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Training, models of implementation, the role of assessment and data collection are all a part of our philosophy statement.

Introduction

In developing a training program for a client we consider the developmental level, the functionality of skills and ways to normalize the environment.

Human development is comprised of a series of processes and tasks that are sequenced and that occur within certain age ranges and stages for all people. When the individual seems most receptive to stimulation and growth, we call that readiness. Development proceeds in a building block fashion so that mastery of early tasks is a prerequisite for more complex skills later.

When we discuss a functional approach, we mean teaching the client those skills that he is ready to learn and that will have meaning and be useful to him in his everyday environment (i.e., learning vocabulary that parallels self-help skills being taught rather than the names of exotic animals).

Normalization reflects a philosophy that attemtps to make the lives of the developmentally disabled as much like the lives of everyone else as possible. In a residential facility that translates to a commitment to improve the quality of life by making it less institutional and more like life outside of the institution. It also implies a commitment to provide opportunities for more decision-making, more choices, and for a broader array of experiences away from the facility when possible.

We find that tying these three concepts together through assessment we can discover where the client is functioning within the developmental sequence, what abilities he has and where his deficits lie - how and under what conditions he learns best. With this information we can then develop training goals that will have meaning for the client in his daily life, making him as independent and social as possible. We then enrich the environment with a variety of experiences both in and out of the facility that support the training goals.

Methodologies

Given that one of the most important models for training of skills appears to be based on a developmental frame of reference, the next question is "how to implement these developmentally necessary sequences?" Many different models are possible; however, only three are discussed here. These models represent those most frequently used in client training. Each model is defined by the degree and type of interrelations among the disciplines serving the client.

The first model, the multidisciplinary approach, may be characterized by little or no interrelationship between services. Within such a model, the programs and procedures are independently designed by each separate service. Since there is no coordination of programs and procedures at the clinical level, the client is fragmented or "parceled out" to various components of a daily activity schedule. With such an approach, there is great emphasis on one-to-one programming. As seen, the multidisciplinary approach is neither pragmatic (1:1's) nor philosophically acceptable (fragmentation of the client).

The second, and somewhat more acceptable, is the Interdisciplinary approach to training. In such a model, the various services begin to communicate with each other although training is still separate. For example, the client may learn to say "ball" in his/her speech program and to play with a ball during the recreation program - but there is no direct carry-over from one program to the other. The client remains fragmented but not so completely as with the multidisciplinary approach. Again, with the interdisciplinary model, there is emphasis on one-to-one programming but small groups are not directly prohibited. As with the multidisciplinary approach, the interdisciplinary model is neither pragmatic nor philosophically appealing.

The most compelling model for client training is the transdisciplinary model. Such an approach focuses on the totality of the client, emphasizing the mutual design of programs by all clinical services. These activities (programs) would have mutually compatible goals and objectives for the client since each service was involved in the initial design. This design would be derived from the needs as assessed by each service.

How People Learn

In order to help our clients learn new skills, we need to be aware of how people learn so that we can make certain that we are providing a climate in which growth and development can take place.

Before learning can occur there are some things that need to be in place. The client has to feel secure, knowing that his basic health and safety needs are being cared for. The environment has to be conducive to learning - quiet but stimulating. For most our clients a great deal of noise and chaos create confusion. And finally the client needs warmth and affection, to feel that someone cares about what he does.

We all learn from experiences and activities that have meaning for us. We learn by participating, by performing a task over and over so it becomes a part of our repertoire. We learn through trial and error and by being reinforced for correct and/or appropriate responses. We learn by becoming aware of the consequences of our behavior. An important step in the learning process occurs when the individual is able to generalize a skill learned in one situation to other relevant situations. We need to be certain that there are opportunities for the person to model, to perform the task over and over again. We want to make sure that the task has been sequenced in small steps, that there is consistency in the teaching process. Then, and only then, can we be certain that we have given the client every chance to realize whatever potential he may have - one of the primary responsibilities of all of us at NVTC.

The Role and Importance of Assessment in Relation to a Curriculum A curriculum is nothing more than a logical and systematic set of procedures for training skills.

