Saturday, September 24, 2011

3 Step Prompting


3 step prompting, or least to most prompting, is a very helpful tool to use with individuals who are Non Compliant. 
Non compliant means the child ignores or fails to appropriately respond to a given directive or instruction. While the term "non compliance" is actually not a behavior (it describes a lack of something), most laypersons often use this term to describe individuals who just don't listen or follow directions. Non compliance can be immediate, delayed, verbal, or non verbal. Examples of noncompliance include: 

  • You tell your daughter to brush her teeth and she screams "No" at you and runs off.  (Verbal and nonverbal noncompliance)
  •  You tell your son to turn off the TV and come eat dinner, and he waits 10 minutes for a commercial to come on before he comes to dinner. (Delayed noncompliance)
  • You tell your daughter to pick up her toys and she starts crying that she doesn't want to. She eventually does pick up the toys, but cries and whines the entire time. (Verbal noncompliance)
  •  You tell your son to set the table, and he knocks over a chair and runs to his room. (Immediate and nonverbal noncompliance) 




There are a few things to know about non compliance. 
Firstly, do not ASK the child to do anything. Make sure you are giving a demand, not making a request. Don't say "Can you turn the TV off?" unless an acceptable answer is "No". Say "Turn the TV off".
Secondly, ask yourself how important verbal noncompliance is. If you tell the child to clean up the toys and they do, but they start crying how important is that? You didn't say "Clean the toys up nicely". So is the crying a big deal? Decide in advance what is acceptable to you and stick to it.
Lastly, do not treat delayed noncompliance as acceptable. When you give a demand the child has a reasonable amount of time (about 3-5 seconds) to comply. If they still have not begun to comply after that time has passed, that is unacceptable. You don't want to teach the child that they can take their time responding to a demand from an adult. In the school setting teachers place multiple demands on children throughout the day and they expect the children to respond quickly. Don't let your child be at a disadvantage by responding slowly.



A child who is consistently non compliant can have difficulties with learning at school, in their ABA therapy sessions, and it makes interacting with the child stressful. It also makes it difficult to transition the child throughout the day from one activity to the next in a timely manner, and everything becomes a battle of wills from simple requests such as "Come here" to more important demands such as "Do your homework".


Three step prompting can best be understood by remembering the following sequence: Tell, Show, Do.
  1. Tell- Give a demand to the child, such as "Clean up the toys". Wait 3-5 seconds for the child to begin to comply. If they comply at this point, provide huge reinforcement. If not, move to step 2.
  2. Show- Repeat the demand, while modeling or gesturing to what you want the child to do. Say "Clean up the toys like this" as you actually pick up a few toys and put them away. Wait 3-5 seconds for the child to begin to comply. If they comply at this point, provide praise and/or reinforcement, but to a lesser degree than if they had complied at step 1. If they don't comply, move to step 3.
  3. Do- Repeat the demand. Go over to the child and physically prompt them to clean up the toys with minimal language and eye contact. Use HOH prompting to have them pick up and put away each toy. Ignore any problem behaviors the child may exhibit such as whining. Do not provide praise or reinforcement once they are done. Do not stop the HOH prompting until the task is done.
Over time the individual will learn that they have two options: comply and contact praise or reinforcement, or refuse to comply, receive no praise or reinforcement, and be physically forced to comply. Non compliance tends to decrease very quickly once 3 step prompting is used consistently. This procedure can be used by anyone who interacts with the child and also during therapy sessions.


Important:


-         The instruction is repeated with every prompt.

-         No step is ever repeated.

-         No other conversation takes place.

-         Reinforce when compliance occurs.

-         Do not reinforce when physical guidance is necessary.


**Quick Tip: If the original demand is an expressive demand, such as "Say bye -bye" and the child refuses to speak, for step 3 you can make the demand receptive and have the child wave instead. You cant physically prompt a verbal response, so just change it to a nonverbal response.

Wednesday, September 21, 2011

Back from Paradise, aka Turks & Caicos Island!

