The document discusses the biomedical model of medicine and its key assumptions. It explains that the biomedical model views illness as caused by biological factors outside an individual's control. Treatment aims to change the physical body, and the medical profession is responsible for treatment. It also discusses how behavioral health and health psychology challenged some of these assumptions, viewing illness as influenced by both biological and psychological factors, with individuals playing a role in both causes and treatment of illness.

1. .
Occupational Therapy and Reinforcement (part 1)

2. What is the biomedical model?
The biomedical model of medicine can be understood in terms of
its answers to the following questions:
■ What causes illness? According to the biomedical model of
medicine, diseases either come from outside the body, invade the
body and cause physical changes within the body, or
originate as internal involuntary physical changes. Such diseases
may be caused by several factors such as chemical imbalances,
bacteria, viruses and genetic predisposition.
■ Who is responsible for illness? Because illness is seen as arising
from biological changes beyond their control, individuals are not
seen as responsible for their illness. They are regarded as victims
of some external force causing internal changes.

3. What is the biomedical model?
■ How should illness be treated? The biomedical model regards
treatment in terms of vaccination, surgery, chemotherapy and
radiotherapy, all of which aim to change the physical state
of the body.
■ Who is responsible for treatment? The responsibility for
treatment rests with the medical profession.
■ What is the relationship between health and illness? Within the
biomedical model, health and illness are seen as qualitatively
different – you are either healthy or ill, there is no continuum
between the two.

4. What is the biomedical model?
■ What is the relationship between the mind and the body?
According to the biomedical model of medicine, the mind and
body function independently of each other. This is comparable
to a traditional dualistic model of the mind–body split. From this
perspective, the mind is incapable of influencing physical matter
and the mind and body are defined as separate entities.
The mind is seen as abstract and relating to feelings and thoughts,
and the body is seen in terms of physical matter such as skin,
muscles, bones, brain and organs. Changes in the physical matter
are regarded as independent of changes in state of mind.

5. What is the biomedical model?
■ What is the role of psychology in health and illness? Within
traditional biomedicine, illness may have psychological
consequences, but not psychological causes.
For example, cancer may cause unhappiness but mood is not seen
as related to either the onset or progression of the cancer.

6. Behavioral health
Behavioral health again challenged the biomedical assumptions of
a separation of mind and body.
Behavioral health was described as being concerned with the
maintenance of health and prevention of illness in currently
healthy individuals through the use of educational inputs to
change behavior and lifestyle.
The role of behavior in determining the individual’s health
status indicates an integration of the mind and body.

7. ■ What causes illness? Health psychology suggests that human
beings should be seen as complex systems and that illness is
caused by a multitude of factors and not by a single causal factor.
Health psychology therefore attempts to move away from a simple
linear model of health and claims that illness can be caused by a
combination of biological (e.g. a virus), psychological (e.g.
behaviors, beliefs) and social (e.g. employment) factors. This
approach reflects the biopsychosocial model of health and illness

8. ■ Who is responsible for illness? Because illness is regarded as a
result of a combination of factors, the individual is no longer
simply seen as a passive victim. For example, the recognition
of a role for behavior in the cause of illness means that the
individual may be held responsible for their health and illness.
■ How should illness be treated? According to health psychology,
the whole person should be treated, not just the physical changes
that have taken place. This can take the form of behavior change,
encouraging changes in beliefs and coping strategies and
compliance with medical recommendations.

9. Who is responsible for treatment? Because the whole person is
treated, not just their physical illness, the patient is therefore in
part responsible for their treatment. This may take the form of
responsibility to take medication, responsibility to change beliefs
and behavior. They are not seen as a victim.
■ What is the relationship between health and illness? From this
perspective, health and illness are not qualitatively different, but
exist on a continuum. Rather than being either healthy or ill,
individuals progress along this continuum from healthiness to
illness and back again.

10. What is the relationship between the mind and body? The
twentieth century has seen a challenge to the traditional
separation of mind and body suggested by a dualistic model of
health and illness, with an increasing focus on an interaction
between the mind and the body. This shift in perspective is
reflected in the development of a holistic or a whole person
approach to health.
Health psychology therefore maintains that the mind and body
interact. However, although this represents a departure from the
traditional medical perspective, in that these two entities are seen
as influencing each other, they are still categorized as separate –
the existence of two different terms (the mind/the body) suggests a
degree of separation and ‘interaction’ can only occur between
distinct structures.

11. Health psychology aims to understand, explain, develop and test theory by:
A) Evaluating the role of behavior in the aetiology of illness. For example:
- Coronary heart disease is related to behaviors such as smoking,
food intake and lack of exercise.
- Many cancers are related to behaviors such as diet, smoking,
alcohol and failure to attend for screening or health check-ups.
- A stroke is related to smoking, cholesterol and high blood
pressure.
- An often overlooked cause of death is accidents. These may be
related to alcohol consumption, drugs and careless driving.

12. B) Predicting unhealthy behaviors. For example:
- Smoking, alcohol consumption and high fat diets are related to
beliefs.
- Beliefs about health and illness can be used to predict behavior.
C) Evaluating the interaction between psychology and physiology.
For example:
- The experience of stress relates to appraisal, coping and social
support.
- Stress leads to physiological changes which can trigger or
exacerbate illness.
- Pain perception can be exacerbated by anxiety and reduced by
distraction.

