Occupational Therapy and Reinforcement (part 3)

Miriam Cho is 35 years of age and lives with her husband
Matthew and 2 children in a terrace in the inner city.
- Miriam enjoys gardening, home decorating, woodworking
classes and restoring furniture.
- She works as a systems analyst in the CBD.
- She has experienced severe pain, swelling and decreased range
of motion in forearm, wrist and fingers.
- In order to prevent symptoms recurring she is being taught to
have a break every hour for 10 minutes, to do no more than 4
hours of keyboard work in a day, use wrist splints, a wrist rest
attached to her keyboard and to keep her body, forearm, wrist
and hand well aligned and supported with the use of well
designed and fitted furniture, particularly when doing
repetitive tasks.

Responsible use of systematic instruction in occupational therapy
Concern is raised occasionally about the use of applied behavior
analysis and systematic instruction. Accusations are made about its
manipulative, coercive nature, or that it is just plain bribery. On
the other hand it is countered that using identified systematic
relationships between events and learning increases the options
available to people and it is more ethical to provide learning
opportunities based on effective, proven and efficient means rather
than guessing.
All of these statements can be true. The motives, rationale and
procedures used in the adoption of any tool, such as applied
behavior analysis, will determine whether or not it is being used
ethically or unethically

Fundamental Principles Guiding the Ethical Use of Systematic Instruction
1. The goals and procedures of the program reflect the expressed
wishes and aspirations of the learner and their personal
priorities, what is most important to them. Where the learner is
unable to indicate their personal aspirations or there is serious
conflict between their personal aspirations and their best
interests then the person’s family members, guardian,
advocates and significant others are consulted with particular
reference to the social validation of goals.
2. The goals and procedures of the program develop appropriate
behaviors and consequently enhanced opportunities. That is for
example they are likely to lead to the person’s participation
and inclusion in the community, they are age appropriate and
likely to contribute to the learner’s role as a valued community
member.

Fundamental Principles Guiding the Ethical Use of Systematic Instruction
3. The goals and procedures of the program are stated objectively
and openly in an understandable form and are therefore open to
critical scrutiny, evaluation and review.
4. The goals established are achievable.
5. The learner and others involved are voluntary participants in the
program.
6. Procedures have been demonstrated to be effective.
7. The therapist and other people involved are competent in
applying the procedures and assisting a person to achieve the
stated goals.

Glossary of Terms
- Acquisition The initial stage of learning when a learner has no information
or very little information about signals, behavior or reinforcement associated
with particular learning objectives and requires this basic information.
- Applied behavior analysis The use of our knowledge about the relationship
between antecedents, behavior and consequences to identify and promote
human learning in natural settings.
- Behavior Motor action or motor activity, which is performed by an individual
and can be observed by others.
- Behavioral objective Specific statement of motor behavior, criterion for
performance and conditions under which performance is to occur. This
statement is used as the specific targeted outcome of a teaching program and is
stipulated before instruction begins.

Glossary of Terms
- Chaining This is related to task analysis. Skills are said to consist of a
chain of smaller component responses. Some skills are best taught starting
with the first step in the chain called “forward chaining” and then moving
onto the next step when that is mastered. Other skills are best taught starting
with the last step in the chain and working backwards in each session to
include the previous step. This is called “backward chaining”.
- Conditions Part of a behavioral objective which stipulates the physical
settings and/or the amount of assistance and/or equipment etc. which will be
present/provided to the learner whenever they are required to perform the
behavioral objective.
- Correction Consequence or action delivered by the instructor or required of
the learner following an error performed by the learner. Its aim is to reduce the
occurrence of errors.
- Criterion The standard of performance which is to be reached before the
behavioral objective can be considered to be achieved. Stipulates level of
accuracy/safety and/or independence to be achieved.

Glossary of Terms
- Cue The stimulus for an action to occur. This can occur naturally as part of
the everyday performance of an activity or action or it can be artificially
introduced by a teacher who wishes to highlight a naturally occurring cue.
Artificial cues can be verbal, gestural/visual or modelled.
- Fading The planned and gradual reduction and removal of any element of
instruction, which was artificially introduced by a teacher to promote learning.
Can be applied to reduction and removal of artificial cues or artificial
reinforcement.
- Fixed ratio Schedule reinforcement is delivered for every correct response,
e.g. one rein-forcer for every correct response of reinforcement where the or a
group of responses in a standard and repeating fashion. 1:1 e.g. one rein-
forcer for every two correct responses 1:2 or one rein-forcer for every five
correct responses 1:5.
- Fluency Learner has some information about signals; behavior or
reinforcement bus is not yet efficient or accurate enough in performance for
the task to be functional.

Glossary of Terms
- Generalization Ability to perform the targeted objective in a range of
environments, with a range of equipment and therefore stimulus conditions
and in the presence of different individuals depending on the functional
requirements of the task.
- Maintenance Sustaining efficient and reliable performance over time after
training has ceased.
- Phases of learning Four main aspects of learning or stages a person passes
through when learning something new: acquisition, fluency, maintenance and
generalization, which are all essential for competence but which require
different teaching strategies and considerations to be applied to promote
learning. These stages are not sequential.
- Prompt Assistance or intervention provided by a teacher to ensure that a
learner’s motor action or behavior is appropriate. Prompts can be verbal,
gestural/visual, modelled or physical.

Glossary of Terms
- Reinforcement The consequence delivered to an individual when they
perform an appropriate motor action in the presence of a specific cue(s). Can
be naturally occurring result of good performance or can be artificially
introduced by a teacher to highlight the naturally occurring positive
consequences.
- Shaping The rewarding of successively closer approximations to a desired
response.
- Stimulus A signal in the environment which indicates that a certain specific
action is required.
- Systematic instruction The application of a defined, replicable process which
reflects currently accepted “best practices” and in particular using
performance data to make modifications to ensure that the learner acquires, a
fluency level of performance, which is maintained and generalized.