So I have been back from my trip to TCI for a few days now, and as promised here are some lovely photos of the island. My client on the island is an innovative educational program for children with Autism, and they also provide informational workshops, training sessions, parent education, etc., to children in the area and on surrounding islands. This is the first program of its kind for this country, and I feel extremely honored to be a part of this organization.

For more information about this wonderful and innovative program on the island of Turks & Caicos, please contact the Director, Nicole Cox. Nicole also runs her own in-home ABA program with her son who has Autism.

Nicole Cox, Dawn Program Director
nicole.cox.tci@gmail.com
http://dawnprogram.blogspot.com




For Related Professionals: Behaviorism 101




Many times when I am working with a family their child is involved in multiple therapies. I would actually be quite surprised to have a client who receives ABA therapy, and that's it.
These other therapies can include speech therapy, occupational therapy, social skills playgroups, hippo-therapy, physical therapy, etc. Not to mention the many teachers and paraprofessionals at school the child comes into contact with. Sometimes  I get the opportunity to meet and connect with the various professionals and sometimes I don't. When I do get the chance I always am grateful for it. It is always beneficial to know the child's strengths/weaknesses from therapist to therapist.

When I meet with these professionals they usually ask me questions about behavior: How do I get the child to sit and attend? How often should I reinforce? Is the child this aggressive at home? Does the child respond to directions with you? How do I redirect the child away from stimming behaviors?

If you work with a child with Autism as a therapist, teacher, nanny, baby sitter, etc, I hope you find this post helpful. These are simple tips to know and be aware of so you can understand behavior management.

  1. Understand the ABC's of behavior. This is your "detective tool kit" to methodically locate the function of any behavior. A=antecedent, B=behavior, and C=consequence. The antecedent means "what happened before the behavior", and the consequence means "what happened after the behavior". For example, if every time you arrive at the house to begin a session (antecedent), the child begins to cry and run away from you (behavior), and you then spend several minutes chasing the child through the house to have them begin working (consequence), then it is very likely the function of the behavior is escape from demand. To correct the behavior, you would find a new behavior that serves the same purpose. Such as teaching the child to communicate that they need a short break before beginning work.
  2. Learn what incompatible behaviors are, and use them. An incompatible behavior is simply a behavior that the child cannot do at the same time as the target behavior. For example, if you are working with a child at a table and the child  knocks the materials onto the floor a simple incompatible behavior is to say to the child "Hands Down" or "Fold Hands" before you place anything on the table. If their hands are busy they have no opportunity to knock things onto the floor.
  3. Consistency! Being inconsistent in your reactions to the child's behaviors is equivalent to intermittent reinforcement. By "sometimes" being firm, and "sometimes" letting things go, you are intermittently reinforcing the behavior which will cause it to increase. Decide what behaviors are unacceptable and have the same reaction every single time.
  4. Understand reinforcement. Reinforcement is a way to increase behaviors you want to see again. If the child does something appropriate, give them a smile, hug, high five, tickle, etc.  Reinforcement is a powerful way to shape behavior and also has the added benefit of making the child more interested in spending time with you. Over time you will become reinforcing to the child because in the past you have delivered reinforcement.
  5. Always finish out a demand. Do not give any demand to the child that you are not prepared to prompt them through if necessary. If the child is across the room playing don't call out to them "Come sit down" unless you are willing to go and get them if they do not comply. A mistake I see often is a therapist arrives at a child's home and the child is tired or in a bad mood. The therapist then says to the parent "He/she doesn't want to work today, so I'm going to leave because the session would just be a bust". The next time that therapist shows up at the house, the child will just repeat the behavior to get them to leave again. Don't back down from demands or let a child escape from a demand.
  6. Fill the child's time with activities. Children with significant Developmental Delays need active engagement and teaching throughout the day......down time, not so much. In a typical session, the only time the child spends not with me and directly involved with an activity is during short breaks. Other than that we are working on some skill or goal, and constantly transitioning to a new activity. If the child has too much down time this can lead to boredom or distraction which can lead to behaviors. Keep the child busy and engaged with you so they don't have the opportunity to exhibit problem behaviors such as throwing things, crying, elopement, etc.


