Wednesday, October 26, 2011

ABA Therapists: Conducting School Observations

As an ABA therapist, you may be asked to visit the classroom of a client you are working with to conduct an observation. There could be a behavioral issue going on, you could be conducting part of an assessment, or the school might request that you come in to provide recommendations to the teacher. I have visited many schools over the years, and varying types of schools (pre -schools/daycares, public schools, private schools, etc.), and I've learned a few things along the way:

  1. Always make sure that that the parents, teacher, and the school know when you will be visiting and the nature of your visit. If you work for an agency, make sure that you have contact information for the family, as well as the school, and inform them both of your plans to visit. If you work directly for a family, make sure they have informed the teacher and the school of your visit. I have been in situations where I was sent to a school by an agency who didn't inform the parents of my visit. Once I got to the school I was denied access to enter because no parent permission form was on file. I have also had the reverse problem, where a family told me it was okay to visit their child's school after a brief conversation with their child's teacher. When I got there the front office informed me all visits had to be approved by the principal, and promptly asked me to leave. Its always best to speak to as many people as you can before visiting a school and explain the nature of your visit. If you email the teachers or Principal, keep a record of these emails.Some schools can be quite welcoming to people coming in for the purpose of helping a child who is having difficulties. Unfortunately, I have experienced much more situations that were the opposite. Schools can make it very difficult for ABA professionals to enter the classroom and observe. Talking to teachers, in classroom data collection, or actually working with your client on school grounds are often flat-out refused. Be prepared that you may encounter serious opposition from school administrators, and if the school does let you in then be super appreciative and courteous to help pave the way for the next professional who comes after you.
  2. Be as unobtrusive as you can. Anyone familiar with Reactivity knows that the simple act of being observed changes the behavior of the subject. In other words, you are a new face in the classroom, you're obviously not a teacher, sometimes even the child you are there to observe doesn't know will absolutely stand out. As much as possible, minimize your disruption of the classroom. Enter the classroom quietly and find an out of the way location to sit and observe. Do not take timers into a classroom if you are taking data, take paper/notepads, and pens. Wear muted, plain clothing and minimal jewelry. Particularly if you are going into a pre-school with very young children, you will likely be sitting on the floor so dress comfortably. Greet the teacher as you enter their classroom, and let them know you would like to speak with them 1:1 if they get the chance. Don't just walk into the classroom and start asking the teacher questions. If the teacher chooses to introduce you to the class, let them do so. Otherwise do not explain to other children why you are there.
  3. Be polite and friendly with the staff, but also professional. Not every teacher will view you observing in their classroom as a positive thing. Sometimes the teachers will be cold or distant towards you. I have observed in classrooms where after the greeting "Hello", the teacher didn't say one additional word to me. As a former pre-school teacher, I can say that teachers don't always know when someone will be entering their classroom, or for what purpose. Some teachers assume you are there because the parents aren't happy, or you are there to "tell them how to do their job". Many teachers feel defensive when a stranger comes into their classroom with a clipboard to sit and watch them. It can be very stressful for the teacher. Enter the classroom with a smile and a greeting and make it clear that you are there to help, not to harm. On the flip side of a cold teacher, is the teacher who is so excited to have you in their classroom they want to chat with you non-stop. Many teachers have said to me, "I know you're here to observe child X, but can you take a look at child Y?? I think something's wrong with her". This has happened to me many times. It is not only unethical to comment on other children in the classroom, it is unprofessional. Let the teacher know in a polite way that you are there for child X, and you cannot make any statements or recommendations about other children. Which leads directly into the next point.....
  4. Discuss confidentiality with the parents before your visit. Some of my clients receive ABA services at home, but their school does not know the child has a diagnosis. Or, the child is in a general education classroom and the teacher does not know the child is on medication. Confidentiality limits are things you need to know before you go to observe. The teachers (or other school staff) may throw questions at you such as "I heard the Dad yells alot at home, is that true?",  "That Mom seems so scattered, do you think that too?", "Is he off  his meds, because he has been climbing the walls all week!",  "Does he just have Autism, or is he also OCD?". Depending on the level of confidentiality the family prefers, you may answer some, all, or NONE of these questions. It all depends on the family. Determine beforehand if the parents want you to discuss their child's diagnosis, services, diet, medications, etc., with school staff. The reverse of that situation could be if the school hires you directly, and does not want you sharing specific information with the parents. As odd as that sounds, it does happen. Sometimes a school wants to try specific interventions or strategies before sharing that information with the parents. In a RTI (response to intervention) model that is allowed. Parents may not need to be informed of learning difficulties until after interventions have failed. Discuss with the school administrators what you can and cant say to the parents.

