Participant and Setting
The participant in this study was Andrew, a 12-year-old boy with Dravet syndrome. An- drew had severe psychomotor retardation and needed constant supervision by the referring adults due to frequent seizures.
He was able to produce 5-word sentences, mainly used to request activities or objects he liked. Andrew attended the first class of lower secondary schools in Italy. During his school years, Andrew had learned to name numbers up to 30 correctly and was able to place them in ascending order up to number 20. However, he was not able to order them in descending order. Andrew was able to name all the components of a face but could not position them correctly. As far as reading is concerned, he was able to name all the letters of the alphabet and read 2-letter syllables correctly.
However, he was not able to read bi-syllabic words independently. Andrew was selected to partici- pate in this study because the family requested specialist support for the continuation of school ac- tivities and behavioral management, interrupted due to the lockdown as a result of the health emer- gency. The setting was the study of Andrew's home, where there was a table, two chairs, and a lap- top computer. Materials that the mother used for school activities were on the table: notebooks, sta- tionery, colors, and sheets.
Experimental Design and Data Collection
For this study, the researchers used an experimental multiple baseline across behaviors de- sign (Cooper et al., 2007). The researchers conducted measurements on the selected skills following an interview conducted with parents during the first remote coaching meetings, specifically concer- ning the items investigating the academic areas where Andrew encountered the most significant dif- ficulties. The parents reported persistent difficulties in mathematical learning, reading, and spatial placement of stimuli. Specifically, the measurements concerned the following skills:
- order numbers in sequence;
- position eyes, nose, mouth and ears on the oval of the face;
- reading bi-syllabic flat
Each baseline and intervention session included the presentation of 5 trials, the results recorded by the researcher, connected via a video-conferencing app. For (a) each request was relat- ed to the positioning of a single number in descending order; for (b) each request was related to the positioning of a part of the face (e.g., the nose); for (c) each request was related to the reading of a bi-syllabic word.
Interobserver agreement
Researchers video-recorded all phases of the study. In the VSM phase, the experimenter (first author) and a second observer (second author) independently viewed 50% of the recordings of the trials submitted to Andrew. The two coders discussed the procedures before viewing the record- ings to reach acceptable levels of agreement. The interobserver agreement was then calculated on discrete trials by dividing the number of agreements by the number of agreements plus disagree- ments and multiplying by 100. The percentage of agreements in the VSM phase was 100%.
Treatment Fidelity
To evaluate the fidelity to the treatment, an observer (second author), viewed 40% of the trials conducted during the VSM phase, measuring the correct presentation of the DTT. Table 1 shows the check-list used. The accuracy in the presentation of the tests was 100%.
Indipendent Discrete Trials Presentation
Get the student's attention before presenting the antecedent. Present faultless antecedents, including written or vocal stimuli. Wait 5 s for the student to respond.
For correct answers, present reinforcement immediately.
For wrong answers, do not use prompts and move on to the next trial.
Table 1. Check-list used to evaluate fidelity to the treatment.
Materials
Interview. The interview administered to parents consisted of 45 Items divided into 3 main areas: (1) assessment of preferences, (2) risk assessment, (3) assessment of academic skills. The au- thors used a modified version of the Vineland Adaptive Behavior Scale (Sparrow, Cicchetti, & Saulnier, 2016), to identify the areas to focus on the telehealth intervention.
Numbers, faces, and words. The materials used for this study were: a series of flashcards measuring 6x9 cm on which were printed the numbers from 10 to 19; 10 sets of stimuli, each con- sisting of a sheet of paper depicting the oval of the face and flashcards depicting eyes, ears, nose and mouth (5 sets were hand-drawn, and 5 sets contained photographs); 40 flashcards on which were printed flat bi-syllabic words written in capital letters).
Video. The experimenter, remotely connected through a video conferencing app, recorded the work sessions, during which the mother presented the requests related to the skills in question, modeling Andrew's behavior with the necessary prompt level. During this phase, the experimenter provided descriptive feedback to the mother about the presentation of the requests, the prompt level used, and the consequences. Starting from the raw video, the experimenter edited 3 videos for each of the skills in question: the videos showed the presentation of the request, the correct behavior, and the correct consequence for its delivery provided by the mother. All the prompts used were removed from the final version of the videos used during the training.
