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- v.13(4); 2020 Dec
- PMC7666261
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Behav Anal Pract. 2020 Dec; 13(4): 955–960.
Published online 2020 Aug 7. doi:10.1007/s40617-020-00471-6
PMCID: PMC7666261
PMID: 33269205
Luca Vascelli,
1,2 Silvia Iacomini,1 Giada Gueli,1 Carlo Cavallini,1 Iris Pelizzoni,1 Francesca Cavallini,1 and Federica Berardo1
Author information Copyright and License information PMC Disclaimer
Abstract
The current study evaluated the effects of training Big 6 + 6 motor skills on untrained daily living skills. Precision teaching suggests that improved speed of component behaviors can lead to better performance of composite skills. Researchers used a pre-post probe single-subject design to evaluate the effects of frequency building on the motor tasks of push and grasp, as well as the associated effects on the composite skills prior to and following intervention on the component skills. Results suggest that the participant increased his frequencies on all of the component skills. The speed and accuracy of composite skills were higher following the intervention. Researchers also assessed for generalization to other significant contexts.
Keywords: Big 6 + 6, Daily living skills, Intellectual disability, Precision teaching
Lindsley (1992) defines precision teaching (PT) as “basing educational decisions on changes in continuous self-monitored performance frequencies displayed on standard celeration charts” (p. 51) to achieve behavioral fluency. Among its various uses, researchers have used PT to teach motor skills to fluent levels. Precision teachers often build frequencies on the Big 6 + 6, which include reach, touch, point, place, grasp, release, push, pull, shake, squeeze, tap, and twist (Binder, Haughton, & Bateman, 2002; Desjardins 1995). Precision teachers build these fine motor movements to a fluent level of mastery to allow people to complete complex tasks, such as activities of daily living (Twarek, Cihon, & Eshleman, 2010). These fine motor movements, often conceptualized as component skills, represent foundational skills required for the execution of complex tasks, named composite skills. When component skills reach a fluent level, they contribute to the growth of composite performance, and any disfluency in these components may interfere with the development of composite performance (Eastridge & Mozzoni, 2005).
Only a few studies have explored the effectiveness of interventions based on the Big 6 + 6 to improve composite skills (Eastridge & Mozzoni, 2005; Fabrizio, Schirmer, King, Diakite, & Stovel, 2007; Twarek et al., 2010). Eastridge and Mozzoni (2005) described the effects of fluency training of Big 6 + 6 skills, including reach, point, touch, grasp, place, and release, on the functional movements of impaired and nonimpaired hands in four participants who had suffered a head injury. The results of the study indicated that participants increased the functional use of the impaired, nonimpaired, and nondominant hands during the execution of the gross motor skills. In addition, participants improved their performance in carrying out daily living activities.
Fabrizio et al. (2007) implemented fluency training to teach the squeeze movement to a child with autism. Results showed that the participant’s progress in performing the component skills allowed him to engage successfully in complex skills that required the use of the new component skills learned. Twarek et al. (2010) evaluated the effects of repeated practice periods on component motor skills related to the execution of a composite skill, as well as the effects of fluent motor skills on the completion of composite skills of daily living. Results demonstrated an increase in the level of independence in the execution of daily life skills (i.e., wearing socks, wearing a T-shirt, and wearing underwear), as well as a decrease in the total time required to execute them, for three participants with autism.
Given the small number of studies that have investigated the application of interventions based on Big 6 + 6 skills for daily life in adolescents with intellectual disabilities, the aim of the current brief practice was to contribute to the investigation of the effectiveness and efficiency of fluency-based motor skill intervention for this population. Researchers investigated whether training on the Big 6 + 6 component skills would improve the frequency of buttoning a shirt once frequencies were increased on the component skills targeted for intervention. In addition, researchers wanted to investigate whether a higher frequency in performing a composite skill could lead to greater involvement in routines within the home setting.
Method
Participant, Setting, and Materials
Greg, an 18-year-old male with moderate intellectual disability, participated in the current investigation. He attended an upper fourth grade class in Northern Italy and received outpatient behavioral services from a private rehabilitation center during the summer holidays. He had persistent difficulties in performing tasks and duties appropriate for his age and an IQ of 55, measured by the Wechsler Intelligence Scale for Children, Fourth Edition (Wechsler, 2003), administered 2 years prior to the implementation of this study.