Glossary of Terms
- Task analysis A series of motor steps listed in sequence, which are observed
when an individual performs an activity. Usually used to break down a
complex multi-step task into a series of single steps. (The instructor will then
decide what assistance will be provided to teach the learner each step.)
- Task analytic assessment The use of task analysis in order to assess an
individual’s performance of a task – usually a functional task. As this is used to
test performance no assistance is provided to help the learner perform each
step and the assessor may or may not complete steps to allow the person who
has become stuck on one step to try performing later steps.
- Variable ratio The learner cannot predict which performance of the behavior
is likely to be reinforced. For example they may be reinforced for the second,
seventh, eighth, eleventh and seventeenth correct responses.

The difference between a verbal prompt compared to a verbal cue is entirely
related to the specific part of the instructional sequence that is being highlighted.
If the signal or stimulus or cue is being highlighted verbally then it is a verbal
cue, e.g. in street crossing the instructor might give the verbal cue “Are there
any cars coming?”.
If, on the other hand, a verbal prompt is being given it is the motor action or
behavior which is being highlighted, e.g. in street crossing the instructor might
give the verbal prompt “Quickly walk across the street”. The same applies to
the difference between a visual cue and a visual prompt and a modelled cue and
a modelled prompt.

Occupational therapists are concerned with enabling clients to engage in
meaningful occupations. To this end, it is often appropriate to assist clients in
acquiring key skills relevant to their occupational goals. Although environmental
modification and adaptation of tasks can support skill learning, the process of
facilitating skill acquisition primarily involves engaging clients in teaching–
learning encounters
Clinical reasoning is the process by which therapists integrate theory and practice
It depends on familiarity with various levels of theory and the manner in which
each relates to the therapeutic encounter. These various levels of theory enable the
principles of occupational therapy to be implemented by guiding the selection of
appropriate evaluation and intervention methods.
In working with clients, particular tools or techniques are used to enable
performance. Tools are the specific therapeutic strategies that are employed
during therapy encounters to bring about change

Conceptual (theoretical) models of practice all help to understand the complexity
of human occupation by focusing on constructs that are central to the profession
such as occupational form, occupational role and occupational performance
Theoretical models guide practice to ensure it remains occupation-centered.
One strategy to maximize occupational performance is to establish, enhance
and/or restore the skills that will enable the client to participate in the identified
occupation

The acquisitional frame of reference draws on classic learning theories. In this
frame of reference, mastery of specific skills is integral to the broader intervention
process. Compensatory, adaptive and teaching–learning approaches all operate
under the set of assumptions hat define the acquisitional frame of reference.
Compensatory approaches alter the environment in which the skill is performed.
Adaptive approaches change the form of the task in order to make it easier to
perform
Teaching–learning approaches focus on structuring the therapy encounter in a
way that enables mastery of the skill in its current form and in its existing
environment.
In teaching–learning approaches used by occupational therapists, the acquisition
of skills is used as a means of improving occupational performance. In assisting a
client to build his or her skill base, therapists seek to enrich the resources the
client brings to the transaction between the person’s skills, the occupations he or
she wishes to perform, and the environment in which he or she performs them.
This in turn enhances occupational performance.

In taking a teaching–learning orientation to intervention, occupational therapists
assume the role of facilitator of learning
Occupational therapists using teaching–learning approaches their progress
through the ZPD by aligning the characteristics of the learner, requirements of
the task and environmental scaffolding. Through this transaction, therapists
enable the client to establish the underlying skills required for occupational goal
attainment.
An essential element in the learning process is the selection of appropriate
strategies at each learning stage. In order for learning to proceed, congruence
must exist between the characteristics of the client, the target skill and the
learning environment.
The learning environment can be considered to include the physical setting, the
strategies employed, and the inter- and intrapersonal factors implicit in delivering
support.

The Four-Quadrant Model of Facilitated Learning provides a structure that can
enhance the knowledge used to inform clinical reasoning when using learning
strategies as part of a teaching–learning approach to intervention.
In quadrant 1, strategies can be considered instructor-led, directly providing
content-focused information about the requirements of the task. These might take
the form of explicit instructions and demonstrations.
In quadrant 2, the facilitator uses indirect strategies to support the learner in task
performance by encouraging him or her to engage in decision-making processes.
For example, the facilitator might provide comments on the learner’s
performance, or suggest that an issue needs to be considered.
Quadrant 3 focuses on learner-driven processes and highlights strategies such as
self-talk or picture cues that a learner might overtly use to enable his or her own
performance by focusing on key points.
Quadrant 4 represents autonomous performance. Scaffolding of performance in
this quadrant is made through learner-driven processes hat are not obvious to the
facilitator. In both quadrant 3and quadrant 4, the learner scaffolds his or her own
performance.

While learning strategies characteristic of each of these quadrants
can all be viewed as valid aids, it is important to recognize that the
strategies in each quadrant address different learner needs. Those
strategies that exhibit dual characteristics of adjacent quadrants
serve an intermediate role, and are shown in the model as leading,
orienting and fading strategies.
Valid and effective use of therapeutic tools is dependent on the
knowledge that underpins them. The 4QM can be used to enhance a
therapist’s understanding of teaching–learning processes, leading to
the selection of optimal learning tools. When learning tools are used
appropriately, the mastery of skills resulting from teaching–
learning encounters establishes competence in skills identified as
central to the target occupation. Improved occupational
performance can therefore result.

