PETHNA: tailor-made toys for the severely retarded and multiply handicapped PETER WOODS,

RAYMOND PARRY,

Pr i nci pa I CI i nica I Psychologist, Bryn-y- Neuadd Hospita I*, Lla nfa i rfec ha n, Gwynedd

Therapeutic Eq u i pm en t Tech n i cia n, B r oug h t on Hospital, Clwyd

*formerly of Broughton Hospital

Introduction Parents, nurses, residential-workers, and teachers who

work with severely and profoundly mentally handi- capped people, often experience considerable difficulty in finding suitable toys and play equipment for them. Their quest is usually for items that will serve one or both of two functions; education and entertainment.

Firstly, they are searching for something that will exercise, and even extend, the few developmental skills that the handicapped child or adult has. Secondly, they want something that will keep him interested and amused for a reasonable period of time. Many parents have rarely, if ever, been able to leave their severely retarded child to play with a toy while they have five minutes rest or get on with their dishes or other chores. A toy that would enable them to do this would be of considerable benefit, both for the handicapped person and for members of his family.

Unfortunately, commercially available toys and play equipment that would fulfil either or both of these functions for many of the more profoundly and multiply handicapped are few and far between. Because of this, a project was initiated at Broughton Hospital in 1979 that was concerned with the design and pro- duction of toys that, hopefully, would satisfy the needs of this population. The project team consisted of an electronics engineer, a clinical psychologist, and a toy maker. The toy maker was initially funded by the Manpower Services Commission’s STEP scheme but was later transferred to the permanent staff of Clwyd Health Authority, which now pays his full-time wages.

Play and toys One of the defining features of “play” is that children

indulge in it without the need for adults to praise or otherwise reward them for doing so. Some would say that play occurs “just for the fun of it”. For most children, including the less severely mentally handi- capped, simply providing toys and puzzles seems to be sufficient to induce them to play. I t may be necessary with some handicapped children to actually teach them how to play but, once the skills have been acquired, they can occur quite spontaneously and independently.

This is not always the case with the more severely retarded, however, who react quite differently and often do not seem to derive the same intrinsic pleasure from most toys. They frequently ignore or discard toys, or use them inappropriately which, because many com- mercially available toys are poorly constructed or made of flimsy materials, can sometimes result in their

Apex. 1. Rrit. lnst. Merit. Hand., Vol. 9 N o . 2. 1981. 53-56

destruction. Many parents have suffered the heartache on Christmas morning when their child has totally ignored the new, expensive toy and has shown more interest in the wrapping paper.

Rewards At the outset of the project we decided that, because

commercially available toys and play equipment did not seem to provide sufficient pleasure and satisfaction for severely mentally handicapped children, we would have to search for alternative things that did and try to build them into our toys. In other words, we were interested in the kinds of stimulation that might keep them entertained and amused. Psychologists might say we were looking for suitable rewards or reinforcers to maintain a child’s play with a toy.

One of the research findings that has been established concerning the behaviour of severely and profoundly handicapped people is that it is impossible to generalise about events or objects that will act as reinforcers (Spradlin and Girardeau, 1966). Also, it has often been reported that quite unusual and idiosyncratic events that act as reinforcers for one child’s behaviour will not do so for another similar child. In an extended Ameri- can study with the profoundly handicapped, one child would only perform a simple manipulative task when it was followed by bursts of a Tommy Dorsey record, and another would only do so in order to turn off recorded children’s stories (Rice and McDaniel, 1966; Rice el d., 1967).

Figure 1. earphones and vibratory cushion.

