Content area
Purpose
This study aims to explore the impact of precision teaching (PT) on living skills in an individual with Dravet syndrome (DS). Focusing on a core case of a 14-year-old with DS, it assesses the role of PT in mastering the daily living skill of putting on a jacket, integrating a component-composite approach.
Design/methodology/approach
The research adopts a within-subject design, emphasising the transition from component skills to composite skills in daily living tasks. Using an environmental modification, it tracks the participant’s progress in putting on a jacket pre- and post-PT intervention.
Findings
Significant enhancements in the independent execution of putting on a jacket were observed, highlighting PT’s effectiveness in refining living skills in DS. The study offers valuable insights into the component-composite framework of skill acquisition and the use of environmental modifications.
Research limitations/implications
While improvements were noted, the study suggests further research to promote the long-term sustainability of PT’s impact on living skills in DS.
Practical implications
The study underscores PT’s practical benefits in enhancing daily living skills among DS individuals. It provides a strategic model for educators and therapists focusing on skill development.
Social implications
This research emphasises the importance of specialised, effective teaching methods like PT in fostering independence and quality of life for individuals with disabilities, advocating for tailored educational approaches.
Originality/value
This investigation examines the efficacy of PT for developing living skills in DS; it contributes novel perspectives to special education and therapeutic interventions.
Introduction
The present study explores the effectiveness of precision teaching (PT) as a method to improve specific motor skills in individuals with Dravet syndrome (DS). This complex neurological condition requires targeted pedagogical approaches. DS represents an uncommon type of epilepsy that begins in childhood and is marked by recurrent and extended seizures along with psychomotor and neurological impairments. These complications can significantly disrupt social interactions and adaptive behaviours (Brunklaus et al., 2012; Steel et al., 2017; Vascelli et al., 2021; Vascelli and Berardo, 2022).
The effectiveness of PT in enhancing motor skills in individuals with intellectual disabilities is supported by various studies. Vascelli et al. (2020) explored the effects of Big 6 + 6 skills training on the daily living skills of an adolescent with intellectual disabilities, noting significant improvements. Abd Aziz et al. (2022) used video modelling to improve manual dexterity in students with learning disabilities, offering a perspective on using PT and related methods to improve specific skills. Bryson and Zea (2023) examined the effects of motor fluency on dressing tasks and the reduction of escape behaviours, suggesting that PT may help reduce challenging behaviours while improving practical skills. Vascelli et al. (2023) demonstrated how using PT can improve daily living skills in adolescents with intellectual disabilities, emphasising the role of repeated practice of component motor skills in increasing the frequency of issuing composite daily living skills.
In PT, analysis of the relationship between components and composite skills is crucial. This approach focuses on developing and strengthening specific skills (components or element skills), which combine to form more complex and global skills (composite or compound skills). A study by Twarek et al. (2010) shows that repeated practice of component motor skills improves speed and accuracy in performing composite daily life skills in autistic children. This result confirms that refining individual components can significantly impact global skills, supporting the idea that acquiring smooth, automated skills in smaller tasks facilitates mastery of more complex skills (Twarek et al., 2010; Vascelli et al., 2020). These studies illustrate how the analysis and training of component skills in PT are critical to improving more complex composite skills, providing a basis for targeted and effective educational and therapeutic interventions.
When working with people with disabilities, it is often necessary to use environmental modification (or Prosthetic Environments; Binder, 1996; Lawton, 1970; Lindsley, 1964, 1965). They are described as environments designed to maximise the behavioural efficiency of people who exhibit behavioural dysfluencies in mainstream environments. Using an environmental modification can effectively compensate for fixed disabilities in daily activities by addressing space management issues and individual differences. Considering the relevance of environmental modification in compensating for fixed disabilities, this study aims to explore how applying PT may facilitate improvement in specific tasks, such as putting on a jacket, for individuals with additional needs. Vascelli et al. (2023) indicate a future research focus on the effectiveness of PT and frequency-building strategies on different composite life skills for people with disabilities. The purpose of the present study was to evaluate whether an intervention involving the use of PT to bring a component skill found to be deficient to a fluent level could improve the frequency of performance in the composite skill of putting on a jacket for a 14-year-old boy with DS.