Quadrant 1 — Direct, facilitator-initiated strategies
A number of strategies are used when the facilitator needs to provide
the learner with specific information about the requirements of the
task, and/or the way it is performed.
These strategies show, tell or remind the learner what to do by
providing clear task-relevant information. They are representative of
the features of Quadrant 1

Explicit instruction and explanation
Explicit instruction and explanation provides the learner with
descriptions of characteristics of the task itself, and/or its
performance. Such strategies can be used to inform the learner of
the requirements of the task (‘Do this’) or key aspects of
performance (‘Do it this way’).
The vagaries of interpersonal communication impose limits on the
effectiveness of these strategies. Incongruence can exist therefore
between the instruction provided by the facilitator, and the way in
which the learner interprets it. To be useful, instruction needs to
effectively balance simplicity of language and explicitness of content

Explicit instruction and explanation
Written or graphic instructions serve the same purpose as verbal
ones in providing specific, content-focused information.
Print-based instructions, as well as recorded instructions presented
by audio visual technology, present equivalent information to
facilitator-based instruction, but deliver it through different
modalities.

Demonstration
A need for learners to establish a mental picture of the required
performance, essential in the early stages of learning motor skills.
Demonstration can be used to highlight specific technical points,
clarify ambiguity in verbal instruction, and/or provide a reference of
correctness for the learner’s own efforts. In practice, Bailey noted
that demonstration should be linked to specific teaching points (such
as body position or movement trajectory) that are relevant to the
learner’s age, skills, language ability and stage of learning.
Facilitator demonstration that occurs simultaneously with learner
performance has been shown to be less useful in skill retention than
demonstration followed by imitation

Physical patterning
The terms ‘physical assistance’, ‘physical guidance’ and‘ manual
guidance’ have variously been used in the literature to describe a
range of physical facilitations, from partial prompts to complete
pattern in Distinction is drawn here between those strategies that
manipulate the client through the entire movement (physical
patterning), those that direct but do not control the movement
(physical assistance), and intermittent strategies that use tactile and
kinaesthetic prompts to ensure motor accuracy (physical prompts)

Physical patterning
The use of physical patterning to establish a motor schema for a
skill is a strategy that evolved from motor learning theory. Identified
are two-stage process in the acquisition of motor skills.
In the first stage, the goal is to establish a general idea of the
movement. At this stage, the construction of a movement pattern can
be enhanced by physical patterning by a facilitator to ensure an
accurate schema. As learning proceeds, the contextual features of
performance can be identified, and diversification of the skill can
occur.
The benefits of simultaneous demonstration and verbal instruction
in establishing a more complete understanding of the task.

Physical patterning
The use of physical patterning to establish a motor schema for a
skill is a strategy that evolved from motor learning theory. Identified
are two-stage process in the acquisition of motor skills.
In the first stage, the goal is to establish a general idea of the
movement. At this stage, the construction of a movement pattern can
be enhanced by physical patterning by a facilitator to ensure an
accurate schema. As learning proceeds, the contextual features of
performance can be identified, and diversification of the skill can
occur.
Physical patterning is most useful when developing the most
elementary understanding of task demands.

Lower order questions
Questioning needs to be used purposefully to target well-defined
objectives. Types of questions have been characterized on the basis
of form and language complexity. More pertinent to this discussion,
however, is the very purpose for which the question is asked.
Bloom’s taxonomy is a hierarchical system of viewing cognitive
skills.
Recalling and understanding, from those that stimulate higher order
productive cognitions
The term ‘lower order questions’ adequately describes questions
used to assess the learner’s understanding of the task and/or
performance. Such questions offer a direct prompt of previously
learned material, or engage the learner in developing his or her
understanding of the task(e.g. ‘What do you need to do next?’).

Quadrant 2 — Indirect, facilitator-initiated strategies
When the learner understands the task requirements, but is unable
to generate an effective plan for performing the task, different
learning tools are necessary.
Strategies that engage the learner in decision-making have different
features to those that specify the task. Although they remain
facilitator-initiated, they are less direct in nature. These strategies
aim to engage the learner in the decision-making process and are
represented in Quadrant 2.

Higher order questions
Higher order questions relate to the higher cognitive levels of
Bloom’s taxonomy, specifically application, analysis, synthesis and
evaluation. They draw attention to particular aspects of task
performance that the learner needs to consider. Questions that evoke
higher level cognitive skills (e.g. ‘Why does the drink keep spilling?’,
‘What could you do differently?’) have been shown to develop
executive functioning capacity.
It should be noted that some statements (e.g. ‘I wonder why that
happened.’) are not structured as questions, but function as such
because they imply the need fora response from the learner. The
cognitive processes engaged by higher order questions are typical of
the strategies employed in Quadrant 2.

Feedback
Much of the literature, particularly that focusing on motor learning,
has centered on the role of feedback in supporting the development
of learner responses. While feedback can be intrinsic, early stages of
learning are well supported by the provision of augmented feedback.
Feedback of this type can take the form of verbal, gestural or
symbolic information (e.g. rating scale, graph) pro-vided by the
facilitator as critique of performance Each of these strategies
supports learners by engaging them in reflection on their own
performance and by orientating them to the use of self-regulatory
procedures.
Feedback should focus on essential parts of performance by using
specific key words or phrases that can be adopted by the learner to
prompt future behavior

Feedback
In the long term, feedback should be internalized by the learner and
used to focus on key points. Where statements instruct the learner
regarding how to change a response (e.g. ‘You need to hold it like
this’), they specify the task and are best considered in Quadrant 1as
Explicit Instruction and Explanation rather than feedback.

Physical prompts
While physical patterning can provide a kinesthetic blueprint of a
motor pattern to be elicited by the learner, other less explicit physical
prompts have also been shown to be useful.
Facilitation that guides the initiation of movement, or provides
direction at various points during the response, embodies the
characteristics of Quadrant 2. Such strategies support the learner to
make successful efforts, but do so in a manner that engages him or
her in the decision-making process.
Physical prompts can vary in form. demonstrated the use of physical
prompts in response to delayed movement initiation as an in
complete cue to the response required. Such cues provided some, but
not all, information required for successful performance, by helping
to initiate movement, but leaving the learner to monitor and adjust
the trajectory.