All the videos used in this study showed mother and Andrew sitting at the table next to each other. In the videos made to teach Andrew to order the numbers in the sequence 10 flashcards representing the numbers 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 were on the table. The mother intro- duced the activity, saying, "Now we will put these numbers in order starting from the biggest one." Then she placed a flashcard in front of Andrew and asked: "What comes before 19?"; the video then showed Andrew while emitting the correct answer, i.e., while placing the flashcard representing the correct number next to the one previously placed in front of him. Finally, the mother presented ver- bal praise (e.g., "Good job!").
In the video made to teach Andrew to correctly position the eyes, ears, nose, and mouth on the oval of the face, a sheet of paper representing a person's face and other pieces of paper repre- senting the components to be positioned was on the table. The mother introduced the activity by saying, "Now we will place all the parts on the face." Afterward, the mother presented the requests related to the task to be performed: "Where does the nose go?"; the video continued showing An- drew positioning the stimulus indicated by the mother. Finally, the mother presented verbal praise. In the video made to teach Andrew to make a textual response, the mother presented Andrew with a flashcard on which was written a flat bi-syllabic word. The mother then presented the request, say- ing, "What does it say?". The video then continued showing Andrew's correct answer and the verbal praise given by the mother. All videos showed 5 trials, with different target stimuli used from one video to another.
Procedure Interview
During the first parent coaching meeting, the researchers presented a structured interview with parents. The assessment of preferences was aimed at identifying Andrew's favorite activities and showed, among others, preferences for watching videos using the tablet. From the section of the interview that was going to investigate the issue of behavior challenging to manage, it emerged that in the presence of requests related to the performance of schoolwork, Andrew tended to avoid the task, moving away from the workstation. As far as the evaluation of academic skills was concerned, researchers asked the family members in which areas encountered the most significant difficulties during the school activities and enhancement phase. Overall, the main difficulties that emerged were related to the presentation of academic requests on tasks of great difficulty for Andrew in the areas of mathematical learning, reading, and spatial placement of stimuli.
The information collected was used to design the VSM strategy to be used to improve the performance of Andrew in the academic areas identified as necessary for empowerment interven- tion. Table 2 shows the items administered that revealed the main critical areas.
Preferences assessment
Which functional items or activities are of interest to the child? Which are the dysfunctional items or activities of interest to the child?
Risk assessment
Does the child exhibit behavior that's difficult to manage? If so, when?
Academic Skills Assessment
Number Skills
Can the child place the numbers 0 to 20 on the number line?
Spatial placement of stimuli
Is the child able to place on an oval representing a face all its components?
Reading
Can the child read flat, bi-syllabic words?
Table 2. Extract from the interview used reporting the items that revealed the main areas of concern
Baseline
During the baseline phase, the mother submitted requests for the VDs measured using dis- crete independent trials; first, she got her son's attention, then presented the request, and if Andrew answered correctly, she reinforced the answer. If Andrew did not give the correct answer, she would not provide any correction and go on to submit the next request. Different target stimuli were used during the baseline and learning verification phases following the VSM procedure than those shown in the videos.
Role playing and performance feedback
Before starting with VSM, the mother was instructed to implement it through few online sessions of role playing and performance feedback. First, the experimenter plays the role of the mo- ther and the mother the role of the boy; then the roles exchanged. At the end of each session of role playing, feedback were delivered describing exactly what the mother performed correctly and cor- rective feedback were delivered specifying what was not performed correctly.
VSM
Vsm sessions were conducted in the home studio. The mother was sitting at the table with Andrew. During the instruction phase, the mother showed the recording of a test of the skill in ques- tion. At the end of the vision, she continued with other activities, such as coloring a drawing. After 10 minutes, the learning was verified: the mother presented the task previously observed on the video, using paper material with different stimuli from those shown in the videos previously ob- served. As for positioning the numbers in the correct order, the mother presented flashcards with various number sequences (e.g., 16-17-18-19-20 or 12-13-14-15-16) and asked her son to order them in decreasing sequence.
On the other hand, if the video showed the sequence to correctly place all its components (eyes, nose, mouth, and ears) on a drawn face, then the mother presented her son with photographs of different people representing real stimuli (e.g., child, adult, elderly), asking him to place them in the correct order. Regarding the reading of flat words, the mother presented the reading of flat words different from those shown in the videos. For each type of test, if Andrew answered correctly, then the mother would reinforce the answer by using social praise ("You did great!"), while if the child answered incorrectly or did not answer, then she would not provide any kind of correction and would continue with the planned activities.