Teach Handwriting Using Auditory Feedback

Editor's note: This text-based course is a transcript of the webinar, Teach Handwriting Using Auditory Feedback, presented by Aditi Mehra, DHSc, OTR/L, and Luca Canever, MA, BA.

Learning Outcomes

• After this course, participants will be able to identify the benefits of using acoustic reinforcement for skill acquisition.
• After this course, participants will be able to identify the steps of using acoustic reinforcement to teach handwriting skills.
• After this course, participants will be able to list 3 other applications of using acoustic reinforcement to teach skills in OT.

Introduction

Aditi: I am going to start this presentation by being somewhat candid. The topic we are presenting today is Teaching with Acoustical Guidance, or TAGteach. TAGteach often strikes a nerve with some people, as it is a training methodology rooted in BF skinner’s operant principles and derived from clicker training for dogs. While the science of TAGteach most certainly works on training animals, the literature also states that it is just as effective for teaching human beings.  

Now, I recognize that there are elements of this strategy that may not be palatable for everyone, but my goal here is that of an informational nature. Not only should we, as OTs, keep ourselves abreast of the latest interventions out there, but it is important that we review the evidence and make our own informed decisions as professionals. That is my goal for you.

Some ABA therapists are certified in this training; however, it is actually more avidly used in the mainstream population by so many other professionals. As we share the literature, you will see how TAGteach is being implemented across various fields: by gymnasts, golfers, dancers, rock climbers, academicians, surgeons, and many more. Why? It is because it is a very simple positive reinforcement strategy that gets amazing results.

Let me tell you how I stumbled across using TAGteach for handwriting. It was about a year ago when I met my co-presenter, Luca Canever, at a conference. Luca, a special education teacher from Italy, was presenting on the impact of TAGteach for handwriting, and naturally, it piqued my interest. The more I learned about TAGteach, the more I realized how valuable it could be when teaching specific tasks or component skills more effectively. I saw it as just another strategy to enhance our repertoire of teaching functional skills, and that is why I decided I wanted to learn more.

The Challenges OTs Face

• Do you ever feel frustrated when your client makes the same mistakes over and over?
• Are you struggling to make progress with students?
• Do you have clients who keep returning to their old habits, no matter how much you work with them?
• Are you constantly looking for evidence-based methods to correct errors and teach skills faster?

I have faced many challenges with handwriting. You may feel frustrated because you teach your students something, but they make the same mistakes, and you cannot seem to get over the hump. They may also plateau or go back to their old habits no matter what you do. They may perform brilliantly for you in your session, but it does not generalize to the classroom.

I am always looking for evidence-based methods to teach things faster, especially in OT, because we have such a short time with students. I like to implement as many strategies as possible to expedite the process of learning. When looking at these challenges, as mentioned above, I feel that using acoustic feedback can help address these.

Acoustic Reinforcement Using TAGteach

• TAGteach is a targeted, organized approach to giving positive reinforcement that facilitates accelerated learning while minimizing frustration on the part of the teacher and learner
• Marker is an item/action used to deliver reinforcement

Acoustic reinforcement is another word for TAGteach. You give positive reinforcement in an auditory format that facilitates learning. It minimizes frustration for both the learner and the teacher. The acoustic sound becomes the reinforcement. In the next slide, I will show you a video to give you an example.

Video Example 1

https://youtu.be/kSKj_bjkooE

This video shows an example of using acoustic reinforcement with handwriting. I hope you noticed how excited that little boy was. I do not have many students excited about writing, so that was lovely. You figure out a tag point, and then you deliver a reinforcer. We will go more into this in a moment. 

• Printing before and after TAGteach by Noah
• A student of a school occupational therapist Mary Handley OTR/L

Figure 1 shows an example of printing before and after using TAGteach. This is an example from an OT. She has done much work on TAGteach with handwriting and shares videos on YouTube.

Figure 1. An example from Mary Handley of TAGteach for handwriting.

I initially used TAGteach in my tutoring company when doing precision teaching. For example, I used it to help my students identify the difference between a b/d and the left and right sides of their bodies. I also used it for dressing skills. Another area was redirecting students to the margins of the paper.

Using TAGteach for handwriting was fast and practical. It was so simple to learn and to deliver that I was like, this is something other OTs need to know.