Remember that you are at the school to gather information about how a student learns and functions within a classroom environment, as compared to their typical peers. You are not at the school to chat with teachers, "hang out" with children, or antagonize school staff.  The way you present yourself during a school visit may impact how future ABA professionals who visit that school are treated.
Tuesday, October 18, 2011

Differential Reinforcement

Differential reinforcement is an ABA concept that basically means you deliver varying levels/intensity of reinforcement contingent upon how the individual behaves or complies with whatever directive you have given. Differential reinforcement is also a shaping technique, where you shape a response by reinforcing certain behaviors and ignoring others.

Sound complicated? Its really not. Many parents and caregivers use differential reinforcement all the time without being aware of it. Here are a few examples:

-Your 14 month old toddler is beginning to move from babbling to making speech sounds and imitating your vocals. You provide eye contact, hugs, and kisses for clear speech sounds and no attention for babbling.

- Your 14 year old often struggles to complete her homework on time. When she whines, complains about, or sighs loudly instead of doing her homework you ignore those behaviors. However when she is on task, quietly working, or asks you for help you provide large amounts of attention.

-Your 3 year old child who you are potty training runs to the potty and sits for 15 seconds, and then gets up without voiding. You reply with a high five and a smile. Later that day you are in a different part of the home and hear your child yell from the bathroom that he just peed in the potty. You run into the bathroom, and give the child a big tickle and tell him what a big boy he is.

These are all examples of how you can use differential reinforcement. It just makes sense to give big reactions to big behaviors, and small reactions to small behaviors. When working as an ABA therapist it can sometimes be easy to overlook using differential reinforcement. There are two main ways I see differential reinforcement misused: reinforcement is given too freely regardless of the child's behavior (Over), or the reinforcement is too minimal for how the child is behaving (Under).

  1. Over: This usually looks like a therapist or parent who "gives away" reinforcement when the behavior isn't deserving. An example of this I just saw yesterday was when I was with a client at the mall. After being at the mall for a while, her child was ready to leave and he began to tantrum and scream. I have trained the parents in 3 Step Prompting, so the mother went directly into the procedure. On the 3rd step of the procedure the child suddenly reached out and knocked over a nearby display case of toys. The mother used Hand over Hand prompting to get the child to pick up all of the toys, which was correct. However while the mother was doing this she was constantly speaking to the child saying statements such as, "You are cleaning up so nice"..."Good job!"...."Almost done sweetheart"...., etc. This child certainly was not doing a good job cleaning up, as all the cleaning had to be physically prompted and he attempted to bite his mother 3 times. A better way to do this scenario using differential reinforcement would be to use Hand over Hand prompting to have the child clean up the toys, while providing minimal to no eye contact or language. Then every few seconds remove your hand and see if the child will clean up independently. If not, thats okay. Just go back to Hand over Hand prompting. If they do begin cleaning independently you can deliver praise such as "Good, keep going". The praise should be small, not large, because remember the child is still in the middle of a 3 step prompting procedure. You wouldn't shout "Hooray" because your child picks up 1 toy after knocking over 15 toys.
  2.    Under: This typically looks like a therapist or parent who focuses so much on the terminal goal of the skill  that they cant appreciate the baby steps, or it looks like reacting in a very monotonous, lifeless way to the child. Here is another example I just saw recently. I was doing a supervision session with a new therapist and she was running an ABA session. Whenever the child did something correctly the therapist would provide praise. Unfortunately the way this therapist would provide praise was to say in a bored sounding voice "Good job", with no change in her facial expression. This was the reinforcement the child received whether he did a puzzle, answered a question, imitated a motor task, or transitioned successfully. From the child's point of view, this is not motivating and it may also be confusing. For a child to understand effort the reinforcement must vary. If I give the same level of reinforcement to a child who independently ties his shoes, as I do to a child who needs me to complete 75% of the shoe tying  then what did that child just learn? The goal is to show the child that More Effort = More Reinforcement. This encourages the child to try hard and do their best. A better way to handle this scenario using differential reinforcement would be to change facial expression, animate your voice, and mix and vary the praise you use. I have a document I give to new therapists titled "100 Ways to Reinforce", because I understand it's sometimes hard to come up with exciting ways to give praise in a 2-3 hour session. You can get stuck on one verbal praise such as "Great" or "Awesome", and without realizing it go through a whole session having said the same verbal praise multiple times.

Using differential reinforcement at the table correctly will decrease boredom in the child, motivate the child to exert more effort, and help to encourage the child for effort based performance even if actual performance of the task was poor.
If I am working with a child on a Block Design program and I see her struggling with the program and beginning to become frustrated, I will make a statement such as "You are working so hard!". I am not praising this child's performance...she isnt doing the task correctly, so I cant. What I am doing is providing encouragement, so she will continue to try. Now if after all that struggle the child suddenly completed the Block Design task independently, Im going to basically throw a party, shout, clap, and provide huge reinforcement.
Monday, October 17, 2011