13. D) Understanding the role of psychology in the experience of
illness. For example:
- Understanding the psychological consequences of illness could
help to alleviate symptoms such as pain, nausea and vomiting.
- Understanding the psychological consequences of illness could
help alleviate psychological symptoms such as anxiety and
depression.

14. E) Evaluating the role of psychology in the treatment of illness.
For example:
- If psychological factors are important in the cause of illness
they may also have a role in its treatment.
- Changing behavior and reducing stress could reduce the
chances of a further heart attack.
- Treatment of the psychological consequences of illness may
have an impact on longevity.

15. 2 Health psychology also aims to put theory into practice. This
can be implemented by:
A) Promoting healthy behavior. For example:
- Understanding the role of behavior in illness can allow
unhealthy behaviors to be targeted.
- Understanding the beliefs that predict behaviors can allow
these beliefs to be targeted.
- Understanding beliefs can help these beliefs to be changed.

16. B) Preventing illness. For example:
- Changing beliefs and behavior could prevent illness onset.
- Modifying stress could reduce the risk of a heart attack.
- Behavioral interventions during illness (e.g. stopping smoking
after a heart attack) may prevent further illness.
- Training health professionals to improve their communication
skills and to carry out interventions may help to prevent illness.

17. Behaviorist
- Learned behavior as an observable event (not a mental process)
- Behavior is conditioned by the environment
- Environmental response alters subsequent behaviors
Relevance to Occupational Therapy
- Analyze and sequence behaviors from simple to complex
- Measure progress as the person completes
- Use strategies including reinforcement, shaping, and rewards

18. Social learning/cognitive
- Integrated behavior, social and cognitive processes
- Learner creates/constructs knowledge through past experience
and interaction with the environment
- Self-constructed knowledge promotes the learner’s motivation for
learning
Relevance to Occupational Therapy
- Emphasize client learning essential skills for living
- Use role-play, peer observation, role modelling, problem solving,
and real-life practice activities to promote learning
- Encourage the client to id the problem, set-goals, develop a plan,
evaluate outcomes

19. Constructivist
- Learner is an active participant in his or her own learning
- Learner creates/constructs knowledge through past experience
and interaction with the environment
- Self-constructed knowledge promotes the learner’s motivation for
learning
Relevance to Occupational Therapy
- Client actively directs what is to be learned end how learning will
occur
- Use strategies including brainstorming, individual problem
solving, independent exploration, asking questions
- OT facilitates but does not direct the learning process

20. Self-Efficacy
- Emphasize a person’s beliefs about how effective he or she is or
she will be
- Efficacy expectations influence a person’s persistence with an
activity
- Efficacy expectations are influenced by the difficulty of the task,
how well completing a takes transfers to other situations, and the
degree to which a person believes that he or she will be successful
- Self-efficacy is developed over time and through experience
Relevance to Occupational Therapy
- Personal accomplishment has the greatest effect
- Self-evaluation, personal appraisal are important
- Task should be challenging but not overwhelming, should be
transferable to other situations
- Vicarious, observation experiences and/or persuasion to enhance
the person’s beliefs to be successful are less effective

21. Motivational
- Learning and change occurs in a spiral fashion, not linear
- A person’s readiness for change will influence the outcomes
- Relapses are common and to be expected
Relevance to Occupational Therapy
- Intervention processes must match behavior stage
- Intervention processes become increasingly active, self-directed
and self-monitored

22. Learning is:
“set of processes leading to relatively permanent changes
in the capability for responding”
Learner experience:
• Readiness to learn
• Orientation to learning
• Motivation to learn
Characteristics that affect learning
• Person
• Task
• Environment

23. Person Factor: Cognition
• Attention
• Awareness
• Memory
• Perception
Information Processing Model
1. Environmental input
2. Sensory registration
3. Automatic transfer
4. Short-term/working memory
5. Storage to long term memory
6. Long-term memory
7. Retrieval from long term memory

24. Types of long term memory learning
• Procedural: knowing how to do something, steps/a routine
e.g. making a familiar meal, driving to work.
HOW
• Declarative/Explicit: knowing facts or information about things
e.g. remembering an appointment or a recollection from the past.
WHAT
• Implicit: procedural, but also automatic responses such as force
generation or coordination of motor skills e.g. reaching for a cup
AUTOMATIC
• Generalized: knowing when and where to apply information.
WHEN, WHERE, WITH WHOM

25. Reasons to think about theories of learning
• Provides a foundation for practice
• Guides and informs practice
• Leads to researchable questions
• Enhances practitioners’ effectiveness and ability to
solve problems
• Promote individualized and creative interventions

26. Learning Process
i. The existence of a stimulus in the natural task environment or
immediate reason to act. An artificial stimulus for a behavior is
referred to, as a cue, additional information provided by an
instructor.
i. The fact that intervention is required if the learner is to learn to
perform the correct behavior. The required intervention can be
referred to as a prompt.
ii. The establishment of an association by the learner between the
consequence or outcome of the behavior and the performance
of the desired behavior. The reward resulting from appropriate
performance can be termed reinforcement. An instructor may
provide additional rein-forcers to increase the likelihood that
the learner will perform the desired behavior.