The front view of a Pethna showing attached

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These results and our own initial investigations told us that there are few, if any, predictive indexes that can be used for determining which events will maintain a child’s play behaviour. Consequently, a “trial and error” approach has to be taken with each individual. Enquiries have to be made about each person’s likes and dislikes as well as the kind of activities he will participate in when given the opportunity. So far, quite a variety of potential rewards have been ascertained. Among the more frequently mentioned are certain TV advertisement jingles and theme tunes (such as for the Muppets, Dr. Who, Emmerdale Farm and University Challenge), ‘‘pop’’ songs, classical music, flashing lights, spinning objects, and various forms of vibration (for example, the feel of a vacuum cleaner, spin-dryer, or car in motion). Some of the more unusual events, that have been suggested by parents and care-staff for specific children, include puffs of air blown on the face, and particular pictures or objects being shown to them. Edibles have been avoided, as they present various problems including those of hygiene.

“Pethna” The toy system we have developed is called a

“pethna”. It incorporates two interchangeable compo- nents which we call the “in-box’’ and the “out-box”. An “in-box” consists of a device that has to be operated in some way by the handicapped person and an ‘‘Out- box” provides a reward of some kind. All the toys are solidly built, extremely robust, and can be clamped to a table top if necessary. They operate with the help of electronic components that are housed in the “out-box” and are powered by replaceable (or rechargeable) batteries. The interchangeable “in-boxes” and “out- boxes” are fastened together and connected by plug and socket systems.

When assembling a “pethna” for a particular child or adult, use is made of information from assessments of his manipulative and discriminative skills in order to select a suitable “in-box”. T~ enable selection of a suitable “out-box”, it is necessary to ask questions about the kind of things that are likely to reward his operating an “in-box”. If he operates the “in-box’’ fairly frequently to obtain a particular “out-box” con- sequence, then we can say that that consequence is working as a reward or reinforcer. If not, then we must try a different consequence, and keep trying until wc find one that will.

Figure 2. An in-box operated by a large wooden nut along a thread of adjustable length. The plug shown connected to the out-box is linked to a vibratory cushion on which the boy is sitting.

Figure 3. an in-box which employs a bistable switch.

A “ball and bent wire” in-box - an example of

Out-boxes “Out-boxes’’ can deliver one form of stimulation or

combinations of different forms. Operating an “in-box’’ switches on the stimulation from an “out-box’’ for several seconds. A timer-switch inside the “out-box’’ enables the length of a bout of stimulation to bc selected (over a range from 2 to 30 seconds).

Cassette players have been built into most “out- boxes”, and endless cassettes are used so that re- winding does not present a problem. Any auditory stimulus can be taped and inserted into the toy. Easily accessible controls inside the toy enable the volume and the duration of the cassette play to be adjusted. For a child who can make use of them, earphones can be plugged into the toys which, as well as having a fascination for the child, can provide a welcome relief for parents and care-staff who might otherwise have to endure a repetitive song or nursery rhyme for long periods of time (See Figure 1).

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Figure 4. operated by a squeeze device connected to an “air-switch’’ in-box by an extension lead. The squeeze device is fastened to her hand with a velcrose strap.

A multiply handicapped girl with a Pethna

Some of the toys incorporate banks of lights that flash on and off, some project a slide on to a small screen, and a form of visual stimulation that is currently being investigated with certain children is that of a spinning object housed in a transparent case. Gusts of air, that can either be directed at the child or used to make ribbons or beads move, can also be featured in certain “out-boxes”.

Of late there has been renewed interest in the use of vibration with the severely handicapped (see, for example, Jones, 1979; 1980). Although it has been known for quite some time that vibration can function as a most powerful reinforcer for the behaviour of some members of this population (see, for example, Bailey and Meyerson, 1969), little practical use of this finding appears to have been made.

A vibratory seat* on which the child can sit whilst operating the toy can be attached to an “out-box’’ (see

Figure 5. An in-box which operates the Pethna when the four pegs are either inserted into or removed from the four-hole board.

Figure 2). A burst of vibration can thus be procured for a pre-selected duration each time the “in-box’’ is operated. This has proved to be a very effective reward with children and adults of a wide range of ability. Other means of administering vibratory stimulation are currently being investigated and could be incorporated in future versions of an “out-box”.

