Sunday, December 8, 2013

Older Clients & Naturalistic Teaching





Most ABA therapists (myself included) start out in this field doing intensive skill acquisition with young children, using DTT methodology. I love DTT because it is so structured, and it is a way to boil teaching down to its most simple state. 1:1 DTT at a worktable has minimal distractions, is instructor led, and teaches broken down skills in high repetition. Many of the reasons I like DTT are the same reasons why it often isn’t appropriate for older or higher functioning clients, as one of my higher functioning kiddos used to demonstrate when he would say “You already asked me that” :-) .
Older/ higher functioning kiddos can require a bit of a different teaching approach in an ABA session, and may become bored if traditional DTT is used.

I have talked about ABA with older kids on my blog before in a general sense, but I haven't worked with many older kiddos. My preference and most of my experience has been in an early intervention capacity (under 5). However, there are some really cool aspects to working with higher functioning and older clients. I remember the first adult I ever worked with, he would stand in his front yard every Tuesday (I saw him on Tuesdays) and wait to see my car turn down his street. As soon as he saw my car, he would begin to smile and vigorously wave. That was a really new experience for me, to have a client be that excited for me to arrive! He was a sweetheart, and I learned a lot from working with him.

When working with an older client, or a client who is higher functioning, instead of DTT a more naturalistic methodology is typically used. This can include the use of task analyses, intrinsic reinforcement, written schedules, community based instruction, and functional living skills, aka daily living skills. Here is an example of how I might structure a session with an older client:

Independent Work, Chores, Community Instruction, Sensory Activity, Play Date, Hygiene/Personal Care, Self-Help Skills, & Homework


I might start the session by creating the schedule of what we will do that day. Particularly for higher functioning clients, I let them give a lot of input on what we will do. There are certain things we must do (the programs), things the parents want done, and then client choice. If the client can read, we can write out the schedule together. If not, then a visual schedule is fine. Reinforcement is embedded by alternating between preferred and non-preferred tasks, such as completing homework before we go on a community outing.

Functional or daily living skills, such as completing chores, bathing, grooming, or meal preparation, are interspersed throughout each session. This will vary from client to client depending on what is important to the family. For example, a 10 year old who cannot independently take a shower. Or a 22 year old who cannot independently answer the phone and take a message. Programs can be written for those skills and they can be taught using a combination of ABA strategies, such as chaining and visual modeling.
With older clients, I am more of a facilitator and less of a “teacher”. I help the individual work through their daily schedule of activities, being sure to provide the least amount of prompting necessary. I find the biggest issue I have to tackle right away with older clients is explaining to the family that they are prompting way too much.  Independence is key. So if the client can wash hands, but only if mom or dad keep the soap locked up (because the client uses way too much), then I will quickly select using 1 pump of soap as a goal. True independence can’t be obtained if the individual needs someone else present to get the soap for them.

A community outing with an older client would gradually increase in complexity and difficulty, from being able to be appropriate in a store, to placing preferred items in the cart, to placing both preferred and non- preferred items in the cart, to participating in checkout, until we can enter a store and I can silently follow behind my client as they independently shop and checkout. Again, independence is key. That means I am not holding my clients hand, they carry their own money, and they create and carry their own grocery list.
 A better way to explain a big difference when using naturalistic teaching, is that the client is more in control of the session. I don’t walk into the grocery store and say “Go here….do this……put that in the cart, etc”. I let the client determine the store, what we will buy, etc., and I am there as a facilitator to make sure they have the supports they need. Those supports may include visuals, prompting, timers, modeling, transition cues, etc.

Here is another look at a sample session breakdown, with a bit more detail:

Homework Completion: Must complete 3 problems independently before using a “help card”
Independent Work: Task Completion  program
Sensory Activity: Play Wii baseball game together
Chores: Laundry, Pick out clothes to wear next day, Ironing
Community Instruction: Create grocery list, count out money needed, go to store
Sensory Activity: Painting to music, Yoga stretches, 15 minute walk around neighborhood
Social Interaction: Play Apples to Apples board game, Play Uno 
Hygiene/Personal Care: Shower, Shave face, Cut/trim nails
Sensory Activity: 20 minutes with Sensory Box
Self-Help Skills: Prepare dinner using a visual recipe, Set table, Serve meal
Chore Completion: Clear table, Wash dishes


Here are some resources for naturalistic teaching with older or higher functioning clients:




 


8 comments:

  1. Thanks for a very informative post! I have a question - is naturalistic teaching part of ABA? I don't understand how, because I'm not sure if any behavioral techniques are being used, as in DTT? Sorry, I'm a bit ignorant on the subject!

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    1. Hi there!

      ABA is a broad science, that includes many different strategies and techniques. DTT is just one technique, and naturalistic teaching can be another. To give you an example, with my older clients I may use ABA strategies such as reinforcement, token economies, data based decision making, 3 step prompting, task analyses, video modeling, etc.

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    2. Ok, thanks so much for the reply!

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  2. Great blog. Recognizable! Our daycare centre uses the combination of ABA/DTT and NET. It's a great mix of activities either inside or outside the building. A mix between gameplay, tablework, leisure and teaching functional skills like shopping and cooking. All with daily changing activity schedules.

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    1. Hi Michel! :-)

      I agree that quality intervention programs should have a mix of "tablework" (DTT), along with instruction embedded into naturally occurring activities, such as teaching self -help skills by having the kids at the center prepare their own lunch, vs having staff hand them their lunch. I want to open a center one day, and the way your center operates sounds great to me.
      We seem to think alike!

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  3. I started with DTT at my prior agency. At current agency, we work a lot with NET and I'm having trouble adjusting. I find it to be more of a moving target in which variables can disrupt session. My kiddo is hard to motivate, he is primarily motivated by electronics which he subsequently becomes satiated on. Managing my materials throughout session is harder too. Since he is older I am constantly carrying around my program book, pen, white board and toys for him as we move about the house and backyard. Some of the BST's who trained me made it look so smooth. I have an overlap with a supervisor today and felt like to her everything I did probably looked disorganized and chaotic. I'm also having trouble managing kiddo's frustration in the NET setting. I can't simply bring him back to table, I have to lure him with reinforcers he is frequently satiated on. The programs are also vastly different. In one program I am providing visual cues, via pictures I draw and also textual cue, giving him some of the words needed to describe the scenario I drew. When transitioning kiddo from play time or break time to a program task I feel clumsy and slow. He knows what's going on and that we aren't just playing. I just needed to vent.

    Thanks, Seachelle.

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    1. Hi Seachelle,

      Venting is often necessary, so I definitely understand!

      I was the same way when I first started learning about naturalistic teaching vs DTT (which is the first thing I learned as a brand new therapist). Your supervisor should be able to help you capture motivation, contrive/modify the environment to keep that motivation going, modify the data so its easier to collect on the go, etc.
      I didn't know how simple naturalistic teaching could be when it was first taught to me, so I really hope your supervisor helps you become a fan of it too! It can really be pretty fun.

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