Physical prompts
Normal movement approaches to the treatment of clients with
abnormal tone have focused on the use of key points of control to
guide and direct the learner’s active movements. Two defining
features of this type of strategy are apparent: that the learner is
required to be actively engaged in planning and generating the
response, and that prompting is offered only after the learner is
given an opportunity to respond independently of the facilitator

Non-verbal prompts
Other forms of non-verbal prompts are also typical of less direct
teaching methods. Learner performance can be initiated, modified
and terminated by an array of gestural, symbolic and sensory inputs
from the facilitator. For the most part, these take the form of facial
expressions, eye gaze, hand and finger movements, and various
forms of touch.
Non-verbal prompts can be used to engage the learner in decision-
making by alerting him or her to a need for action, but without
specifying exactly what that action might be. An essential feature of
non-verbal prompts is that they are presented by the facilitator
rather than the learner.

Think-aloud modelling
While modelling of physical skills can be provided through
demonstration, guidance on the use of cognitive strategies can be
illustrated using think-aloud modelling. In this strategy, the
facilitator audibly describes the decision-making processes that are
occurring as he or she performs the task. Dialogue describes the
recognition of errors (e.g. ‘Uh-oh, some-thing’s gone wrong’), as
well as the problem-solving process.
By verbalizing his or her thoughts, the therapist can encourage
clients to understand and imitate the use of self-instructional
strategies.
While demonstration of physical skills has been shown to provide
the learner with task-specific information, think-aloud modelling
makes the necessary decision-making processes more overt. For that
reason, it is best conceptualized within Quadrant 2

Quadrant 3 — Direct, learner-initiated strategies
The term self-regulation is used in this context to describe all overt
and covert learner-initiated strategies, including audible self-talk
and internalized self-monitoring processes. Early forms of self-
regulation include learner-initiated self-prompting to focus on the
key features of performance. These features might be procedural
(such as the steps of the task), outcome-focused (the goal of the
task), or strategy-based prompts (tactics related to the
performance).Observing the changes that underpinned the learning
process

Self-regulation is fundamental to participation in educational,
vocational and leisure pursuits, making it a desirable part of the
learning process. Learning is a complex phenomenon involving the
interaction of affective, cognitive and metacognitive processes
The affective component establishes the context for learning. It
consists of the volitional and attitudinal characteristics of teacher
and learner, as well as the interpersonal relationship between them
Affective variables influence the way in which the learner engages
with the other two processes. Cognitive strategies are task specific
and help the learner to process and manipulate information.
Metacognition has been defined as ‘knowledge of one’s cognitive
abilities and processes related to thinking’

Metacognitive strategies are executive in nature and are used to
evaluate learning behaviors. In short, affective variables create the
learning climate, cognitive strategies formulate responses, and
metacognitive strategies monitor them.
Both cognitive and metacognitive strategies can take a variety of
forms, some of which are explicit and overt, and others that are
internalized. The strategies employed by the learner included in
Quadrant 3 are noticeable to the facilitator, while those
characteristic of Quadrant 4 are not. The defining feature of these
groupings is not the content of the strategy, but the degree to which
its use is obvious to others.

Priming
Priming and practice are related but distinct concepts. The goal of
practice is to increase the capability to perform a skill in future
situations. While practice is an essential part of the skill acquisition
process, it is not a learning strategy in its own right. Rather, practice
is an opportunity to implement and/or respond to strategies in an
environment that is contextually and temporally appropriate to the
stage of learning.
Priming strategies, by contrast, aim to bring together the various
performance components prior to performance. There is a
distinguish between those strategies that involved repeating
procedures that were already learnt (practice), and those that
involved analysis, manipulation and application of cognitive
strategies to enhance learning (priming).Priming strategies rehearse
learned procedures to ensure that the intended response is the
correct one.

Priming
The goal of priming, then, is to prepare performance rather than
improve it.
Priming strategies use physical and/or verbal procedures to organize
a response that meets the temporal and contextual demands of the
imminent performance.

Mnemonics
Mnemonics are associative learning strategies that enable learners
to increase their capacity to store and retrieve information.
Mnemonics aid recall of key features, processes, facts and
procedural steps. They include the use of link words, acronyms,
nonsense phrases and rhymes. suggested that mnemonics are most
useful if they incorporate episodic, contextual, associative or
categorical recall cues, so as to provide either nearness in meaning
to recall data, or personal relevance.
Although a facilitator might aid in the development of a mnemonic,
its use becomes the responsibility of the learner, making it
characteristic of direct, learner-initiated strategies.

Verbal self-instruction
Thinking out loud’ can provide observers with evidence of
engagement in cognitive and metacognitive processes.
It is generally acknowledged that verbal self-guidance can be an
integral part of the move towards autonomous performance for
some individuals on some tasks. While for many individuals self-talk
might occur spontaneously, it can also be facilitated through the use
of think-aloud modelling.
Scripts differ from verbal self-guidance in that they are recitations
of the procedural steps required, rather than an audible dialogue of
the decision-making process. Rote script strategies can be
considered together with verbal self-guidance under the more
general term of verbal self-instruction. Such tools support both
cognitive (e.g. memory) and metacognitive (e.g. self-monitoring)
processes

Visual cues
Visual strategies used by learners to recall steps or to prompt action
also serve to orientate the learner to key features of performance. A
series of visual strategies including mind maps, graphic organizers,
visual displays and computer-assisted instruction that have been
used with students with learning disabilities in secondary
classrooms.
The effectiveness of a range of self-management strategies
including picture cues, computer-generated visual prompts and
object cues in enabling occupation for people with disabilities.
Several studies have provided evidence of the success of visual self-
prompting strategies, including the use of mirrors and video, in
enabling the performance of both children and adults with
disabilities

Kinaesthetic self-prompting
There is a paucity of literature discussing the use of kinaesthetic
self-prompting strategies to enhance or direct attention during
learning. Such initiatives might involve the learner touching a
picture cue to orientate to it, tapping the desk to redirect eye gaze or
touching a body part to prompt its use. Although the use of these
strategies can be identified in clinical practice, the absence of
discussion in the literature may suggest that such prompts are not
normally apart of the learning process for most individuals.
Nevertheless, they are another strategy that might promote self-
regulated learning for some clients
The definition of kinesthetic relates to learning through feeling such
as a sense of body position, muscle movement and weight as felt
through nerve endings.