27. Cues
A cue is a stimulus for an action to occur. It is a signal to a person
that a response is necessary.
The world in which we live is full of cues that may trigger us to
behave in certain ways. Objects, events, sights, smells and
physical feelings can all be cues which cause us to begin or
continue to do something. Some cues tend to elicit a uniform
response, e.g. the sound of the platform announcement would be
likely to encourage passengers to board their train. Other cues
may produce a variety of responses, e.g. the sight of a large dog
could arouse fear, indifference or pleasure.

28. Cues
The presence of a single cue may not be sufficient to bring about
action. If we reacted to every cue our lives would be very
confused, e.g. stopping to wait for a bus every time we see a bus
stop, regardless of what else we are doing, is not functional.
Cues are particularly important to consider in the learning
situation. In order to live independently people learn to react to
relevant cues in the natural environment, and gain an
understanding of when it is appropriate to respond to such cues.
Cues can occur naturally as part of the everyday performance of
an activity or an action OR they can be introduced by a teacher to
highlight a naturally occurring cue.

29. Factors which influence an appropriate response to a cue are:
• Knowledge: Knowing that the cue is a trigger for certain
behavior, e.g. when a ball is thrown to a child he or she will try to
catch it, but only if they know what a ball is and that catching is
an appropriate response.
• Routine: Frequently one activity is a trigger for another activity
even if the cues for a number of actions are present
simultaneously, e.g. when we have had a morning shower, then we
may get dressed before having breakfast.
• Design or desire: We may choose to respond to the cue if we
wish, e.g. the sight and smell of a fast food outlet may be a trigger
to go in and have something to eat. If we are hungry we can
choose to eat, or if we are on a diet and saving hard we can decide,
despite being hungry, not to respond to the cue.

30. Prompts
A prompt provides extra information or assistance additional to
the cue and helps people perform a specific motor action in
response to the cue. Prompting as an instructional technique
provides the learner with the necessary information to complete a
task. Its purpose is to enable the learner to succeed in performing
the motor steps in a task.
Many cues occur as an ongoing part of our environment and may
be essential for behavior to be initiated; prompts are not a
necessary part of behavior – they are something which may be
introduced by an instructor, although in the course of daily living
people are often encouraged or assisted to complete a task.
Prompting as an instructional technique is considered temporary.
It is gradually withdrawn so that the person will learn to
participate in an activity or part of an activity without undue
dependence on others.

31. Reinforcement
If we want people to learn we ensure they have a reason to do so.
Activities which inherently give rise to rewards or pleasant
consequences tend to be repeated.
This fact is important in maintaining appropriate behavior in the
course of daily living, although in adult life the relationship
between the activity and the reward is often highly complex. In
the instruction situation, this reward is referred to as
reinforcement.
Reinforcement is described as positive if it serves to increase the
action which immediately precedes it. In other words positive
reinforcement increases the likelihood that the learner will do the
same thing again under the same set of circumstances. Thus a
positive rein-forcer motivates the learner.

32. Reinforcement
• Reinforcement is anything that increases a behavior
• Reinforcement can be positive getting good things
e.g. attention, toys, food
• Reinforcement can be negative e.g. reprimands and
negative attention
Both good and bad behaviors are strengthened by
reinforcement

33. Connectionism
Learning is the result of associations forming between stimuli and
responses. Such associations or “habits” become strengthened or
weakened by the nature and frequency of the S-R pairings.
• The law of frequency
• Skinner and operant conditioning
• Reinforcement vs reward
Operant Conditioning
Operant conditioning is a learning process through which the
strength of a behavior is modified by reinforcement or punishment.
It is also a procedure that is used to bring about such learning
• Type of learning where behavior is controlled by
consequence
• Reinforcement contingency

34. Key concepts:
- Positive reinforcement
- Negative reinforcement
- Positive punishment
- Negative punishment
Positive reinforcement
• Behavior is followed by the delivery of an appetitive stimulus
• Increases the probability of that behavior
Negative reinforcement
• Behavior is followed by the removal of an unpleasant stimulus
• Increases the probability of that behavior

35. Punishment
Positive punishment
• Behavior is followed by the delivery of an aversive stimulus
• E.g. Touching a hot stove = pain that punishes behavior
• Decreases the probability of that behavior
Negative punishment
• Behavior is followed by the removal of an appetitive stimulus
• E.g. parent preventing child from watching TV after child hit
brother
• Decreases the probability of that behavior

36. Intervention using behavioral theory:
• Task/activity analysis
• Provide opportunities for the client to participate in first very
simple exchanges progressing systematically to more complex.
• Using principles of reinforcement, shaping, prompting, and
reward.
• Progress measured and documented by observed occupational
performance (turn-taking) in increasing more complex and
natural situations.

37. Social Learning Theory: Assumptions
• People can learn by observing others
• Learning is an internal process
• People are motivated to achieve goals
• People can regulate and adjust their own behavior
• Reinforcement and punishment may indirectly affect behavior

38. Social Learning Theory: OT Strategies
• Role-play
• Observation
• Problem solving
• Practice in real life situations
• Group treatment

39. Constructivist Learning
“Everyone’s construction of the world is unique even though we
share a great many concepts”
• Access
• Alter
• Integrate
• Create

40. Constructivism: What’s needed
• Learner must be an active participant
• Capable of creating his or her own knowledge
• Developed ability to think critically
• Also called “discovery learning”
• e.g. Life skills for people with MH/substance abuse issues

41. Constructivist: OT Strategies
• Asking questions
• Independent exploration
• Identify problems
• Brainstorming
• Therapist is facilitator of clients exploration

