When considering what will be the most successful way to increase Tony’s ability to tolerate or be successful in certain environments whether it be with crowds or for structured activities, I have to focus on multiple elements that need to be addressed at the same time. One of the things I have noticed in the past months is that our little man has regressed in his tolerance for the noise of hand dryers in bathrooms, as he overall has had a reduced exposure to a variety of places with them over the course of the pandemic. He cannot, if you are new here, tolerate the feel of sound cancelling headphones on his head. So the first thing I have needed to plan for on all outings is how we are going to help him regain those skills and provide workarounds that respect his comfort level in the meantime. Again, these represent my chosen strategies, the outgoing ABA team has not been participating in discussions for or doing the work arounds for these challenges.
When we first started trying to get Tony to use public toilets after he was successful in transitioning out of diapers in the home setting, we used french fries to reinforce and earn his cooperation for entering into bathrooms he was afraid of. Reinforcement was eliminated as soon as he was comfortable entering in and using those bathrooms on his own. I noticed when we took a hiking trip up north a couple of months ago while we were in the McDonalds there that french fries were not sufficient at this time in helping motivate him to enter a bathroom with hand dryers in a crowded area, so new strategies would need to be developed.
The first and most obvious one is to take him somewhere less crowded. As we have started to reintroduce therapy goals aimed at recouping his tolerance of crowds, one of the things I have been choosing to do is stop at a bathroom I know he will be more comfortable with closer to the location we will be working in. Next, I identify what bathrooms if any he could be more comfortable using within an environment.
I already know that when we work in the zoo, for example, that the bathrooms by the entrance often have far too many people for his preference in that area and he won’t approach or enter them at this time. But the bathroom at the very back as one is approaching the camels often has very few people near it, so the strategy I settle on for zoo trips for the time being is stopping at a QT near the zoo, then working our way to the back as quickly as possible. Even on days that are less crowded by the standards of others, it is still enough people to make him anxious right now.
For outings to Tanger, during crowded times we had to start out taking him off premises when he needed to use the bathroom, such as the local Carl’s Junior. Andy and I located a family bathroom in one of the restroom corridors at Tanger and offered him a cookie to enter in during a visit with fewer people. A picture was taken to show him when he gets scared by more people being present, so that he can be reminded that there will be a bathroom in the hall where he can go without the hand dryer being on. And he is offered some form of reinforcement for going into any restroom he is initially hesitant to, and given the item if he is successful. For Arrowhead, generally the department store bathrooms are less crowded so that is where his comfort level and willingness to enter one for reinforcement align.
In places where there are loud hand dryers and no other options, a member of the group will go in and verify whether or not there are people in the bathroom. Once the bathroom is empty, Tony and I will run in, he’ll be allowed to verify that nobody is in there, and given reinforcement for using the bathroom. Because he’s that scared of the hand dryers right now, he’ll often choose to want to leave immediately when finished if someone else enters, rather than staying and washing his hands, so we respect that and give him some hand sanitizer outside the door.
We will wait outside of bathrooms with hand dryers going off as he is comfortable to help him adjust to the sounds, but nothing here is forced. If another member of the group needs to use the bathroom, and he’s too scared to enter, we will find a bench nearby where he feels safe and either Andy or I will wait with him, offering him variable reinforcement for staying in the area. As he regains comfort with the noises and the crowds, we will still need reinforcers for a while to get him to enter into crowded bathrooms with hand dryers, but we will work to fade reinforcement as quickly as his comfort level allows so that he doesn’t come to consider them an essential part of his routine.
As we go forward, we have learned this past week that our very good friend, the fabulous Miss Emily, will be returning soon for a time to do some hab work with us on the weekends, which will help maintain Tony’s ability to generalize to others. I’m super excited and grateful about this because she and I have always worked well together, she listens to my feedback and I certainly listen to hers, and her background with Tony (as both a music and hab therapist), and as a teacher in the public school system, will certainly benefit our ability to be successful with what we are trying to do. Any strategies that come from her as we are discussing anything we are working on together will be designated as such, anything that comes from me likewise.