Quadrant 4 — Indirect, learner-initiated strategies
When learners do not exhibit signs of self-prompting during
successful performance, they can be considered to be functioning in
Quadrant 4. While this can be representative of autonomous
performance, it is not necessarily indicative of occupational goal
attainment, as mastery of many skills may be necessary before
occupational performance goals are met. Nevertheless, a reduction
in the use of overt self-instruction corresponds to an important stage
in the therapeutic encounter

Quadrant 4 — Indirect, learner-initiated strategies
The fading of mediators as part of the internalization of self-
regulatory strategies. Private speech was thought to give way to
inner speech, which marked a progression from the overt self-
guidance of earlier stages of learning to internalized cognitive and
metacognitive processes.
Inner speech is thus a sophisticated form of verbal self-instruction.
It can be used to engage in a range of cognitive and metacognitive
processes. Covert cognitive strategies that help the learner to process
and manipulate information include mental imagery and problem-
solving. Metacognitive strategies that help control thinking and
direct the use of cognitive skills include three major covert
processes: self-instruction, self-questioning and self-monitoring
Metacognitive strategies refers to methods used to help students understand the
way they learn; in other words, it means processes designed for students to 'think'
about their 'thinking'

Mental imagery
Mental rehearsal has been advocated as a means of helping the
learner to focus on task-relevant skills. As a learning strategy,
various forms of mental imagery can support decision-making,
planning and other cognitive strategies. Although mental imagery
may exhibit subtle signs of engagement (e.g. closing of eyes, failure
to respond to stimuli), it is a process that occurs entirely within the
learner’s mind, making it best represented in Quadrant 4

Self-instruction
The use of inner speech to direct the learner’s actions is symbolic of
the internalization of verbal self-instruction strategies. Self-
instruction helps to direct the use of problem-solving strategies
Self-questioning
As with self-instruction, inner speech can be used to engage in silent
reviews of performance, development and critique of plans of action,
and clarification of goals. Self-questioning utilizes internal dialogue
to analyze information and regulate the use of cognitive
Self-monitoring
Self-monitoring processes enable the learner to use specific
strategies appropriately, analyze their effectiveness, critique
performance and assess the need for modification

Problem-solving
Various cognitive processes are employed for solving problems
Planning, judgement and reasoning. Individually, each of these
processes can be used in either observable or internalized ways to
overcome difficulties in performance. The synthesis of these
processes in deciding on a course of action, however, is a covert
process

Automaticity
A final, autonomous stage of learning where performance appears
unregulated by cognitive or metacognitive activity. Responses are
not resource-demanding and appear to take on an involuntary
nature. Although fundamentally formed to describe well-learned
motor behavior, the term can be extended to describe other habitual
responses.
In each case, contextual and temporal features are detected and
processed without impacting on attentional load. As automaticity
develops, processing is said to occur without the forms of
internalized self-prompting that mediated earlier autonomous
stages. Responses become routine, consistent and predictable, and
occur in the absence of conscious effort.

Intermediate strategies
Teaching–learning approaches are employed in occupational
therapy as a means of developing key skills relevant to occupational
performance goals. Target skills would normally be those elements
that are within the capability of the client during the current
intervention.
Since learner needs change as skill acquisition continues, the
strategies employed at any point should change to mirror the
learner’s requirements.
While the learner might not have needs in each of the four
quadrants, some general progression towards autonomy in key skills
is anticipated. At the same time, performance might fluctuate from
one occasion to another, making the selection of appropriate
strategies a fluid process that is temporally responsive to need.

Intermediate strategies
Some strategies do not fall neatly within the boundaries of each
quadrant of the 4QM, and can best be conceptualized as lying on the
border of two quadrants. They might perform dual functions, or link
the content of one quadrant to that of another.
For clients making slow progress towards mastery, or for those not
demonstrating a previously attained level of performance, the use of
intermediate strategies can provide a way of encouraging the learner
to focus on other aspects of his or her learning.
Three forms of intermediate strategies are discernable

Leading
Incomplete statements that challenge the learner for completion
(e.g. ‘Next you need to … (pause)’), partial demonstrations, physical
assistance (guidance that leads movement initiated by the client),
and some forms of questioning (e.g. ‘What part of your body should
you use to overcome that problem?’) reflect characteristics of both
task specification (Quadrant 1) and facilitation of decision-making
processes (Quadrant 2). These strategies might provide effective
links between the information-giving strategies of Quadrant 1 and
the thought-provoking strategies of Quadrant 2. As such, they can
be described as leading strategies. Such tactics challenge the client
to become more engaged in the learning process by collaborating
with the facilitator to develop the solution.

Orienting
Strategies that share the characteristics of Quadrant 2 and
Quadrant 3 help orientate clients to the need for self-regulated
learning strategies. For example, a facilitator might point in the
direction of the learner’s picture cue chart, or ask, ‘What could you
look at to remind yourself?’ as a means of encouraging him or her
to use it to self-prompt.
Intermediate strategies like these can be termed orienting strategies.
They are facilitator-initiated and include verbal and non-verbal
strategies that provide no information to the client apart from a
suggestion to use self-prompting(Quadrant 3) procedures to focus
on key aspects of performance

Fading
A process of sub-vocalization (whispering) that facilitated the
internalization of ego-centric speech. This can be identified as a
form of fading that provides evidence of the internalization of
Quadrant 3 strategies, without being representative of the covert
self-instruction of Quad-rant 4.
Gestural prompts (such as counting silently on the fingers) serve the
same purpose of internalizing procedural prompts through a
different modality. A further form of fading is evidenced when a
sequence of picture prompts is chunked into a single picture that
represents multiple steps in task performance