Mary Handley, another OT who used TAGteach,  quoted this from her experience.

"At that 4-week point, I was amazed beyond my expectations. I knew this would work in the right circumstances, but it worked better than I anticipated. I just don't see that in my week-to-week therapy. The retention was pretty amazing. His teachers were amazed. Even the librarian made a comment. This has positively impacted his whole attitude toward school." – Mary Handley, OT.

She was amazed at how fast acoustic reinforcement was delivered in learning experiences after it took her weeks to teach concepts using other methods. Here is another example from Luca in Figure 2.

Figure 2. An example from Luca Canever of TAGteach for math.

It shows you how to address the alignment and orientation of numbers using TAGteach.

TAGteach for Handwriting Fundamentals

• Handwriting research lies mostly within discipline-specific boundaries, hindering knowledge transfer across disciplines into academic skills instruction in schools.
• Combining knowledge on handwriting from both fields would help facilitate more well-informed, practical diagnosis and intervention to address children's handwriting problems.

(Lee, A. S. S., Lee, L. W., Low,  H. M., Ooi, S. C., 2022)

Unfortunately, there is not a lot of research in OT for acoustic reinforcement. If you are an OT student, this method may be something to study. You can reach out to us.

Research tells us that handwriting tends to be in the OT domain for the most part. However, because we do not have much research using this method, this can hinder our progress.

The above article talks about combining knowledge, and I am a huge proponent of interprofessional collaboration, especially because OT is such a holistic field. Applying information from other fields that we can use in OT can benefit our students.

TAGteach for Positive Reinforcement and Learning

• The quasi-experimental design of 2 groups, experiment & control class.
• 24 students in each class applied cluster random sampling.
• The instruments used were tests and questionnaires.
• The results of the research showed:
  • (1)there was a significant effect of positive reinforcement on students' writing achievement.
  • (2)the students have a positive perception about the implementation of positive reinforcement in teaching writing.

(Gaffar, S., Atmowardoyo, H., & Dollah, S., 2022)

We all know about positive reinforcement. This research article highlights two significant points. One is that positive reinforcement naturally enhances a student's writing achievement. When we pull students out of class for handwriting, they typically struggle with the task and do not feel good about it. The other thing that positive reinforcement does in this situation is it pairs something that might be hard with something pleasant. It can change the perception of handwriting for a lot of students.

TAGteach as a Motor Learning Approach

• Is advocated in the literature as a useful strategy in handwriting remediation.
• Defined by Schmidt (1988) as "a set of processes associated with practice or experience leading to relatively permanent changes in the capability for responding" (p. 346).
• Feedback and practice, considered by Schmidt (1988) to be the two most potent learning variables

(Zwicker, J.G., & Montgomery, I., 2012)

The other piece of literature I found is about the motor learning approach in handwriting. With handwriting, you are practicing a motor activity and providing feedback, whether auditorily or in other ways. This feedback strengthens the cycle and delivers permanent changes for the student. These two factors are considered the most potent learning variables and can expedite learning. 

Let me now introduce Luca to talk more about TAGteach.

What is TAGteach?

• "A methodology that streamlines communication between teacher and student"
  • Theresa McKeon, TAGteach co-founder

Luca: Hi, everyone. I am Luca from Italy. TAGteach is a methodology that streamlines communication between teachers and students. You can think about TAGteach as a funnel. We use a funnel to pour liquids or water from one bottle to the other. The funnel concentrates all the water in one single point, but you cannot have too much water within the funnel, or it will spill. Likewise, you must be careful about how much information you disseminate to ensure you deliver all the content without losing or "spilling" some. TAGteach "pours" all the knowledge one step at a time without losing any part of the information.

As you saw in the first example in the video, we try to minimize talking, but at the same time, we try to give as much information as possible for the learners to be successful in the behaviors that they are learning.

Traditional vs. the TAGteach Approach

There are two different approaches. In the traditional approach, we give a lot of instruction because we want to be sure that our learners have all the information before they try to do the behavior. We also focus on incorrect responses. Our feedback is, "This is correct, but you forgot to do XYZ," or "Next time, try to improve XYZ."

