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 adults 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, Board Games, 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 older 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:


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