Zone of Proximal Development
• Use of Scaffolding
• Use less intense prompts whenever possible
• Set the client up to succeed, not to fail
• Reinforce successive approximations
• Use partial participation strategies
• Up the “ante” gradually
• Pair the old behavior with the new behavior
• Gradually withdraw your support

How to move through the quadrants:
• Leading strategies
• Orienting
• Fading
Phase of Learning
Q1: Acquisition
Direct- Explain
Demonstrate
Physically Guide
Verbal questions to focus attention
Q2 Acquisition
Problem-solving questions Leads to Fluency
Feedback
Prompts
Think aloud

Phase of Learning
Q1: Acquisition
Direct- Explain
Demonstrate
Physically Guide
Verbal questions to focus attention
Q2 Acquisition
Problem-solving questions Leads to Fluency
Feedback
Prompts
Think aloud
Q3 Maintenance
Mnemonics
Visual cues
Self-prompting
Q4 Generalization

How to move through the quadrants:
• Leading strategies
• Orienting
• Fading
How to determine which quadrant/strategy to use?
• What are the core tasks that need to be mastered to enhance
Occupational Performance?
• How does the person currently do the task?
• Does the person have the essential performance components
(strength, dexterity etc)

Goal/Behavioral Objective Writing
• To ensure that everyone is clear on:
• The target objectives for the student
• The expectations under which the objective should occur
• The criteria under which the goal will be met
• How the objective will be addressed
To ensure that important target skills are addressed for a student
• Write goals for deficit areas
• Write goals for important functional life skills (social, engagement,
and independence- ‘alternate domains’ )
• Write goals to target challenging behaviors
• Write goals so that the student can meaningfully participate in
regular classroom/home activities

Reminder SMART Goals
S – SPECIFIC: what, why and how are you going to do it
M – MEASURABLE: evidence that the goal will be achieved i.e.
data collection
A – ATTAINABLE: goal needs to be challenging but reachable
R – RELEVANT: goal should measure outcomes not activities
T – TIME BOUND: deadline that the goal needs to be achieved by

Components of a behavioral objective
1. Identify the learner (i.e. John will….)
2. Identify the target behavior
a) exactly what the student will be doing
b) Ensures that we are consistently observing the same bx
c) Facilitates continuity of instruction
d) See or hear bx or see or hear direct product of the bx
Target behaviors
• The verb used to describe behavior should be directly
• Observable
• Measurable
• Repeatable

Dead Man’s Test
• Goals should be based on OBSERVABLE behavior
• If a dead man can do it, it’s not a good observable behavior
• Child will not get out of their seat.
• Child will not hit.
• Child will not run in the hall.
Components of a behavioral objective
3. Identify the conditions under which the behavior will be displayed
a) Verbal requests or instructions
b) Written instructions or format
c) Demonstration (model)
d) Materials to be used
e) Environmental setting or timing
f) Manner of assistance

• Goals need to be functional
• Think short term and long term (priorities for life)
• Be careful with cognitive/academic goals (these can be hard to
make functional)
• Goals need to be attainable
• Able to be met within the IEP year
• Consider PLOPs (where the student is now/baseline)
• Consider what is developmentally appropriate
• Consider your students phase of learning (acquisition, fluency,
generalization, maintenance)
• Goals can be written for more than acquisition

Systematic Instruction: Major considerations for planning
The student’s primary learning and performance characteristics:
• the number of skills the student may acquire
• the complexity of the skills the student may acquire
• the number of instructional opportunities and the amount of time
• needed for the student to acquire skills
• potential forgetting and need for recoupment
• the student’s ability to transfer and generalize skills; and
• the student’s ability to synthesize.

Other considerations
• physical ability
• sensory processing
• social/emotional states
• motivation factors
• preferences for interaction
• creativity traits and preferences;
• learning styles

Other considerations
• physical ability
• sensory processing
• social/emotional states
• motivation factors
• preferences for interaction
• creativity traits and preferences;
• learning styles
Setting clients up for success
By providing instruction that is:
• Direct and explicit
• Errorless
• Matched to client’s achievement level

Structure is a powerful antecedent
• The physical arrangement of a class or pediatric clinic, home
• Each area should have visual boundaries that are free from
distractions. Dividers are great for keeping students from getting
distracted from what is going on in other areas.
• VISUALS VISUALS VISUALS!
Visuals!
• Visual daily schedules so that the students know what to expect for
the day.
• Visuals that label each area of the room
‐ E.g. play area, the work area, the computer center, etc.
• Visual rules
‐ No more than 5, all stated positively
• Visuals that show where everything goes
‐ E.g. pictures that show where each toys goes in the play area, for
where to crayons go, etc.
‐ This shows students that everything has a place. Additionally, it
helps teach them to independently clean up.

Environment
• Natural vs. Prosthetic
• Therapeutic
• Physical and social
Routines and Schedules
• Routines and schedules need to be taught directly.
• Routines and schedules may vary.
• Based on level of children’s interest.
• Should be inherently flexible (to allow for fire drills, field trips, etc.).
Routines are important because:
• They influence a child’s emotional, cognitive, and social
development
• They help children feel secure
• They help children understand expectations
• They help reduce behavior problems
• They can result in higher rates of child engagement

Routines and Activities
Social routines
1. Play with objects/constructive
2. Pretend Play
3. Physical play
4. Social games
Caregiver routines
1. Comfort related
2. Dressing related
3. Hygiene related
4. Food related
5. Fishing with Granddad

Routines and Activities
Community activities
1. Library
2. YMCA
3. Park
4. Going to Grandparents
Pre-academic routines
1. Reading books-shared reading
2. Songs and rhymes
3. Computer, TV, video
4. Art play
5. Early numeracy

