Using Music and Applied Behaviour Analysis to Introduce an Adaptive Mobility Device to a Student with Multiple Disabilities: A Case Study

Joey was six years old when he started kindergarten in a life skills classroom in a public school setting. He qualified for special education services as a student with congenital blindness and intellectual disability. Joey had the gross motor skills necessary for walking but had skipped crawling entirely which made transitional movements very difficult for him. Protective reactions that children typically master in their first year had yet to develop. Joey engaged in a great deal of self-stimulatory behaviour, such as rubbing and patting his face and body, waving his hands in the air, and clapping them together.

At the beginning of this study, Joey was not motivated to engage in independent tactile exploration of objects or his environment. If he encountered an object, then he would either ignore it, mouth it, or throw it. He required extensive hand-over-hand support in order to use objects in their designated manner, for example stacking blocks or placing them into a container. He did not exhibit tactile defensiveness and frequently brought an adult’s hands to a specific part of his body he wanted rubbed. This indicated that he had some body awareness. A multisensory approach that incorporated concrete object symbols, with no delay between auditory information and presentation of action or object was recommended by the assessment, review, and dismissal (ARD) committee.

Joey was assigned an O&M instructor who spent a great deal of time building rapport with him, and assessing his preferences, strengths, and sources of anxiety. Though Joey received many services at school, he only attended on a part-time basis because of the additional therapies he received outside of school hours. As is often the case with students who have multiple impairments, Joey’s frequent illnesses led to even more absences from school. His initial O&M lessons focused on room familiarisation and learning the simple route from the classroom door to his seat. He used trailing with his right arm as a means of locating landmarks. Joey’s team confirmed that he responded to music and soothing voices, and that repetition and consistency yielded results. It became apparent that loud noises led to anxiety and more frequent and severe self-stimulation. Through consultation with the occupational and physical therapists, a simple movement routine synchronised to music was developed to reinforce Joey’s body awareness. It was noted that these music sessions helped relax Joey to a large extent.

An important topic discussed at Joey’s IEP team meeting was the need for independent travel which would begin with learning to grasp an AMD. The supportive verbal prompt objective for everyone who worked with Joey was to incorporate the same simple vocabulary, “reach” and “hold” into their respective activities. During O&M lessons, Joey was told to “reach” as he trailed the wall. Additionally, a piece of PVC with cane grip material was presented during lessons so that he could become accustomed to holding it.

An AMD called the T-Wheeler cane was custom built for Joey because it provides additional feedback and protection when walking (Figure 1). A traditional long cane has a single tip that touches the ground at one point of contact, whereas the T-Wheeler cane’s wide base provides a higher probability of making contact with objects which addressed one of Joey’s objectives. The heavier base of the T-Wheeler cane also decreased the likelihood that Joey would lift the cane off the ground and wave it in the air. The accompanying IEP goal was “to improve Joey’s walking skills by walking with an assistive device and supervision (with only verbal cueing) on smooth level surfaces, at least 50 feet.” Joey began his lessons by simply holding the T-Wheeler cane in front of his body every time he exited his classroom with his O&M instructor.

Figure 1.

There were several factors to consider when planning O&M lessons for Joey. First, Joey did not grasp objects continuously unless a pleasant stimulation resulted. For example, he liked to touch things that vibrate. Second, Joey’s stimming behaviours were also interfering with holding items such as the cane. Joey constantly craved sensory input and his hands were the most convenient source. Finally, while he had a basic understanding of cause-and-effect, it was unlikely that he would understand the purpose of holding a cane or receive any pleasant stimulation from doing so.

Music was a soothing positive reinforcer for Joey and used to encourage him to hold his cane. Lim (2010) noted that music stimuli can function as antecedent variables and automatic reinforcement. In this case, various songs were played for Joey so that his reactions could be noted. A favourite walking playlist was collected for Joey using an iPhone. These walking songs differed from the movement routine music so as to not confuse Joey.

A simple O&M routine was developed and implemented at the beginning of the spring semester which continued over 16 weeks comprising 13 weekly sessions (Joey did not attend school during weeks six, seven, and eight). Each lesson began with Joey retrieving his AMD from the same location by the door with the instructor’s support. The two exited the classroom holding the AMD using the hand-over-hand teaching method. Once outside, the instructor said, “time to hold” and started Joey’s playlist. Using hand-over-hand the instructor supported Joey to hold the cane during the first 3 – 5 seconds of the music while repeating the word “hold.” Then the instructor released Joey’s hand. If Joey opened his hand, then the instructor immediately stopped the music. The music reinforced the grasping of the cane. In this way, the antecedent, A, the need to self-stimulate, was minimised by soothing music. If the behaviour, B, opening the hand occurred, then the consequence, C, stopping of the music, was applied. Each time the AMD was dropped, Joey, with the instructor’s physical assistance, bent down to pick up the AMD, and the pattern was repeated. In order to minimise fatigue and boredom, only a portion of each O&M lesson focused on AMD use. The lesson followed an I-route (return) which is a straight line of travel with no turns that began outside the classroom door. The endpoint was determined based on student stamina. Relaxing and fun activities for example, spinning with support or songs were completed at the end of the I-route. Then the AMD was used to return to the classroom door.

Thirteen O&M sessions were completed over16 weeks. Data were collected that revealed the (i) frequency Joey opened his hand and released the AMD (ii) duration of the O&M session (iii) duration of the AMD session and (iv) distance between each release (in feet) (Table 1).

Table 1.

During the first session Joey walked less than two feet before opening his hand. It took a long time to physically guide him to bend down and pick up the AMD. The routine was repeated two more times and the longest distance covered between AMD releases was only nine feet. Less than 15 minutes was spent on the AMD routine and the remaining O&M time was spent in engaging in the familiar, relaxing movement routine.

Progress was relatively consistent. The AMD portion of each lesson increased to about 25 minutes in the seventh session. This was broken down as follows: 10 – 12 minutes AMD usage in one direction; 10 minutes of relaxing and/or fun activity at midpoint; 10 – 12 minutes AMD usage back to classroom; 10 minutes of a relaxing activity. The midpoint fun activities could be spinning, familiar movement routines in standing positions, or clapping and singing. The maximum distance covered between AMD releases also increased consistently. In the sixth session, there was no change in the number of feet between releases and an increase in the number of releases during the session.

Joey did not attend school for three weeks between the fifth and sixth sessions. The O&M instructor noted that there were several false starts in session six, but ultimately, the number of feet between the last two releases was back to the previous maximum of 20 feet. During session six, a condition was altered to support Joey’s independence. A strap was added to the cane grip to prevent the AMD from falling to the ground upon release. Joey started working on re-grasping the cane independently and was successful in session 11. This made it more difficult to discriminate how frequently releasing occurred in future sessions. During session seven, the music started to be faded out. Upon return from the midpoint, music only played until Joey had the strap around his wrist and the AMD in his grasp. The tenth session was the first session where music was not used during the entire route, but only at the midpoint and endpoint activities. Joey met his IEP goal during the thirteenth session.

Applied behaviour analysis in the form of descriptive A-B-C observation data was successfully used to change behaviour in the student with disabilities. When introducing an AMD to a student, it is important to identify individual behaviours and whether or not these need to be increased, like grasping, or decreased, like releasing. Understanding the student’s temperament and preferences is crucial for determining optimal lesson times and appropriate reinforcers. Joey was able to meet his IEP goals of holding an AMD for 50 feet with only verbal prompting. Manipulating the self-stimulation antecedents Joey enjoyed encouraged positive behaviours in cane holding and travelling with the consequence of increased independent travelling.