Tuesday, September 20, 2011

Prompting 101



Hello All!

I am finally back from my international trip, I had a wonderful time.

I had a supervision session yesterday with a new therapist, that made me think of a topic for a blog post: Prompting

Prompting in ABA is a method or tool used to get the learner from incorrect responding to correct responding. When done correctly, prompting increases the rate of responding, lowers frustration, and helps the individual learn more efficiently. If I know you don't know how to bake a pie, I wouldn't give you a demand to "Make a cherry pie" and then just stand back and watch you struggle. Practicing errors impedes learning. I would step in to provide you with prompting and guidance as much as you needed, in order to help you be successful.

There are many ways you can prompt:

Hierarchy
(Some prompts will be much more intrusive than other prompts. This is not an exhaustive list of ALL possible prompts. it is simply a way to understand types of prompting)

  • Physical - Hand over Hand (HOH), leading a child by the hand, or physically moving a child
  •  Verbal - Can be partial verbal or full verbal
  •  Model - Demonstrating for the child what you want them to do
  •  Gestural - Gesturing, pointing, making a non verbal motion to show the child what to do (*note: don’t combine with words, that’s actually 2 prompts) 
  •  Visual - Larger stimuli, brightly colored stimuli
  •  Spatial (proximity) - Putting the correct choice nearer to the child than the incorrect choice
  •  Sequential (order in which things are presented) - Working on easy tasks first and building up to difficult tasks
  •  Textual (written) - Writing out the steps of the task
  •  Tactile - Using the actual stimuli as a prompt/reminder, such as placing a briefcase by the front door so you don’t forget it the next day

To increase prompting to improve learning, move UP the prompting hierarchy (from least to most intrusive).  To fade out prompts and prevent prompt dependency move DOWN the prompting hierarchy (from most to least). Generally, the most to least prompting hierarchy would be: Full physical, partial physical, full vocal, partial vocal, modeling, gestural.

During tablework you will use many different types of prompts at different times, usually when teaching a new skill. The child shouldn't need much prompting for a known skill. If they do you may want to examine your teaching procedure and also make sure the child has the prerequisite skills needed for the current target.


The therapist I worked with yesterday was making a common error that can happen with new therapists and also with parents. She was over prompting the child and then reinforcing those prompted responses. The therapist would put out her materials, give the SD, and then glance at the correct card for a few seconds. The child would watch her face, select the card the therapist glanced at, and then receive a candy for getting a "right" answer. I brought this to the therapists attention who was completely unaware this was a prompt. She asked me, "How do I know if something I am doing is a prompt?"  There is an easy way to determine this. Ask yourself, "If I remove this step, would the child still be able to do the task?" If the answer is no then you are over prompting.

Something I used to do as a new therapist was place my materials on the table with the distractors closest to me, and the target closest to the child. There was no reason I did this other than that it was easier for me to lay the cards out that way. Well one day while being supervised I moved the cards around in a different way than normal. The child immediately began missing responses. So then I had the fun task of trying to explain to my supervisor why this child was missing all these tasks that I "knew" he could do. We both realized I had been inadvertently prompting the child to always reach for the closest card.

Prompting can be very easy to accidentally do, and sometimes you have to purposely change the way you do something to see if you are using a prompt.

If you remove a glance, a touch, a word, a facial expression, or a gesture, and the child "suddenly" cant do the task anymore then you were prompting the task all along.
Friday, September 9, 2011

To spank, Or not to spank?



Spanking, or corporal punishment as it is also called, can be a somewhat controversial topic in this field. I had a meeting with a parent this week who is very upset that an older family member is very-pro spanking. The parent wanted me to talk to the family member and make her "less spanking" and "more ABA".
As a professional in this field it isn't unusual for clients to ask for your opinion or recommendations on services, therapies, methods, schools, etc. The best practice is to provide the family with solid evidence based knowledge. It is not advised to recommend something to a client you really dont know much about. So if a parent asks you "Should I spank or not?", what should you say??