Researchers selected Greg to participate in the study because, although he was able to dress independently, it took him a significant amount of time to engage in the fine movements related to fastening his shirt. Therefore, the participant preferred clothing that was easier to wear (e.g., T-shirts) and that did not require the help of an adult.
All sessions were conducted in a private rehabilitation center room, 5.0 m × 6.0 m, containing a table and several chairs. During the sessions, in addition to Greg and the experimenter, other students were conducting rehabilitation therapy sessions. Researchers used a long-sleeved shirt, several euro coins, a round container open on top, a piggy bank, data sheets, and a timer during the sessions.
Dependent Measurements
Fastening shirt
Researchers measured the composite skill of fastening a shirt. A correct response was defined as a button fully inserted in the corresponding buttonhole. An incorrect response was defined as a button partially inserted or inserted in a nonmatching buttonhole. Researchers measured the performances using a 1-min interval and then counted the number of buttons correctly fastened during the interval.
Grasp
The component skill grasp was defined for both hands as grabbing a coin placed on the edge of a table using the thumb and forefinger. An incorrect response was defined as grabbing a coin using other fingers (e.g., middle finger, ring finger, or pinky finger). Researchers measured the performances using a 15-s interval during the intervention phase and a 45-s interval during the endurance phase, and then counted the number of coins grasped correctly at the end of the interval.
Push
The component skill push was defined for both hands as completely inserting a coin into a slot in a piggy bank. An incorrect response was defined as partially inserting or dropping the coin. Researchers measured the performances using a 15-s interval during the intervention phase, and a 45-s interval during the endurance phase, and then counted the number of coins inserted correctly at the end of the interval.
Researchers selected the specific fine motor component skills by observing the accuracy of performance for the execution of the behavioral chain required to complete the composite skill. The results of this observation showed that the component skills grasp and push warranted intervention because they were related to the execution of the steps in the chain of fastening buttons on a shirt that the participant had encountered most significant difficulty with.
Design
Researchers used a pre-post experimental design to evaluate the effects of the intervention on composite skills (Cooper, Heron, & Heward, 2007). Researchers measured the composite skill prior to and following the intervention on the component skills of grasp and pull, and took additional postintervention measures of application, stability, and retention for the composite skill. The family of the participant also received a questionnaire to record the participant’s behavior at home to assess for generalization.
Procedure
Initial measurements
During the first phase of the study, researchers measured the participant’s performance on composite and component skills during two sessions. In this phase, no help was given to the participant during the execution of these skills. The observations were video recorded in order to allow for a more precise and accurate measurement of the frequency, as well as to assist the researchers with the identification of the component skills to train.
Researchers also evaluated the performance of peers and adults in executing the target behavior. After collecting data on each peer’s performance, researchers established a range of the lowest and the highest performance level for each skill. Researchers observed a range of 119 to 134 for grasping with the right hand, 110 to 132 for grasping with the left hand, 65 to 80 for pushing with the right hand, and 55 to 65 for pushing with the left hand. With regard to buttoning a shirt, performance ranged from 8 to 10 buttons fastened. These ranges served as the frequency aims for each skill.
Last, Greg’s parents also completed a short questionnaire related to the type of family routines involving buttoning and unbuttoning a shirt that Greg engaged in, as well as the type of clothes typically chosen by the participant during the course of 1 week. The family also answered questions about the involvement of the participant in activities related to the domestic routine in which he had never participated, such as replacing pillowcases of bed pillows and fastening the closure buttons. In addition, the family monitored the choice of clothes worn by the participant for 3 weeks.
Intervention
During the intervention sessions for the skill of grasping, the experimenter asked the participant to grasp a coin, between his thumb and forefinger, that was placed on the edge of the table he was seated at, with half of the coin’s surface protruding beyond the edge in order to facilitate grasping. A total of 40 coins sat on the edge of the table. The experimenter sat next to the participant during this time and held a container in which the participant could release the coins during the session. The experimenter gave the instruction, “Let’s see how many coins you can grab,” and activated the timer when the participant executed the first behavior.
