Saturday, February 18, 2017

Off to Preschool? Or off to Therapy?





Photo source: www.peacefulplaygrounds.com, www.speechbuddy.com

 Here is a scenario I encounter on a regular basis with the clients I serve:
After receiving a diagnosis of ASD the parents receive a list of recommendations about what to do next. Things like speech therapy, occupational therapy, special needs school settings, and early intervention/ABA therapy are almost always on that list.

Invariably, there is a small problem. Due to the intensive nature of ABA therapy (especially if its provided in an early intervention context) the parent soon realizes they have to make a choice. Should the child be enrolled in a local preschool? Or should the child receive several hours of therapy per day? Which one is “best”?

I see so many parents facing this dilemma, without the needed information to make a decision. Obviously no matter what they choose there will be pros and cons, but I like to help people make informed decisions as much as possible. So if you were my client, what follows is what I would typically say :-)

  1. Is it really Either/Or? – I have worked with families who were able to enroll their child into a part time preschool setting, which allowed for plenty of time each week for therapy. I have also seen many scenarios where the preschool/daycare allowed the therapists to enter the classroom, to fully maximize therapy hours. So before moving straight to making a choice, find out if a compromise is possible.
  2. Pros of preschool/daycare option- The main benefit of placing a child with a developmental delay in a setting with their peers, is socio-emotional development. The child is learning to socialize with peers, seeing how typically developing children play/talk/behave, and learning to receive instruction from adults other than mom and dad. For many of my clients, the daycare/preschool setting is also their first experience with following a schedule/having routine in their day. However, the biggest issue I see is the appropriateness of the preschool setting. If the setting is not conducive to catching the child up developmentally, then it’s pretty similar to just sticking a plant in a room full of toddlers.
  3. Pros of intensive therapy option- The main benefit of pursuing intensive therapy  (intensive usually means 20 hours per week or more) is overall development and skill acquisition. Pursuing a rigorous therapy schedule means that the core deficits the child is exhibiting will be clinically evaluated and treated, as well as reducing or replacing problem behaviors that impede learning. Also, part of intensive therapy is parent training, which is priceless for most families. Having a team of professionals help you learn how to better engage, teach, or correct the behavior of your child can be life- changing. However, working with a therapist 1:1 cannot compare with the social opportunities provided in a classroom. While social opportunities can be embedded into treatment, often it’s not as varied or frequent as what the child would get at school. Add to that, many of my clients just feel very strongly that they want their child to have the same option of a school experience as any other child.

Clearly, this isn’t a decision to make lightly. 
With different clients, I give different recommendations about which option would be “best”. There is no way to make a blanket statement about what all young children with Autism need the most, as far as treatment.


Making this decision should involve the child’s treatment team, include observation of the classroom the child would be placed in, as well as careful review of the yearly learning objectives for that classroom. 
By the end of the year, what skills will the child have gained? How will skills be taught? Does the classroom teacher have experience/training on ASD or behavior management? What is the school policy on addressing challenging behavior? These are just a few examples of the kind of questions the preschool/daycare should be able to answer.


*Free Resource: This simple handout can be very helpful to evaluate your local preschool options and decide if they can offer the support your child needs. Unfortunately, you may find that your local options are severely lacking or inadequate. In that case, intensive therapy may need to be pursued. Placing a developmentally delayed child in a school setting that cannot appropriately support them could waste precious time, or possibly worsen/create challenging behaviors.
Friday, February 3, 2017

Show & Not Tell





Photo source: www.pinterest.com, http://blog.kevineikenberry.com

*Recommended Post: 3 Step Prompting

This post is really about 2 issues, but I almost always see them done at the same time: stating instructions over and over, and delivering utterly non-concise instructions.

There is almost a quizzical cause and effect thing going on, where the more times the parent delivers the instruction to the child the more and more unclear the instruction becomes. I’ll give you an example:
(parent is trying to get child to touch a flashcard)-->“Okay Nicholas, touch the frog…..Come on, touch the frog….Hey—are you looking? Nicholas……Nicholas?....Nicholas!.....Nicholas, touch the frog…..Look, the green FROG right here……Just touch it…..” etc., etc.

I promise I am not exaggerating, I saw an exchange very similar to this just this week. These 2 issues that I will really boil down to 1 issue (stating non-concise instructions over and over), are extremely non- helpful whether your child has Autism or not.
An individual with communication delays (receptive or expressive) is not likely to respond well when instructions come at them too quickly, in a jumble of other words, or without any prompting to help them understand what they are supposed to do. Children with communication delays or impairments can struggle to comprehend language spoken to them, understand abstract words/terms, make inferences, read facial expressions, and respond appropriately to spoken language.

Since most of my client base consists of children with pervasive communication deficits, one of the first things I work on teaching parents is how to deliver a concise instruction. This seems like something that should be common knowledge, right? I disagree. I think most of what ABA professionals do is not common knowledge to the average parent, so it’s important to take the time to explain these concepts and strategies that we love to implement.

