Elemy Yeme is a Board Certified Behavior Analyst (BCBA), cofounder of ElevABA LLC, and most importantly, Jaxon’s best friend. Since 2015 she has worked with individuals diagnosed with a variety of developmental, neurological and learning disabilities. She specializes in creating greatly individualized treatment plans for individuals with behavioral challenges, and has an undeniable passion for improving the lives of the clients and the families that she serves. Her particular interest is to find effective behavioral interventions for those with complex developmental disability profiles and learning needs with a comprehensive knowledge approach. She holds a master’s of education from the Arizona State University, and currently resides in San Diego, California. In her free time, Elemy likes to camp, read, and play with her dog Hula.
Please be sure to read the disclaimers at the end of this article!
Context and Background
Let me start by providing you with some context to shed light on just how hopeful you should remain that your child, too, can master wearing a face mask! Jaxon was not only not wearing a face mask, he wanted to have absolutely nothing to do with them, and he did not want anyone else to have anything to do with them either. Prior to intervention, whenever a face mask was presented to him, whether in close proximity or someone wearing it, aggressive episodes were a legitimate concern. If you were wearing a mask, Jaxon would start by not looking at you, put his head down, gesture confusion and discomfort with his facial expressions, and then launch into a fast and heavy grab . He then would vocalize, and get close to your face until you took the mask off. If a face mask was presented to him, he would say “no,” shake his head “no”, and leave the area entirely. Sometimes, he would even grab it and throw it if he felt annoyed enough to actually touch the mask.
When the masking order was put into place, I found out about it through Monica, Jaxon’s mom! There was absolutely no delay between her finding out and her messaging me about it, haha! I responded and said “okay, let’s get Jaxon to wear a mask then. We’ll work on it” to which she responded “yeah, good luck! You will never get my kid to wear a mask,” and here he is wearing a mask, rocking Covid times, and taking names!
My point here is that Jaxon was nowhere near a level in which he could successfully wear a face mask! If you think that your child’s conditions are not conducive, whatsoever, to teach him/her the skill, just know that Jaxon’s were not either, and he did it anyway. In order to reach success, we had to systematically plan for skill development and ultimately broke down his learnings into the following goal and objectives, while significantly leveraging 2 key strategies: use of social stories and shaping. See the details below:
Jaxon will wear a face-mask for prolonged periods of time within the next 1.5 months.
- Enhancing Jaxon’s understanding of rationale for wearing face-mask
- Tolerating others wearing a face mask
- Tolerating wearing a face mask on self
- Establishing Rules and Expectations
Key Strategies Used
Social stories are individualized short stories about social situations that the child may encounter. Social Stories are a therapeutic technique, often used with children on the Autism spectrum, that foster the exchange of information with the child that are highly personalized and illustrated. Many caregivers and therapeutic professionals find Social Stories to be especially helpful when trying to describe events, activities, social norms and managing expectations (Adams et al., 2004; Gray & Garand, 1993).
Our social story was a crucial aspect of our intervention because we truly individualized it for Jaxon. The trick about social stories is understanding that any story with OUR language will mean absolutely nothing to your child. A story with words and concepts he/she doesn’t understand will be just that, words. The key is to create a story your child can relate to. The way in which your child relates to people, objects and events needs to be identified first. Jaxon has an incredible memory, and loves pictures. So, I used pictures of him, his family, and things he knows. I used the pictures to create the message I wanted to teach. See below for a more detailed description of how we used social stories.
Shaping is a process that reinforces close approximations to the behavior we want to see (Cooper, Heron & Heward, 2019). We shaped wearing a face mask by requiring little increments each time and rewarding the small successes instead of requiring the whole thing at once. For example: requiring Jaxon to wear the mask for 5 seconds, then 10 seconds, and slowly increase the duration until the desired time.
Objective 1: Enhancing Jaxon’s understanding of rationale for wearing face-mask
- The first social story we presented was a “Coronavirus” social story. We taught about Coronavirus, reasons for not going to school, and the inability to access preferred things and places. We taught page by page, relating everything to Jaxon. Once he demonstrated some receptive understanding we introduced the face mask social story.
- The face mask story included several pages (more than 10). We began with talking about one page only! (We wanted him to not lose interest and be rewarded quickly). Then we added a second page, and a third, until we were able to go over the whole story in one sitting.