During the intervention sessions for the skill of pushing, the experimenter gave the instruction, “Let’s see how many coins you can put in the slot,” while holding the opening of the piggy bank parallel to the tabletop and keeping it in place while the participant performed the action. The participant had to insert the coins completely into the slot after grabbing them between his thumb and forefinger. At the end of the timing, the experimenter reinforced the participant’s behavior with social praise combined with descriptive feedback on performance (e.g., “Good job! You were very fast!”), as well as corrective feedback for any mistakes made. Corrective feedback entailed a model of the correct behavior.
Researchers used the following criteria for decisions: (a) each training session could include a minimum of one to a maximum of five timings for each skill; (b) if the participant reached the daily target during any timing, the experimenter would finish the session related to the skill in question; (c) if the researchers observed a downward trend at the end of the fourth timing, they ended the timings; and (d) if the researchers observed an ascending trend, they proceeded with the last timing. Researchers reported the highest frequency of each skill on the standard celeration chart (SCC) (Pennypacker, Gutierrez, & Lindsley, 2003).
Retention, endurance, application, and stability (REAPS)
Researchers wanted to investigate whether training on component skills would improve the frequency for a targeted composite skill once frequencies were increased on the component skills targeted for intervention. To test for fluent performance, researchers performed an experimental evaluation to measure the REAPS of performance (Cihon, 2007). Retention is defined as the ability to perform a skill or recall knowledge long after learning programs have ended. Endurance is the ability to maintain performance levels for extended time periods. Application is the ability to combine and apply what is learned to perform more complex skills. Last, stability is the ability to maintain performance while resisting distraction.
For the component skills, researchers only conducted endurance checks. After the participant reached his frequency aims for all component skills, researchers conducted checks for endurance. The participant engaged in three timings of the skill in an identical fashion as the intervention, but the researcher tripled their duration to 45 s. For each component skill, the researcher recorded the timing with the highest frequency on the SCC. Researchers did not do a check for stability, because the setting in which the training was conducted was full of external stimulations that could act as distractors; in fact, there were other people in the room at the same time who carried out the therapy with their respective therapists. Additionally, researchers did not do a check for retention, because it proved infeasible to interrupt the training to measure retention due to the timing of Greg’s therapies at the facility—the summer vacation was ending, and Greg would soon resume full-time schooling.
Researchers conducted application, stability, and retention checks on the composite skill. During these measurements, the participant engaged in fastening the front buttons of a shirt during 1-min timings, and researchers recorded the number of buttons fully inserted in the corresponding buttonhole. Application was evaluated immediately after the end of the component skills training by measuring the number of buttons correctly fastened during 1-min trials. The researchers used the frequency of this performance as a direct comparison to preintervention performance. To assess stability, researchers measured the performance in the presence of distracting environmental stimuli. This entailed peers asking the participant questions while he was engaged in the task. For retention, researchers measured the performance of fastening buttons 3 weeks after the end of the application sessions.
Interobserver Agreementand Treatment Integrity
Researchers calculated interobserver agreement (IOA) for 40% of the component skills training sessions, with an average value of 97% (range 91%–100%). During pre- and postevaluation sessions for the component and composite skills, researchers calculated IOA for 90% of the sessions, with an average value of 95% (range 92%–98%). Treatment integrity was also calculated for 92% of the sessions, with an average value of 94% (range 91%–97%).
Results
Figure Figure11 displays Greg’s grasping and pushing performance with his right hand and with his left hand. Greg began timed practice on all the component skills on August 11, 2019. With the right hand, performance increased from an initial 54 grasping responses per minute at the beginning of the training to 124 responses per minute (a x2.29 improvement and a x1.11 celeration). For the left hand, performance increased from an initial 60 responses per minute to 116 responses per minute (a x1.93 improvement and a x1.11 celeration). For the right hand, performance increased from an initial 32 pushing responses per minute at the beginning of the training to 72 responses per minute (a x2.25 improvement and a x1.2 celeration). With the left hand, performance increased from an initial 24 responses per minute to 58 responses per minute (a x2.42 improvement and a x1.17 celeration). The endurance checks show values of 100 grasping responses per minute for the right hand, 102 grasping responses per minute for the left hand, 48 pushing responses per minute for the right hand, 52 pushing responses per minute for the left hand.
Fig. 1
Results for Greg’s grasping and pushing. The shaded bars represent the aims for each component skill. Dots represent Greg’s frequency of correct grasping and pushing, and “x” represents the frequency of incorrect responses
Figure Figure22 displays the average results of the frequencies per minute of buttons fastened by Greg during initial measures of performance, as well as measures of application, stability, and retention of the composite skill. During the initial measurements, Greg fastened buttons at a frequency of one button per minute. The results of the application, stability, and retention measures show an equal increase in frequency to three buttons fastened per minute across all three measures.