42. Self-efficacy
• A person’s beliefs about how successful or unsuccessful they will
be, will greatly influence their performance
Developing Self-efficacy
• Performance accomplishments
• Vicarious experience
• Verbal persuasion
• Physiological states

43. Motivational Learning Theory
- Pre-contemplation Strategies are not effective- lacks
awareness
- Contemplation Consciousness-raising strategies to
learn about problem, role play strategies, assessment
of how behavior affects others
- Preparation Values clarification exercises to promote re-
evaluation of feelings or self-perception
- Action Goal setting
- Maintenance Development of social support, alternative +
behaviors, avoidance of dangerous situations, rewarding
oneself

44. Applied Behavior Analysis
• Concerned with the functional relationships between
behavior and the teaching environment
• Stresses positive reinforcement and scientific
demonstrations of effectiveness
• Highly individualized, contextual, flexible
• Complex and intricate, comprising many techniques

45. Applied Behavior Analysis
• Application of scientific principles or laws of behavior
(e.g., rein-forcement) to improve socially significant
behavior to a meaningful degree
• Many applications in addition to autism
• Based on the work of many researchers and
practitioners
• Effective for building skills and reducing problematic
behaviors in people with and without disabilities

46. Applied Behavior Analysis and Occupational Therapy
OT intervention approaches seek to:
1. Promote health and performance:
- Reinforcement, shaping, chaining, time delay,
priming
2. Maintain performance
- Token Systems, peer modelling
3. Modify context or activity demands
- Prompting, PECS etc
4. Prevent disability

47. Behavior definition
• Behavior is “the manner of conducting oneself.”
• Psychologists say: behavior is any external or internal
observable and measurable act of an organism.
What is a functional behavior assessment
• A process for identifying clear, predictive relationships
between events in a person’s environment and
occurrences of challenging behavior

48. Why conduct a functional assessment?
• Provides clear information
• Allows strategies to be based on function(s) of
challenging behavior
• Leads to more durable outcomes
• Reduces the need for reactive interventions and crisis
plans
• Addresses the needs of an individual
• Increases quality

49. What is person-centered planning?
“Our quality of life everyday is determined by the presence
or absence of things that are important to us - our choices,
our rituals.”
- Expressing preferences and making choices in everyday life
- Being present and participating in community life
- Continuing to develop personal competence
- Gaining and maintaining satisfying relationships
- Having opportunities to fulfil roles and live in dignity

50. Steps in Functional Behavioral Assessment
1. Gather information: Data collection (ABC)
2. Define behaviors in observable and measurable terms
3. Develop a hypothesis
4. Build a Positive Support Plan
5. Evaluate effectiveness of the plan and modify as
needed to fade for generalization and independence.

51. Steps in Functional Assessment
Antecedent: Any stimulus that precedes a behavior,
something that the child can hear, feel, see, taste, or smell
Behavior: The response that the child displays; anything
the child says or does after the antecedent
Consequence: Stimulus that occurs after the behavior,
anything that the child will or won’t receive following the
child’s behavior, praise, attention, a sticker, a lolly

52. What are antecedents
Slow triggers
• Present over a longer period of time e.g. illness, a
crowded area, an unfamiliar setting or unexpected
change in routine
Fast triggers
• Occur immediately prior to challenging behavior e.g.
loud noise, a difficult task, “no”, denied access to
favorite activity

53. Functional Ax Step 2: Define the behavior
• Definition of behavior needs to be clear, concise and
specific
• A description of what you will see when the behavior
occurs
• Written so that everyone can agree when the behavior
occur

54. Functional Ax Step 3: Develop hypothesis
• Why does a person engage in problem behavior?
To get something
• Attention, preferred activity or item, social
reinforcement, sensory stimulation (internal)
To avoid or escape something
• Tasks or demand, people, attention (adults/peers),
sensory stimulation (pain or discomfort)

55. What causes negative behaviors?
• Many negative behaviors are caused by inadvertent
reinforcement
• Negative behaviors may get attention, reaction,
reprimands, etc.
• Negative behaviors may get access to rein-forcers
• Negative behavior may allow one to avoid undesirable
activities

56. Developing a hypothesis
Scenario… Wade is watching TV
Antecedents
• Fast Triggers- Direct instruction to “turn off TV, go to
bed, mother turns off TV
• Slow Triggers- lack of sleep (child yawns)
Behaviors
• Crying and screaming, pounding fists, kicking feet
Consequences
• TV turned back on, mom says “5 more minutes”

57. Write a hypothesis statement
When____________________________occurs
(antecedent/fast triggers and slow triggers)
he will _______________________________
(the behavior)
to access/avoid (circle one) _________________ .
(consequence/function)

58. Functional assessment step 4: Develop a Positive
Behavior Support Plan
• Clearly written person-centered action plan
• Incorporate team and family values
• Identify resources and training needs
Contain these components:
1. Hypothesis (as per previous step)
2. Prevention strategies
3. Replacement skills
4. Consequences strategies (responding)
5. Long term strategies

59. Defining characteristics of a Personal Behavior Support
Plan
• Person-centered
• Collaborative ongoing approach
• Data-driven decision making
• Positive, proactive strategies
• Meaningful outcomes

