Keywords

Introduction

Safety skills are those many things that a person learns as they develop, which helps them to successfully navigate their environment in order to avoid situations or elements that can lead to harm. In the typically developing population, these skills are developed with age and the cognitive ability of an individual plays an instrumental role in the successful implementation of these skills. In persons with intellectual and developmental disabilities (IDD), there is often a mismatch between cognitive or behavioral abilities and the environment, which may result in the person with IDD being placed in an unsafe situation. Due to cognitive impairments, the individual may be unaware of danger or lack the ability to correctly implement safety skills (Gaebler-Spira & Thornton, 2002). Given that these skills follow a typical developmental course, children with IDD are at particular risk for not developing these skills appropriately. Children with IDD may have impaired skills such as the ability to learn and obey safety rules, to estimate their own physical strength, to understand the risks of a given situation, and to understand the cause of an injury after its occurrence (Schwebel & Gaines, 2007). The risk of injury for individuals with IDD is further exacerbated due to the presence of related physical disabilities (e.g., poor gross motor skills, visual impairment) or comorbid psychopathology (Sherrard, Tonge, & Ozanne-Smith, 2002). As a result, these individuals are either not aware of the harm that can be caused to them if they are exposed to dangerous situations or they lack the skill to carry out an escape plan (e.g., how to find the exit in case of a fire). All of these factors put individuals with IDD at an increased risk for injury or victimization.

Typical day-to-day environments, such as home, school, or public places, present with a number of hazardous situations. Harm may come to persons with IDD if they do not possess the skills to identify and appropriately handle these situations. For instance, in the home environment, individuals are exposed to elements like cleaning products, sharp household items (e.g., knives, forks, scissors), and broken glass (Winterling, Gast, Wolery, & Farmer, 1992). Obviously, if these elements are not handled appropriately, then serious injury may occur.

Harm may not only come from passive sources such as cleaning products or kitchen knives, but also active sources such as caretakers, peers, and community members (Lennox & Eastgate, 2004). Predators may target individuals who show signs of an inability to recognize unsafe situations, verbally protest, or escape from such situations. As such, it is also very important to teach individuals with IDD how to identify and protect themselves from physical and sexual abuse. Further, if a crime occurs, such individuals are less likely to know that it is important to report the incident. Individuals with IDD may not comprehend that they have a right not to suffer this abuse. Enabling people with IDD to become aware that abuse is illegal is an important first step in countering abuse (Reiter, Bryen, & Shachar, 2007).

Researchers have identified that there are a number of factors that play a part in increasing the vulnerability of individuals with IDD. In general, researchers report that these individuals are at a higher risk due to poor communication skills, physical disability, gullibility, and the tendency to acquiesce with requests from others (Greenspan, Loughlin, & Black, 2001; Howlin & Jones, 1996; Sullivan, Brookhouser, Scanlan, Knutson, & Schulte, 1991; Zhu, Xia, Xiang, Yu, & Du, 2012). Further, research by Howlin and Jones (1996) and Sullivan, Brookhouser, Scanlan, Knutson, and Schulte (1991) indicated that due to limited communication skills, children with disabilities might lack the ability to disclose abuse. As a result, they may be seen as easy targets. Such abuse could manifest as physical or sexual and may involve their peers or caregivers (Lennox & Eastgate, 2004).

Gullibility and acquiescence are of particular note for persons with IDD. Individuals with IDD often have an unquestioning belief and tend to put their trust in others (Kempton & Gochros, 1986). Additionally, individuals with IDD often have a learning history of being reinforced for compliance with requests. A prevalence study done in the UK noted that in 84 % of the instances the perpetrator of sexual abuse faced little to no resistance (McCarthy & Thompson, 1997). However, training compliance is also essential for many important daily activities such as taking medications, eating, and dressing, to name only a few examples. The key element then is in teaching the individual to identify inappropriate requests and to create transparent and accountable systems of care for those persons who are unable to acquire the discrimination skills.

Sociocultural factors also play a part in the abuse of individuals with IDD. The attitudes of peers may increase the risk of bullying, ridicule, or acts of violence (Hodges & Perry, 1996). In social settings, an individual with IDD may not comprehend or develop awareness of cues that alerts them that a situation is unsafe.

Given the increased risk for persons with IDD, teaching safety skills is of the utmost importance. However, in spite of the potential for serious injury or victimization, the training of appropriate safety skills may be neglected in the education of persons with IDD (Petersilia, 2000). In this chapter, we look at safety skills across seven broad categories: fire safety, first aid, accident prevention, fall-related prevention, pedestrian, self-protective, and emergency telephone skills.

Epidemiology

The prevalence of injury in children and adolescents with IDD is 1.5–2 times higher than typically developing children (Slayter et al., 2006). The most common unintentional injuries in this population are burns, poisoning, foreign body injuries, fractures, dislocations, and internal injuries (Rowe, Maughan, & Goodman, 2004). According to the US Department of Homeland Security (2011), every year an estimated 85 deaths and 250 injuries occur due to residential building fires involving individuals with IDD. In 40 % of the cases, the fire was intentional and an IDD was the human factor contributing to ignition.

Adults with IDD have a higher rate of injuries and falls as compared to the general population (Finlayson, Morrison, Jackson, Mantry, & Cooper, 2010). The authors reported that over a 12-month period, incidence of at least one injury was 20.5 % in which falling was listed as the cause of the injury in 12.1 % of the reported injuries. In a population-based comparative study specifically designed to investigate public health implications of injury in young people with IDD, Sherrard et al. (2002) found that this group had mortality rates from injuries that were eight times higher than the general population. In their study, falls were the most frequent cause of injury (60.2 %) followed by burns (7.3 %).

In regard to victimization, Wilson and Brewer (1992) found that adults with IDD are twice as likely to experience crimes against the person (physical assault, sexual assault, robbery, and personal theft) and 1.5 times more likely to experience property crimes such as breaking-and-entering and household property theft. Concerning sexual abuse, Sobsey and Mansell (1994) reported that 15,000–19,000 people with developmental disabilities are raped in the USA. Further, women with IDD are assaulted, abused, and raped at a rate two times greater than women without disabilities (Sobsey & Mansell, 1994). Unfortunately, it is not uncommon for individuals with IDD to also be physically, sexually, psychologically, and financially abused by family members, neighbors, and peers (Sobsey & Varnhagen, 1988; Williams, 1995).