In TAGteach, we deliver a few instructions and focus on success. As you saw in the video, the sound of the tagger when completing the line was his focus or tag point. The therapist ignores the errors. We will see why we can ignore the errors and focus on success later in our presentation.

What Are TAGteach Benefits?

• Minimal Verbal Intrusion
• Shaping (teaching without words)
• Clear Information
• Focus on:
  • Behavior components (break it down)
  • Learner's Success

These are the benefits that we can get from using TAGteach. We use minimal verbal intrusion. For example, when working with autistic students, they may respond better to less verbal instruction. The less we talk, the better for the student.

We can also rely on shaping with nonverbal students. We are providing clear information. By the end of my instructing the students, the students will know 100% what they are supposed to do, and that is where they can find success.

We focus on breaking down the behaviors and the learner's success. For every task, we find the minimal level of competence, and we start from that point to build new competence and abilities until the behavior is learned and the learner has met our goals. In this step-by-step process, the focus is consistently on the learner's success. 

Role of the Tagger (Marker)

• Peculiar to TAGteach is the use of the Tagger:
  • Strengthen desired behavior
  • Consistent
  • Non Verbal
  • Cheap
  • Portable

Figure 3 shows the Tagger from TAGteach.

Figure 3. Tagger from © TAGteach Italia & TAGteach Int.

We reinforce behaviors with the sound of the tagger. We use the sound because it is consistent. Our voices can change, but the tag is always the same. The tagger is cheap and portable. Some models are electronic, and some you can use with your feet.

Other Types of Markers

• Visual: Penlight
• Tactile: A tap on the shoulder
• Needs to be succinct
• Novel stimulus
• No negative associations

In some situations, we can use other types of markers. For example, you do not want to use the tagger in a classroom, as it can be noisy. I sometimes use a pen light. When using other markers, we do not call that a tagger because the tagger is paired with the sound. Another marker could be tactile, like a tap on the shoulder. You can even use the click of a pen.

Whatever you use needs to be succinct and short because otherwise, it may stop the learning process. It should also be something novel without any negative associations for the learner. We want the experience to be positive, not negative.

TAGteach Applications

Let me give some examples of the use of TAGteach in Figure 4.

Figure 4. Examples of TAGteach applications © TAGteach Italia & TAGteach Int.

The first example is in a training program at Montefiore Hospital in New York. They use TAGteach to train orthopedic surgeons to learn how to do procedures like handling a drill or making a knot. This program has had success using this method.

On the bottom, there is an example of parenting using TAGteach. You can use it for every skill you want to teach your child, even if they are minimal. I have seen a video with a 9-month-old girl learning to wipe her nose using TAGteach. As this is a course on handwriting, you can see a writing example on the top. This 12-year-old boy in my class wrote all over the page. I got him to write letters on the line in the green highlighted area by tagging him for each letter touching the line. It was a short 30-second program. After that, you can see that the lines beneath that he wrote are all in the proper position.

My son is another example of parenting where we were teaching him how to handle a knife.

TAGteach has been used in properly handling fish and for safety procedures within the vessels and was highly successful. Fishing crews can have people from different areas of the world, and often, they do not have a shared language. Using a tagger makes a massive difference for these programs.

TAGteach started in 2003-2004 within the gymnast world. One gymnast tags the other for a specific position on the beam in the bottom middle image. The last photo shows someone working with a child using a horse and the TAGteach method.

TAGTeach for Orthopedic Surgeons

• Two specific tying knot behaviors were taught to the 2014 Postgraduate Year (PGY)-1 class and first- and second-year medical students.
• Operant learning procedure incorporating precise scripts along with acoustic feedback.
• Both groups perform the two tasks at about the same speed.
• The operant groups were more precise and more proficient.

(Levy, I. M., Pryor, K. W., & McKeon, T. R., 2016)

This is the study I was talking to you about for the surgeons in New York. They taught these students how to tie a specific knot at the shoulder. They were trained to "see one," "explain one," and "do one." They viewed the procedure within the surgery room, explained the procedure, and then asked them to do the procedure on a living person. As you can imagine, this was a lot of pressure. They did have some hands-on training before the surgery.

There were two groups, one with additional teaching and the other with the TAGteach method. Both groups performed the tasks at about the same speed, but the TAGteach group was more precise and proficient in the surgery room.

