I Love ABA!

Welcome to my blog all about Applied Behavior Analysis!

This blog is about my experiences, thoughts, and opinions on ABA. My career as an ABA provider is definitely a passion and a joy, and I love what I do.

This is a personal blog: The views and opinions expressed here represent my own and not those of the people, institutions, or organizations that I may be affiliated with.

Thursday, November 12, 2015

The Lure of "Sensory Protocols"

Photo source: www.forbes.com, www.rompa.com

If you have spent any time with ABA people you may have picked up on the fact that we're all about data. We collect data, analyze data to make decisions, and look for the evidence, or data, behind strategies or techniques before we implement them.
So where do we stand on the issue of “sensory diets/sensory protocols/sensory interventions”? Well, many items or activities often included in a “sensory intervention” (I keep placing that in quotation marks because one of the problems is there is no set definition of this term. It means many things, to many different people), such as koosh balls, massage, tickles, dark lighting, aromatherapy, scented oils, pillows, etc., are quite enjoyable and can be very reinforcing to individuals with Autism.

Did you catch that?

Okay, I’ll say it again: Many items or activities often included in a “sensory intervention” such as koosh balls, massage, tickles, dark lighting, aromatherapy, scented oils, pillows, etc., are quite enjoyable and can be very reinforcing to individuals with Autism.

And there is the problem. “Sensory protocols” are often implemented as a response to problem behavior, in order to quickly remove the agitated child, let them de-stress, and to give them a quiet and relaxing space to gradually de-escalate. So what happens if you apply an enjoyable and possibly reinforcing activity after problem behavior has occurred? You inadvertently reinforce, or strengthen, problem behavior.

Many center programs or schools are now setting up separate cool down areas where some type of “sensory protocol” is applied, such as the child sits on a beanbag and listens to soft music while a teacher or aide gives them deep pressure and joint compressions.
These professionals often are unaware that the very protocol designed to reduce or prevent problem behavior is actually causing problem behavior to increase. Here’s a sample scenario to show you what I mean:

Child in math class--->hates math class--->bored--->throws book across room, yells, and stands on desk---->immediately removed from math class (yay!)---->taken to the cool down room---->now laying on a fur blanket, sipping on water, and holding a koosh ball---->awesome!

For all the parents and educators: there is NOTHING wrong with using preferred items to bring about behavior change. Just pay attention to WHEN you present these items/activities. Preferred, enjoyable items and activities should be presented when desired behaviors occur and not when problem behaviors occur. When problem behaviors repeatedly occur, your best plan of action is to conduct a FBA, and create a Behavior Plan.  

So why do “sensory protocols” or other interventions without empirical support persist, or even gain traction among professionals and educators? What is the lure? Well, Lilienfield et al (2015) provide a few answers to that question:
  • Parents are often desperate for Autism treatment options
  • Behaviors often wax and wane naturally as children age and mature, so it can seem that sudden short term improvements are due to a particular treatment or intervention
  • The internet and technology brings a mass of information to people quickly, and most people would rather read something online than in a research article
  • At a psychological level, once someone believes in something it can be quite difficult to convince them otherwise

Over the years working with parents, educators, and related (non ABA) professionals, I absolutely agree that fad treatments can seem very alluring. It’s like that fast food place that you know you shouldn’t eat at, but the food is cheap and convenient. You probably wouldn’t listen to me telling you about the dangers of a McNugget right as you are about to eat one. 30 minutes later…maybe. :-)

Based on my experiences with this issue, here are the main captivating lures I see when it comes to “sensory protocols”:

The Lure
The Truth
Typically easy or quick to come up with, can be implemented or created by anyone
Most quality, evidence based interventions require the use of credentialed or licensed professionals who have specific expertise
Materials/objects are often cheap and readily available, some can even be made
Gather together all of these cheap and readily accessible items and use them as reinforcers, not as a “treat” that only comes out after the child has aggressed at someone. If the only time the child can access all these amazing items is after they have become severely disruptive, then Houston, we have a problem
Can appear to have an immediate effect, or in the short term can appear to be working
Especially for an escape maintained child, yes….these types of interventions will appear to work like magic. Unfortunately, that is only until the child gets sent back to class or a high demand situation. What I typically see is a high cycle of: behavior, calm down room, behavior, calm down room, etc. Another important point to consider is do you plan to create a sensory room in all environments? No? Then what happens when problem behaviors occur at the beach, the post office, or at Grandmas house?
A “sensory room”, particularly in a school, can serve as negative reinforcement for the teacher (escalated and disruptive student is quickly removed from the classroom)
If at all possible, it’s best not to remove the child from the location where problem behavior began, or for another educator/professional to come to the “rescue” and remove the student. This sends a message to the child you don't want to send: that you cannot handle the child’s behaviors, and if they want to quickly leave a certain setting all they have to do is exhibit problem behavior
If the child enjoys it, what’s the harm?
Lemon treatments waste money, time, efforts, and energy that could be directed at effective interventions based on data. They can also shape up problem behaviors and make them far worse, or more entrenched over time

The persistence of fad interventions in the face of negative scientific evidence: Facilitated communication for autism as a case example
Lilienfeld SO, Marshalla J, Todd JT, Shane HC (2015) Evidence-Based Communication Assessment and Intervention

Saturday, November 7, 2015

How Much Therapy?