Interactions across routines
• Prepare child for activity
• Announce what and what will happen
• Place materials appropriately
• Use special adaptations
• Provide opportunities to communicate
• Provide opportunities for use of movement strategies
• Encourage sibling and peer interaction
• Provide opportunities for participation
• Provide consistent prompts/cues
• Provide appropriate feedback
• Wait for child to respond
• Let the child know the activity is finished

General teaching techniques
• Demonstrating
To show
• Describing
To give an account or representation in words
• Encouraging
Helps with perseverance through difficult tasks
Praise can become meaningless and irritating
Helping is NOT taking over
Positioning items and people in the environment
• Facilitating/scaffolding
Providing temporary guidance and support to learners moving from
one level of competence to another (providing just right challenges)
• Feedback (Provision of information before, during, after an experience)
• Modelling (Learning by coping the behavior of others)
• Questioning

High rates of positivity 4:1
Be specific.
Respond positively to appropriate behavior immediately after it
occurs.
Use a variety of positives
Telling and Instructing
• Direct instruction
• May become bored/ passive
• Picture instructions may be used.
• Stories are good ways of teaching new skills.
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

Outcomes of Teaching
• Increasing “access” to locations, settings, activities
• Increasing “participation or engagement”
• Increasing child’s enjoyment of an activity or routine
• Promoting maintenance of newly learned skills
• Decreasing behavior that interferes with participation
• Building relationships/or skills to develop relationships
• Promoting learning of targeted skills
• Promoting generalization of new skill across new family members,
settings, new routines

Antecedent strategies
• Adaptations to the visual, auditory, and positioning aspect of the
physical environment.
• Level of support that you need to provide for the child to be
successful.
• The natural occurring steps in a routine or activity serve as a
powerful antecedent.
• The antecedent conditions should increase the probability that the
targeted behavior occurs.
• The antecedent conditions should be a natural part of the activity if
possible.

Behaviors
• Determine the child’s behavior that is being targeted.
• Break the behavior down into small sequential steps if the student is
not successful.
• The specific form being targeted may need to be “shaped” into the
final, targeted form.
• The child may need supportive accommodations.

Consequences
• The consequences should be directly related to the antecedent and
the behavior.
• Select highly motivating toys, interactions, food initially
• Different potential motivators should be continuously assessed to
avoid satiation.
• Generalized consequences may need to be considered for older
children.
• The consequences for challenging behaviors need to be assessed to
determine the function the behavior is serving

Antecedent procedures
1. Prompting
2. Shaping
3. Modelling
4. Task Analysis
5. Chaining
6. Errorless learning
Prompting Three basic types
1. Auditory prompting
‐ Verbal instructions and sound signals (e.g. time buzzer)
2. Visual prompting
‐ E.g. gestures, demonstrations, hand signs, pictures, drawings,
schedules, highlighted words
3. Physical prompting
‐ Lightly tapping a students arm to gain attention, hand-over-hand
guidance, manual assistance

Prompting
• Speeds up the learning process
• Reduces frustration
• Used in a hierarchy
• Must be faded
Prompting
• Increasing assistance
‐ Least to most
• Decreasing assistance
‐ Most to least
• Graduated guidance

Recommended procedures for using physical guidance
• Exert no more force than is needed to move the students hand in a
desired direction.
• At the start of each trial, use the minimum force needed (a touch),
building slowly until the students hand starts moving.
• Decrease guidance when movement begins and continue decreasing
as long as movement continues.
• If movement stops, increase force gradually until it begins again.
• If the student resists or pulls away, apply just enough pressure to
keep the hand motionless. When resistance ceases, gradually apply
enough pressure to guide the hand.
• Provide verbal praise during guidance only when the student is
actively participating; not when student is resistant or passive.
• Follow the exercise through to completion; do not quit or interrupt
before the final step.
• Use either shadowing or spatial fading once guidance has been
reduced to a touch.

Hierarchy of Prompts
Prompt Hierarchy Levels
• Independent
• Indirect (Verbal or Nonverbal)
• Direct Verbal
• Gesture
• Modelling
• Partial Physical Assistance
• Full Physical Assistance

Fluency
• Accuracy and speed
• Quality and pace
• Doing the right thing without hesitation
• Automatic or ‘second nature’ response
• True mastery
Techniques for teaching fluency
• Practice!
• Reinforcement scheduling
• Ensure sufficient learning opportunities.
• Use assessment data to make future instructional decisions.
Therapeutic use of feedback
• Extrinsic feedback
‐ Usually verbal form
• Intrinsic feedback
‐ Received through senses

Rationale for practice
• Behaviors that aren’t practiced do not become habitual and do not
become fluent
• Behaviors practiced successfully in context, under circumstances
closely resembling real situation, are more likely to be demonstrated
in real situation
• Practice provides opportunities to be successful
Generalization
• Learning to perform the skill in situations other than training
situation
• The goal is to extend the skill to other environments
• Promoting Generalization
• Extend training to other environments
• Reinforce generalized use of the skill
• Recruit reinforcement in other environments

Maintenance
• Learning to perform the skill after teaching has ceased
• Goal is to perform the skill when necessary in the natural
Environment
Promoting maintenance
• Ensure that you are teaching functional or useful skills
• Over learning
• Thin the reinforcement schedule
• Delay the rein-forcers

Teaching self-management
Reduced reliance on therapist initiated external cues
Occurs through:
• Collaborative dialogue
• Modelling
• Role pay
• Performance feedback via videotape
• Community-based instruction

Self-determination
• The person acts autonomously, of his/her own preference
• Free from external influence
• The person’s behavior is self-regulated
• The person acts with the belief that they have the capacity to do a
good job
• The person acts with knowledge of their strengths and limitations.
• e.g. making suggestions and voluntarily helping others