Evidence-Base for Treatments: Review of Research

Fire Safety Skills

The alarming number of fire-related injuries and deaths among individuals with IDD brought a good deal of attention during the late 1970s and 1980s to the development of programs to teach fire-related safety skills (US Department of Commerce, 1978). Although fire emergencies occur less frequently than other accidents, due to their devastating effects, it is important to teach individuals with IDD skills to prevent and safely react to fires (Mechling, 2008). Many studies and reviews on fire safety skills have been conducted (Bannerman, Sheldon, & Sherman, 1991; Cohen, 1984; Haney & Jones, 1982; Jones & Thornton, 1987; Katz & Singh, 1986; Knudson et al., 2009; Luiselli, 1984; Matson, 1980b; Mechling, 2008; Rae & Roll, 1985; Rowe & Kedesdy, 1988). As such, research on the area of fire safety skills with individuals with IDD is well established and demonstrates that individuals with IDD are able to learn fire safety skills through behavioral training.

One of the earliest studies to teach fire safety skills to person with IDD was conducted by Matson (1980b). In his study, he developed task-analysis steps for escaping fire and used classroom training to teach five adults with moderate IDD to safely escape from a fire (Matson, 1980b). The task analysis steps included: (1) crawl out of bed keeping the face down and go to all fours; (2) crawl to the nearest door with little smoke; (3) open the door while staying bent down and go outside as fast as you can without running; and (4) stay outside and wait for directions from authorized persons. The participants were first taught to verbally describe the steps to escape a fire using verbal instructions and social reinforcement. Then the instructor modeled step-by-step target behaviors using the cardboard model of the living area and figures. With verbal and physical prompts, the participants imitated and rehearsed the step-by-step behaviors . Matson (1980b) found the participants were able to verbally report how to respond to a fire emergency and maintained the knowledge 7 months after the training. Results of the study revealed that the participants with moderate IDD who lived in an institution for a long period of time were able to verbally describe how to escape a fire.

Although Matson (1980b) demonstrated that the participants could successfully gain appropriate knowledge of fire escape skills, the question remained whether individuals with IDD could perform these skills in real-life situations . To address this question, Haney and Jones (1982) taught four children with moderate and severe IDD to exit from their living environment in fire-emergency situations. The participants were 12–16 years of age and resided on the second floor of a group home. Each training session lasted approximately 20 min and consisted of verbal instructions, modeling, behavioral rehearsal, corrective feedback, and social reinforcement. Role-playing was used to help generalize these skills, and simulated environments using props such as a tape recording of the house’s fire alarm, a heated pad, a cool pad, a blow dryer, and pictures of smoke/fire were used. The multifaceted behavioral training was effective in teaching children with moderate to severe IDD to safely exit simulated fire emergencies from their home; across their participants, 60–100 % successful performance was achieved in 10–30 training sessions. Furthermore, the participants demonstrated maintenance of the learned skills at 6 months follow-up.

Further research has expanded on these results, showing that similar behavioral techniques including verbal instruction, reinforcement, prompting, and feedback are effective techniques for teaching adults with IDD to perform fire safety skills. For example, Luiselli (1984) taught fire safety skills to a 43-year-old man with severe IDD who resided at a residential facility. After 3 months of unsuccessful attempts to teach him the skill, he was referred for behavioral training which consisted of instruction, prompting, feedback, and reinforcement . More specifically, during the initial 2-h session, the participant was taught to go outside upon hearing the fire alarm and successful performance was reinforced. The participant was further trained over 13 consecutive days, practicing one fire drill each day. When the participant successfully evacuated the residence and met at a predetermined location within 2.5 min of an alarm ringing, he was rewarded. When he did not meet the 2.5 min criteria, he did not get the reinforcer and was told why he did not receive it. After failing to exit on the first 2 days, the participant successfully performed fire safety skills on 11 consecutive days, averaging 54 s to exit. The participant learned to independently evacuate the facility after 2 weeks of behavioral training. The participant also demonstrated 100 % successful performance during seven post training drills all within 2 months of the training. At the 1-year follow-up, the participant successfully evacuated the building within 2 min upon hearing the alarm.

Similarly, Cohen (1984) taught fire safety skills to a 30-year-old male with profound IDD and blindness who resided at a group home. The participant learned to independently evacuate the bedroom using instruction, forward training, reinforcement, and verbal prompting. The forward chaining procedure was used to teach safety skills, which were divided into ten steps. The mastery criterion for each step consisted of five successive independent correct responses. Upon demonstration of the correct response, the participant was given social praise and edible reinforce. A verbal prompt was provided if the participant did not respond independently. It took a total training time of 2.5 h to teach the participant to independently exit the building; the average exit time was 28.5 s which met the 2.5-min requirement set by the state. Furthermore, the skills were generalized across different locations and were maintained at a 1-year follow-up. The rapidity of training was attributed to the simple procedure.

Rae and Roll (1985) implemented an intensive fire safety training program for ten individuals with profound IDD, ages 22–42 years, who resided on the tenth floor of their group residence. The training program consisted of daily fire drills for 1 year. Following the verbal cue, the fire alarm rang to signal the drill. When the participants did not respond within 30 s, verbal and gestural prompts were provided. If the participants did not respond within 60 s, then physical prompts were used. All participants received social praise upon completion of the drill within the time limit. After 1 year of daily practice. The mean evacuation time for all participants decreased from 87 s to a mean of 24 s. Also, the amount of physical prompts given significantly decreased from 57 to 7 %. Noticeable progress was observed after 6 months of daily fire drill training.

Following these studies, Katz and Singh (1986) extended upon previous research on fire safety skills and taught more comprehensive fire safety skills such as exiting a burning building, reporting fire, and extinguishing fires by using the stop, drop, and roll procedure to adults with mild to moderate IDD. Five females and four males, ages 30–50 years old, who resided in a group home participated in the current study. The exiting training was conducted in the participants’ bedroom and other safety skills such as reporting and extinguishing fires were taught in various locations to ensure generalization. Props such as pictures of smoke and flames and a hair dryer were used to simulate more realistic environment. Training procedures consisted of verbal instructions, modeling, rehearsal, feedback, and reinforcement. All participants acquired knowledge of more comprehensive fire safety skills, and these skills were maintained over 6–18 weeks follow-up.

Consistent with previous research, Jones and Thornton (1987) also successfully taught fire evacuation skills to four adults with IDD, ages 30–55 years. In addition to teaching fire safety skills, the authors aimed to enhance the maintenance. An average of eight daily sessions was conducted lasting approximately 15 min. Training consisted of instructions, modeling, behavioral rehearsal, feedback, and reinforcement. The participants were trained in their own apartments using simulated fire cues and in vivo situations. All participants successfully learned to evacuate during fire emergencies. In order to promote maintenance, a maintenance program was followed over a 30-day period. The maintenance program consisted of presentation of mastered situations, self-evaluation, and booster sessions and showed that the acquired skills can be maintained over a 6–8-months period. Rowe and Kedesdy (1988) used a time-limited fire evacuation program to teach 37 institutionalized adults with mild to profound IDD. The participants were taught to independently evacuate their two-story cottages within 2.5 min of a fire alarm ringing. Backward chaining , delayed least-to-most prompting procedures, reinforcers, and social praises were used to teach target skills. Following 3 weeks of training, a large percentage of participants passed training drills. Participants continued to improve and their evacuation skills maintained at 3- and 6-month follow-ups.