Photo source: www.cyclingtips.com.au, www.crossfitdownunder.com

"Intensity"  is a term often used when describing very rigorous or challenging fitness programs, but did you know "intensity" is also how ABA treatment dosage is described? So when you wonder to yourself, or question the ABA team about "How much therapy does my child need? How much ABA is enough? Is this too much therapy? What if I can only afford a few hours a month?", what you are really asking about is intensity of treatment.

First, a little background information:
The 1987 Lovaas research article (which is THE study in the field of ABA) reported on the results of intensive, highly structured behavioral treatment with a group of children who-- at the time-- were largely considered to be hopeless and unteachable.  From this article and many others since, we now know that intentionally intensive treatment (40 hours/week) can bring about huge gains across functioning domains (language, social skills, behavior reduction, etc), that skill/behavior gains often fade after treatment without proper generalization, early intervention produces the most gains, it is important to provide services in the child's natural environment (e.g. home), and the involvement and training of the parent/caregiver is critical for treatment success.

In 2014, the BACB published a helpful guide for insurance companies who must make decisions about how and when to fund ABA therapy. In this guide the ideal "magic number" of treatment intensity is described as an analysis of multiple variables, such as intensity of treatment goals, client needs & severity of deficits, and client response to treatment. A range of 10-25 hours/week for focused treatment and 30-40 hours/week for comprehensive treatment is recommended.

So now that you have some background information, what does all of this mean?

Basically, determining the ideal treatment dosage of ABA therapy for your child is a complex decision. Many factors have to be considered. Added to this, is that funding source recommendations may not line up with what the clinical team is recommending. In other words, your insurance provider may approve 10 hours of therapy/month, but the BCBA may tell you at least 15 hours/week will be necessary. What I see happen very often, is that the families I work with receive the therapy amount they can afford and not the the therapy amount that is needed.  

I know this question of "How much therapy does my child need?" is confusing and frustrating for the average parent. So here are some takeaway tips to aid your understanding. When I am making a decision about how much therapy to recommend for a particular client, these are some of the points I consider :
  •  What are the treatment goals? - The more intense the treatment goals, the more likely 20+ hours per week will be recommended. During a client intake, if the parents are telling me they want to work on feeding, toileting, language, severe behavior reduction, etc., what I am hearing them describe is an intensive and comprehensive ABA program. Think about it like this: for just one of those goals, literally hundreds of learning trials could be necessary for your child to master the skill. Its very unrealistic to ask for comprehensive treatment, but only want to pay for a few hours of therapy per week.
  • What is the treatment setting?- Will therapy sessions occur at home, at school, in the community, or at a clinic/center program? This can impact how much therapy the child can receive. For example if you only want behavioral help at your child's karate class, that limits the frequency of therapy to when the karate class is held. Conversely, if the child is not in school and therapy will occur at home then treatment intensity should increase to maximize the availability.
  • Can relevant stakeholders be considered on the "team"? - Buy In. Read it, learn it, live it. The less involved the parents, teacher, or related professionals (e.g. the private OT) with the ABA treatment plan, the more the weight of treatment integrity will fall on the ABA team. I see this all the time: a family is receiving ABA services, the ABA team expresses that the child is making huge gains, and the family disagrees. Why? Well, if the parents are not involved with treatment/not generalizing treatment then they likely won't see the gains that the therapists see. While your child will use words with me, when I leave your house they will go back to pulling you by the arm to indicate what they want. The more the ABA team can count on the family to reinforce the treatment plan, the more confidence they will have in decreasing therapy hours.
  • How therapeutic are the child's non-ABA hours? - This is closely related to the previous point. How much of the child's non-ABA hours are contributing to or generalizing the skills and behaviors being addressed? Ideally, there would be generalization across individuals and settings. I recently had to discuss this with a client, whose son has in -home ABA and is in an inclusive classroom. Unfortunately, the classroom environment is such that it encourages and reinforces the very problem behavior the ABA team is working to reduce. So in that scenario, I could not count school hours as therapeutic or likely to promote skill acquisition... quite the opposite. So this would be a situation where I recommend increasing the intensity of ABA services.
  • Are there any company policies/limitations to consider? -  Some companies won't staff a case for less than 5-10 hours a week of services. Scheduling wise, it can be more difficult to find professionals if you only want minimal therapy hours. Another example is if your insurance provider will pay for 40 hrs of ABA a week, does the company have enough staff to cover that? Sound like a silly question? Believe me, issues like this happen both with very low treatment intensity and very high treatment intensity.
  • Where are we in the course of treatment? -  Is the client new to ABA and an early learner, or have they received therapy for years and are now close to terminating services? This also must be considered when deciding how much therapy the individual should receive. It is typical that the intensity of ABA begins very high, and then is carefully reduced over time until services are no longer necessary. If therapy services will be fading soon, or the client needs focused/short term help, then a lower intensity of therapy may be fine.