The obvious questions become (1) "What skills should we teach?" and (2) "Where do we begin?" We don't want to spend valuable training time teaching skills the client already does. Likewise, we don't want to spend the same valuable training time teaching skills that are drastically beyond what the client is currently capable of doing.

The answer to these questions and dilemmas is to assess the skills of the client. An assessment is an evaluation of where the client is currently functioning with respect to specific skills. In other words, an assessment is an objective statement about those skills a client is currently capable of performing and the conditions which are necessary for those skills to be demonstrated. Obviously the assessment tool must be compatible with both the curriculum and data collection system in order for all facets to interface properly. Once the assessment is completed we are ready to implement the training program.

Implementation

Based upon the results of the assessment, the ID Team selects skills from a number of areas that help lead the client to further independence and a richer life. These areas may include such skills as communication, socialization, leisure time, etc. Often, these skill areas are taught as completely separate entities.

Example:

Indeed, there are times when it is appropriate to do this; however, skills become more functional and are more likely to be generalized if they are taught and are used in relation to other skills. The four skill areas used in the above example could be combined and presented as a game or as play. Variations can be designed so that staff can offer clients choices.

Certainly, one-to-one teaching situations are ideal, and some things can only be taught in a one-to-one model. However, for us the weakness of one-to-one training is that only a small number of clients can be programmed daily while the remainder are unsupervised with no activity. A system that seems to be more successful at NVTC is small groups scheduled several times a week for one half hour to one hour depending upon the functioning level of the clients. On some units the small groups move from one module to another. In this system clients spend time at a variety of leaning stations. Time at each station varies according to the attention span of the client and the interest being shown. Generally, each module emphasizes training in a particular skill area; however, the modular style makes it easier to work on several skill areas at the same time because they are being handled in the framework of that period of time.

Types of Tasks

In teaching skills, there are at least three major strategies for combining or choosing various activities.

Teaching a skill by using functional tasks. An example might be to teach sorting objects (skill) by having clients separate their laundry into various piles such as socks, pants, shirts, etc. (activity).

Teaching a skill by using social game format. In such a format, the use of a skill is made to be fun for the client. However, in general, only activities or tasks which can be generalized should be selected. An example might be to teach appropriate clothing selection (skill) by holding a fashion show (activity).

Teaching a skill by repeated practice tasks. In such a strategy or format, the client is given many opportunities to practice the skill. Clients usually require many sessions of repeated practice in order to acquire, master and maintain a skill. If the opportunity to practice a skill is available to the client only once a week, for example, retention of the skill and further acquisition of the skill are likely to be very poor. On the other hand, as more opportunities to practice a skill are available to the client, there is greater retention and further acquisition of the skill. One method of securing more practice for the client is to coordinate unit programming with the client's day program so that the client has multiple opportunities to practice a skill and also to generalize the skill in at least two locations.

Implications for Unit Programming

A critical component of unit programming is good organization of time and materials. A central and easily accessible location of materials needs to be identified. Materials, as they are used up or worn out, need to be restocked and ready for use so that staff do not have to spend valuable training time searching for materials or unnecessarily organizing the materials.

Data collection, although essential to document the client's progress or identify specific problems, cannot be the sole purpose or programming. Collecting data too often can directly interfere with the client's learning process as staff become more involved with the mechanics of data collection rather than the teaching of the skill. For example, gross motor data could be collected on Monday, communication data on Tuesday, etc. Days when the responsible clinician is scheduled to participate in unit programming are ideal data collection days. Although organization of time and materials and data collection systems are important aspects of unit programming, the most crucial component is determining the number of staff available for programming on any given day. Programming should be designed based on the minimum number of staff expected rather than the maximum. On those days when more than the minimum number is available, the program remains the same; only the staff-to-client ratio changes. To design unit programming around the minimum number of staff available will assure greater frequency and consistency of programming.

Data Collection

In any set of training procedures (i.e., curriculum), data are necessary to substantiate progress of the client toward specified goals. In other words, data are on-going progress assessments. Without data, the progress is determined by subjective impressions which may vary from person to person - and may even be conflicting. Data are based on observable events of the client's behavior and are documented as such. Granted, there may be some residual subjectivity even in these observations; however, if everyone is following the same procedures, progress (data) should be observable to everyone and subjectivity is minimal.

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