Fig. 2
Results of the frequencies per minute of buttons fastened by the participant during initial measures of performance, as well as measures of application, stability, and retention
The questionnaire given to the family revealed that following the intervention, the participant began to collaborate in the execution of new activities related to the family routine, such as removing pillowcases from pillows, putting the pillows inside clean pillowcases, and fastening the buttons on them. Parents also reported that, as a result of the intervention, the participant started wearing the shirt twice a week without help, something he did not do before the start of the training program.
Discussion
The current brief report investigated whether an intervention consisting of repeated timed practice of the components skills of pushing and grasping could increase the frequency of fastening the front buttons of a shirt for an adolescent with an intellectual disability. Furthermore, researchers wanted to examine whether a higher level of frequency in performing a composite skill could lead to greater involvement in routines within the home setting.
The participant reached the individual goals for the component skills at the end of the repeated practice. The results obtained during the endurance measurements, however, showed a decay in performance when the participant engaged in the task for longer periods. These results are, therefore, not predictive of a completely fluent performance, confirming the results reported by Fabrizio et al. (2007). It should also be noted that not all fluency outcome checks were conducted for the component skills examined. These two elements represent limitations of the study. Future research could focus on identifying accurate frequency aims that predict fluent performance, as well as conduct all REAPS fluency checks on component skills.
The REAPS results for composite skills showed that Greg improved his performance following the implementation of component skills training, although the values remained significantly lower than those of the reference sample. Greg’s performance cannot be described as fluent, although the rhythm of execution after the end of the training is more compatible with the needs of everyday life. The study, therefore, does not empirically demonstrate that Greg’s performance showed all the fluency characteristics. Still, the progress in trained component skills was sufficient to allow Greg to engage in a broader range of everyday activities.
This result had a positive impact on an essential skill in the participant’s daily routine, as suggested by Twarek et al. (2010). In the present study, data suggest that composite-level performance generalized to daily routines and situations. The data collected through the questionnaire show an increase in the use of clothing rarely worn by Greg prior to the study, as well as increased involvement in routine domestic activities. However, readers should interpret these results with caution, as the researchers did not directly measure the generalization of performance. The information obtained from the delivery of the questionnaire does, however, represent a measure of high social validity. Consequently, this result supports the effects of PT in promoting the individual’s level of independence.
The present study lasted a total of 9 weeks. With regard to the training for component skills, the participant worked for a total of 6 weeks, with 3 days of training per week. For each skill, the total time in intervention averaged 1.15 min per day, and the total time in intervention was 74.15 min.The procedure used, therefore, appears to be economical when one compares the total time it took to produce the outcomes. Further, researchers conducted the current project during summer school run by the rehabilitation center, which included intensive client attendance during the short period of time. Thus, researchers may consider using similar procedures when professionals need to teach more in a shorter time.
Although the current project produced positive outcomes, it also has additional limitations worth noting. First, only two component skills were evaluated, so the findings are limited. Similarly, the experimental design does not demonstrate a functional relationship, thus weakening the internal validity. Pre-post designs do not allow for researchers to assess the components of baseline logic. Future studies might, therefore, include more participants or use different single-case designs that allow for tighter experimental control.
The current study contributes to research on PT, broadening the existing evidence of Big 6 + 6 procedures. Future studies could also broaden the comparison between the effectiveness of interventions that promote the emergence of composite skills using PT technology and the effectiveness of other treatments aimed directly at complex ability. An analysis, in terms of the effectiveness and efficiency of treatment and social impact, could serve as an important finding that helps practicing behavior analysts best select procedures that produce optimal learning.
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.
Footnotes
Implications for Practice
• Precision teaching (PT) on the Big 6 + 6 fine motor skills can be an effective procedure for increasing the frequency of execution of composite skills.
• Retention, endurance, application, and stability outcomes can be used to assess the effects of the training on the target composite skill.
• Interventions based on the Big 6 + 6 can be a viable strategy for promoting the independence of individuals with intellectual disabilities, through generalization of routines in a home setting.
• The procedure appears to be efficient in providing the anticipated results in a relatively short time.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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