Toothbrushing!

Yesterday I had my 6-month cleaning at the dentist's office. While I was sitting there, I thought I would do a little research.  Here are the ADA's recommendations for toothbrushing.  :)

* The American Dental Association recommends that we begin brushing a child's teeth as soon as they first appear and that we "help" brush their teeth up to age 8. Did you know they also recommend that children see their dentist for the first visit at no later than 1 year of age?
* Use toothpaste that does not contain flouride until at least age 2 (or longer) to ensure the flouride is not swallowed.
* Brushing should occur at least 2 times a day, perferably 3 times per day, after meals/ before bed.
* We should spend at least 2 minutes brushing teeth each instance, spending equal time on all tooth surfaces.

* We should begin flossing our children's teeth as soon as they have 2 teeth that touch. (Yeah, I've gotta admit, I'm not the best at this one, here! But the individual flossers make a huge difference!)
* We should also brush gums, the roof of the mouth, and the tongue. (At our house, we call this, brushing "the pinks".)
* Brushing should be in a circular motion (if not using a specialized toothbrush, like Sonicare).
* The brush should be held at a 45 degree angle when brushing.

This post is my contribution to the conversation. Below is a task analysis and some suggestions for teaching your children to brush their teeth. For a reminder on how to teach steps in a task analysis, see the post I wrote here.

* Use full physical prompts when initially teaching your child to brush his/her teeth. Have him/her hold the toothbrush with the appropriate grip (probably the way you hold your toothbrush). Then place your hand over his/hers in the same position.
* Remember, make the task fun or at least appealing. Chances are, at bedtime you are stopping preferred activities such as playtime, movies, games, books, etc. to start the bedtime routine. Very few children are going to be excited for that! Use the Premack Principle (great article here), otherwise known as "Grandma's rule". Set up the schedule so the (probable) non-preferred or "less" preferred thing (toothbrushing) is followed by a preferred thing (bedtime stories, singing time, throwing a full water balloon in the tub, drawing pictures on the mirror with dry erase markers, etc.).

Task Analysis
1. Get toothbrush and toothpaste.
2. Open toothpaste.
3. Hold toothbrush in non-dominant hand. Put pea-sized amount (for young children) of toothpaste on tooth brush.
4. Put toothbrush down.
5. Close toothpaste and put it away.
6. Pick up toothbrush with dominant hand.
7. Turn on water (low).
8. Wet toothbrush.
9. Turn water off.
10. Using circular motions, brush top-front teeth (making sure to also brush gums) for 10 seconds. You can even count aloud. (In our house, we call brushing the front and side surfaces of the tops and bottom teeth "doing the eeee's".)

11. Using circular motions, brush top-right side teeth (making sure to brush gums) for 10 seconds. Again, feel free to count!

12. Using circular motions, brush top-left side teeth (making sure to brush gums) for 10 seconds. 

13. Brush top-left INSIDE teeth (making sure to brush gums) for 10 seconds. (In our house, we call brushing all of the inside surfaces of our teeth "doing the ah's".)

14. Brush top-front INSIDE teeth (making sure to brush gums) for 10 seconds.

15. Brush top-right INSIDE teeth (making sure to brush gums) for 10 seconds.

16. Spit into sink.
17. Using circular motions, brush bottom-front teeth (making sure to brush gums) for 10 seconds.

18. Using circular motions, brush bottom-right side teeth (making sure to brush gums) for 10 seconds.

19. Using circular motions, brush bottom-left side teeth (making sure to brush gums) for 10 seconds. 

20. Brush bottom-left INSIDE teeth (making sure to brush gums) for 10 seconds. 

21. Brush bottom-front (middle) INSIDE teeth (making sure to brush gums) for 10 seconds.

22. Brush bottom-right INSIDE teeth (makin sure to brush gums) for 10 seconds.

23.  Spit into sink.
24. Fill cup with water and rinse out mouth (We call this the "swish and spit" step at our house.)

25. Rinse out tooth brush.

26. Turn water off.

27. Dry face.

28. Put tooth brush away.

29. Smile!

So at our house, when we're prompting our children to brush their teeth well, we tend to say, "Remember to do your ah's and eeee's and don't forget your pinks!"

