INDIVIDUALIZED THERAPY

Purpose of Study

The children and adolescents (hereafter called “students”) that we serve have had years of traditional therapy prior to coming to Devereux Glenholme, with limited success.  A substantial percentage of these students present with social skill deficits, and/ or disruptive behaviors.  These students lack positive skills to meet their needs in socially acceptable manners.  In order to address this, clinicians frequently model skills, give directed modeling assignments by identifying skilled peers for the student to observe, and role-play with the child.  With this approach, the student will often learn to perform these skills one-on-one with a preferred adult, but they may not be able to utilize these skills in other contexts.  Therefore, when faced with the environmental triggers (e.g. peer provocation, socialization opportunities, task demands) that have typically led to maladaptive behavior, the student may not utilize their newly learned skills.

“Individualized therapy” focuses on assisting children in developing and utilizing skills.  Initially, skills are demonstrated and practiced in one-on-one sessions within an office.  Children are then coached by clinicians to use these skills in the child’s environment, thus the clinician joins the child in the classroom or cottage prompting them in real-life situations.  Ultimately, these skills will be coached using “bug-in-ear” equipment, providing the least intrusive and most realistic intervention.  With this approach, skill acquisition and generalization are addressed simultaneously. 

The Individualized Therapy Model

Individual Sessions (Teaching): Clinicians meet with students in one-on-one sessions to develop treatment plan goals and objectives, establish rapport, discuss personal issues that may be causing discomfort or distress, and to begin skill instruction.  During these sessions, the student and clinician identify the situations where the student is most likely to have difficulty, and the consequences that may be maintaining that behavior.  The student and clinician also determine alternative responses to these situations which will meet the student’s needs (e.g., provide the same maintaining consequences).  Through the processes of problem-solving and role-playing with their clinician, the student will identify and begin to practice more adaptive coping skills.

In-vivo Sessions (Coaching): In order for students to begin learning and generalizing the skills that they have identified in individual sessions to the settings where they are most needed, clinicians observe and interact with the student in their own environment.  While in the student’s environment, clinicians predict for the student the emergence of socialization opportunities or environmental triggers for maladaptive behavior, and cue the student to utilize the skills that have been identified in individual sessions.  Following the student’s socialization attempt or utilization of a coping skill, the clinician provides constructive feedback regarding the student’s performance, including discussion of both successes and further learning opportunities. 

All in-vivo feedback and coaching is provided in as discreet a manner as possible.  Thus, while interacting within the student’s environment, the clinician coaches or provides feedback on performance in such a manner as to not be overheard by the student’s peer group.  Ultimately, live wireless video cameras are used to observe and listen to children interacting in real-life situations while the child is equipped with an ear-bud connected to a walkie-talkie.  The clinician observes from a remote location and prompts and verbally reinforces the child through the walkie-talkie for utilization of their targeted replacement behaviors when exposed to a trigger.

How this Model Differs from Other Approaches

The literature was scanned to find models similar to what was envisioned for Individualized Therapy.  The closest match was Goldstein’s work with Skill Streaming, however, this maintains a heavy emphasis on cognitive instruction, modeling, and role-play of scripted scenarios and skills, all of which has been ineffective with the children served.  Our approach places a far stronger emphasis on cueing and reinforcement of skills in the child’s natural environment, thus prioritizing acquisition and generalization.  It also provides for in-the-moment modifications, through video and audio technology.  Specific studies were not found measuring an approach such as In-Vivo sessions for the population that we are serving.  The purpose of the current study is to analyze data that we collect while providing this service in order to determine whether this model of therapy is producing positive changes for the students that we serve.

Methods

Participants
Participants were a sample of children and adolescents enrolled in the specialized boarding school program at Devereux Glenholme between June 2006 and June 2007.  Participants in the treatment condition were selected based on the implementation of the treatment model by the clinician during the period of time studied.  Those who had begun In-Vivo sessions prior to December 2006 were excluded from the treatment and matched-control group conditions, as no baseline data were available.  Students in the treatment condition were selected for treatment by the clinicians and/or clinical director based on their behavioral and clinical presentation.  Randomization did not occur.  Those in the matched-control group were selected based on a presentation similar to the treatment condition, and will start In-Vivo sessions at the conclusion of the current study. 

Variables
During In-Vivo/ Coaching sessions, clinicians keep counts of the frequency of targeted behaviors on a tracking form.  This form becomes the session note for the child, so that when the session is over, the therapy note is already completed.  This form is used to track the first three dependent variables listed below.

Problem Behaviors- Clinicians keep track of the frequency of targeted problem behaviors displayed by the student during the session on their session note/ In-Vivo form.  These targeted problem behaviors are the behaviors that the skills being coached are designed to replace.  The display of a target behavior is therefore interpreted as a missed opportunity to display a replacement behavior.

Cued Replacement Behaviors- Clinicians track the frequency of replacement behaviors displayed by the student during session immediately following a visual or verbal prompt by the clinician.

Uncued Replacement Behaviors- Clinicians track the frequency of replacement behaviors displayed by the student during session without a visual or verbal prompt provided by the clinician.

Treatment Plan Objective Progress Rating- eCET records were reviewed for ratings of attainment of treatment plan objectives.  Ratings in rank order were:

Results

Based on our analyses, students receiving In-Vivo sessions have demonstrated reductions in the frequency of targeted problematic behavior (see graph 1).   Students receiving In-Vivo sessions have also demonstrated increases in utilization of targeted functional replacement behaviors (see graph 2) as measured by the display of uncued replacement behaviors, and progressively less reliance on prompts or cues in order to display these behaviors (see graph 3) as measured by the display of cued replacement behaviors.  Most importantly, children receiving In-Vivo sessions are obtaining more of their treatment plan goals (see graph 4) as measured by the percentage of students rated as making “excellent progress” on their treatment plan objectives when compared to a matched-control group that has not yet received In-Vivo sessions.

GRAPH 1: Problem Behaviors Displayed Per Coaching Session

GRAPH 2: Uncued Replacement Behaviors Displayed Per Coaching Session

GRAPH 3: Cued Replacement Behaviors Displayed Per Coaching Session

GRAPH 4: Progress on Treatment Plan Objectives by Type of Therapy

Discussion

While social skills can be taught in a structured one on one or group setting, it has been noted that many students do not generalize the skills outside of these sessions.  In-Vivo sessions have allowed the clinicians to assist students in progressing towards meeting their goals at a faster rate than they would without this service, and to simultaneously focus on the generalization of the newly learned skills.  Clinicians work with the child in the child’s environment, thus naturally addressing the triggers for problematic behavior that are often missed during traditional therapy sessions. 
This leads to greater customer satisfaction as the student is able to progress further in meeting their goals then they would without this service.  Parents, educational consultants and funding sources have been impressed with the program’s ability to assist the students in this way.  It is a service delivery method that makes a great deal of intuitive sense, but one which is not utilized in the population which we serve.  It is particularly beneficial for the high number of students with social skills deficits in our program.

Various approaches are utilized with the students during In-Vivo sessions.  These are determined by assessing what the student responds best to.  The wireless video and bug-in-ear technology provide for the least intrusive coaching and are beneficial in fading the stimulus of the clinician to further enhance generalization. 

The clinician reviews the progress that the student is making and assesses the ability to generalize the skill to the home setting.  During family sessions and/or in-home consultations, the clinician reviews the technique with the parents and teaches them how to apply it with their child.  This has been an effective approach which encourages parent participation in the treatment process.