- As we were going over each of the pages in the story, we would take discrete and particular messages and relate it to things he understood (a very important step in the process). We did not just read the story out loud, instead we would pause and show him via actions, additional words, objects or pictures what the message meant (see below for examples).
- Outside of the social story time, we would talk about the places that he really enjoyed going to, and the reasons why they were currently “unavailable.” We did that by relating those instances back to the story. For example, we would say things like “Oh yeah boomers! It’s not available. Remember? People are sick (mock a sneeze). So, they have to clean it (show pictures of Jaxon’s preferred animated show that talks about germs)” or statements like that.
- Within the story, wearing a face mask was introduced. Jaxon’s sister was amazing and put a mask on a bunch of images of Jaxon’s preferred items and sent them my way. Additionally, I had everyone in his family including his ABA team take pictures of themselves wearing masks and I included those in the story.
- Once he was familiar with the story and he showed some receptive understanding of the situation, we introduced tolerating a face mask on others, as well as himself.
Objective 2: Tolerating others wearing a face mask
We started by priming Jaxon before we put a face mask on. Specifically, we would have the mask in hand and say “Hey Jaxon! I just want to let you know that I am putting my mask on, okay?” and we would require him to acknowledge it by saying “yes” or giving us a thumbs up. Acknowledging was important as that indicated he received the message, and he agreed to it. This establishes a sense of accountability. We would put the mask on, and at the beginning we would keep it on for 5 seconds, reward, then 10 seconds, reward, until we could wear it for extended periods of time in Jaxon’s presence and he was no longer fazed by us wearing it.
Objective 3: Tolerating wearing a face mask on self
As mentioned above, we used shaping, so we broke this objective into smaller skills and rewarded each step of the way. The steps we followed were:
- Tolerating mask in close proximity (3-4 ft away)
- Tolerating mask being closer and closer (2 ft, 1 ft, inches, next to him, almost touching him)
- Touching the mask with his hand
- Putting one loop of the mask on one ear
- Putting both loops of the mask on each ear while keeping the covering by his chin
- Putting mask over mouth and nose
- Once he was putting the mask on properly, we started increasing the duration of wearing the mask. After he would put the mask on (with our help), we would require him to keep it on and we counted with him. We started at 5 seconds, and we increased it as follows: 10 seconds, 30 seconds, 1 minute, 2 minutes, 3 minutes, 5 minutes, 10 minutes, 15 minutes, and we stopped counting (and he wasn’t taking it off anymore!).
It is important to note 2 things related to the list of skill-builders above:
First, time between each of the skills (and thus, time it takes to develop or build each of the above skills) will vary from child to child. Consider similar skills you have attempted to develop with your child and time it took to build that skill. Furthermore, exposure and frequency of opportunity to work on each skill also influences the time it takes to develop the skill.
Second, if maladaptive behaviors occur, it would be advisable to first find out why. What happened before and after? What do we think it is? What about the intervention presents a barrier? And with that information make adjustments. If maladaptive behaviors occur, it is important to take a step back, or as many as needed where the behavior is not occurring and go from there.
Objective 4: Establishing Rules and Expectations
Once Jaxon acquired the skill, we made wearing a face mask a requirement (expectation) for any preferred or desired item. Below are a few important notes on actions we consistently had to take:
- We constantly reminded him, and continue to do so! Every time we go out in the community the mask is a requirement, and he needs to follow those directions. We repeat it on a consistent basis.
- We also point out people wearing a mask, all the time! “Look Jaxon! He is wearing a mask, he is being safe” or statements of the sort.
- We point out when we are putting our masks on. For example: “Jaxon! I am going to put my mask on and then I will come help you, okay? I need my mask to be safe” or such.
- We also followed through and continue to do so with the expectation. For example: if we go to get a smoothie to Jamba Juice, the rules/expectations are: if you want your smoothie “keep mask on,” if he follows through, he gets his smoothie, if he does not, he won’t. If at any given point he takes the mask off, we do not follow through with the outing. Example: walking to Jamba Juice, takes mask off, “Okay, no mask, no smoothie! Back to the car” or such.
- Once the skill was acquired, it simply became an expectation, and we don’t budge. He either has to wear it, or he has to wear it!
Detailed Description of Our Use of Social Stories:
As I mentioned earlier, the social story was a very important aspect of our intervention. It was very effective due to the level of individualization of the story and how we ensured the messages related to things, people, and events Jaxon understood and remembered. We did a coronavirus and a face mask story.