Remember, you can add or take away steps as needed. Maybe your children don't need to be prompted to turn the water on/off or maybe they need an extra teaching step focusing on teaching them to hang the face towel back on the rack. When I wrote this post, I changed up the order of the steps at least 3 times. I'm not even sure that this is the order that my kids or I normally brush are teeth. :) Feel free to change the order to something that feels right for you. 

Now, since I started this post, my daughter (the one in the pics) has had a terrific report on her dental hygiene from our dentist. I take my other 2 children in for their 6-month check-ups tomorrow. I hope their report adds to my credibility!


**I get that the toothbrush my daughter is holding may seem too big for her. Normally we use an Oral-B electric toothbrush. However, she had just been to the dentist and this is the toothbrush they gave her. She was obsessed with using "the new one."

What do you think?  How do you teach your children how to brush their teeth?  What have you struggled with? Have you come across fantastic ideas that have helped you out in the past? Please share in the comments section! 

How Young is Too Young?

I have to admit, I was a "behavior analyst" long before I became a parent. When I started using ABA to teach children with autism in 1996 it just "made sense" to me. The data analysis, adjusting teaching based on performance, shaping, prompting, fading, all of it just made sense to me. I couldn't imagine teaching any other way. I earned my BCBA certification in 2002 and became a parent in 2003.

As you've probably heard (or learned from experience), children don't come with instruction manuals. I'd heard this many times before we brought our newborn home from the hospital but it still surprised me. We came home with a baby and literally no instruction AT ALL! I did what I knew how to do. We fed her, changed her and recorded everything! We wrote down when she drank every bottle, how much she drank, when she slept, and every diaper change. This just lasted for the first few days, I think (maybe the first week... or two?).  We got the hang of things. However, I didn't really know how to be around her without feeling like I needed to teach her. The only way I knew to teach was with ABA! No, I didn't take data on every nursery rhyme I taught her or when she started independently doing the actions with them. Though, I did keep track of all of her baby signs and every vocal mand/tact.  I taught her how to mand, with full sentences, purposefully, a step at a time. (Her first 3 word mand was, "I want [marsh]mellow!".  We quickly added, "please".) I remember thinking that maybe all parents didn't teach "that way" but I didn't really know how to do it differently. I started teaching her how to read at around age 3. I used a programmed reading primer developed by graduate students at the University of Kansas (Go Jayhawks!) decades ago. We then used Programmed Reading until she started reading chapter books sometime in first grade.

The thing is, once she entered school, I started having more contact with other parents and with teachers.  Parents were pretty interesting. They said things like, "Oh, it's so silly when parents start teaching their kids to read so young! Wasted time! They all end up about the same in elementary school, anyway!"   Teachers said things like, "Don't worry, by the end of first grade, her peers will catch up to her." Right, just what I wanted to hear.  But it all did make me think. Was I pushing her (and eventually my son, as well) to do more than she was "supposed" to do?  Was I more rigid than most parents? We didn't have set times to read or "learn language". It was just built into every day.  But was I making it too important? Should we have just "played" more? I can't imagine we didn't play and sing and dance enough. We did a lot of that! And I have no voice and no moves!  I just wonder if they would have been the same or different either way? I happened to stumble upon the coolest, most fun, and scientific way of teaching children when I was 19 years old. What would have happened if I didn't? Would it have mattered? If teaching them early learning skills while they were "so young" was wrong, what was I supposed to do instead? What do other parents do?

Understand that I don't believe I did the wrong thing. I cannot parent another way because I don't know any other way to parent. But I tend to be pretty open to ideas from others and not very outspoken. I'm not a fan of conflict and would most of the time rather not respond when I feel another parent has a strong opinion about something. (This is not true in my "work" as a behavior analyst, however.) My kids read well. Math comes easily to them. I don't feel like it was wasted time.  But is there such a thing as teaching academics to children who are too young? It seems a bit relevant. I came across this movie, Nursery University on Netflix the other day. Does this seem too extreme? Would you feel differently depending on the teaching methods that are used to teach?  What about this story from NPR? Lots of parents are comfortable with "Baby Einstein". Why?  What's the difference between the Nursery University crowd and the Baby Einstein-ers?  What do you think about "teaching" babies?

