How occupational therapists, physiotherapists, and speech and language therapists can benefit from precision teaching Open Access

Occupational therapists (OTs), physiotherapists (Physios) and speech & language therapists (SaLTs) all work with individuals, many with intellectual and developmental disabilities, to help them better interact with their environment in meaningful ways. Physios improve client’s function and movement when affected by illness, injury or disability (Chartered Society of Physiotherapy, 2024), OTs enable clients to live their best life at work, home and anywhere (Royal College of Occupational Therapists, 2024), and SaLTs administer care, support and treatment to adults and children who struggle with eating, swallowing, drinking and communication (Royal College of Speech and Language Therapists, 2024). Precision teaching (PT) has the potential to enable these respective professions to measure and evaluate specific clinical interventions better.

PT uses repeated timed practice of precisely defined element skills followed by a set protocol of corrective feedback called frequency building (Kubina and Yurich, 2012). This is done to build fluency in various skills, such as academic or motor skills, to improve performance on more complex compound skills that depend on those fluent elements (Binder, 1996). Fluency is on display when behaviour looks effortless and automatic, often described as having the accuracy and speed that accompany the skill. PT and frequency building have a promising literature base building fluency in foundational motor skills, known as the Big 6 + 6, to improve performance on more complex compound skills. The Big 6 + 6 consists of the fine motor movements of reach, touch, point, grasp, place, release, push, pull, shake, squeeze, tap and twist. Research has shown that bringing these basic motor skills to fluent performance levels can enhance a learner’s ability to perform daily living skills that rely on those foundations. The Big 6 + 6 are elements that, when used together, can form a compound (Kubina, 2019). For example, fluency with the elements of grasping and pushing improved an adolescent’s compound shirt buttoning in one study (Vascelli et al., 2020).

When precision teachers design interventions that involve complex behaviours, such as putting on clothes, they conduct an element-compound analysis (a.k.a. component-composite analysis) to identify the elements of the compound (more complex) behaviour required for fluent performance. For example, putting on clothes requires elements found in the Big 6 + 6. Similarly, getting in and out of bed requires arm, hip, trunk, leg and head movements, while eating requires complex coordination between arm, finger and mouth movements. In PT, motor movements required to develop essential daily living skills are broken down in element-compound analyses to help bring those abilities into a learner’s behavioural repertoire (Kubina, 2019).

Students with intellectual and developmental disabilities often struggle with motor skills and activities of daily living, requiring coordination and fluency (Eastridge and Mozzoni, 2005; Sandjojo et al., 2019). PT offers frequency building as an evidence-based approach to building fluency in foundational skills, enabling students to perform more complex compound skills efficiently. Foundational skills are the building blocks of more complex behaviour required for daily living, many of which are found in the Big 6 + 6. The Big 6 + 6 framework focuses on fine and gross motor elements but can be expanded. OTs and Physios could use PT and frequency building with the Big 6 + 6 and additional motor skills to facilitate the development of critical skills needed for daily functioning.

As already mentioned, PT and frequency building use timed intervals, repeated skill practice and frequency data to track student progress and guide clinical decision-making (Johnson and Street, 2012). Rather than mastery based on accuracy alone, fluency incorporates both speed and accuracy. Research shows fluent element skills increase retention, endurance and application to untrained compound skills (Kostewicz et al., 2020; Twarek et al., 2010). PT has a robust literature showing how frequency building, a systematic practice technique, leads to behavioural fluency (Binder, 1996; Kubina and Yurich, 2012). OTs and Physios could use their expertise to pinpoint prerequisites that are lacking and then quantify their interventions’ effectiveness.

The founder of PT, Ogden Lindsley, discouraged precision teachers of his time from publishing discoveries in academic journals (Binder, 2023). He stated that since discoveries were occurring so rapidly by the time findings were published, they would be obsolete. This may be a contributing factor to the reason fewer scholarly articles on PT exist than one might expect. Thankfully, researchers have been trying to catch up in recent years.

Notably, Twarek et al. (2010) used the traditional Big 6 + 6 hand skills of grasp, reach, pull and place to improve compound daily living skills of putting on socks, shirts and underwear in three autistic children aged 3–5 years old. During the intervention, the participants engaged in repeated 15-s timings of the target Big 6 + 6 skills until they reached fluency aims. Results revealed that all participants achieved fluency in the practiced Big 6 + 6 component skills and improved accuracy in the daily living skills compound skills following the related element skill training. For example, one participant increased from 0% of steps completed for sock donning at baseline to 100% after frequency building on grasp and reach. The study demonstrated how PT and frequency building of foundational Big 6 + 6 motor skills can translate to daily living skill gains. However, a limitation was the exclusive focus on hand and arm movements. The sock-donning task, for instance, may have benefitted from additional leg and foot skill training.

Vascelli et al. (2020) built upon the Big 6 + 6 work by incorporating both hand skills like grasp and push to improve shirt buttoning in an adolescent with intellectual disability. The participant increased buttoning speed and accuracy over 8 sessions on hand push fluency. Results provide initial evidence that expanding motor fluency beyond upper limb skills can further enhance daily living performance. The study demonstrated the effectiveness of targeting specific element skills (grasp and push) to improve a compound daily living skill (buttoning a shirt). This highlights the potential for PT to be used in a focused, goal-oriented manner that aligns with the individualised treatment plans often developed by therapists.