TAGteach for Life Skills

• TAGteach vs. video modeling to improve accuracy on daily living tasks for adolescents with ASD.
• Participants included three 17-year-old male students diagnosed with ASD who made minimal progress in acquiring these skills in the past
• Results: both produced immediate improvements in performance on targeted tasks for all three students.

(Wertalik, J. L., & Kubina, R. M., 2018)

This is another example of using this method for life skills. Three 17-year-old male students improved their performance using TAGteach compared to video modeling.

Video Example 2

This is a video example of a child with autism. They could not get her to walk through the hallway because they reinforced her behavior by guiding her in the right direction. Touching her was the reinforcer.

https://youtu.be/x4c_YPnfjYc

As the video progresses, you can see that she gets a tag for each step in the correct direction toward the classroom without using verbal or tactile reinforcement.

TAGteach for Walking

• Determined toe walking was a sensory behavior
• Paired the "click" sound with a preferred item
• Established the sounds as a conditioned reinforcement
• Delivery acoustical feedback (click) upon appropriate walking
• Gradually removed the acoustical feedback
• Results: Increase in appropriate walking

This study is about toe walking, which is a characteristic of boys and girls with autism. They established the sound of the tagger as a conditioned reinforcer. Sometimes, you do not need to pair the sounds to a tangible item like a Skittle, like in the first video. You tell them that this means yes, and they quickly get the idea. When the heel touched the floor, that was the tag point with the result of an appropriate heel strike.

Why Not Use Just Verbal Reinforcement?

• Inconsistency
• Slow
• Inaccurate
• Aversive (to some learners)

We do not use verbal reinforcement in TAGteach like, "Good job," because it is inconsistent and can be stated in different tones. It is also harder to use your voice to tag the behavior in the proper moment that it is happening. Using a clicker is much faster. Also, if we are talking, we are not paying close attention to what they are doing. If I am focusing on saying, "Yes, good job," I will not be 100% focused on what the learner is doing. With this method, I can observe and be much more accurate. Especially with students with disabilities, you want to be 100% accurate because even a split second can make a huge difference in their behavior. Language can also be aversive for some learners.

The Steps in TagTeach

• Set the goal
• Define the steps (tag points)
• Reinforce each step
• Provide opportunities for practice

How do we implement TAGteach? The first thing is we set the goal. We want to know right from the start what will be the final behavior of the student. The goal for Amanda is to walk from the entrance to her classroom without stopping. Lear's goal is to write his name from the first letter to the end. For each of these examples, we define the steps.

For Amanda, I may need to tag each of her steps for one week. Then I could tag every two steps, every three steps, and so on. Lear was writing the letter E, and the first step was working on the horizontal stroke, which would be the first tag. We would then identify a different stroke. Finally, all the movements would be one tag point. The most important thing is to provide practice opportunities. The more they do, the more they learn.

They are getting attention on the correct behavior, like Amanda's 100 tags for walking from the entrance to her classroom. You can imagine she is getting the positive feeling of getting this feedback, "Yes, you are doing the right thing," within a minute.

The Role of the Tag Point

• A tag point is the behavior highlighted by the Tagger
• A tag point must meet the WOOF Criteria
• WOOF:
  • What you want
  • One thing
  • Observable
  • Five words or fewer

A tag point is a specific behavior that the learner will do. For example, in the Amanda video, the tag point is each step.

A tag point must meet the WOOF criteria. It has to be something that we want. I want Amanda to step towards the classroom, which is very different from saying I do not want Amanda to waste her time in the hallway. We do not use "No" or "Not" in TAGteach. Instead, we focus on what we want. I want Amanda to walk, and I want Lear, which is the first boy, to make a horizontal line.

It has to be one thing. For Amanda, the tag point could not be, "Walk to the classroom and be silent." There are two behaviors within the tag point. Thus, you do not know what to tag if the student is doing behavior A and not doing behavior B. It will be confusing and cause errors.

The specific behavior should be observable, meaning both the teacher and learner know the behavior. Is it taking one step, making a line, or brushing your teeth? The student needs to agree before performing the behavior. This is why we avoid focusing on errors because even before they start, students know what they have to do. If they do not, they can self-assess and try again. If Amanda, for example, stopped walking, she would not get the tag. This would inform her that she had to keep walking to get the tags and to class.