Shoe Tying

Okay, teaching children to tie their shoes does not have to be difficult. It usually just takes practice (lots of trials) and a consistent method. I've seen lots of different ways of tying shoes but this is the one with which I've had the most success.

A task-analysis for shoe tying:
Start with laces straight out to each side of the shoe. 

Take the right lace (A) and cross the front of the shoe.
Set it down on the left.

Take the left lace (B) and cross it over the shoe (and other lace).
Set it down on the right.

At the top of the shoe, pull up on lace (A) with your left hand to make a little tunnel (with B still on top of A). Hold on to it.

Pick up the end of lace (B) with your right hand (right side of the shoe) and drive it through the tunnel you are still holding with your left hand (sometimes this comes with train noises, "choo choo!").

Let go of lace (B) once it enters the tunnel, then grab it again with the same hand on the other side of the tunnel.
Let go of lace (A) and grab the end of lace (A), which should still be on the left side of the shoe. Now you are holding the ends of both laces.
Pull both laces.

Let go of both laces.
Make a loop on lace B (right lace) by touching the two dots together and pinching.

Do the same with lace A (left lace).

Cross the tops of both loops, with the right loop in front of the left.  Make sure there is a space under the loops.

Make 1 loop do a "flip", turning one loop completely under the other by pushing it over the other loop and through the space below the 2 loops.  Don't let go of either lace!

Pull them tight. The shoe is tied!

At this point you can pull on each lace until the ends are not dragging.

Keys to remember:
It is often helpful to start with extra-long shoe laces. You remember, right? Having laces that are too short can turn an otherwise successful attempt at tying shoes into a frustrating moment right at the end when you pull your loops and the end of the lace gets pulled out of the knot.  Start with long laces. It's also helpful to put 2 dots on the each lace where the points on the"loop" should touch. Kids can use them to learn how big the loop should be in order to tie successfully. (Most kids will start out using nearly the whole lace to make the initial loops.)

When teaching kids to tie their shoes, show them then physically help (prompt) them to do it. Don't be afraid to help until they don't need it anymore. Reduce the potential of frustration by practicing "success" (with you helping). This will help the activity become more reinforcing to them and will help them demonstrate persistence in learning the skill.

Demonstrate and Help/prompt from behind. Put the shoe in between their legs (right in front of them), facing the same direction it would be if it was on their foot. Initially, I wouldn't start with it on their foot simply because they will be putting a lot of effort into concentrating on completing the "right" steps (physically and mentally). We don't want to wear them out because it takes more effort to fold up their leg and keep it close to their body to reach the shoe in the first place. If you demonstrate how to tie the shoe from behind, they'll be looking at it from the same point of view as you. And when you help/physically prompt from behind, your fingers will be in the same positions their fingers should be in.

Follow the same task analysis every time. This is important as it will lead to mastery much quicker if the same steps are being practiced in the same order every time. If more than one person is teaching this skill to your child, make sure you are all on the same page.

Fade prompts (your help) gradually. Initially, physically help your child complete every step in the chain. Then fade how much you are physically helping (prompting) them. Normally, I like to teach skills by backward chaining. However, I've found that kids like to complete at least the first 3 steps in the shoe-tying chain independently pretty quickly. Just make sure that if they can complete a step independently, let them do it. If they are shaky or are not able to be independent, provide a prompt BEFORE they miss a step or complete an "error". This will reduce frustration and prevent practicing incorrect steps.

Initially, reinforce EVERY accomplishment, big or small. Tying shoes is hard. There are a lot of steps and most kids haven't had a ton of "that kind" of fine motor practice prior to learning how to tie their shoes. Reinforce independence as it happens (with each step). Make a big deal out of accomplishments at every level.