Self-determination: underlying elements
• Actively seeking information
• e.g. gaining attention, asking questions
• Expressing oneself
• e.g. disagreement or satisfaction
• Initiating activities without adult prompting
• Planning one’s own use of time
• Controlling conditions and outcomes
• e.g. adjusting environment to seek comfort, negotiating with
parents, teachers, coworkers, etc.
• Contributing to situations
• e.g. making suggestions and voluntarily helping others

Underlying Performance Components
• technological skills
• initiative
• self-advocacy skills
• choice making
• decision making
• problem solving
• goal setting and attainment
• self-observation skills
• self-evaluation skills
• self-reinforcement skills
• self-management
• an internal focus of control
• positive feelings about one's ability
• self-awareness
• self-knowledge (e.g., of preferences)
• independence
• persistence

Self-determination people with intellectual or
multiple disabilities?
• NOT independent performance
• NOT absolute control
• NOT always successful behavior
• NOT self-reliance and self-sufficiency
• NOT just skills or just opportunity
• NOT something you do
• NOT a specific outcome

Fostering/promoting self-determination
• Long term commitment
• Integral part of transition planning
• Team must understand components of self-determination
4 necessary components
1. Know the student
2. Option-rich lifestyle
3. Systematically teach skills
4. Supportive contexts

Putting it all together
• Assessment
• Objectives/goal setting and priority
• Teaching strategies/lesson planning
• Moving through the 4 quadrants and phases of learning.
• Setting up for success
• Progress check
• Next steps

What to teach?
• Assessment:
– Identify individual and functional strengths and needs by asking
the client/family:
• Personal Profile
• Home Life
• Community Activities
• Work History
• General Education Curriculum
• Future Hopes and Dreams
• Functional Needs
• Priorities
• Think COPM
• Peer inventory
• Community inventory
• Gather information from team members
• Permanent records and prior information

Evaluate by observing
• Can be planned or spontaneous
• Can be anecdotal or formal
• Can be through video, dialogue about past events, interviews,
reports, or live observations
Evaluate by observing: Questions to ask
Options include
• Observe and take notes to talk at a later time?
• Comment and ask questions as things occur?
• Then model some strategies and techniques?
• Video tape so that we can review together?

Evaluate by observing: Questions to ask
• Could you show me how you ____?
• Let’s give ____ a try, would that be ok?
• Would you like me to try it and then you take a turn?
• Do you feel more comfortable trying this when I am not here?
How to decide what to teach?
• Communication Skills
• Self-help skills
• Personal and Social Skills and Values
• Creative and Critical Thinking
• Technological Skills

Developmental approach
• Established scope and sequence of typical development
• Comparison to norm deficit-based assessment
• Access through readiness
• Progressive order (simple to complex) of development
Functional approach
• Based on skills learned by typical students and essential life skills
• Predetermined scope and sequence
• Access through readiness

Ecological approach
• Based on the relationship between students skills and the
environments frequented
• Skills chosen through social validity
• Constantly evolving as student progresses
• Age appropriate skill development
• Context-specific instruction relevance to the student’s present and
future environments
Teaching priorities using ecological approach
• Should be determined by transdisciplinary/collaborative process
• Goals should be relevant to:
‐ maintain health and vitality
‐ enhance participation in current and future inclusive environments
‐ increase social interaction, including interaction with peers

Goal setting using ecological approach
• Maintain health and vitality
• Enhance participation in current and future inclusive environments
• Increase social interaction, including interaction with peers
• Have frequent or multiple applications across a variety of
environments and activities;
• Be essential for further development;
• Be a student priority, which includes individual preferences or
interests;
• Be a family priority; and
• Be a priority of a significant person in a target environment

Establish a thorough client profile
• Learning style is considered
Student learning profile should include:
• Cognitive - memory, generalization skills, categorization
• Physical - general health, medication, motor control
• Sensory - hearing, vision, tactile preferences
• Social/emotional - temperament, interaction skills
• Motivational - what encourages performance? tangibles? praise? A
activities?
• Interactional - prefers small groups over large groups
• Creative - likes music, art

What Phase of Learning?
• Acquisition
• Fluency
• Maintenance
• Generalization
Setting students up for success
How?
- Appropriate instructional tasks and task level
- Analysis of skills and routines
- Appropriate prompts, cues, and fading
- Appropriate feedback
- Plan for generalization

The Instructional Process - Acquisition
• The skill or routine itself
• Task analysis
• I do, we do, you do
• Best method of presentation/teaching
The Instructional Process – Fluency and Maintenance
What comes after instruction?
• Therapeutic use of feedback
- Progress monitoring
• Therapeutic use of practice!

Feedback
• Be explicit
‐ Be enthusiastic
‐ Language level
• Reinforcement
‐ Natural vs. contrived
‐ Shape responses
• Generalization

The Instructional Process – Generalization
Three forms of knowledge:
1. What: factual information about a topic
2. How: procedures for using the information in specific ways steps to
follow to complete a task
3. When: when and where to apply the information
The Instructional Process – Generalization
• Teach the range of examples
• ‘How to’ vs. ‘when to’
• Authentic practice is the key to Generalization

Teaching for generalization
• Strategy checklist for student to use
• Identify the cues to trigger the use of the skill
• Encourage other instructors to coach the skill
• Standardize routines across settings
• Pair rewards with naturally occurring reinforcement
• Expand student responses
Strategies to promote independence
• Can’t Do vs. Won’t Do
• Methods of prompting
• Choice making
• Schedules

Prompt Hierarchy
• Least restrictive
Visual
Gestural
Indirect-verbal (keep going)
Direct-verbal (get the towel)
Modelling
Physical guidance
• Most restrictive

Reducing prompt dependency
• Use systematic routines
• Use natural cues
• Use wait time
• Plan to fade prompts
Self reinforcement
Administering a reinforcement to yourself after you have reached
your goal!
Requires:
• Self imposed criteria of performance established before monitoring
• Self determination that the performance criterion has been met
prior to reinforcement
• Free access to rein-forcers

Occupational Therapy and Reinforcement (part 3)

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