From the Coronavirus social story there is this page with a picture of Jaxon when he was sick. Typically, when Jaxon does not feel well and gets sick with the common cold, he signs “sad” as a way to communicate that he does not feel well. So, when talking about this story we told him about being sick, and feeling sad because of being sick, etc. This allowed us to establish “coronavirus” as a virus and a producer of sickness.
This page introduced Covid/Coronavirus. Something associated with sickness. When talking about this, we would read the page and sign “sad” as Jaxon typically would, mock sneezes, repeat “virus,” show pictures of the cartoon viruses he likes to watch, etc.
This page introduced having to wear a face mask because of coronavirus (sickness). We would explain that we did not want to be sick because of coronavirus. We wanted to be safe, so we needed a face mask.
We would show him the picture of him being sick and we would shake our head “no” repeating we did not want to be sick, and be sad.
This introduced the feeling of the mask, and we related it to things he does not like. Also, his favorite drink from his favorite place (Carl’s Jr.) has a face mask on! We paired positive things that mattered a lot to him such as the Carl’s Jr. cup with the negative parts of wearing a mask.
Here we explained what the mask consists of. When reading this, we would pause and show him with our own mask. We also added a picture of Jaxon’s sisters wearing a mask. Again, associating familiar people (positive) with the mask.
This simply introduces that the more we do it the more comfortable we get with it. Additionally and most importantly, these two pictures are the front cover of two magazines that Jaxon loves with a mask! This helps relate wearing the mask and pairs it with something positive.
This one simply introduces that masks may look different to make sure the variety of masks in the community was not a surprise to Jaxon. We would look at pictures of people with different face masks and show him. Also Jaxon is into puppies! So, of course, we have a puppy with a mask to make it a positive thing.
Jaxon identifies doctors, and relates to them well. So, we wanted him to relate the difference. Additionally, he talks about animals a lot due to his particular interest in the zoo and the carrousel. Jaxon particularly likes talking about horses with Monica because her horse noises are hilarious!! And Jaxon really enjoys them! Therefore, Monica thought adding a horse to the mix was appropriate (it also gave the rest of us a good laugh!).
Here we introduced the community aspect of wearing a mask. To this point, we got Jaxon to understand that there is a virus, that we needed to wear a mask that may be uncomfortable, and now, we needed him to know why? Why does it matter? Well, because if you want to go into the community, you have to be safe. We explained this by showing him YouTube videos of his favorite places, or places he often went to and referred back to wearing a mask if we wanted to visit those places.
Here we just added that everyone is wearing a mask! And we put some familiar pictures to normalize the act of wearing a mask and also making it positive.
Here we continued to add that we want to be safe, and not be sick and therefore sad. The two ladies in the picture are Jaxon’s ABA therapists wearing a mask!
This sums it all up. Jaxon wearing a face mask keeps him and those around him safe, it makes him a functional member of society, it gives him access to things and places he could potentially not have access to without it, and at the very least, it provides him with an extra shield to protect him against potential exposure. It also gives Monica and Aaron some peace of mind!
I truly hope you find this information helpful, and I highly encourage you to see the possible in the impossible. If you have any questions or would like any additional resources, please reach out, I am happy to share!
1. Elemy Yeme is a Board Certified Behavior Analyst and does not make any additional representations or warranties regarding her credentials or experience. This information does not create any patient-provider or client-professional relationship, and should not be used as a substitute for professional treatment.
2. All Content is for informational purposes only and should not be construed as specific therapeutic advice for your situation. Behavioral strategies are selected based on the specific qualities and characteristics of each individual. Individual results may vary. Elemy Yeme does not guarantee results of any of the information provided, and you must not rely on such information as an alternative to individualized advice from a behavior analyst, medical professional or healthcare provider. For individualized advice requiring a BCBA, please contact one in your area.
3. Some of the information includes client experiences, reviews, comments, and testimonials (collectively, “Testimonials”). All Testimonials are unsolicited and persons providing Testimonials are unpaid. The Testimonials reflect the real life experiences of individuals who have received my services. However, individual results may vary, and Testimonials are not necessarily representative of what any other individual may experience.
4. Elemy Yeme is committed to ensuring that any personal information received is safeguarded against unauthorized disclosure. Some of the information includes client experiences and personal information. With proper consent, it is permitted by federal privacy laws to make uses and disclosures of protected health information of the individual. To ensure the privacy of client’s records, informed consent for release of information was obtained from the clients.