Working with clients with disabilities is often as fun as it is challenging. It is very rewarding, particularly when he or she achieves a goal that the client has contributed to. Sometimes, it is difficult to figure out what that goal or task might be, other times, he or she figures out how to tell you. It might be as simple as tying shoes or as difficult as cooking a meal. In my opinion, cooking a meal is more difficult due to the safety issues involved. Another concern is the method that we teach them to do the task and communicating that successfully to both the client and the caregiver.
In therapy sessions, it is often helpful to create a video of the task with the client. It is also helpful to provide some sort of prompt schedule. Both methods are recommended for each task, I would like to discuss the video component first. Videos become important for the following reasons:
1. The therapist becomes the model for the caregiver and the client.
2. The caregiver can learn the prompts that the therapist uses to help the client learn to complete the targeted task.
3. The client can review the task as it was learned and problem areas can be addressed.
4. Generalization of the task to other areas, locations and included in other larger tasks, i.e., shoe tying as part of dressing in the morning.
Let’s take the example of shoe tying. A client [with Autism and limited language skills] is trying to tie his shoes. The client becomes perseverative [repetitive] at the knot tying step. For the therapist, it is clear that the shoe tying method needs to be adapted so that the client can circumvent the step or move past the step. Prompts need to be individualized so that the client can consistently follow the steps. A method of demonstrating the task by the therapist is important for the caregiver and an additional segment with the client completing the task is reinforcing. Clients are often proud of accomplishments and their ability to successfully communicate the desire to achieve that task. He or she will demonstrate their pride by watching the video over and over. This may also become perseverative and it is important to build on each new success.
Videos with the therapist, as instructor, should be made from the client’s perspective. In other words, the camera should be placed above the shoe and the shoe should be positioned so that it is in the same direction as when the client will tie the shoe. The heel of the shoe, or back of the shoe, should be toward the client or bottom of the viewing screen. In that way, the hand movements appear the same, as if the client were moving his or her hands. A tripod becomes very important part of each therapist’s bag or tricks. Videos can also be inserted into a PowerPoint presentation which maybe the caregiver’s preferred method of prompts.
The next step is to develop prompts [verbal, visual, and/or gestural] that will trigger the correct motor response from the client. For the shoe tying client, it was important to circumvent the initial knot when tying the shoe. A knot was placed at the point of pinch to form the loops. Using the double loop method of shoe tying, the client was prompted to pinch the knots; make two loops; make an “X” with the loops; then one loop goes over the other through the space (bottom of the “X” created by the loops) then pull. Hold the loops; make an “X” with the loops; one loop over the other; through the space and pull. Once the client is successful in the task, the video is made of the client completing the task.
When developing the prompts, the method of delivery becomes an important factor to determine. A number of methods are available from simple technology [pencil, paper and scissors] to tablets, iPads and computers. Whatever method is chosen should be easy to use and modify by both therapist and caregiver. These methods can include:
1. Acronyms
2. Simple list
3. Checklist
4. Simple line drawings of each step on a prompt board.
5. True object pictures [photographs] of each step, again, on a prompt board.
6. True object pictures in a PowerPoint program with or without a video.
7. Using a tablet and app to develop prompts using pictures or graphics.
The method of training should also be explored, remain consistent and included in the video. The methods can be a forward chaining model in which the steps are taught from beginning to end. Another method is called backward chaining. In backward chaining, the steps are completed by the trainer from the beginning and the client completes the last step. As the client becomes more successful, the next to the last step is added to the training and so on. There is also the consideration of a schedule of reinforcement, if required. This should be discussed with other team members including the caregiver.
So as you can see, working with clients with a disability can be as rewarding as it is challenging. With organization and planning, clients with a disability can achieve great success. We need to be very organized, patient, encouraging and kind in addition to being firm in our expectations. Therapists also need to be adaptable and look for clues as to what our clients want to learn. The more open a therapist is to his or her client, the more successful the client becomes.