Considerable versatility has been achieved in the range of “out-box’’ consequences available. As tapes can be changed, and the mode of stimulation can be altered or added to, the effect of novelty wearing off can be avoided and the advantages of variety can be gained.

In-boxes An extremely wide range of “in-boxes’’ have been

designed and the scope seems limitless as literally any manipulable device could be used. The variation in complexity of actions that a child must make to operate an “in-box” covers a broad range of manipulative and discriminative skills. At one extreme, simply pressing on a touch-pad is all that is required to operate the toy. More complex “in-boxes’’ include peg-boards and shape- boards that have to be assembled or dissembled, and “matching-to-sample’’ tasks involving colours, shapes or sizes. Things to blow, pull, squeeze and dial have also been incorporated.

Some “in-boxes’’ make use of a bistable switch for activating the “out-box”. For example, one “in-box’’ incorporates a ball and bent wire (see Figure 3). The ball has to be pushed over the bent wire and, on land- ing, it activates a switch. To operate it again the ball has to be pushed back to the other end of the bent wire, and so on. Knobs that have to be pushed along a groove, and nuts that have to be wound along a thread, make use of the same operating principle.

“In-boxes’’ are usually located at the front of the toy, nearest to the child. However, for multiply handi- capped children who would experience difficulty in reaching to an “in-box”, an extension lead can be added to run to a device placed in the child’s hand that has to be squeezed (see Figure 4). An air-filled bladder can be constructed to fit perfectly into the contours of the hand, with a tube running from it to connect it to an air-switch in the “in-box”. If the child is likely to drop the bladder frequently, a strap with a velcrose fastener can be used to prevent this so that when the child closes his hand it is still available for operating.

Shaping Most “in-boxes’’ are adjustable so that the response

required from the child in order to activate the toy can be varied. This allows for the gradual “shaping” of responses, a technique that is in wide use for the education and training of the mentally handicapped. Shaping involves gradually increasing, over a period of time, the complexity of some aspect of the response needed in order for a reward to be delivered. The use of shaping with a “pethna” is perhaps best explained by example.

Example I The “in-box’’ shown in Figure 2 uses a bistable

switch and is operated by winding a large nut along a thread. Microswitches are housed in the upright support- ing brackets and are operated when the nut touches

We are grateful to .Niagara Therapy (UK) Limited for providing vibratory equipment for the prototypes.

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them. I t is possible to set this “in-box’’ so that the nut has to be wound a distance of, say, six inches along thc thread in order to reach and operate a microswitch. However, iE this requirement were set immediately, many handicapped people would tire of winding the nut before it reached the switch and so would not be rewarded. They would probably reject the toy fairly quickly.

On the other hand, if initially it were only necessary to wind the nut along the thread a distance of a quarter of an inch, it is more likely that a severely handicapped person would successfully achieve this and would be rewarded for doing so. As time went by, the distance that the nut had to be wound could be gradually increased to half an inch, one inch, two inches and so on, until eventually the final six inch requirement was met.

Such increases can be made at a rate that is suitable for the individual being taught. If any increase made is too great, then it is possible to go back to a shorter distance and to increase it again later more gradually. An adjustment mechanism in the “in-box’’ enables the desired distance between the two switches to be set and locked in order to facilitate this.

Example 2 Figure 5 shows an “in-box” which requires four pegs

to be either inserted or removed in order to operate the toy. For some children, however, it will be necessary to start with a single peg “in-box”, and perhaps progress through two and three peg boards before the four peg “in-box’’ would be suitable. It is also possible to start with a single peg “in-box’’ which has an extra wide hole to make it easier for the peg to be inserted, and to then progress gradually to a tighter fitting version.

Pressure, force, distance moved, and degree of diffi- culty, are all dimensions of a response required to operate an “in-box” that can be varied. The adjustment of operating requirements means that a child’s skills can be stretched a t a rate appropriate to his level of progress. In this way the toy serves a useful educational function.

