jaws up and down while usingthe tongue to mash foodagainst the roof of his or hermouth.

Pushing food out of the mouth with the tongue may be an early reflex, and isnot necessarily a rejection of food being offered.

18

3. Once the baby is confortablysucking the botUe, gently placehis hands on the bottle.

2. Place the nipple of the bottlein his mouth, and continue tohold the bottle.

4. Asthechildgetsfingergriponthe bottle, gradually relax yourhold on the bottle.

Holding milk bottle

1. Keep the baby up right onyour lap.

19

Observe the child eating.Notice if the child moves thetongue, to touch food a1 thesides and top of mouth.

2. If you are not able to see tongue movements, try placing smallamounts of sticky food (jam) on the roof of the child'smouth nearthe front and between the cheek and gum.

3. Observe the child's use of thetongue to retrieve the food. Ifyou note difficulty, during eachfeeding, place nis preferredfood at the point of mouth,requiring action for retrieval.

20

Development of tongue movements

1. If the child is able to sit with/without support, make him sitin a comfortable position.

3. Bring the cup to the child'smouth and tilt it slightly.

5. Hold the cup about an inch awayfrom the child's mouth and wait forhim to lean towards the cup.

2. Select a cup which isappropriate for the child, andtake a small amount of thickerliquid (milk or a mixture of milkand cereal).

4. Wait for the child to cooperate

actively to sip.

Drinking from cup held by parent

21

Holding and drinking from cup

1. Take approximately anouthfuIof liquid in the cup.

3. Gradually reduce your helpand guide him to return thecup to the table.

22

2. Place both hands of the childaround the cup and bring thecup to his mouth to drink. Lethim open his mouth and tiltthe cup slowly into the mouth.

4. During meal time, observehow the child holds the cup.Provide assistance if heappears to be unstab'e inhandling the cup.

5. Letabrother/sisterOftheChildprovide assistance to the childto learn to drink.

Steps in drinking

Sits comfortably

23

6. Select a variety of cups thatthe child may come in contactwith.

Takes the cup from the table

V

Tilts the cup

swallows

sips

24

Brings to mouth

Repeats the above steps till the cup is empty

Keeps the cup down

FINGER FEEDING

1. Make the child sit withnecessary support in front of a

tray/table.

3. Gradually add more pieces inthe plate.

25

2. Start with food items that donot stick in hand, such aspieces of chappati, bread, anddosa. Place one piece at atime in the plate and allow thechild to pick up and eat.

4. Rice and dal can be mixedand made into small balls andgiven in the plate, allowing thechild to pick up and eat.

to lift hands to mouth and to release it.

Gradually reduce help

26

5. When he gains competencyloosely mixed food can beintroduced.

Train him to grasp,

1. Offer the child one edible andnon-edible item. For eg. asmall toy and a sweet/biscuit.

3. If he puts the non-edible item.in the mouth, make a face andverbally tell him to remove itIf necessary remove it by

2. If she eats the edible item andplays with the toy, praise her.

Recognizing edible and non-edible substances

yourself.

27

4. Observe the child's behaviourwhen he plays alone. If heputs non-edible items in hismouth tell him to remove itimmediately.

Drinking from a tumbler1. When the child asks forwater,

show him where the water isand how to fill the water.

3. Show him ways of tilting thetumbler, so that a minimumamount of water comes to hismouth.

28

2. Help him to hold the tumbler;and lift towards mouth.

7. Whenever he asks for water,make him fill the water in thetumbler to drink.

4. Gradually reduce the help totilt the tumbler, while the childdrinks. Initially useunbreakable tumbler.

C6. Observe how well the child

uses a tumbler. When he isready teach him to fill water ina tumbler.

5. Show a variety of tumblersbreakable and unbreakableand demonstrate how tohandle the tumblers.

Help him to develop hygienic habits. For example,not to share someone else's tumbler; to see whetherthe tumbler is clean before filling the liquid.

29

Drinking through a straw

1. Provide opportunities for thechild to observe when othersdrink through a straw.

2. After making him sit comfortably, keep a tumbler withbeverage (water/milk/lemon juice) in front of him. Put astraw inside.