The majority of studies within this domain have included participants who were verbal. Bannerman et al. (1991) extended upon the research by demonstrating that these techniques could also be used for nonverbal adults with severe and profound IDD. The participants included three adults, ages 25–40 years. The participants were taught to evacuate their group home residence within 2 min of surprise fire drills. Modeling, rehearsal, prompting, and reinforcement were used. All participants successfully learned to exist independently and demonstrated maintenance for 3–16 months. In addition, all participants demonstrated generalization of target skills across locations and people.

Many studies have successfully taught fire safety skills to individuals with IDD, but are limited by the contrived nature of the teaching environment. In order to ensure better generalization, it is necessary to set-up a seemingly real fire emergency and train individuals without their knowing that they are being assessed. Towards this end, Knudson et al. (2009) conducted a study to evaluate training procedures for teaching individuals with severe and profound IDD in the most naturalistic way possible. Seven participants with severe and profound IDD were taught to exit their residence upon hearing a fire alarm when they were not aware of the assessment. The participants were taught to immediately engage in exit behaviors until they were safely out of the building upon hearing a smoke detector. A multiple baseline across-subjects design was used to evaluate the effectiveness of behavioral skills training and in situ training. The first trial consisted of the experimenter modeling the correct behaviors. Each subsequent trial involved the experimenter using the least intrusive prompt necessary to get the participant to exit the building. The results of this study showed that one of the seven participants learned to exit the group home quickly without prompts and four participants required less intrusive prompting to exist the building.

In summary, previous researchers have successfully taught fire safety skills to individuals with varying degrees of IDD and ages; the participants in these fire safety studies ranged from children to older adults, and their level of IDD also varied from mild to profound. Earlier studies increased the participants’ knowledge by teaching them to verbally describe what to do in a fire emergency. Although knowledge is an important part of safety training, researchers pointed out that knowledge alone does not necessarily generalize into actual skills. Thus, many researchers have focused on teaching the individuals to perform fire safety skills and have reported promising results. Based on these studies, it is clear that when teaching individuals with IDD fire safety skills, behavioral techniques including verbal instruction, prompting, reinforcement, rehearsal, and feedback should be used. The fire safety skills research is limited by several factors. Because it is difficult to simulate a real fire in training, creating a more naturalized environment still is a limitation. Each study varied in training time, from several weeks to 1 year. More research is needed to determine which factors increase or decrease the training time. Moreover, only a few studies had long-term follow-up data. Taking the participants’ low intellectual functioning into consideration, future studies should conduct long-term follow-up assessments to determine longevity of the treatment effects.

First Aid Skills

Knowing what to do in emergency situations can prevent more serious injuries, harm, and even death. Injury rates for individuals with IDD are higher than those without disabilities due to their cognitive and behavioral deficits (Matson, 1980b). As such, an additional focus on safety skills training should be on teaching individuals with IDD to perform basic first aid.

In the same study that used classroom training to teach five adults with moderate IDD to escape a home fire, Matson (1980b) also taught the same participants how to care for of a minor cut and to properly respond to a person having a seizure. Task analysis steps for taking care of a cut included letting the cut bleed to wash out the dirt, washing the cut, putting on a bandage, and informing staff members if the cut does not get healed. Task analysis steps for taking care of a person having convulsions included catching the person if possible, lowering the person to the ground, turning the person’s head to the side, and not putting objects in the person’s mouth. The participants were taught to describe the steps and to demonstrate the behaviors by role-playing. After the classroom training only, the participants were able to describe the steps of target behaviors; however, this knowledge did not lead to correctly performing the skill. Upon receiving both role-playing and classroom training together, the participants successfully performed the first-aid skills.

Spooner, Stem, and Test (1989) replicated Matson’s study (1980b) and taught three adolescents with moderate IDD, ages, 16–17, to demonstrate first-aid skills for minor injuries and choking. The trainer led short group discussion on different types of wounds (e.g., scrapes, punctures, bites, burns), bandages (e.g., types, sizes), signs of choking, and foods that make can make people choke. Following the discussion, the trainer conducted individual training sessions using modeling, rehearsal, prompting, and reinforcement. The total training time ranged from 90 to 165 min. All target first-aid skills were acquired and maintained at 12-weeks follow-up.

These methods were later extended to teaching first aid skills to children with IDD by Marchand-Martella and Martella (1990). In their study, four children, ages 7–11, living in a behavioral residential treatment facility, were taught to perform first-aid skills. Of those four children, one child was diagnosed with IDD. The study used a first-aid training program called Mouse Calls . The program consisted of puppets, a first-aid kit, and an activity book which included task analysis steps for treating minor wounds that bleed, scrapes that stop bleeding, and minor burns from heat. First, the trainer read task analysis steps, which were described in a story format with illustrations. Then the participants performed first-aid skills using the puppets and the first-aid kit. Ketchup and/or a red mark were used to represent injuries (i.e., blood, burn) on the puppets. The participants were provided with reinforcement and corrective feedback. The participants reached the mastery criteria when they performed all steps at 100 % across four consecutive sessions. The participants acquired, generalized, and maintained the skills up to 66 weeks. This study added to existing research by successfully teaching children to demonstrate basic first-aid skills.

Marchand-Martella, Martella, Christensen, Agran, and Young (1992) also conducted a study that used peer-administered behavioral training to teach first-aid skills to children with moderate IDD. Four children, ages 7–11 years, with moderate IDD were taught to treat simulated abrasions, burns, and cuts by two peers with mild IDD. After target skills were modeled and verbally instructed, the participants practiced the skills on simulated injuries on their own and others’ bodies. Feedback and social praise were provided during the training. Overall, the participants learned to apply first aid skills, and the skills were generalized across sites and injury locations.

To evaluate the impact of a time-delay procedure on teaching first-aid skills, Gast and Winterling (1992) evaluated students with moderate IDD. The participants, ages 17–21, were taught to properly respond to a minor cut, a burn, and an insect bite. A first-aid kit containing tape, gauze pads, antiseptic, cleaning towels, tissues, cloth, plastic bag, lotion, and cotton swabs was provided; ice cubes that were used on the insect bite were located in the classroom freezer. Injuries (e.g., cuts, burns, insect bites) were simulated using costume make-up. The task analyses for first aid skills were developed and validated with the American Red Cross guidelines and professional registered nurses. Each first-aid skill was taught using a backward chain with instruction and a 5-s constant time delay procedure. A multiple probe design across participants and behaviors was used to evaluate the treatment package. Following training, all students were able to apply first-aid skills.