There are a few common objections that I almost always hear from a parent when we start working on this issue:
Objection #1- “But what if s/he didn’t hear me the first time?”
Objection #2-“But I KNOW s/he can do this, so I just keep asking”
Objection #3- “S/he doesn’t respond unless I yell/get “firm”.

My lovely rebuttals to these objections:
Rebuttal #1- Many of the families I work with tell me during our first meeting that they actually had their child’s hearing evaluated, because it truly seemed that the child had hearing loss. Definitely, make sure your child’s hearing is working normally. But lots of my clients can ignore people so well that it seems like something must be wrong with their ears (their ears are fine).
Rebuttal #2- How do I know what you know? By what you show me. If you show me inconsistent behavior, then I cannot say with certainty what you know. In the absence of consistency, I have to treat the behavior like an unlearned skill.
Rebuttal #3- I usually respond to this by reminding the parent that I don’t have to yell, get aggressive, or anything else like that to get their child to comply (and if I did, they should fire me immediately!). Do you think the child’s teacher has to yell? What about their nanny? What about their speech therapist? I hope not, because that’s a lot of yelling :-)  What this objection is actually saying, is that the child has been conditioned over time to know that mom/dad are not serious, and do not mean business unless they get angry and threatening. The goal is for the child to know you mean business wayyy before that point.


Now that you thoroughly understand how NOT to give instructions, let’s jump into what I mean by Show & Not Tell.

A little trick I like to teach to parents is that when they give an instruction, start a mental countdown clock. Example: “Tameika, go brush your teeth (1….2….3)”. Once the clock in your head has counted to 3, this means it’s time to move from Telling to Showing. Does that sound radical, impatient, or worse? How long do you think teachers give your child to respond? Or a friend on the playground? You don’t want to unrealistically teach your child that its ok to respond to a question the 4th or 5th time the person asks it.

Let me back up just a bit, and repeat the original instruction: “Tameika, go brush your teeth”. This is a concise instruction. It tells the child what to do using simple and clear words. Now that a full concise instruction has been given, there is no need to repeat it. That’s right, once you have given the concise instruction you want to only use less language. Why? You want to make it clear to the child that you do not have to repeat yourself, you know they heard you, and that ignoring instructions does not gain more of your attention. I know parents don’t intend to do this, but amping up your reaction after your child starts ignoring you is actually giving them WAY more attention for ignoring you, than for listening to you.

The next (and shorter) instruction should be combined with some type of prompt. Remember, inconsistently correct behavior is still inconsistent behavior. Show the child what they need to do, and don’t assume they already know.
You may have noticed something else about the Show & Not Tell: it’s faster. Have you ever used a timer or stopwatch to see how much of your day you spend telling your child to do something over and over? Well, I have. I do it at work all the time :-)  Most parents don’t realize how much time is wasted when each instruction is given 5 or 6 times before the child responds. Buckets and buckets of time. Do you have buckets and buckets of time to waste? I doubt it.

Want a handy -dandy example of all of this in motion? Here you go:

“Tameika, clean up these blocks”
Clear, simple language. Use the fewest words necessary for the child to understand. Gain their attention before you give the instruction. Once you say the instruction, start your mental clock.
(Approach the child and use some level of prompting to SHOW them what to do) “Clean up”
Remain cool and calm. Use less words than you did the first time. Move in quickly to provide assistance/a prompt. Assistance does not equal completely allowing the child to get out of following the instruction.
(Move quickly through the prompting to get the task completed. Make a brief and neutral statement at the end) “You cleaned up/This is cleaning up/All done with blocks”
Continue to remain cool and calm. Avoid lectures or reprimands about how the child does not listen. Use short, simple words. IF the child had complied right away they would have received praise and/or reinforcement, so at this point provide neither.


*Resources:

Kennedy Krieger Institute article about teaching ASD children
Monday, January 23, 2017

FAQ: Common Questions Parents Ask about ABA


Photo source: www.saveonphone.com, www.sunflower.k12.ms.us 

When parents make that initial phone call or send that initial email to inquire about starting ABA therapy, there tend to be a few questions that are asked right out of the gate. I spend a lot of time talking to mothers and fathers who want to know how to start services, and I have developed a quick little mini-summary of general information they need to know. Let's call it my "ABA in a nutshell" speech.

For parents, wouldn't it be helpful if you had a resource to review beforehand that could answer many of your burning questions?
For professionals, wouldn't it be helpful if you had a resource to share with new referrals, or to prepare you for the common questions parents ask?


Well then check it out!

Free Download:
Parent FAQ- Common Questions when Initiating ABA Therapy
Sunday, January 8, 2017

Being a Big Meanie to Promote Language Acquisition





Photo source: www.quotesgram.com, www.toptenz.net

Yes, I admit it: I am a huge meanie who spends lots of time forcing small people to communicate. Yup, guilty.