Method
Participant
Paul, a 14-year-old boy with DS, participated in this research after his parents provided informed consent. Because of his frequent seizures, he required continuous adult supervision. Paul attended school for 25 h per week, assisted by a specialised teacher. For three afternoons a week, he participated in rehabilitative therapies at a learning centre aimed at improving his daily living, verbal, academic, and behaviour management skills. Paul presented with severe psychomotor difficulties, autistic traits, deficits in visual function, as well as motor and orthopaedic difficulties. He was chosen for the study because he could not put on a jacket independently; Paul’s family had unsuccessfully tried various strategies to develop this skill. At the time of the training, he still needed assistance to complete this task.
Setting, materials and data collection
Practice timings and composite skill probes occurred in an Italian learning centre’s room. A generalisation probe occurred at the participant’s home. No other individuals except the therapist, the experimenter, and the parents were present during the generalisation probe.
Materials used included a table, two stools, a container with several pieces of Lego inside, each about 10 cm long, a timer, and a smartphone to videotape the sessions. We used a long-sleeved jacket with a zip, provided by the family, that Paul usually wore in the winter months. All timings and probes were recorded on a data record sheet and charted on an electronic Standard Celeration Chart.
Experimental design and dependent variable
In the study, we employed a within-subject design to measure, evaluate, and promote behavioural change in the participant (Twyman, 2014). We used probes on the composite skill throughout all study phases to monitor progress and guide intervention. The primary dependent variable was the correct and incorrect responses per minute. Behavioural metrics were also calculated, namely celeration, a frequency-derived measure quantifying the direction and magnitude of performance changes across time (i.e. count/per unit of time/per unit of time). Performance increases across time are depicted with the multiplication symbol (x), while decreases with the division symbol (÷). Celeration values near x1.00 suggest no change in performance across time, while celeration values on or above x2.00 are considered the gold standard in PT (Johnson and Street, 2012).
Procedure
Baseline.
Initial measurements. In this phase, we observed the frequency of performing the composite skill, precisely putting on a jacket hanging on a coat hanger. We made three observations without providing any help to the participant while performing this skill. We videotaped the observations to allow for more precise and accurate frequency measurement and to identify component skills to be trained. Considering the collected results, we verified that the participant could not put on the jacket when placed on the coat rack.
Composite skill. Due to Paul’s difficulties in initiating the behaviours required to put on the jacket, we adapted the environment to assist him. We developed the task analysis to put on the jacket, considering the environmental modification where the jacket was placed on the table and Paul standing in front of the jacket. This adjustment allowed Paul to begin the actions needed to put on the jacket. The structure of the task analysis is shown below:
grabs the edge of the jacket (resting on the table) with the right hand;
slightly lifts the jacket;
slips the left arm into the sleeve while leaning slightly towards the table;
returns into an upright position;
pulls the jacket towards himself with his right hand;
feels for sleeve hole with right arm; and
tucks the right arm entirely into the sleeve.
We measured the frequency of the steps completed independently during free operant sessions.
Component skill. Observations showed that the participant struggled to complete steps six and seven of the identified behavioural chain. Therefore, we developed training to support Paul in improving the frequency of performing these two steps. The training involved Paul sitting on a backless stool with a table in front of him and the experimenter sitting beside Paul. The experimenter placed a small object slightly under the participant’s right shoulder blade and asked him to pick it up and place it in a container placed on the table in front of him. In this way, Paul had to rotate his right arm to reach the object, thus performing a movement similar to that required to complete the critical steps in the behavioural chain.
We then measured the performance on the same task of three students with similar characteristics as Paul and two therapists. The results allowed us to identify the range for AIM to be achieved, which was set between 20 and 28 movements per minute. We set the mastery criterion at three consecutive sessions with a frequency of correct responses with values within this range.
Intervention.