Most recently, Ozkan (2013) expanded upon previous research by comparing peer and self-video modeling in teaching three children with IDD, ages 9–14. Two videos were recorded for each child. In the peer-model video, the participants watched their peer apply first-aid skills, and in the self-video model, the participants watched the pre-recorded video of their performing first aid for bleeding and burns on other children. The first aid for the bleeding was 3 min, and the burns video lasted 8 min. Make-up and paint were used to illustrate simple bleeding and burns. The results of the study showed that both peer and self-modeling were effective and efficient in the acquisition and maintenance phase for teaching first aid skills to children with IDD. Of particular note, the participants who played the role of sufferers acquired both sets of first aid skills by only observing their peers.

The available studies demonstrated that behavioral techniques such as modeling, rehearsal, prompting, and reinforcement were effective in teaching first-aid skills to individuals with IDD to treat minor injuries (e.g., abrasions, burns, cuts, inset bites). In general, verbal instructions alone were not effective in generalizing the skills; role-playing and practicing the skills were especially important for the participants to acquire the first-aid skills. Studies varied in the degree to which maintenance data were collected. This is an important component of training any skill. Spooner et al. (1989) provided an example of how individuals with average cognitive functioning were encouraged to have yearly refresher courses in CPR training . Therefore, periodic check-ups and booster sessions were highly recommended in training individuals with IDD as well. In terms of role-playing and other attempts to improve generalization to real-life situations, most studies reported participants were trained to treat minor injuries on themselves or on a puppet.

Accident Prevention Skills

As noted above, persons with IDD have a much higher prevalence of injuries due to accidents. While first-aid skills are useful when an injury has occurred, the prevention of the injury altogether is obviously preferred. Previous studies on accident prevention focused on teaching simple precautionary tasks such as locking up poisons and sharp objects and proper disposal of broken materials. The available studies examining accident prevention skills used various measures such as written checklists of task analysis and instructional manuals. A few studies used reactive, behavioral intervention to teach home accident prevention skills.

O’Reilly, Green, and Braunling-McMorrow (1990) used written checklists and task analyses to teach home accident prevention skills to four adults with brain injuries, ages 18–37 years. Potential home hazards were identified and task analyses for each dangerous situation were developed. The specific task analysis described hazardous situations for different locations (e.g., kitchen, living room, bedroom, bathroom) and steps to prevent the potential accident. One of the hazardous situations in the kitchen was identified as paper napkins placed on stovetop. Behavioral steps for this particular situation were to remove the paper from stovetop and to place it in trash. The participants were instructed to read the written checklists, follow instructions, and check off each step. Feedback, praises, and prompts were used. The participants were able to appropriately remediate potential hazards using the checklist, and the acquired skills were maintained over a 1-month period.

Many studies used the delay procedure and multiple exemplars during instruction. For example, four adolescents with moderate IDD were taught to read key words from product warning labels using flash cards using a progressive time delay procedure (Collins & Stinson, 1994). Target words (e.g., caution, contamination, irritant, swallowed, vomiting), and their definitions and the contextual examples were written on white index cards. The teacher presented the flash card with the target word, and praise was given on a continuous reinforcement schedule for correctly identifying target words. Praise was eventually faded to a variable ratio schedule. In order to facilitate observational learning, training was conducted in dyads. The progressive time delay procedure was effective in teaching the students with IDD to read warning labels; however, generalization across products and settings was poor. More instructions may be needed to facilitate generalization so that students understand the meaning of the labels and have a truly functional skill. Based on previous studies, Collins, Belva, and Griffen (1996) further taught four children with moderate IDD to perform a safe, age-appropriate response to warning labels. The participants were presented with multiple exemplars of products with warning labels and were taught to demonstrate safe responses to potentially dangerous products using a constant time delay procedure. Praise was given on a continuous reinforcement schedule for correctly identifying and responding to target word and was eventually faded into a variable ratio schedule. The students were guided to demonstrate a safe motor response to a dangerous product on their daily, generalization, and maintenance sessions. The participants were taught to appropriately demonstrate both verbal and motor responses to potentially dangerous products using the constant time delay procedure and multiple exemplars. This procedure was also effective in generalizing responses to novel settings and materials.

Winterling et al. (1992) also conducted a study that taught three students with moderate IDD (17–21 years) to appropriately respond to potentially harmful situations. Specific skills taught included removing and discarding broken plates and glasses safely from a sink, countertop, and floor. The study used a multicomponent treatment package, which consisted of an orientation lecture, simulation, multiple exemplar training, and the time delay procedure to teach the target skills. A multiple probe design across participants and tasks was applied to evaluate the training. All participants learned the target skills; however, their levels of maintenance yielded mixed reports. Overall, the results showed that the treatment package was effective in teaching appropriate and safe responses to potentially dangerous situations.

When parents with IDD are not taught adequate parenting skills, their lack of knowledge and skills may result in unintentional child maltreatment (Feldman, Case, Towns, & Betel, 1985; Keltner, 1994). Because being able to recognize home hazards may prevent accidents, Tymchuck, Hamada, Anderson, and Andron (1990) taught four mothers with IDD to understand home hazards and to implement safety precautions. The mothers were trained as a group in a community facility and individually in their own home. Two assessment instruments, the Home Safety Observation Inventory (HSOI ) and the Safety Precautions Inventory (SPI ) were developed. These instruments included 14 categories: fire, electrical, suffocation by ingested objects, suffocation by mechanical objects, fire arms, solid/liquids, heavy objects, sharp objects, clutter, inedible, dangerous toys, cooking, general safety, and other. During weekly training, the mother and the trainer discussed accidents from each criteria in detail and how they could have been prevented. They developed a plan for each danger by identifying the best ways to remove the identified danger. At the end of the training, the authors found that two mothers with mild IDD could be trained to identify home dangers and to implement precautions and concluded that future research is needed to identify the mothers who need additional support given the variability in their results.

Given that some individuals with IDD could learn parenting skills to provide safe environment for their children, Feldman and Case (1999) further wanted to develop the self-instructional material for those who do not have resources to receive intensive behavioral interventions. The authors taught safe parenting skills to ten parents with mild IDD using self-instructional audiovisual manuals. The manual consists of illustrated picture books depicting 25 child care skills from birth to about 2 years of age and the checklist covering topics such as newborn care, feeding and nutrition, health and safety, and positive parent-child interactions. Each picture also has a brief text describing a task analysis of a specific skill. In addition, the participants listened to audio recordings of the manual; the instructor on the audiotape directed the listener to look at the picture and read the text. Prompting, discussion, demonstration, feedback, and reinforcement were also implemented when necessary. The results of the study showed that audiovisual self-learning was an effective and efficient method to improve safe child care skills in parents with mild IDD.