When I am starting a new early intervention case, something I like to do is give my staff an “Early Learner Protocol”. Over the years I realized there are  so many important skills to teach and not enough hours in the day, so I wanted my staff to have a tangible understanding of the focus of intervention for the little ones. To summarize: reducing problem behavior and increasing imitation skills, play/socialization skills, and LANGUAGE are usually the main things we are intensively targeting with young clients.
I try to get staff and parents to understand that everything involved with working with early learners is all about Pushing. If you can grasp the concept of pushing, then you will do just fine as an ABA therapist for any young child.

Pushing could look like, “He manded for a sip of juice, lets try having him mand for a bite of cookie”, “She labeled 2 toys in the bath last night, lets push for 3 tonight”, “He waited 10 seconds before I opened up the pretzels, now I’ll push for 12 seconds”. See, push.


I remember the mother of the first client I ever worked with telling me that her son was perfectly content to allow me to do everything for him, if that is what I chose to do. I didn’t really believe her at the time, and thought to myself she was just too hard on him (she was just being a meanie). So what if he needed help putting his shoes on…every day. My job was to help him, right? Then there was the day I observed him with another ABA therapist and it went a bit like this:
Therapist- “Put your shoes on”
 Child- (promptly put his shoes on)

Imagine my shock :-)  After the shock faded then I just felt like a chump. I had been putting this child’s shoes on for weeks, and the entire time he was fully capable of doing it himself. Lesson learned!

To parents and new ABA staff, I know it feels like helping but it can actually be harmful if you neglect to push the child to learn new skills, dress themselves, talk, display manners, etc. It’s kind of like saying “Since this child has special needs, I’ll just lower my expectations”. You would never say that out of your mouth, right? Well then don’t say it with your actions.

When it comes to teaching/expanding on language, motivation is KEY. What motivates you and I to communicate with others may not at all be motivating for your child/client with Autism. Or let me put it like this, have you ever considered why the child should communicate? What do they get out of it? If they don’t communicate, is anything different? Does communicating make their life better somehow?

Here are some practical ways you can start to push more, to increase language, build independence, and teach skills. Many of these are things I do on a weekly basis across my clients.

  • When the child wants something (a toy, to watch a TV show, etc.) place a demand on getting it. Connect some form of communication to accessing the most preferred items, instead of giving them away for free.
  • Embed language trials into daily activities, such as eating breakfast, walking to the park, or getting dressed. As your child is getting dressed say , “Pick up the SHIRT/Give me your SHOES/Pull your shorts UP”. Repetition and prompting are how you get the child to respond to your language. I embed language into almost everything I do with an early learner.
  • Mimic and imitate the child’s sounds. This is also a great way to get spontaneous eye contact (my clients usually stare at me like I’m crazy), and this can become a fun social interaction. Sit or lay down near the child and make the same sounds they are making, including pitch, intonations, etc.
  • Look and sound like someone worth talking to. With my early learners, I smile big and keep animation in my facial expressions. Everything is a bit exaggerated. Talk a bit louder than usual, and lay the praise on super thick. If interacting with you is fun and exciting, the child will approach you more which just gives you more opportunities to push.
  • Don’t give up too fast on manding trials. This is a mistake I see all the time. The child wants something, so you withhold it and try to get a mand. Then the child cries, walks off, or stares blankly at you. This is totally normal, and doesn’t mean the child is confused. It could mean they don’t want to mand, or they just don’t want the item anymore. What it definitely should not mean, is you give up on the manding trial and just give them the item. If problem behaviors occur, just silently withhold the item. If the child leaves or walks off, let them. If they really want the item they will come back. When they do, just restart the manding trial.
  • Sing songs to the child, or with the child. Music can work wonders for teaching or expanding on language. I’ve had many clients who would sing or hum far-r-r before they ever said words. Don’t just play music though, remember this is about pushing. Sit down with the child and sing songs that have movements, such as Itsy Bitsy Spider. Remember to be fun and animated, with lots of praise. Or, dance/hop around while singing together and then stop and look intently at the child. They might keep singing (we call this “fill ins”), or tug/pull at you as a way to request more singing. I also like to do songs that include suspense or surprise, such as “….we all fall (pause and freeze dramatically) DOWN! (lightly pull child to the floor and tickle them)”. After you do this a few times, the child may start requesting more of this game such as tugging or pulling at you to do it again. That is when you add a demand, such as the child saying or signing “more”.
  • Receptive language is language too! “Receptive” just means an action is required and not a vocal response. I rarely see parents think to work on receptive language with their children, but it’s a very important part of language development. Get some flashcards or pictures and have the child match them as you label the item (“Tree”), or line up cards and then point to each one and label it. Lots of my clients like to line things up, so pushing would mean embedding language into that activity. If the child likes to sit and look at cards or photos (many of my clients do) then sit with them and say the names of the items on the cards. A way to expand this further, would be to require the child imitate your label before they pull out another card. This means if you say “car” they also have to say “car” before you let them pull out another picture.

*Recommended Post: Teaching Communication to Non-Verbal Children