What I typically do is explain to the client that research does support that spanking can have many negative effects that can be long term. I then advise the parent do their own research and reading, and make a decision as  a parent what they want to do.  What often happens, is a grandparent who views ABA as being "too soft" on the child will make a statement to me about how all the child's behaviors would just go away with one good spank/swat/pinch, etc. Its not uncommon for family members who are older, or who do not know much about special needs, to make such comments. If this happens to you take the opportunity to educate the family member. Don't become defensive or upset, as that will just close down communication. Remember: successful ABA intervention requires a team. The more members of the family you can get on your side the better.

Below is an example of how I would respond to a client or relative of a client who asks me "Whats so bad about spanking?!":

"I do understand your opinion about spanking, as many people were spanked as children, and view it as a discipline tool. There is quite a bit of research on the topic of spanking and corporal punishment,  and I can recommend some books too if you are interested. I can tell you that in general, reinforcement will always be more effective than punishment. I think it is up to the parents to decide if they want to have a spanking or no-spanking household. However, I do have a few questions for you--
 How effective is the spanking? Is the behavior decreasing as a result? As with any behavior intervention, if the target behavior does not decrease then the intervention isnt working. Are you having to spank your child daily, or every few days? If so, then that is not an effective intervention. Also, what are you doing to teach the child what to do instead? Spanking doesnt teach anything, its a reactionary measure. Lastly, are you concerned about inadvertently teaching your child that hitting is okay? I have worked with children who get spanked, and will hit/swat at peers when angry or upset. I would suggest you think about all of these possible concerns, and if you need help creating a new behavioral intervention to try instead of spanking I would be glad to be of assistance."

Just remember that as a professional you want to give informed, evidence based recommendations. If you have limited knowledge of a topic, tell a client that before answering their question. If a topic is very sensitive or controversial to you, you must remove your own personal biases before giving advice to a client. Also, I am careful to preface advice with "In my opinion" unless I am directly referencing research. Especially a topic like spanking, which can be a cultural issue. Avoid judgmental statements and instead start a dialogue with the client where the two of you solve the problem together. The family asked you for your professional opinion, not for you to judge their parenting.

*Quick Note: I have had clients who were pro-spanking until they realized spanking had no effect on their child, or that their child enjoyed spanking. Some children with Autism may have sensory processing deficits, in which case painful stimuli can feel good. I have seen children get popped on their hand by a parent, and then hold out the other hand to request a second pop. When that happens, parents are usually shocked and don't know quite what to do. Clearly spanking will not be effective if your child enjoys the sensation.



Recommended Reading:

Straus MA, Sugarman DB, Giles-Sims J: Spanking by parents and subsequent antisocial behavior of children. Archives of Pediatrics and Adolescent Medicine 1997, 151:761-767.

Gershoff ET: Report on physical punishment in the United States: What research tells us about its effects on children. Columbus, OH: Center for Effective Discipline; 2008. OpenURL


Straus MA: Beating the devil out of them: Corporal punishment in American families and its effects on children. 2nd edition. New Brunswick, NJ: Transaction; 2001. OpenURL

Baumrind D, Larzelere RE, Cowan PA: Ordinary physical punishment: Is it harmful? Comment on Gershoff (2002). Psychological Bulletin 2002, 128:580-589.
Monday, September 5, 2011

Whats so Great About Being an ABA Therapist ??



Happy Labor Day everyone! I thought it would be very fitting and appropriate on this holiday to blog a little bit about what I think is so great about the career field of ABA. 
The whole point of this blog is my love and passion for ABA, but I also hope that someone who has never heard of ABA before might consider joining the field as a result of stumbling across my blog. So consider this a recruitment ad for becoming an ABA Therapist.





ABA wants you!

Do you love your job? Or is it just a means to a paycheck?