More recently, Llewellyn, McConnell, Honey, Mayes, and Russo (2003) evaluated a home-based intervention to teach child health and home domestic safety skills to parents with IDD. The authors used instructional lessons to teach child health and domestic safety skills to 45 parents with IDD. Home Learning Program (HLP) , which was designed to help parents learn the skills to safely manage home dangers and accidents, was delivered by a trained educator during weekly visits to the participant’s homes. The HLP consisted of ten sessions, each lasting about 1 h. During each session, the educator went over the illustrated booklet, covering lessons such as identifying and properly responding when a child is injured and preventing potential home hazards. All participants received the HLP but depending on which group they were placed in, it determined when they received the HLP and what other conditions that would participate in. The findings showed that parents’ ability to recognize home dangers significantly improved and the gains were maintained at 3 months post-intervention. Also, the participants’ knowledge of health and symptoms of illness and life-threatening emergencies managing skills increased.

Overall, existing research on accident prevention demonstrated that skills to identify potential dangers and safely respond to hazardous situations could successfully be taught in individuals with IDD. The studies focused on teaching accident prevention skills (e.g., reading warning labels, identifying dangerous situations, performing safe responses) using written checklists, instructional manual, and behavioral techniques. The results of the reviewed studies showed clear evidence that simply teaching to identify what is dangerous was effective in increasing the participants’ safety knowledge, which could potentially save lives by preventing serious accidents. Most of the studies taught skills that were relevant in the home environment; future studies should target generalizing these skills to other environments such as workplace, school, and community settings.

Fall-Related Prevention Skills

Individuals with IDD are at an increased risk for physical injury caused by falling (Hale, Bray, & Littmann, 2007; Tannenbaum, Lipworth, & Baker, 1989). Falling may result in serious consequences, as it may cause individuals to be institutionalized and decrease physical activity (Bruckner & Herge, 2003). In addition, falling may result in higher health care costs, increased fear of falls, and decreased quality of life (Bruckner & Herge, 2003). While research in fall prevention in the older adult population has been widely examined, there is a general lack of studies investigating fall prevention in the IDD population. Currently, there are a few epidemiological studies investigating fall incidence and risk factors in individuals with IDD; however, studies teaching skills to prevent potential falls are limited.

In the review by Willgoss, Yohannes, and Mitchell (2010), the authors examined risk factors and preventatives strategies in the IDD population. Seven studies met the inclusion criteria using search terms: “intellectual disability,” “falls,” “injury,” “fractures,” “risk factors,” and “prevention.” Four studies were epidemiological; from these studies, the authors concluded that up to 57 % of individuals with IDD have previously experienced a fall, which caused approximately 50–62 % of recorded injuries. Risk factors for falls included older age, decreased mobility, other comorbid conditions and challenging problems. However, no intervention studies teaching preventative skills were identified in this review. The authors suggested that a multidisciplinary approach, addressing environmental hazards, and exercise interventions are needed, and more research is warranted to develop effective strategies for fall prevention.

Carmeli, Merrick, and Berner (2004) conducted an exercise intervention that examined the balance capability in 27 adults with mild IDD, age 55–77 years, living in a foster home. The participants were divided into two groups. One group received balance exercise training, and the other received muscle strength training. The balance training program included warming-up movements, large body movements in sitting and standing positions (i.e., toe-to-heel walk on straight and rounded lines, side walking), dancing, rolling a ball, pushing, pulling, lifting, catching, and throwing. Balls, balloons, bands, sticks, and scarves were used in the program. The muscle strength program consisted of warming-up movements, weight lifting, and repetitive exercises that focused on extension and flexion movements of different body parts. Both programs lasted for 6 months. The results showed that the participants who underwent the balance exercise program had significantly more improvement in balance, social function, and quality of life. Therefore, the authors concluded that balancing, which is a key aspect of gait, may help to reduce falls in people with IDD.

Despite the fact that there is a high incidence of falling accidents in individuals with IDD, no research was conducted in teaching fall-prevention strategies in the IDD population. One study (i.e., Carmeli et al., 2004) focused on improving balance in individuals with IDD to reduce injuries by strengthening their physical health. In addition to exercise interventions, studies teaching skills to identify and address environmental hazards that may cause falls should be conducted. Given that other behavioral strategies were effective in teaching other safety skills in this population, future studies should incorporate such strategies in teaching fall-prevention skills .

Pedestrian Skills

Previous literature for teaching pedestrian skills to individuals with IDD is well established. Pedestrian skills include identifying traffic signals and signs, using sidewalks, and safely responding to traffic-related signs. The following studies used task analysis, most-to-least prompting, and progressive time delay procedures in simulated and in vivo settings. Some studies used simulated instruction to teach pedestrian skills.

One of the earliest study teaching pedestrian skills to individuals with IDD was conducted by Page, Iwata, and Neef (1976). They taught pedestrian skills to five individuals with IDD, ages 16–25 years, using the classroom model . The authors reported that the classroom intervention provided fewer environmental problems than training at community streets. The environmental factors included inclement weather conditions, additional time and staff, inherent dangers of the community streets. A simulated model using the poster board was constructed, and street, houses, cars, trees, and people were drawn or glued to the board. Target skills included recognizing intersection and pedestrian lights and properly crossing the street with pedestrian signals, tricolored traffic signals, stop signs, and no signals. One-on-one training was conducted in a classroom. First, the trainer gave instructions and the participants performed the target skills using a model city and a figure. The participants explained their behaviors as they performed them. Praise, feedback, modeling were provided as necessary. The training was evaluated using a multiple baseline design across participants and behaviors. All participants learned the pedestrian skills, and the skills generalized to the actual street. The acquired skills were maintained at 2–6 week follow-up.

Matson (1980a) also taught pedestrian skills to 30 adults with moderate to severe IDD, ages 21–55 years, using the classroom training. He compared the effectiveness of classroom training versus independence training . Target behaviors included proper sidewalk behavior, recognition of an intersection, and crossing the street. Task analyses steps for each target were developed. The participants were divided into three groups: classroom training, independence training, and control group. The classroom training used a model intersection and figurine. Shaping, social reinforcement, instructions, and various prompts were used in the training. The independence training included an additional training component that emphasized self-evaluation of performance, provided more information, and encouraged more involvement. In addition to using the model intersection and figurine that were used in the classroom training, cardboard traffic signs, feedback and evaluations were provided at the end of each training session for the independence training. While both classroom and independence training were effective in teaching pedestrian skills, the independence training was significantly more effective than the classroom training.

Following the early studies, Horner, Jones, and Williams (1985) taught pedestrian skills to three individuals with moderate to severe IDD, ages 12–53 years, using community streets . One-to-one training was conducted using multiple community cross streets including one-way, two-way streets with traffic signals, stop signs, and no traffic signals. The trainer instructed the participants to cross the street and stood behind the participant and provided verbal and physical prompts when necessary. Social praises were given upon correct crosses. The trainer slowly faded prompting, reinforcement, and feedback. The training was evaluated using a multiple baseline design across participants. Two participants showed significant improvement in their street crossing skills and generalized their skills to novel streets.