4. If he has difficulty to drinkthrough the straw, selectappropriate size of the strawor cut the size of the straw.

30

3. As required, eiLher assist himto hold the tumbler orbring hislips towards the straw.

5. Explain the use of acceptablehealth habits while drinkingthrough a straw. Example notsharing the straw with others.

31

6. Give him opportunities to drink through a straw, especially when the family goesfor a party or a restaurant.

Eating with a spoon in an appropriate manner

1. Select the appropriate size of the spoon for the child. In case the child hasdifficulty in holding the spoon, use a modified spoon.

2. Let him observe when others eat with spoon.

32

3. Position him appropriately.Keep rice in a plate or porridgein a bowl in front of him.

5. Help him to lift the spoon withfood and direct to mouth.

33

4. Physically help him to hold thespoon properly and take foodin the spoon. You be behindthe child when you providephysical assistance.

6. Gradually reduce the physicalhelp, as he masters the skill.

Using a napkin appropriately

1. Show the child a variety ofnapkins (paper and cloth) anddemonstrate their use.

2. Demonstrate wiping yourmouth with a napkin. Givehim a napkin and help him towipe his mouth, when needed.

Have the child opportunities to use the napkin. Explainthe need of using a clean napkin.

34

Eating in a socially acceptable manner

1. During meal time, let the child imitate you for eatingsmall mouthfuls of fluid; taking small sips of liquid,chewing with mouth closed and using a napkin.BE AGOOD MODEL.

2. Guide him to request to pass the food which he wants.

3. Demonstrate how to pass the requested food toanother person.

4. During meal time, encourage the child to practiceserving and requesting food. Praise him for doing itappropriately.

5. Explain to him that he should eat food only from hisown plate. Discourage him from eating food fromsome one else's plate even if he just wants to taste it.

35

Meal time manners

1. Washes hands

3. Positions plate, tumbler,spoon in front.

36

2. Sits in a proper p'ace

4. Takes proper amount of foodin the plate.

I

7. Waitsforotherpeopletoservefood.

37

5. Passes the food to otherswhen required.

6. Fills water in the tumbler.

8. Takes small bites.

.1

10. Requests food if needed

11. Passes food requested byothers

12. Uses napkin when needed

'I9. Chews with mouth closed

38

Following meal time manners in a family setting

Setting the table. As the childgrows, train him to set tablebefore eating. Ask him to countthe family members, and tokeep plates, tumblers, spoonsetc for all members.

3. Tell him to get the food itemsfrom the kitchen and keepthem closed properly on thetable/dining place. Initially lethim handle those food itemslike curds, papad and pickle

which are not hot.

V 2. Remind him to see whetherthey are cleaned and wipedbefore setting the table.

39

7. When he finishes, tell him to waitfor others to finish and wash hishands in proper place.

40

4. Let him inform familymembersthat meal s ready.

5. After sitting in his place withother family members, guidehim to serve food in his platein proper quantities.

6. Lethim pass foodwhen othermembers request for food.

8. Once everybodyfinishes, trainhim to keep the remaining foodin the proper place.

10. Train him to wash and drythe plates, tumblers, andspoons if she is old enoughto do so.

9. Train him to clean the table!dining area before heleaves.

11. Initially, let the child observe you. As a next step tell him to doand physically help him if needed. Gradually reduce thephysical help and tell him what to do next. Praise him at everyattempt, as he improves in mastering the skill.

41

Following meal time manners in restaurants/other places

Asthe child learns to follow the mealtime manners in a familyset up, give him opportunities to use it in other environments-fnend's houses, restaurants

2. In order to generalize what he has learned in home set up,take him to different places where he has to follow differentstyles. For example using a dining table, sitting on the floorand eating, selecting a menu from menu card, orderforfood,eating during social functions

Give a mentally retarded child moreopportunities. He learns by experience. Includehim in all family functions. Give him chances tosocialize.

42

3. Meals with family members

4. Meals with family members (using dining table)

43

3.

5. Meals in a restaurant withfamily members.

44

4. Having tea from a locai teashop.

Meals in a friend's/relative'shome

6. Meals in a social function.

45

Having meals together is a sign of sharing. Give

opportunities to a mentally retarded person to

join the group for meals in different occasions.

It is one way of accepting him as a member of

the family and society at large.

46