60. 10 keys aspects of Personal Behavior Support plan
1. Improve quality of life
2. Develop and build skills
3. Work in partnership with person and family
4. All behavior is for a reason
5. Based on ABA (antecedent, behavior, consequence),
predict and change behavior
6. Can include other EBP intervention
7. Decisions based on fact and research not opinion
8. Formal Ax for clear structured plan
9. Tells people what to do to manage behavior
10. Supported in long term

61. Positive Behavior Support Plan
What can we do FOR the child PRIOR to the behavior
instead of what do we do TO the child AFTER the
behavior has occurred?
What are some prevention (antecedent) strategies?
• When the function of the behavior is to obtain something?
1. _____________
2. _____________
3. _____________
• When the function of the behavior is to avoid something?
1. _____________
2. _____________
3. _____________
(Prevention strategies reduce the likelihood that the child will need
or want to use the challenging behavior)

62. Prevention strategies: Obtain
• Modify task length
• Modify expectations
• Modify materials
• Modify instructions
• Modify response mode
• Provide more frequent attention/reinforcement
• Activity schedule
• Contingency for activity completion
• Schedule time with adult or peer
• Schedule access to desired object/event
• Choice of activity material and/or partner
• Peer support
• Provide frequent offers of assistance
• Incorporate child's interest
• Use timer, alarm to delay reinforcement

63. Prevention strategies: Escape
• Select rein-forcer prior to activity
• Incorporate child’s interest
• Use timer
• Self-management system
• Provide peer supports
• Provide visual supports
• Follow least preferred with most preferred
• Modify task length
• Modify expectations
• Modify materials
• Modify instructions
• Modify response mode
• Break task down
• Modifying seating arrangements
• Reduce distractions
• Provide activity schedule

64. Replacement: Teach new skills
• Teach alternatives to challenging behavior
• Replacement skills must be efficient and effective
(work quickly for the person)
• Consider skills the person already has
• Make sure the reward for appropriate behavior is
consistent

65. Possible replacement skills – Obtain
• Ask for break
• Say “all done”
• Ask for help
• Ask for a turn
• Ask for a hug
• Ask for an item
• Use a schedule
• Identify and express feelings
• Ask for adult intervention
• Request attention
• Use supports to follow rule
• Anticipate transition
• Say “no”
• Take turns
• Participate in routine
• Choice

66. Possible replacement skills – Escape/avoid
• Request break
• Set work goals
• Request help
• Follow schedule
• Participate in routine
• Choice
• Self-management
• Say “no”
• Say “all done”
• Identify and express feelings
• Use supports to follow rules
• Anticipate transitions

67. Responding/Consequences
• What adults will do when the challenging behavior
occurs to ensure that the challenging behavior is not
reinforced and the new skill is learned.
• A good basic strategy is to redirect the child to use an
alternative skill or a new skill.
• Make sure rewards for appropriate behavior equal or
exceed the rewards for challenging behavior

68. Examples of responding
• Redirect child to use replacement skill.
• Praise/reinforce when replacement skill is used.
• State exactly what is expected.
• Cue with appropriate preventions strategy
• Use ‘wait-time’
• Praise/reinforce when replacement skills is performed

69. How should logical consequences be implemented?
• Should be presented to a child as a choice
• Be certain child understands the options and can choose
(i.e., clean up or no outdoor play)
• Child may engage in the expected behavior to access an
activity, object, person, or material
• Behavioral options logically link current activity to
resulting action

70. How should logical consequences be implemented?
• Discuss logical consequences with the child before
implementation
• Only select options that you’re willing or able to enforce
e.g. outdoor play
• Don’t help the child by intervening before the
consequences take place
• You might offer the child a chance to try again later if
the team agrees
• Logical consequences should not be threatening or
punitive

71. Possible outcome of using logical consequences
• Using logical consequences should result in rapid
changes in the child’s behavior within the targeted
routine or activity e.g. cleanup
• If using logical consequences is not successful, think
about why the child is engaging in the challenging
behavior and consider other ways to support the child

72. Problems with punishment
• Ethically questionable
• Difficult to make work
• Does not teach what to do
• Causes negative emotional reactions
• People try to escape
• Does not get at the function of the inappropriate
behavior

73. Organizing instruction
Once the priorities of the individual have been determined and
behavioral objectives written, the therapist makes decisions about
how best to implement the program.
It will be necessary to examine carefully current performance to
determine the stage of learning and also to apply our knowledge
of the learning process to decide on instructional techniques
suitable for the person’s occupation and the environment.
Instruction is organized and documented to facilitate learning and
achieve program objectives. This entire process depends on
careful social and educational validation.

74. Organizing instruction
It is advisable to work with the person through the entire sequence
of activity steps (as identified in the task analysis) each time a
specific short-term objective is targeted for teaching. Some steps
may require assistance or adaptations, others may be performed
independently and some will be targeted for systematic
instruction.
Systematic instruction relating to a specific task or skill then takes
place as part of a meaningful whole activity. In this way, previously
learned parts of the activity are practiced frequently and some
parts not yet targeted for formal instruction may be learned
informally. Natural cues and reinforcement will also occur at
appropriate times in the sequence

75. Overview of stages of learning
Research indicates that there is more than one stage of learning.
The instructional techniques used vary between each stage. It is
important to determine which stage a learner is in for a particular
skill before attempting to intervene in promoting performance.
There are at least four aspects of learning:
• Acquisition
• Fluency
• Maintenance
• Generalization.