Some studies used both classroom simulation and community-based interventions to teach pedestrian skills. For example, Marchetti, McCartney, Drain, Hooper, and Dix (1983) taught pedestrian skills to 18 adults with IDD, ages 19–59 years. The authors compared the training administered in classroom or community. Target skills included crossing at an intersection with no signs or traffic lights, crossing with a stop sign with cars moving in the same direction as the pedestrian, crossing with a stop sign with cars crossing the path of the pedestrian, crossing with a pedestrian lights, and crossing with a single and multiple traffic lights. The participants were placed in either the classroom group or the community group. The classroom training used a model city and doll, and the participants rehearsed the target skills. The participants in the community training performed the skills in natural settings. Both training techniques were conducted in groups. Prompting and social reinforcement were implemented and were gradually faded. The results of the study favored the community training, demonstrating that participants in the community training showed significant improvement in pedestrian skills while no significant changes were noted in the participants who received the classroom training.

In a further evaluation of the effectiveness of in vivo instruction, Collins, Stinson, and Land (1993) compared teaching with and without a preliminary simulation component in teaching eight students with moderate IDD, ages 15–19 years, to cross streets. The in vivo training was conducted in natural settings. The task analyses for street crossing were developed, and the participants practiced the target skills with a delayed prompting procedure. The simulation training session was conducted in the participants’ classroom; the teacher simulated a street using two parallel strips. A multiple probe design across participants was used to evaluate the training methods. The results showed that both training procedures were found to be effective in teaching street crossing skills, and the authors also found that teaching first in simulation did not have an effect on instructions within the community.

Branham, Collins, Schuster, and Kleinert (1999) taught three secondary students with moderate IDD, ages 14–20 years, community skills including safe street skills. The classroom simulation was conducted using a masking tape to simulate the edge of the streets, and peers served as approaching cars. Videotaping modeling instruction consisted of a videotape of a peer crossing a street. A constant time-delay procedure was used with three instructional formats: videotape modeling plus community-based intervention, classroom simulation plus community-based intervention, and videotape modeling plus classroom simulation plus community-based intervention. The results showed that all instructional formats were effective in teaching target skills and demonstrated generalization to novel settings. Efficiency data showed that classroom simulation plus community-based instruction was the most efficient format.

In a recent study, Kelley, Test, and Cooke (2013) extended upon previous studies by teaching the participants to navigate back to starting locations with a focus on independent travel. The authors investigated the effects of using picture prompts displayed through a video iPod on pedestrian navigation with four young adults with IDD, ages 19–26 years. Correct and independent travel of a route to and from specified locations and the percentage of correct pictured landmarks reached for each route were measured. A multiple probe design across participants and behaviors was used to evaluate the treatment. The participants were given a video iPod with pictured landmarks and were instructed to use the pictures to guide them to get to a location and back to the starting place. Prompts were provided upon requests or if they navigated off the route for more than 30 s. Results of the study indicated a functional relation between the picture prompts displayed on the video iPod and pedestrian navigation skills for all four participants. All four participants became confident and did not rely on the video iPod much, by the second or third walk with each route. The iPod then started to serve as a backup if they forgot a turn or one of the featured landmarks. This indicated the iPod was used as a prompting device.

In summary, early pedestrian studies used classroom training with simulated environment (Matson, 1980a; Page et al., 1976). More studies in the 1980s and 1990s incorporated more naturalized settings to teach safe, street crossing skills to individuals with IDD (Branham et al., 1999; Collins et al., 1993; Horner et al., 1985; Marchetti et al., 1983). Some studies showed mixed results in comparing the classroom and community training (Branham et al., 1999; Marchetti et al., 1983). Overall, existing research demonstrated that individuals with IDD effectively learned basic pedestrian skills using behavior techniques including reinforcement, modeling, prompting, and feedback.

Self-Protective Skills

Sexual Abuse Prevention

Individuals with IDD are more vulnerable to exploitation due to their disabilities, lack of social skills, and poor judgment skills (Chamberlain, Rauh, Passer, McGrath, & Burket, 1984; McCabe, Cummins, & Reid; 1994; Sobsey, 1994). Chamberlain et al. (1984) revealed that among 87 female patients with IDD who attended an adolescent health clinic, 25 % had a known history of sexual assault. Hard (1986) also found that among their 95 adult participants with IDD, 83 % of women and 32 % of men reported being victims of sexual abuse. The incidence of sexual exploitation among individuals with IDD is higher than those without disabilities (Horner-Johnson & Drum, 2006; McCabe & Cummins, 1996; Sobsey & Mansell, 1994). According to one study, women with IDD have twice the risk of sexual abuse than women without disabilities (Sobsey & Mansell, 1994). Children with disabilities are 3.4 times more likely to experience maltreatment (including sexual abuse) than those without disabilities (Sullivan & Knutson, 2000). Therefore, it is crucial to teach those with intellectual disabilities skills to help protect themselves from these predators.

Over the past 30 years, only a few researchers have evaluated methods to teach self-protective skills to individuals with IDD. In 1984, Foxx and his colleagues used a training program to teach social/sexual behaviors to six female residents with mild and moderate IDD (Foxx, McMorrow, Storey, & Rogers, 1984). The target behaviors involved verbal action or reaction to sexually related situations, and the participants were taught using a card game called ‘Sorry.’ The program trained the participants to differentiate between public and private sexual behavior and to safely and appropriately respond to boyfriends, acquaintances, or strangers. Positive and negative feedback, self-monitoring, reinforcements, and individualized performance criterion levels were used. The results showed that the participants’ appropriate social responses to the social/sexual skills program improved and generalized to untrained situations.

Later, Haseltine and Miltenberger (1990) taught self-protection skills to eight adults with mild IDD. The training curriculum covered topics such as the concepts of private body parts, good and bad touch, and safety skills (i.e., say no, get away, and tell). Instructions, modeling, rehearsal, feedback, and praise were used to teach skills to safely respond to potential abduction and sexual abuse situations across nine 25–30 min sessions. Most participants successfully learned self-protection skills and maintained them at a 6-month follow-up.