Probes. The intervention began by making probe measurements relative to the composite skill. We performed the probes using the multiple opportunity method (Cooper et al., 2020). The experimenter instructed the participant to wear the jacket; if the participant independently completed the intended steps, the experimenter provided no consequences. If the participant failed to complete the predicted step within 10 s of the discriminative stimulus (i.e. completion of the previous step), the experimenter completed the step (i.e. positioning the sleeve hole near Paul’s right arm) and instructed the participant to continue in the behavioural chain. Probe measurements continued following the introduction of component skills training and upon achievement of the intended aims. We conducted probe measurements three times a week before introducing component skill training and approximately once weekly during and after the training. We conducted the probes at the beginning of the intervention sessions before any training scheduled for the sessions took place.
Component skill training. We used a Feel-Reach learning channel set to teach Paul the correct movement; he was required to extend his right arm backwards to reach for the Lego the experimenter held slightly under his right shoulder blade. Before initiating the exercise, the experimenter encouraged the student, saying, “Paul, let us count how many times you can get the object.” The timer was set at 30 s and started when Paul initiated his first movement. The experimenter offered verbal encouragement for every two correct actions during the exercise, such as “Good!” or “Keep it up.” After Paul successfully placed the object in a container placed on the table before him, the experimenter quickly held another Lego slightly under Paul’s right shoulder blade. After the timing, the experimenter gave additional specific praise, such as, “Very well! You are doing a great job at extending your arm because praise has been functioning as a reinforcing consequence in the past. In addition, to provide a preferred consequence to increase the behaviour targeted, the experimenter arranged for Paul to have access to a preferred activity after each timing. For each incorrect response produced during the timing (e.g. performing an incorrect movement with the arm), a correction was presented at the end of the timing; the experimenter presented the request (“Paul, get the object”) and used a physical guidance procedure to get Paul to produce the correct response. The number of timings for each session changed depending on the participant’s performance, with a minimum of two and a maximum of 10 timings. A subsequent timing was administered if the participant’s score in the final timing matched or surpassed the score from the day’s initial timing. Conversely, if the score decreased, we ended the session (Vascelli et al., 2023, 2024).
RESA.
For learners to become fluent, they need to meet specific criteria, including metrics for retention, endurance, stability and application, collectively known as RESA (Fabrizio and Moors, 2003). Retention is the ability to perform after a hiatus from practice. Endurance is the capacity to sustain performance over extended durations. Stability is the ability to maintain performance amidst distractions. Finally, application demonstrates trained behaviours in response to new, untrained stimuli. When Paul reached the aim for the component skill frequency, we measured retention, endurance, and stability.
We conducted endurance measurements for the component skill by conducting one timing three times the usual duration (1 min:30 sec) in the learning centre’s room. We conducted stability and retention measurements on the composite skill. Stability was measured in Paul’s home to evaluate performance in a different environment than the one in which the training was conducted; the retention measurement was taken approximately one month after training on the component skill in the learning centre’s room. We measured stability and retention using the same procedure during probes: recording the frequency of correct steps per minute. All RESA checks were conducted by the experimenter. We didn’t measure application.
Inter-observer agreement
We determined inter-observer agreement (IOA) based on the total count for 100% of the probes on the composite ability, obtaining an average agreement of 97% (range: 95%–100%). As for the component skill training, IOA was calculated for 58% of the sessions, recording an average of 99% (range: 94%–100%), and for 100% of the checks on RESAs, with an agreement of 97% (range: 96%–100%).
Results
Figure 1 shows the results for composite and component skills (measured in the environmental modification condition). For composite skills, the initial tests showed a deceleration for correct responses of ÷1.14. We observed a deceleration of responses, with a trend in the counter-therapeutic direction. The average frequency of correct responses was 1.22 per minute. During the training on the component skill, the celeration for correct responses was x1.38. A change in the therapeutic direction of the celeration of correct responses was noted.
Upon concluding the training on the component skill, we conducted final probes. These revealed an acceleration for correct responses in the composite skill of x1.04, indicating a minimally accelerating trend in the therapeutic direction. We recorded an average frequency of correct responses of 29.44 per minute. In the context of the stability check, we determined the response frequency to be 23.33 per minute. Similarly, we recorded a response frequency of 12.41 per minute during the retention evaluation. For component skills, 25 sessions were required to reach the mastery criterion. The acceleration of correct responses was x1.13. Therefore, the response trend was in the therapeutic direction as the frequency of correct responses increased during the continuation of the training. The endurance check recorded a frequency of 20 correct responses per minute.