Eldevik, S., Hastings, R. P., Hughes, J. C., Jahr, E., Eikeseth, S., & Cross, S. (2010). Using participant data to extend the evidence for intensive behavioral intervention for children with autism. American Journal on Intellectual and Developmental Disabilities, 115, 381-405.

Monday, November 2, 2015

Whats your Favorite-Favorite?

Photo source: www.heatherwilsoninternational.com

Suggested Reading: Selecting Reinforcers

I once had a client who referred to things/activities/places that he really, realllllly, liked as his "favorite-favorite". As in, "French fries are my favorite- favorite". How cute is that??
Whether you work with individuals with Autism, or your child has Autism, I am quite sure a question you are regularly asking yourself is how to identify and properly build upon the child's motivation in order to teach or correct behavior. In other words: 1) what is it that the individual wants, 2) what is the individual willing to do, and NOT willing to do for what they want, and 3) how can I use this knowledge to teach?

And here I am to answer those questions for you. Aren't you lucky :-)
Say hello to Preference Assessments.

What is a Preference Assessment? Basically, conducting a preference assessment on an individual will equip you with valuable (highly valuable) information about what they like, what they find enjoyable, and how much they like something You may already know that your son Nicholas likes trains, Barney, and toy cars. But do you know which one he likes the most? Do you know which one he satiates on the fastest? Do you know which one he likes the least? Wouldn't you like to know these things?

Ultimately, we are all teachers. If you're a parent, then you may be teaching your children respect, manners, or household chores. If you are a professional, you may be teaching your client to count, ride a bike, or to have a conversation. As a teacher, it is essential that you approach instruction thinking about "whats in it for this kid?". As the adult we can often get caught in the trap of "do this because I say so", or its unfortunate cousin, "just doing this should be its own reward". No and no. 

When you approach instruction by first taking the time to determine what the learner is motivated for, and the degree of motivation (more on this in a sec), you win AND the learner wins. Obviously the learner wins because they are now highly motivated to comply with instruction in order to get what they want. You win because instead of an uphill battle with a child who just wants to get away from you, you now have an attentive and cooperative learner who is ready to be taught.

Now that you understand why preference assessments are so important, you may be thinking this is some magic technique that you do once, write the information down, and then you are free to get on with your teaching for the next few years.

Proper use of preference assessments means you will conduct them regularly (interests will change!), you will be on the lookout for satiation (being "full" on the item), you will watch out for competing stimuli or items, you will make sure the response effort does not outweigh what is being offered, and you will understand that while a strong preference is usually an indicator of a potential reinforcer, this is not always the case. I have worked with clients who may LOVE to be praised, but no way are they going to work an entire therapy session just for praise. So once you have a list of highly preferred preferences (edibles, tangibles, activities, people, etc) just know that not everything on that list may serve as a reinforcer.  Remember that by definition, the stimuli must increase the future likelihood of a behavior to be called a reinforcer. So if you regularly give your little learner a sticker after they exhibit a specific behavior, and the behavior does not increase over time then guess what? Those stickers are not reinforcers.  

I will often teach my staff to conduct brief preference assessments before each teaching block of  trials (not session, trial). That is how much I value preference assessments, and approaching the learner with what they want. If you find yourself approaching the learner for instruction, and just reaching out and grabbing an item as their "reinforcer"...stop.  Don't be a lazy instructor. Yes, preference assessments take time, they take practice to learn how to do them, and there is data collection involved. However, for your diligence and effort you get a super motivated and attentive learner to teach. I say that's a pretty good deal.