A follow-up study by Vascelli et al. (2023) provides the most robust example to date of expanding motor fluency for daily living skills. Expanding beyond the Big 6 + 6, the study trained element skills beyond the standard Big 6 + 6 framework, including leg/foot movements like pushing with the foot (for sock donning) and the “swipe” motion used on touchscreens (for iPad use). This was done with three adolescents with intellectual disabilities in Italy and demonstrates how PT can be adapted to a wider range of component motor skills relevant to daily living. All participants showed increased accuracy and speed in the compound daily living skills after frequency building on the corresponding element skills involving both hands/arms and feet/legs. The results demonstrate that expanded motor skill training can improve daily living skills functioning.

While the Big 6 + 6 framework provides a starting point targeting foundational fine motor skills, research suggests further developing gross motor and other skills not encapsulated in the Big 6 + 6 can also facilitate gains in function and independence (Twarek et al., 2010). For example, incorporating additional skills like stepping, crawling or throwing into PT and frequency building could bolster mobility and adaptive behaviour improvements. As OTs and Physios evaluate areas of need for individual students, any skills that serve as building blocks for compound functional skills can be incorporated into PT programmes to promote fluency.

Along with fine and gross motor skills, PT has also been applied to oral motor repertoires. Specifically, Aravamudhan and Awasthi (2021) examined the use of PT, lip-tongue-teeth position prompts, feedback, priming and frequency building to improve the echoic articulation of syllables in a 17-year-old autistic girl with profound speech sound disorder. The researchers targeted the syllables “thu”, “fu” and “cu” in brief timed practice trials. All three syllables reached the fluency aim of 60 correct responses per minute. Post-intervention tests showed retention, endurance, and stability of gains, indicating fluent performance was achieved. Accuracy in echoing words containing the trained syllables without direct instruction increased from very low baseline levels to between 60% and 100%. The results suggest PT can effectively and efficiently build fluent syllable production to improve word-level articulation. However, it is worth noting that speech and language therapy also involves working with receptive and expressive language and does not focus solely on speech sound production. Nevertheless, this research provides a clear example of how PT could be used in this domain.

PT offers a powerful framework for quantifying and accelerating progress towards clinical goals in occupational therapy, physiotherapy and speech-language therapy. However, the process of learning to use the Standard Celeration Chart (SCC) and designing PT interventions can be time-intensive (Kubina and Yurich, 2012). One efficient approach to integrating PT into therapeutic practice could be establishing a collaborative intervention model where a precision teacher partners with an OT, Physios or SaLT for a designated period.

In this model, the precision teacher would work closely with the therapist to operationalise and measure the clinical goals they have set. The precision teacher’s expertise in defining measurable pinpoints, selecting appropriate targets for frequency building and charting progress on the SCC would complement the therapist’s domain-specific knowledge and treatment planning.

The PT literature provides evidence that expanding Big 6 + 6 motor frequency building to involve more body parts can enhance daily living skills in people with intellectual and developmental disabilities and improve speech sounds. OTs, Physios and SaLTs can use PT to assess the current frequency of their clients’ performance on essential element skills. By adopting interventions developed by precision teachers, they can set fluency goals for these skills and measure progress using the highly sensitive SCC. Some fluency aims found by precision teachers are provided (see Table 1), where the higher frequency is provided first to encourage reaching higher performance levels (Fabrizio et al., 2001; Kubina and Yurich, 2012). These aims indicate the frequency range necessary to obtain the benefits of fluency that make the behaviour more accessible for use across different environments. The aims can be adjusted based on initial student performance levels and individualised goals. The key is repeated practice to build speed and accuracy in discrete skills that serve as important components supporting more complex, functional daily living activities. Tracking progress quantitatively allows therapists to evaluate if students are gaining the desired fluency. Research suggests that building fluent behaviour has benefits in RESAA, an acronym that stands for retention, endurance, stability, application and adduction (Johnson and Street, 2012). Retention means the learner can perform the skill or behaviour at a high level after not emitting it for a long period of time. Endurance is when a behaviour can maintain a high level of performance over a longer time periods (e.g. for 5 min instead of 1). Stability is when a behaviour can persist at a high level, even when distractions arise. Application is when the behaviour can be used in a new situation. Adduction is when element skills are re-combined, leading to a more complex skill emerging. All of the previously mentioned critical learning outcomes resulting from fluency benefit those served by OTs, Physios and SaLTs.

Research in PT suggests that building fluency in foundational skills through repeated timed practice and corrective feedback can improve performance on more complex compound skills that depend on those fluent elements (Binder, 1996). Building fluency in fine and oral motor movement elements, such as those shown in Table 1, can help clients of OTs, Physios and SaLTs improve compound skills that enable clients to interact better with their environments. Interventions based on PT can serve as effective and efficient tools to supplement OTs’, Physios’ and SaLTs’ treatment packages, as PT provides reliable methods for measuring, monitoring, and improving motor movement, daily living skills and speech and language skills.