Most recently, Egemo-Helm et al. (2007) evaluated the effectiveness of a combined program to teach sexual abuse prevention skills to women with IDD. The researchers combined behavior skills training (BST) and in situ training to improve upon generalization to real-life situations. The participants in the study were seven women with mild to moderate IDD, ages 26–47 years. The training and assessment sessions were conducted in either the group home or the apartment where each women lived, respectively. The target behavior was the reaction exhibited by the participant when a research confederate posing as a staff member initiated a lure for sexual abuse. A scoring system was put in place and one point was given for each of the following reactions: (a) did not comply/engage in the behavior requested; (b) verbally refused; (c) left the situation or asked the staff member to leave; and (d) reported the incident to a safe staff member. The participants received a maximum score of 4 points if they exhibited all the behaviors listed above, and they received a score of 0 if they complied with the request of the staff member. The participants were taught sexual abuse prevention skills using self-report (i.e., participants were asked how they would respond to a particular scenario) and role-play (i.e., where the trainer acted as the abuser and the participant asked to react). The other strategy used was in situ training using a research assistant unknown to the participant. In this scenario, the participant was not told in advance that they were being assessed. A mastery criterion for the in situ training was a score of 4 for three consecutive in situ assessments. Two of the seven participants terminated their participation during baseline and early training. For the remaining five participants, three required between 1 and 2 in situ training sessions; one of them required 12 in situ training sessions and an additional three booster sessions; one of them quit the study after 2 in situ sessions. The results indicated that the safety skills were generalized to the natural environment. At the 1-month follow-up, three of the four participants performed at criterion and at 3 months, two of the participants performed at criterion. While these results are promising, the number of early withdrawals from the study is concerning and may indicate that the training method is not appropriate for all individuals with IDD.

Lures of Strangers

In addition to sexual exploitation, abduction is another problem that may result in serious consequences. Early research demonstrated that typically developing children were able to learn skills to avoid abduction (Miltenberger & Thiesse-Duffy, 1988; Poche, Yoder, & Miltenberger, 1988). Given that individuals with IDD are at higher risk of being victims of such abuse, it is imperative to teach similar skills to children with IDD. Watson, Bain, and Houghton (1992) taught self-protective skills to seven children with moderate and severe IDD, ages 6–8. Three target behaviors included to firmly say/sign/gesture ‘no’ toward the stranger who made an inappropriate request, to ‘go’ by leaving the stranger and the scene within 15 s of the interaction, and to ‘tell’ by reporting the interaction to a known, safe adult. The participants were taught across 15 sessions to describe and identify a stranger using questions, guided discussion, pictures of known/unknown people, and role-playing. Six participants showed improvement in self-protective skills against the strangers, and a 14-day follow-up showed maintenance of the taught skills.

Peer Pressure

Collins, Hall, Rankin, and Branson (1999) described a program, called “Just say ‘no’ and walk away,” that taught students with IDD to resist peer pressure (i.e., behaviors or persons that are harmful to one’s health and achievement). The instructor defined inappropriate behaviors and discussed consequences of these behaviors. Then the correct responses to these inappropriate behaviors were modeled and role-playing was implemented to practice the correct responses. Daily probe sessions using a confederate were conducted, and instructional sessions were provided following incorrect responses. The results showed that teaching peer pressure resistance to individuals with IDD was effective.

As previously discussed, individuals with IDD are more prone to be victims of abuse; therefore, it is critical to teach self-protective skills to prevent sexual abuse and resist lures of strangers and peer pressure to individuals with IDD. Available research showed that such protective skills can be taught to individuals with IDD using feedback, self-monitoring, reinforcements, and role-play. In situ training and assessment should be used while evaluating the self-protective skills to promote generalization; however, in situ assessments should be used with caution because it may cause distress and/or trauma for the participants.

Emergency Telephone Skills

Making emergency telephone calls is an important safety skill to obtain assistance in case of an emergency. The following studies taught children, adolescents, and adults with ID of varying levels to make emergency telephone calls in various scenarios. Smith and Meyers (1979) taught 60 adults with moderate to profound IDD telephone skills. The participants were placed in one of six experimental groups: (1) individual modeling and verbal instruction; (2) group modeling and verbal instruction; (3) individual modeling only; (4) group modeling only; (5) Individual control group and (6) group control groups. All participants improved on the telephone skills; they learned to pick up the telephone, dial, accurately report the fire and relevant information, and correctly request to see the doctor.

Extending from previous research that taught skills such as dialing the correct number and making emergency calls, Risley and Cuvo (1980) focused on more advanced telephone skills such as deciding whom to call (i.e., fire, police, doctor). The authors trained three adults, ages 26–52 years, with IDD to make emergency phone calls. The participants were taught to decide whom to call, locate the telephone number in the directory, dial the number, and answer questions by the operator. Successive levels of prompting (e.g., verbal, modeling, physical) were implemented during the training. Praise was provided after a correct response with and without prompts, and the feedback was given after each training trial. All three participants acquired the skills, and the target skills were generalized across different people and settings and maintained at 1 and 2 weeks follow-up.

Spooner et al. (1989) taught three adolescents with IDD, ages 16–17 years, to use home telephones to call 911 and explain different types of emergency situations (e.g., fire, poison, falls, shock). The training procedure included modeling, rehearsal, prompting, and reinforcement. All participants learned to communicate an emergency rapidly, and the skills were maintained at 6 and 12 weeks follow-up.

Collins et al. (1993) compared the effectiveness of in vivo instruction with and without a preliminary simulation component in teaching eight students with moderate IDD, ages 15–19 years, to operate a payphone. The in vivo training was conducted in natural settings (e.g., entry street to the high school, public pay telephones). The task analyses for telephone use were developed, and the participants practiced the target skills with a delayed prompting procedure. The simulation training session was conducted in the participants’ classroom; the teacher simulated a street using two parallel strips and placed a disconnected telephone and an empty cardboard box. A multiple probe design across participants was used to evaluate the training methods. The results showed that both training procedures were found to be effective in teaching telephone skills.

Taras, Matson, and Felps (1993) taught three children with visual impairments (two of whom had borderline to mild IDD) to make an emergency telephone call. Group training was conducted; remaining participants listened while the selected participant performed the task. Verbal instructions and physical prompting were used using the least to most intrusive prompting. Once the participants completed the steps, they were asked to self-evaluate their performance and provide explanation. Then, feedback and positive reinforcement were provided by the trainer, and their peers who listened to their peer perform the task. Furthermore, all participants received edibles for attending the session regardless of their performance in order to maintain motivation. Different emergency situations, reporting addresses, and types of telephone were incorporated to increase generalization. All children successfully completed the task analysis of calling 911, and their skills were maintained at 10-months post-treatment.

Recently, Ozkan, Oncul, and Kaya (2013) conducted a study to evaluate the effectiveness of computer-based instruction (CBI) to teach emergency telephone skills to students with IDD. This study focused on teaching children which emergency service to call in a specific situation. Five students, ages 8–13 years, were taught to identify the correct emergency service to call in a specific situation and the number to call. The CBI consisted of audiovisual presentation of animated scenarios along with verbal instructions on a computer screen. Each scenario was linked to a different service and the corresponding number to call for that specific service. Clapping animation and verbal praise were provided at the end of the program. The results of the study proved CBIs to be an effective technique. However, different numbers of sessions were needed by different participants in order to reach criteria. The number of sessions required in order for the participants to know which emergency service to call after seeing a scenario, ranged from 14 sessions to 29 sessions. The number of sessions required for associating the correct number with the right service ranged from 21 to 46. The target skills were maintained at 4, 8 and 12 weeks after training and were generalized to different responses.