Let me know if this "makes sense". Are there other "tasks" you'd like to see "analyzed"?

Teaching Skills: Task A-What?

"In or Out" Program Update: The kids are remembering to take off their shoes AND to shut the doors on the way in or out of the house! Score one for the momma! We still need some work coming in or out when they are talking to someone in or out of the house (not standing in an open doorway). My husband and I will shape this up by making sure that if they are talking to us, we will gesture to the door and not address their question until they are either in or out. :) If they are talking to someone else (and this might be the "hold-out" behavior that takes the longest to "fix") it will likely require the husband or I to give them a little nudge (physical prompt) in or out of the house to finish the conversation.

Task Analyses
Frequently we want our children to gain independence in tasks that have multiple steps such as washing hands, getting dressed, or tying shoes. I frequently target each of these tasks with children that I work with. The goal when I teach any skill is to teach it efficiently and in such a way that the child WANTS to continue learning from me. One way of teaching skills with multiple steps is to write, then follow a "task analysis". A task analysis of a skill basically breaks the skill down into small, discrete, manageable steps; for example, opening a door. I bet you thought opening a door just involved one step, "Open door", right?  Well, for some kids, in order to master the "whole task" of opening the door, you might need to break it down into smaller steps. A task analysis of opening a door with a knob might be: 1. Put hand on door knob. 2. Grasp knob. 3. Turn knob. 4. Pull door open.  Voila!
Now that we have a task analysis of opening a door, we can decide how we want to teach it. We can "forward chain" the task or "backward chain". Typically, I recommend backward chaining. This means that I might physically prompt a child through the whole task, from the first step to the last (hand on knob, grasp, turn, pull).  When the child is following all of my prompts reliably, I start to fade the prompts at the end of the task. In the case of opening a door, I would physically help the child put his/her hand on the door, then grasp it, then turn it, then pull. When he/she is completing all of these steps (with help) reliably, I would ease up on my prompts of pulling the door. Instead of physically prompting the "pull", maybe I would just tap her fingers once we had turned the knob. When the door opens, I would praise her for opening the door.  The next time we practiced opening the door, maybe I would fade the prompts even more. Maybe I would prompt through the first 3 steps, then wait for her to "pull" the door open. Wow! She just completed the last step of the task analysis independently! Reinforce like crazy!  Maybe after a few more successes, I'd target the next step in the task analysis, turning the knob (see where the "backward" in backward chaining comes from?). I would fully physically prompt putting her hand on the door knob and grasping it, but prompt only half of her turning the knob, allowing her to complete the step.   See where I'm going with this?
Eventually, she would complete the whole task herself but along the way, she'd get lots of descriptive praise and reinforcement for completing the baby steps leading up to the "whole task".

Some things to remember when chaining:
1. Ideally, the child will know how to complete each of the steps in the task analysis independent of the chain. In the case of opening a door, I'd want to make sure the child could "grasp" objects, could turn her wrist back and forth and "pull" before targeting the skills in a chain "opening the door".
2. Reinforce baby steps, initially. Reinforce independence. Ultimately, reinforce task completion. Once you get to the last teaching step, you want to be able to only reinforce the completed chain, not necessarily every step in-between... you don't want to teach a child not to move on to the next step of opening a door until you praise each tiny step that comes before the door being open... so reinforce like crazy but fade your reinforcement, too.
3. Don't be afraid to follow the child's lead a bit. If you've been working on a 10 step chain and you are only on step 3 but suddenly the child is indicating that he/she can complete 7 of the 10 steps independently, go with it! Just make sure you are there to prompt steps that still need to be taught until the whole chain is mastered.

I wrote about tasks analyses today because I want to post some basic self-help/independence programs such as brushing teeth, getting dressed, tying shoes, etc. This should help give you a general idea of the concept.  Are there other programs you'd like to see?  And, maybe it's too late but I just couldn't think of a clever way of saying "teaching skills" up in the heading. Any ideas? :)