ABA isn't just my job, its something I am passionate about and a science I believe in.
Here are the main reasons why I think being an ABA Therapist is great:
  1. Its a job that combines psychology, counseling, social work, education, and organizational management all in one. So if you have an interest in one or more of those areas, you would love this job.
  2. What you do as an ABA Therapist  is important. Can you say that about your current job?? What you do as an ABA Therapist effects not only the life of a child, but their family, neighbors, community, etc.
  3. For the most part, you set your own hours and determine your own salary. You can work as little or as much as you would like, and as your experience and education grows so will your income.
  4. Its incredibly rewarding. Imagine working with a child for weeks to get them to say the word "Hi", and then eventually reaching a point where they are talking non stop. It makes you feel like you just won the lottery.
  5. Creativity, free thinking, and flexibility of mind are encouraged. Outside talents such as playing an instrument, or being an amazing painter can be incorporated into an ABA session. Teach the child to play an instrument or paint a portrait, have an ABA session at the park or beach, create a slideshow of the child's favorite photos. If you love music, play music during your session for you and your client. Get creative!
  6. Job security. When you look at the demand for ABA professionals compared to the supply, you can easily see that this is a field that will need qualified professionals for a long, long time.
  7. If you already have an interest in a particular group of people, you can choose to work with minority groups within the Autism population. Minority groups can mean individuals who are blind and have Autism, individuals who are African American and have Autism, individuals who have seizure disorders and have Autism, etc. Also, if you have a specific disability or disorder you might be able to bring something very unique to the job of being an ABA Therapist. I have worked with a few great therapists who had Aspergers, OCD, or Anxiety disorders. Due to their own difficulties, they were really able to relate to their clients.
  8. You teach skills that these individuals may use for the rest of their lives. Pretty heavy, huh? That 4 year old girl who you teach to wash her hands will be washing her hands for the rest of her life.....and you had a small part in that.
  9. Unique reinforcement. I can only speak for myself, but the biggest reinforcement I get from my career has nothing to do with a paycheck. My biggest reinforcement is turning an anxious, screaming child into a calm and happy child who can communicate their wants and needs.
  10. No two days have to be the same. There are some therapists who like routine and sameness, and want their sessions to be the same from day to day. I prefer a more varied schedule, because I tend to get bored easily so I am always trying new activities and strategies to help my clients learn.
  11. You get to help people, in real time. With some professions, yes you are helping people but you don't always get to "see" the results of that. If you work as a customer service representative and you help someone fix their problem over the phone that's a very removed kind of help. However, if you are an ABA Therapist and working with a family who you see everyday you really get to see the immediate consequences of your effort. Family interactions improve, stress levels go down, and parents feel empowered as they learn ABA strategies and techniques.
  12. You get to be a "mini- scientist". If you are into developing theories, Pavlov & Skinner, statistics, data analysis, standard deviation, and the like, then ABA is a very satisfying career field. Every time I am contacted about a behavior that a family wants to change in some way, I must observe and define the behavior, measure the behavior, create a hypothesis/theory to explain the behavior, identify confounding variables, implement the intervention, and evaluate the success of the intervention. Much more exciting than what my friends do at work, that's for sure!
  13. I work with some of the most ADORABLE, smart, creative, curious, interesting, and diverse group of children you could think of. Autism affects each child differently, and the more children I work with the more I get to see the many facets of Autism. 
  14. Once you learn how to modify behavior, you are then equipped with the tools to modify anyone's behavior. Yes, that means you can get your husband to load the dishwasher! :-)
  15. There are so many different things you can do within the field of ABA, or working with children with Autism. You can work with families in their home, work in a school, work in a group home or residential facility, work in a hospital or center, you can work locally or internationally, with children or adults, with low or high functioning individuals, etc. You don't ever need to feel bored or unchallenged by what you do in this field. If you don't enjoy working with children, work with adults. If you find working in a school system unsatisfying, work in the home setting.
  16. The greatest thing about what I do is telling people what I do. In a social setting, very quickly people tend to ask the "So what do you do?" question. Its very amusing and interesting to see people react to my explanation of what I do. Its a hard job to explain in a nutshell, but if you have a few minutes to explain to someone what an ABA Therapist does they usually react with something close to "Tell me more!" 