76. Overview of stages of learning
During acquisition the learner cannot perform the skill
accurately. Initially the percentages correct are zero, indicating
the need to acquire competency in the target skill. Once the
learner can perform the task correctly, the fluency stage begins.
At this point the speed of performance or proficiency is the
objective.
In addition to accuracy and speed of performance, the learner will
need to be able to perform the skill, after formal training is
completed, under new conditions. Maintenance training teaches
the learner to maintain accuracy and speed of performance in the
absence of instructional prompts and reinforcement.
In generalization training, the objective is accurate and fluent
skill performance across materials, settings and or trainers

77. Overview of stages of learning
It is necessary for the therapist to attend closely to the stages of
learning to ensure that the learner is fluent in skill performance in
integrated environments and can maintain performance without
the therapist and a training environment.
Secondly, the therapist considers what materials, prompts and
instructional settings are most appropriate to the stage of learning
and the future opportunities and demands that will be
encountered by the learner
Although many instructional texts imply that each of the phases is
entered sequentially in learning, teaching initiatives relative to
each phase are planned and implemented from the very first
teaching contact. For example strategies to promote skill
generalization can be implemented from the first contact, such as
using a range of situations and materials.

78. Ecological inventories are informal assessments that require the
therapist in consultation with the learner and significant people in
the learner’s life to determine skills and tasks necessary for that
learner to function interdependently within their occupational
roles.
Each major performance area is considered, including self-
maintenance, productivity, leisure, sleep and rest, and the
environments in which they occur – home, school, work and
community y.
Each current and potential environment is examined in order to
identify what are the fundamental skills and tasks required for
interdependent functioning within that environment with
reference to non-disabled peers of the same chronological age.

79. This is commonly referred to as a top-down approach to skill
building.
That is, it starts with the requirements of the real environment
rather than all of the supposed prerequisites. This also ensures
that skills targeted will be meaningful and relevant for the learner
and thus are more likely to be maintained and generalized.
Each step in the process is formulated with reference to the
unique needs of the individual learner

80. Steps in conducting an ecological inventory:
1. Decide what instructional domains are most pertinent
according to the perceived needs of the learner e.g.
productivity, leisure/play, self-maintenance etc.
2. Pinpoint present and future environments in which the
performance area may occur. Identify the specific
environments in which the learner currently lives, learns,
studies, works or plays. Don’t forget to indicate potential or
future environments of relevance in order to ensure the
learner is prepared for new roles and opportunities.
3. Delineate sub environments within each environment
identified in step two. Each of the sub environments is relevant
to the performance area and the learner also.

81. 4. Delineate and classify all the activities that represent the
domain and that are already available or may occur in those
environments.
5. Allocate activities to be taught according to the following
criterion:
a. Activities that are essential for successful functioning
b. Activities that occur across a range of environments and
performance domains
c. Learner’s current skills
d. Learner preferences and interests
e. Priorities of significant others
f. Physical characteristics, accessibility, relevance, availability,
equipment etc. of the setting
g. The degree of meaningful partial participation of the student
h. Chronological age appropriateness

82. 6. Task analyze priority activities in order to assess and also in
order to identify components of the task that need to be taught
and which will form the basis of specific learning objectives
otherwise known as behavioral objectives.

83. Preparing instructional objectives
Having spent time identifying, with the learner and significant
people in the learner’s life, the most critical instructional needs of
the learner, these needs are restated as long-term goals and short-
term objectives for the person.
Long-term goals describe specific skills or activities (shopping,
eating at a restaurant, preparing a meal), but as they typically
consist of complete clusters of behaviors it is unlikely that
instruction can begin simultaneously on all aspects for any
individuals.
Therefore the long-term goals are broken down into segments
representing realistic instructional targets for an individual. The
number of these short-term objectives or behavioral objectives will
be determined by the complexity and or difficulty of the long-term
goals, but represent behaviors or skills that can be mastered by an
individual during instruction.

84. Defining instructional objectives
Behavioral objectives are clear and precise statements describing
the skill or behaviors that a person will be expected to acquire as
a result of intervention.
The statements describe (a) the behavior that will be
changed as a result of intervention, (b) the conditions under which
the behavior will be performed, and (c) the standard or criterion that
will be used to judge the success of the intervention.
These statements are as concise as possible and include sufficient
detail so that independent observers would agree upon each
occurrence or non-occurrence of the behavior under the same
conditions.

85. Behavior
The behavior to be changed as a result of intervention is described
in observable and measurable terms.
When teaching ‘Robert’ to purchase canned grocery items, he
selects canned items from the shelf that match the picture
contained in his shopping list. When describing this, skill words
such as ‘will identify’ and ‘will discriminate’ are avoided because
these do not describe observable behaviors. Rather, how Robert
will demonstrate this knowledge is specified, e.g. Robert will ‘pick
up’ the correct items and place it in the grocery trolley.

86. Behavior
The ‘size’ of the behavior to be monitored will depend on the
learner’s skills and the goals of intervention.
In the initial stages of training for a person with a severe disability
‘hand washing’ may be too large.
It can be measured more effectively if we evaluate the specific
behaviors involved (turns on the cold water, wets hands, picks up
soap), however, when Robert has mastered a series of self-help
skills we may simply count each skill before he goes to work (hand
washing, tooth brushing, shaving and appropriate dressing).
If performance on the components of each skill were satisfactory,
more precise breakdowns of the specific tasks would be
unnecessarily cumbersome.