Finally, the tag point is stated with five words or fewer. As stated earlier, a short amount of water (information) can go through the funnel. We keep this information as short as possible, using five words or fewer. Examples are "Take one step" or "Draw a line."

Video Example 3

This is another example of a boy with autism. You will see in this video that when using the tagger, you can switch roles. For example, if you want to assess the level of comprehension of the tag point that you are planning to use with your students, you can ask the student to be the teacher and see if he understands the correct behavior. I think she is drawing straight lines in this example, and he is supposed to tag that line. Notice that he is getting his token for each correct tag point he gives to his teacher.

https://youtu.be/uNXrumAHu0E

Video Example 4

This is a bit longer video. Take a look at the body language of the girl. Two therapists are discussing what she is doing. You can see how her attitude changes when TAGteach is implemented with her.

https://youtu.be/G_hOZPnG2x0

Video Example 5

This is an example of teaching the grip of a pen with this method. The first tag point is two fingers from the tip. The second tag point is a pinch, and the third is pushing with the middle finger for the correct grip.

https://www.youtube.com/watch?v=xOxmLr8NRt4

Handwriting Example

Here is another handwriting example in Figure 5.

Figure 5. Handwriting example.

This child was writing very small. I tagged him for writing a little bit larger, and this is the result. This was a short intervention I did in a kindergarten with a student. I asked her to do a pinch around the pencil, and she got the correct grip right from the start.

TAGTeach Summary

• TAGteach strengthens one observable behavior at the time

We give the learner one piece of information linked to one specific behavior. We provide them with a lot of practice opportunities using the tag points.

Video Example 6

One final video is about teaching a girl how to lift a glass full of water. She did not like the weight of the glass with water in it, and as such, she was not drinking by herself. This is how we implemented TAGteach.

https://youtu.be/TEThq7AgE0k

I am going to pass it back to Aditi for the questions.

Other Applications of TAGteach in OT

• Dressing
• AROM
• Grasping pattern
• Strengthening
• Motor imitation

Aditi: What are some of the applications you can use with TAGteach in OT? There are a plethora. We do a lot of teaching and training in OT, and often, we break tasks down into several small steps. This is where TAGtech can be very useful. TAGteach can help our clients learn those component skills much faster, which means they can then learn and perform the entire activity more efficiently.    Examples include dressing, range of motion, grasp patterns, and strengthening. For example, I can ask clients to squeeze a Digiball and tag them when they use a full squeeze versus a partial squeeze.

I also had a student who had no awareness of his thumb. This made it difficult for him to use scissors when cutting or grasping a pencil with a pincer grasp. I used TAGteach to increase his body awareness of his thumb. We practiced the “thumbs up” exercises, and I would tag him when he did this correctly. This enabled him to learn how to not only be more aware of his thumb but he was able to isolate his thumb more effectively for functional grasping patterns.

Resources

TAGteach International has an abundance of resources. There is a brilliant story if you get a chance to read this (Figure 6), and it can be found on my blog.

Figure 6. Story by Luca Canever.

We want to thank you for joining us. TAGteach is a very specific format and process; it is not just grabbing a clicker and using it. If you want to get the results you are looking for, you have to be certified in the process. Luca does offer that process, and it will be available on my website at some point. Feel free to check it out and email us if you have any questions.

Questions and Answers

How do you remove acoustical feedback?

Luca: You can do this in two ways. The first way is to start staggering the tagging like every other step, or 3rd step in Amanda's case. This leads to fluid behavior. Students do not need reinforcement when they get to that level of fluency or proficiency in their behavior. The environment will provide the reinforcer, like getting to the classroom, writing the letter, or writing their name will be enough of a reinforcer for the students.

What is the difference between the tag versus the marker?

The tagger is the device, and the tag is the device's sound. A marker could also be something you use within the TAGteach process instead of using the tagger, like a flashlight, a touch on the shoulder, or something different.

Is TAGteach considered an ABA strategy?

In ABA, you assess the situation and devise a plan to implement this situation. I think TAGteach would be a part of the plan versus the whole process. ABA is about getting the behavior you want. TAGteach would be a tool to get the behavior that you want. 

References

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