Suggested Post: Super Hero Recruitment
Sunday, September 4, 2011

Sensory Boxes




Sensory boxes are a tool you can use as a reinforcer, a NET tool, or for calming purposes, as sensory play can be very soothing.
Sensory boxes can also be taught as a leisure skill activity to replace less repetitive appropriate behaviors, such as spinning pieces of lint. Sensory boxes can be as diverse and varied as they need to be, in order to be functionally equivalent to the self-stimulatory behaviors the child exhibits. Then provide reinforcement to the child when they interact with a sensory box, to increase the likelihood that the child will play with the sensory box again in the future.

Get a container with a lid that can be securely closed and fill it with various items such as pieces of fabric, beads, beans, rice, clay, sand, flour, water and ice, water and bubbles, glitter, confetti, pieces of string, lace, etc. A word of caution: before creating a sensory box check with the family first and make sure the child has no allergies. For example, if the child is allergic to latex that is something you need to know before making a sensory box. If you are working with a child who has mouthing behavior be sure to supervise them closely when they are manipulating a sensory box. I would also avoid very small items, such as beads, with a child who mouths. Look for larger items like pieces of fabric, or large chunks of play dough or clay.


I typically use sensory boxes with clients who become overstimulated and need a calming, structured activity to engage in. I will also use a sensory box during transitions. For example, when I arrive to a session I might place a sensory box on the table as I prepare my materials so the child has something to engage with. Then when I am ready to begin work I add myself into the child's play and use language and eye contact to get them engaged with me. Once they are looking at me and speaking to me (or if nonverbal, responding to my receptive instructions) then I slowly add in work, and remove the sensory box.

Sensory activities should not be used as a way to reinforce inappropriate behaviors, or to allow a child to escape a task. Please be careful not to use sensory tools, toys, or items in ways that will strengthen problem behaviors.

Sensory boxes can be used by anyone who interacts with the child and they are very simple and cheap to make. I am always a fan of free/ low cost ideas that can be incorporated into therapy. ABA does not need to break your wallet. All of these containers can be purchased at Wal Mart or even Dollar Tree for about $2 each, and the items inside the boxes I get at craft stores or Wal Mart.


Below are different types of sensory boxes that I have made and use regularly:




This is a sensory box filled with sand. I use purchased sand rather than sand from a beach or park so I know it is clean and not filled with dirt, bacteria, or things like pieces of wood. I place a few items inside the box for the child to manipulate such as the multicolored rings. This way you can work on language as well as calming the child by saying things like "Give me the red ring" or "Pour sand on the orange ring".


These boxes are filled with varying pebbles/marbles and stones. Again, I purchase these rather than collect them from outside. I put in different textures, colors, and sizes so they are more interesting to manipulate. 




This is a pasta box. You can use any type or color pasta you would like. Some parents dont like to use sensory boxes with food items inside (flour, pasta, etc.), because the child will try and eat the items. You can either not use food items, or you can teach the child rules for playing with the sensory box. One of the rules would be "No mouth". A visual for each rule could be taped or laminated onto the lid of the box, to help with teaching how to appropriately interact with the sensory box.




This box has beans inside. Another way to incorporate language into this activity is to suddenly close the box by placing the lid on, and then look at the child. They can then use their method of communication  to request that you open the box or to request using a label, e.g. "beans".  I have some clients who love these boxes so much they do not want me to put my hands into the box. They will push at my hands or become upset. When that happens I prompt them to communicate to me that they want to play alone. So we alternate between alone time with the box and cooperative play.



This box is filled with rice. The rainbow effect on the rice can be obtained by adding a few drops of food coloring to the rice, stirring the rice, and then letting it sit and dry. Another language tip is to use the sensory boxes to teach choice making. To do this I will place a highly preferred sensory box on the table, and something that is very non preferred, like a book. The child can then receptively or expressively indicate which item they want.

For parents, if you have difficulty in public situations such as waiting at the doctors office try bringing a small sensory box along so your child has something to do while they are waiting. Manipulating these items can also have a calming effect which is good for sensory modulation.

*Resource: A parent told me about this GREAT website called Small Potatoes that has some of the most creative and imaginative sensory boxes I have ever seen!