Here are your basic preference assessment options:

  • Observe and/or Interview - This can be done by simply observing what the learner freely does in an environment, and what they choose to engage with or do. Or, you can prime the area with items you think the learner enjoys or have previously seen them interact with. Then stand back and observe what they go to, and how long they interact with each item. You can also interview the parents, teacher, or the learner (if appropriate) to find out information about likes/dislikes and get a rating scale of preference. I usually collect the interview information via a simple form or checklist.
  • Structured presentation - Items are presented either in pairs or as a group, and the learner is told to "pick one". Items may or may not be replaced as the learner makes choices, depending on which type of preference assessment is being conducted: forced choice (paired method), multiple stimulus with replacement (MSW), or multiple stimulus without replacement (MSWO). Data is collected on how long the learner interacted with the item, as well as which item they selected  (they cannot select multiple items), in order to calculate a hierarchy of preference.


Sunday, October 25, 2015

Having a Special Needs Friendly Halloween

Photo source: www.learnfromsam.com, blog.easystand.com

Halloween is rapidly approaching, and for anyone with special needs children this can be a time of anxiety and worry, as you wonder if your child will be able to participate in the various parties, events, and trick or treating.

Here are some tips specifically for successful trick or treating, although some of these tips can be used for any Halloween event. These are things I have seen work with various clients over the years who had a variety of behavioral concerns (not just Autism). 
The biggest tips I have for any parent wanting their child to participate in Halloween activities are: make a plan A, make a backup plan B (in case plan A unravels), and remember to have fun. Sometimes with all the anxiety, planning,  and "Put your pants back on!" moments,  fun can be left by the wayside. :-)

Trick or Treating Tips!

  • Preparation - So maybe you think getting ready for Halloween starts on October 31. Silly rabbit! Thats not true at all. My rule of thumb? At least one week before the event, start preparing your child for what will happen. In language they can understand, explain what you will do, where you will go, and what they need to do. Practice what happens when you trick or treat, and make this as real as possible. I suggest visiting a friends home, have your child knock, have your friend open the door, etc. The more real the practice, the better prepared your child will be for the real event. Also, part of preparation includes letting your child know behavioral expectations. For example: "I expect you to stay with me, to use walking feet, and to keep your costume on". 
  • The Costume - You know your child, so you are already knowledgeable of their sensory/tactile sensitivities or dislikes. Maybe the face mask isn't such a good idea, and ditto on the cape with the string that cuts into their neck. If you buy the costume in advance, you can try it on your child to make sure the outfit is something they find comfortable and easy to move around in. There is also the option of editing the costume in order to remove whatever your child doesn't like about it. Maybe they want to wear the Frozen (Elsa) hair braid, but refuse to put the dress on. Okay, who cares? Involve your child in selecting the costume, as well as communicating to you (whatever their mode of communication may be) which parts of the costume they do NOT like. 
  • Look for local special needs friendly events - In addition to (or maybe in place of) trick or treating, consider looking for local events that are intentionally welcoming to individuals of varying abilities. These may be labeled as "special needs friendly", "non traditional", or "sensory friendly". These events are often smaller (think: less crowds), not as focused on candy (which some special needs individuals can't eat), and are more focused on activities and play (think: hold short attention spans). These events may be held at schools, churches, local therapy clinics, etc. 
  • Go to known areas 1st, or exclusively - Consider only trick or treating at the homes of people you know, and who already know your child: family, friends, etc. There are lots of advantages to skipping the homes of strangers: you can prep people in advance how to greet your child/how to prompt a greeting from your child, you can request your child be given healthy treats or toys, and your child may be more comfortable with the experience if he/she recognizes the people answering the door. 
  • Go in a group - This isn't the holiday to try and be brave and do things by yourself. Take someone with you. This could be your ABA therapist, the babysitter, your spouse, etc.  Trust me, you will be happy to have another set of eyes on your child, and another pair of hands to help if things start to go badly. There will be lots of kids around, it will be dark (another tip: consider going earlier in the day rather than at night), and if your son is dressed like Iron Man, odds are there will be at least 15 other Iron Mans running around. 
  • Forget "Normal" - As I already said earlier: Who Cares?? So your child wants to trick or treat in her pajamas, or refuses to wear shoes, or is making loud "AHHHHHH-AHHHHHHH" sounds as you walk from house to house, or your 25 year old child with Autism wants to go trick or treating. Whats the problem?? Your trick or treating experience does not have to look like what the neighbors are doing. Just focus on making sure your child has fun, on what can be a very overwhelming and confusing night for children with special needs.
  • Safety First - If your child wanders or elopes, consider placing them in a wagon or stroller. Before you leave the house, label your child somewhere on their costume with their name and a number to contact if they get separated from you. Take a photo of them in their costume so that in case of emergency, you have a photo of them in their current clothing. Again, for safety reasons I highly recommend going in a group. This is especially important if you will have multiple children with you.

*Resource - The National Autism Association offers a free download of Thank You/I have Autism cards that can really be helpful for nonverbal individuals.
Here is a link.