87. Conditions
It is necessary to delineate clearly the conditions under which
observations of behavior will take place.
This will include factors such as the physical setting, people
present, the instructional materials and cues to be provided and
any other relevant variables that are expected to influence
performance. It will also specify the most rigorous conditions
under which you expect the individual to perform. Even if some
training will be conducted in a simulated setting, the objective
includes a description of the natural environment in which the
behaviors are needed.
This is crucial. This last consideration is critical because it has
been demonstrated that many objectives written for people with a
severe disability target functional skills but fail to describe the
settings where the skill will be performed

88. Standards or Criteria
The standards delineated in the behavior statement describe the
type or quality of performance that the individual will be
expected to achieve as a result of intervention. Depending on the
target behavior, the therapist will delineate the performance
standards of response latency (the person responds appropriately
within five seconds of the shop assistant asking ‘Can I help you’),
frequency (the person will complete two assembly tasks per
minute) or the number and or type of errors that cannot be
tolerated.
Standards are not set arbitrarily, but rather are carefully tailored
to the type of behavior being taught. It is important not to prolong
training by insisting on unnecessarily rigorous performance
standards; however, a safe and functional level of performance is
required.

89. Factors of safety, public appearance or social standards may need
to be considered when writing the criterion for an intervention
program.
Safety concerns would indicate that errors could not be tolerated
in a street crossing program. Some social standards may dictate a
particular criterion, e.g. forgetting to put on socks occasionally is
acceptable but forgetting to put on trousers is not.
Conversely, for other skills, the criterion can be less stringent and
still guarantee that the person demonstrates a functional level of
performance: social manners need not be ‘perfect’ and some
errors when engaging in a leisure activity are probably
acceptable. Thus describe errors that are considered acceptable (if
any), and their acceptance frequency, as well as errors that cannot
be allowed under any circumstances

90. There are a number of criterion that can be used to evaluate the
success of instruction and the adequacy of instructional planning
including goal setting.
In clinical settings the occupational therapist will consider:
a. Clinical significance
Does the change resulting from instruction result in an
improvement in the functional performance of the individual,
which is relevant to them and their family.
b. Social validation
The degree of proficiency required to most tasks is more difficult
to establish that it is for an activity such as street crossing. Thus,
social validation procedures can be used in order to determine
whether or not the learned behavior is functional or meaningful.
Indeed at this phase in the curriculum development process, the
therapist has already addressed one aspect of social validation –
social validation of instruction goals

91. Social Validation
When goals are selected that will facilitate the learner’s
independent functioning, one can say that these goals are socially
valid.
Social validity also addresses the results of intervention. That is
what standard of performance is to be reached.
Social comparison ensures that the criteria set for performance
will represent a standard of behavior comparable to that
demonstrated by non-disabled peers.
This will prevent the therapist from setting too stringent a
standard or stopping training before an adequate standard has
been reached.

92. Analysis without errors – this allowed realistic standards to be set
by researchers for the performance of learners with disabilities.
Subjective evaluation uses the opinions of those who by their
familiarity or expertise are able to judge performance or set
standards.
This may involve parents or other staff or advocates; for example,
videotapes of adolescents with severe disability before and after
training in vocational skills being viewed by parents and non-
disabled peers to determine whether or not they were more
interested and involved in activities. Such procedures provide
some assurance that the learner’s behavior change is
meaningful and will facilitate function in the intended
environments.
To maximize progress very precise individual procedures are
needed. These procedures are planned carefully and implemented
systematically.

93. Educational validity
There are three elements upon which this can be decided.
First, that of internal validity – did the person’s performance
change as a result of the instruction provided?
Second, was the intervention, which was proposed, carried out
with educational integrity?
Third, was the change, which occurred as a result of instruction
considered valuable by significant others in the learner’s life.

94. Quality of life
This concerns an examination of the extent to which the instruction
and target goals attained can be related to improvement in the
quality of the individual’s life.
For example:
- Did the achievement of this goal enhance the positive perception
of this individual by others around them?
- Did it enhance participation in age appropriate community
environment?
- Was there an improvement in opportunities for choice and
decision making by the learner?
- Did the instructional program contribute to expanding the social
networks of the individual?
- Did the program foster the interdependence of the learner
amongst significant others in their life?

95. Principle of partial participation
Although some individuals with high support needs may not be
able to function independently in all environments, they are
entitled to the dignity of opportunity and support to perform or to
participate at least partially in identified community-based
environments.
If participation in an activity is going to be partial, attention to
meaningful components of an activity as an index of progress
becomes especially important. Focus on components that the
learner or others perceive as meaningful and that offer the learner
control of the activity.
Involvement can be promoted in a number of ways such as
changing task sequence, materials, assistance, rules or environment.
This requires monitoring to ensure that opportunities to participate
are keeping pace with competence

96. Task analysis as an assessment and instructional tool
In order to go from long-term to short-term objectives, it is often
necessary to carry out a task analysis so that the short-term
objective is defined in behavioral terms.
Task analysis typically proceeds through a process
1. Use ecological inventory results to identify an individually
functional and age-appropriate skill that is an important target
for a particular person.
2. Define the target skill simply, including a description of the
settings and materials most suited to the natural performance
of the task.
3. Perform the task and observe peers performing the task, using
the chosen materials in the natural settings, while noting the
steps involved.