Existing research indicates individuals with IDD were able to learn to dial emergency telephone numbers, give relevant information, and identify which emergency services to call (Collins et al., 1993; Ozkan et al., 2013; Risley & Cuvo, 1980; Smith & Meyers, 1979; Spooner et al., 1989; Taras et al., 1993). Most commonly used behavior techniques include instruction, reinforcement, modeling, and prompting. While the skills were maintained after the training, it is not yet known if the skills would be generalized in real emergency situations. Future studies need to incorporate in situ training without informing the participants that they are being assessed. Moreover, most telephone skills research was conducted several decades ago. Since then, telephone has evolved immensely; pay phones are difficult to find and traditional landline telephone usage has decreased as the use of cell phone is continuously increasing. This change may affect the older population who may not be familiarized with newer cellphones (i.e., different designs, smaller sizes, touch screen). More studies are warranted to accommodate to this change .

Translation of Research to Practice

Teaching safety skills to individuals with IDD has been extensively investigated over the last 30 years; previous studies examined a variety of methods to teach safety skills to individuals with IDD of different age groups and different levels of functioning. Results of the reviewed studies in the current chapter showed that individuals with IDD were successful at identifying harmful situations and implementing safety skills to prevent potential emergencies.

Research showed that education-based training is effective for teaching the individual to verbalize the skills; individuals with or without IDD were successful at exhibiting knowledge of safety skills after receiving education-based training (Feldman & Case, 1999; Gatheridge et al., 2004; Llewellyn et al., 2003; Matson, 1980b). However, this does not necessarily mean that they can successfully execute the skills in actual dangerous situations. In fact, many studies showed that those who received instructional procedures only were not able to demonstrate the safety skills very well (Gatheridge et al., 2004; Himle & Miltenberger, 2004). Researchers found behavioral skills trainings that incorporated behavioral approaches such as modeling, prompting, role-playing, and feedback to be more effective for teaching the desired safety skills. Typically developing children successfully demonstrated safety skills upon completion of behavioral skills trainings (Bevill & Gast, 1998; Gatheridge et al., 2004; Himle & Miltenberger, 2004). Furthermore, individuals with IDD who received behavioral skills training were also able to perform safety skills including teaching fire safety skills (e.g., Bannerman et al., 1991; Cohen, 1984; Haney & Jones, 1982; Jones & Thornton, 1987; Katz & Singh, 1986; Luiselli, 1984; Rowe & Kedesdy, 1988), first aid skills (e.g., Gast & Winterling, 1992; Marchand-Martella et al., 1992; Marchand-Martella & Martella, 1990; Spooner et al., 1989), accident prevention skills (e.g., Collins et al., 1996; O’Reilly et al., 1990; Tymchuck et al., 1990; Winterling et al., 1992), pedestrian skills (e.g., Branham et al., 1999; Collins et al., 1993; Horner et al., 1985; Kelley et al., 2013; Marchetti et al., 1983; Page et al., 1976), self-protective skills against crime (e.g., Collins et al., 1999; Egemo-Helm et al., 2007; Foxx et al., 1984; Haseltine & Miltenberger, 1990) and emergency telephone skills (e.g., Risley & Cuvo, 1980; Taras et al., 1993).

One common limitation of many of these studies is a lack of generalization; skills that were taught through behavioral training may not always generalize to the natural environments. It is important to incorporate stimuli that are common in the natural environments. More specifically, in response to fire safety skills, future studies should consider using more generalized stimuli such as real, contained fires, smoke, and heat to better simulate a real fire emergency situation. Additionally, training during nighttime (Knudson et al., 2009) and learning to use a fire extinguisher (Mechling, 2008) should also be considered. Prevention skills such as abduction prevention skills, pedestrian skills, and fall prevention skills should be conducted in the generalized setting (e.g., school, outside, road, playground).

During in situ training, a simulated safety threat is presented in natural environments without informing the individual to determine if the individual will perform the safety skills without being prompted or cued. Previous studies showed that although behavioral skills training was effective in acquiring the skills, the behavioral training itself was not sufficient to produce consistent safety responses as children often failed to demonstrate safety skills during an in situ assessment. The use of in situ training significantly enhanced generalization of safety skills (Gatheridge et al., 2004; Himle & Miltenberger, 2004). Therefore, in situ assessments should be conducted following behavioral training to ensure that the skills can be generalized to more naturalistic conditions (Miltenberger, 2008).

Moreover, maintaining safety skills over an extended period of time is as important as acquiring the skills. Unfortunately, results of the reviewed studies yielded mixed reports of maintenance of the skills. Therefore, conducting in situ assessments at periodic intervals is recommended (Miltenberger, 2008). If the individual fails to demonstrate safety skills at periodic intervals, follow-up training is warranted.

The current chapter’s literature review shows that research on teaching skills to individuals with IDD is well established; however, it is interesting to note that most research in this area was conducted in the 1980s and 1990s. Only a few studies have been conducted in the early 2000s (Carmeli et al., 2004; Egemo-Helm et al., 2007; Llewellyn et al., 2003). Over the last 30 years, technology has been rapidly changing and advancing. With this advancement, the use of assistive technology devices has increased as well. Mechling (2008) suggests that with such advancements, safety skills research should be revisited as it closely relates to innovative technologies. Interestingly, the most recent studies on safety skills have all used devices such as speech-generating device, an IPod, videos, and a computer to teach safety skills (Davis et al., 2013; Kelley et al., 2013; Ozkan, 2013; Ozkan et al., 2013), and results of these studies that incorporated technology into their training are promising. Technological innovations may expand training opportunities, especially in dangerous and unethical situations that are difficult to present the actual safety threat (Dixon, Bergstrom, Smith, & Tarbox, 2010). For example, being able to track and locate persons and their locations using wireless communication and alert devices (Mechling, 2008) may expand procedural options. Virtual environments that closely mimic the natural environment may also tremendously help to expand generalization of safety skills.

In summary, existing research in safety skills showed promising results in teaching appropriate safety skills to individuals with IDD. Future researchers should focus on generalizing and maintaining safety skills, as they remain main issues in teaching safety skills in individuals with IDD. Combination of behavioral techniques and technology may provide more realistic and creative training in teaching safety skills. Therefore, future researchers are recommended to use behavioral techniques that are already proven to be effective and incorporate new technology and innovations.