10.3 Clinic DTT, Prompting, and Token Economy Lab

Clinic teaching scenario lab

The client arrives at the clinic for a 90-minute session with programs for receptive identification, imitation, listener responding, and functional communication. The written plan includes a DTT block for identifying common objects, a least-to-most prompt hierarchy, an error-correction sequence, and a token economy. The token system says one token is earned for independent correct responses, five tokens exchange for two minutes with an approved activity, and prompted correct responses receive brief praise but no token.

The RBT has been trained on the programs and has the supervisor available by message if a clinical question arises.

The first risk in this setting is accidental prompting. The RBT places three picture cards on the table, says, Touch spoon, and unknowingly looks at the spoon card. The client touches spoon. If the RBT records the response as independent, the data may suggest the client responded to the spoken instruction when the client may have followed the RBT's gaze. DTT requires neutral presentation, consistent instructions, planned response windows, and careful stimulus rotation. A trial is only as clean as the cues that control the response.

In the scenario, Trial 1 is independent correct. The RBT delivers a token immediately and marks independent correct. Trial 2 has no response after the response interval. The plan says to use a gestural prompt, then model prompt if needed. The RBT gestures, the client responds correctly, and the RBT marks prompted correct with the prompt level. The RBT gives brief praise if the plan says so but does not give a token. Trial 3 is incorrect. The RBT follows the error-correction sequence, records the error as specified, and does not convert the trial to correct because the client got it after correction.

This kind of scoring protects data quality.

Token economies in clinic can drift into bargaining. A client may say, Two tokens for iPad now. The RBT should not renegotiate the exchange rate unless the plan contains a choice or adjustment rule. The RBT can point to the token board, state the earning rule briefly, and continue the program. If the client becomes distressed because the backup reinforcer is unavailable or the exchange seems too delayed, the RBT follows the behavior plan, records the event, and tells the supervisor. The RBT does not add new backup reinforcers, remove token requirements, or use tokens as threats.

Prompt fading also requires supervision. If the client is correct after a model prompt on several trials, the RBT may feel ready to switch to time delay or remove prompts. That change might be appropriate, but the RBT needs a written decision rule or supervisor direction. The RBT can report, Client required model prompts on 8 of 10 trials for spoon and cup, with no independent responses after the gestural prompt. That tells the supervisor whether the current hierarchy may need adjustment. The RBT should not quietly invent a new hierarchy and then submit data as if the original plan was implemented.

A clinic fidelity checklist:

• Review the program target, SD, materials, prompt hierarchy, correction procedure, reinforcement schedule, and scoring codes.
• Prepare cards, token board, backup items, timer, and data system before the client sits down.
• Arrange stimuli neutrally and rotate according to the program.
• Present each instruction consistently and avoid extra hints.
• Wait the programmed response interval before prompting.
• Deliver tokens only when the response meets earning criteria.
• Exchange tokens at the written price and duration.
• Record trial data immediately and include prompt level.
• Report repeated errors, prompt dependence, low motivation, or reinforcer problems to the supervisor.

The RBT should also maintain dignity in structured teaching. DTT should be brisk but not harsh. The RBT should not ridicule errors, insist on eye contact unless that is part of a supervised and ethical target, or continue a block when the behavior plan requires a break. If the client shows signs of distress, such as pushing materials away, crying, or repeatedly requesting all done, the RBT follows the plan for assent-related responses, breaks, or functional communication. Objective data include both correct responses and participation variables.

A useful end-of-block summary might say: Completed 20 receptive ID trials. Spoon: 4 independent, 3 gestural prompted, 3 incorrect. Cup: 6 independent, 2 model prompted, 2 no response. Tokens delivered for 10 independent correct responses. Two exchanges completed. Client requested break independently once and with model prompt twice. The RBT noticed possible prompt dependence on spoon after the gestural prompt and requested supervisor review. This summary gives a clear picture without stepping into clinical decision-making.

The integrated skill is precision. The clinic may be quiet, materials may be ready, and the supervisor may be nearby, but the RBT still needs to implement with exactness. Clean prompting, clean reinforcement, clean data, and timely questions are what make the session useful.