97. 4. Adapt the steps to suit the person’s disabilities and skill
strengths, employing the principles of partial participation and
component analysis as needed to enable participation that is
both age-appropriate and functional.
5. Validate the task analysis by having the person perform the task,
but provide assistance on steps that are unknown, so that
performance of all steps can be viewed.
6. Explore adding simple, non-stigmatizing adaptations to steps
that appear to be unreasonable targets in an un-adapted form;
revise the task analysis.

98. 7. Write the task analysis on a data collection form so that steps
(a) Are stated in terms of observable behavior
(b) Result in a visible change in the product or process
(c) Are ordered in a logical sequence
(d) Are written in second-person singular so that they could
serve as verbal prompts (if used), using language that is not
confusing to the person and enclosing in parentheses details
essential to assessing performance

99. During the breaking down of the task into its component parts,
there is often considerable confusion about the degree of specificity,
or the appropriateness of the size of steps to be delineated.
Although the degree of specificity used in the task analysis will
necessarily be related to the learner’s characteristics, it has been
found that learner’s taught with fine-grained task analysis (one
response per step) made significantly fewer errors during training
than learner’s taught with a task analysis requiring two or four
responses per step.
It appears that the number of steps in the task analysis will have a
significant impact on performance.

100. During the breaking down of the task into its component parts,
there is often considerable confusion about the degree of specificity,
or the appropriateness of the size of steps to be delineated.
Although the degree of specificity used in the task analysis will
necessarily be related to the learner’s characteristics, it has been
found that learner’s taught with fine-grained task analysis (one
response per step) made significantly fewer errors during training
than learner’s taught with a task analysis requiring two or four
responses per step. It appears that the number of steps in the task
analysis will have a significant impact on performance.
Task analysis yields information that lets the therapist formulate
treatment strategies and specify conditions and performance criteria
more accurately, therefore facilitating the development of
instructional objectives and intervention strategies.
Task analysis can also be used to monitor performance.

101. The therapist ensures that each learner is learning as quickly as
possible. You can measure the effectiveness of the techniques you
are using by measuring performance each time you teach.
If adequate progress is not being made then therapists can
make appropriate alterations to the program to ensure success.
In order to evaluate the impact of intervention procedures developed,
specific strategies for collecting frequent, repeated, objective
measures of learner performance are formulated. Such monitoring is
crucial, since there is no way to predict accurately whether or not a
teaching strategy will work for an individual learner or for a
specific skill.
Further, it has been demonstrated that when staff fail to use
systematic data collection procedures, they are unable to judge
learner progress accurately

102. Programs that do not result in satisfactory rates of learning can be
modified, so that valuable instructional time is not wasted on
ineffective procedures. The data is collected in an accurate and
reliable manner.
Although the data collection procedure selected will be largely
determined by the characteristics of the target behavior, the
therapist also selects the simplest method possible.
Unnecessarily complex data collection procedures are likely to
interfere with activities and are difficult to implement, thus raising
questions about the accuracy of the obtained data.
Above all in order to be meaningful, the data reflects important
and significant behaviors that are valued by the learner, their
family and community.

103. The therapist also determines how often data will be collected.
Although many recommend that data be obtained every day, such
a standard may be unnecessarily rigorous in some situations.
Rather the therapist considers the type of behavior, the rate of
learning, as well as balancing the convenience of less frequent
data collection with the risks of unnecessarily prolonging a
program, which is not yielding satisfactory learning
There are many ways of collecting information about progress, for
example we can monitor the rate of performance or the duration of
performance
Take analytic assessment is a variation of a frequency measure in
that a sequence of behaviors is measured at one time. It is probably
the most valuable method for the informal assessment of a
learner’s performance on specific tasks

104. Before using task analytic assessment procedures, the therapist will
have developed a task analysis. To conduct the assessment the steps
of the task analysis are entered on the data sheet so that it can be
used to guide the observation.
The person will be observed under the conditions specified in the
behavioral objective and the therapist then judges the quality of
the performance on each step of the task analysis.
A symbol for (+) correct or (–) incorrect is then entered on the data
sheet beside each step

105. At least two different task analytic procedures can be used to assess
performance: single opportunity or multiple opportunity.
The single opportunity method is carried out as follows
1. Conditions (including materials) are arranged as described on the data
sheet.
2. The instructional cue (if any) is given when the learner is attending.
3. The person’s response to each step in the task analysis is recorded as correct
or incorrect (performed correctly or not performed at all). The following
rules can be used to handle errors, periods of no response and inappropriate
behavior.
a. Testing is stopped after the first error and all remaining steps are scored as
errors.
b. After a specified period of no response (3 seconds), testing is stopped and all
remaining steps are scored as errors.
c. After a specified period of inappropriate behavior (10 seconds of stereotypic
behavior) or after a single inappropriate response (throwing soap, or towel),
testing is stopped and all remaining steps are scored as errors.

106. In most cases, steps performed are scored as being correct if they
correspond to the task description, regardless of the order in which
they are carried out, as long as the end result is satisfactory;
however, in some cases, such as assembly tasks, order may be
crucial to the successful completion of the activity.
Therefore, the first step out of sequence will be scored as an error.
In addition when the rate of performance is important (as specified
in the criterion or the standards) the maximum length of time
might be specified for testing