Individual tailoring It is possible to fashion the dimensions of the toy

to the needs of a particular individual. This is often necessary if there are physical handicaps that make the operation of an “in-box’’ difficult. The size, shape and amount of pressure required to operate a squeeze switch, such as that shown in Figure 4, can be tailored precisely to the needs of the person. For some people it might be necessary to fashion a device that can be operated by a foot, or by bending an elbow.

Sometimes, an “in-box” can be constructed that helps to overcome particular difficulties. Recently we saw a severely retarded, pre-school girl who spent long periods of time with one of her hands, or an object, in her mouth. She soon learned to operate and enjoy a “pethna” with a press-pad “in-box”, but she usually did so with one hand whilst her other hand remained in her mouth.

An “in-box” was produced for her which consisted of two levers that had to be pulled or pushed simul- taneously with both hands. The distance between the levers and the amount of force required to operate them was tailored to her particular requirements. The operating mechanism was adjusted so that a reward was continually delivered while she had both hands in

contact with the levers, but so that it ceased immedia- tely if she removed either or both of her hands. She now has a toy that entertains her, encourages her to use her hands and ensures that a t least for a short period during the day she does not have a hand in her mouth.

Feedback and evaluation A counter can be fitted into an “out-box’’ to enable

a more objective evaluation of the effectiveness of a particular “pethna”. The counter accurately records the number of times that an “in-box” is operated over several hours, days, or weeks. This information is especially useful when comparing different rewards in order to determine which is the most effective and durable for an individual.

The initial trials of these toys have produced an enthusiastic reception from schools, toy-libraries, and parents. Parents of profoundly and multiply handi- capped children and adults have told us that a “pethna” is the first toy, or indeed any item, that their child has been able to operate independently without supervision and has played with for sustained periods of time.

Further field-trials. modifications, and developments are currently being undertaken, but already there seems to be room for optimism regarding the contribution that this project could make to severely and profoundly mentally handicapped people and their families in the f u t ure.

Lindsley (1964), a pioneer in the use of the behavioural approach to special education, noted that: “Children are not retarded. Only their behaviour in average environments is sometimes retarded. In fact, it is modern science’s ability to design suitable environ- ments for these children that is retarded” (p. 62). In the same vein we would contend that use of technology to further develop prosthetic toys and play equipment could contribute considerably to raising the level of dignity of the more severely and profoundly mentally handicapped.

Acknowledgement We are grateful to Mr. W. Meredith and Mr. B.

Roberts for providing extensive electronic expertise for this project.

References Bailey, J., Meyerson, I.. Vibration as a reinforcer with the

profoundly retarded child. 1. App. Behav. Anal., 1969; 2 :

Jones, C. The uses of mechanical vibration with the severely mentally handicapped. Apex, 1. Brit. Inst. Ment. Hand., Pt.

Lindsley, 0. R. Direct measurement and prosthesis of retarded behaviour. J. Educ., 1964; 147: 62-81.

Rice, H. K., McDaniel, M. W. Operant behaviour in vegetative patients I. Psychol. Record, 1966; 16: 279-281.

Rice, H. K., McDaniel, M. W., Stabbings, V. D., Gatz, M. J. Operant behaviour in vegetative patients 11. Psychol. Record,

Spradlin, J. E., Girardeau, F. L. The behaviour of moderately and severely-retarded retarded persons. Internat. Rev. Res. Ment. Retard., 1966; 1: 257-298.

135-137.

I - 1979; 7: 3, 81-82. Pt. I1 - 1980; 7 : 4, 112-114.

1%7; 17, 449-460.

Requests for off-prints or further enquiries about this project should be sent to Dr. P. A. Woods, Principal Clinical Psycho- logist, Bryn-y-Neuadd Hospital, Llanfairfechan, Gwynedd LL33 OHH

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