Discussion
The present study explored the effectiveness of PT in increasing the frequency of performing the composite skill of putting on a jacket in a 14-year-old boy with Dravet syndrome, a condition characterised by significant cognitive, behavioural and motor dyfluencies (Brunklaus et al., 2012; Steel et al., 2017; Vascelli et al., 2021; Vascelli and Berardo, 2022).
Regarding response frequencies relative to the composite skill, the average frequency of correct responses shows an overall improvement, rising from 1.22 to 29.44 per minute, indicating effective learning. During the stability check, the response frequency decreased to 23.33 per minute, suggesting a slight loss of skill when practised in a different environment. In the retention test, the response frequency decreased to 12.41 per minute, indicating that, although learning has occurred, maintaining learned skills over time is a challenge. Regarding component skill, after reaching the expected frequency range, the frequency of correct responses in the endurance check was 20 per minute, suggesting a good ability to maintain skills under stress or for extended periods. In summary, these results suggest that training focused on specific component skills can be very effective, but the challenge remains in maintaining and generalising these skills over time.
The results of this study find support in the literature regarding the effectiveness of PT in improving motor skills in individuals with various disabilities; the use of PT can help to increase speed and accuracy in the composite skills of adolescents with intellectual disabilities, both in terms of fine and gross motor skills (Abd Aziz et al., 2022; Bryson and Zea, 2023; Vascelli et al., 2020, 2023). These results align with our study, where we observed significant improvements in the participant’s ability to wear a jacket independently. These improvements suggest that PT may be effective for developing specific motor skills, even in individuals with Dravet syndrome. Such consistency in results strengthens the argument that PT and frequency-building are valid and versatile interventions for improving motor skills in various contexts.
In the context of our study, analysis of the relationships between composite and component skills was critical to identify which specific (component) skill needed to be improved to positively influence the performance of a more complex, global (composite) skill. This approach focuses on developing and strengthening specific component skills, which, when improved, combine to form more complex composite skills. For example, the study by Twarek et al. (2010) shows how repeated practice of component motor skills improves speed and accuracy in performing composite daily life skills in children with autism, confirming that refining individual components can significantly impact global skills. In our case, we identified and improved a critical component skill, which led to improvements in the overall ability to wear a jacket, demonstrating the effectiveness of this approach in the context of Dravet syndrome. Behavioural prostheses (Binder, 1996; Lawton, 1970; Lindsley, 1964, 1965), which is the process of adapting the environment to facilitate learning and execution of specific skills, significantly improving performance and, consequently, developing greater autonomy for Paul. In this case, placing the jacket on a table rather than on a coat rack offered the participant an alternative option that made it easier for him to perform an otherwise complex task. This environmental modification helped reduce physical and cognitive obstacles, allowing the participant to focus on learning the specific skill of wearing the jacket. In addition, dividing the composite skill of wearing a jacket into smaller steps made it possible to assess the dysfluent component skills, allowing the development of practical training to teach Paul a life skill that was important to him.
We believe that the objectives of this intervention were socially important. We taught Paul a socially important behaviour, especially with the environment modification. Reaching these objectives allowed Paul to better function in the environment he frequented. The effects of this intervention were socially significant: the family reported a decrease in the time needed to put on the jacket and the support needed to complete this activity in the home context. This case is a clear example of how slight modifications can significantly impact supporting people with disabilities.
Limitations
Despite the positive results, it is essential to recognise the limitations of our study, mainly related to its research design, which does not allow a definitive functional relationship to be established between the intervention and the observed improvements. A further limitation is a slight deterioration in performance; this factor raises questions about the sustainability of improvement without continued or reinforced intervention. Finally, we needed to assess the level of treatment integrity.
In summary, our study adds evidence to the effectiveness of PT in improving motor skills in individuals with Dravet syndrome, highlighting the potential of this approach in special education and rehabilitation. Further research is needed to explore the use of PT in various settings and for individuals with different needs.
Compliance with ethical standards.
Conflict of interest: No authors have a conflict.
Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent: Informed consent was obtained from all individual participants in the study.
Availability of data and materials: The authors confirm that the data supporting the findings of this study are available within the article.
Figure 1Results for composite and component skills
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