Program: Fine Motor

Today's post is about a program I usually write for children with minimal or no fine motor skills, or for a child who has motor problems, or difficulty in the classroom. Fine motor refers to using the hands and or fingers versus large (gross) motor which would be legs, arms, etc. Problems with fine motor skills can show up in a variety of ways: The child might avoid certain activities, such as coloring, because they have weak fine motor abilities. The child might avoid, or be unable to, feed themselves, dress themselves, open doors, groom themselves, write, etc. Looking at it from a broader point of view, a child who is unable to grasp, point, make a fist, grab, or use a pincer grasp will struggle in a classroom setting, or during play and leisure time. Many toys require good fine motor ability to appropriately engage with the toy; the child must lift, push, pull, wind up, or shake the toy to get it to respond.
If your child receives Occupational Therapy it is likely they are working on fine motor or gross motor skills. However, these skills can also be taught at the table during an ABA session.

Typically, depending on the deficits the child has I will write a Fine Motor Imitation (FMI) program, or a Fine Motor Development (FMD) program. A FMI program is teaching the child to imitate actions that the therapist must first model. The therapist can use shaping techniques to help the child get closer and closer to correctly imitating the fine motor action. I would start at this program for a child with very limited fine motor skills. The program is more general, and teaches a variety of fine motor skills such as opening the hand, making a fist, making a peace sign, thumbs up, etc.
With a FMD program, this is more for a child with just a few fine motor tasks they struggle with, or cannot do. For example, an 8 year old who has difficulty writing his homework (homework is very sloppy or illegible), or a 6 year old who still hasnt learned to tie shoes, and can only wear shoes that buckle or snap. Both of these children could benefit from a much more focused and specialized FMD program. I would write the program for the specific skill they are struggling with, in small increments of difficulty.

If you are a therapist or parent who has a relationship with an Occupational Therapist, they are a great resource for strategies to build fine motor muscle tone. Please see the list below for a few ideas to help your child with fine motor difficulties. Remember that if this is a deficit for your child, the skill has to be taught. You cant just buy these items and hand them to the child. Get on the floor and help them manipulate these items, encourage them to do activities they normally avoid (such as pulling up a zipper), and create multiple opportunities throughout the day for the child to practice:


  • Many simple toys can help to develop fine motor skills, including ring stackers, shape sorters and foam boards. These toys may have blinking lights, vibrate, play music or do all three as a naturally occurring reward when your child manipulates the toy correctly. This provides motivation to keep your child from becoming easily distracted. Many toys speak when certain buttons are pushed, helping your child to learn letters, numbers, colors and other concepts while also fine-tuning motor skills.

Play Dough

  • Many fine motor skills can be developed with the use of play dough. Help your child mold large balls with her palms, small pea-sized balls with only her fingertips and long snake-like shapes between her hands or with her hands and a smooth surface. Many autistic children also enjoy squeezing things, which is great for improving forearm strength, so play dough is a perfect choice for this activity. Use tools to manipulate play dough as well. Cut with plastic knives or cookie cutters, make ridged designs with the flat side of a fork, press it onto buttons, fabric and other textures and show the child the designs he created.

Small Tools

  • Teach your child to use tools such as plastic tweezers to pick up mini marshmallows, cheerios, and pennies. Use an eye-dropper to suck up colored water and then squeeze it out for painting.  Help your child use screwdrivers, such as those in an erector set, or give them undersized, silly items that require a firm grip, such as a small novelty pen.

Writing and Drawing

  • Your child can begin to learn how to write and draw by finger painting, drawing lines, shapes, numbers and letters with their fingers. Use paints, or get out whipped cream and let your child have some fun. Magnet board drawing toys or large mats that change color with water-tipped pens can help your child learn to grasp and control a pencil.

Modified Toys and Activities

  • If your child is easily frustrated by the toys she already has, consider creating similar toys with modifications so that she feels successful, then move on to the more difficult toys. Instead of a lacing board with many holes, make your own home made version out of cardboard, punching three to six holes instead of a dozen. Create your own peg board with plastic water bottles filled with water and glitter that fit into holes in a cardboard box. Fill some small boxes with sand and use these as blocks; they will be easier for your child to stack than regular blocks.

Monday, October 10, 2011

To Stim, or Not To Stim; THAT is the Question......

To be or not to be? No, actually a very popular question I get asked is: "To stim, or not to stim??"

Sterotypy, aka "stimming" (see my Glossary for an explanation why the term "self-stimulatory behavior" is misleading), can take many forms and can be quite frustrating to parents and caregivers.  These repetitive behaviors can be very enjoyable and automatically reinforcing to the individual doing them, but at times can prevent learning, social interactions, or can cause social stigma.

From a teaching perspective, when children engage in sterotypy they can also completely shut out the outside world and may not respond to demands, requests for eye contact, or even touch. Some of my clients will engage in loud vocal sterotypy so they literally cant even hear my demands while they sing, yell, or make prolonged vocalizations ("AHHHHHHH - HHHHHHHH!").
I often will say to myself "Oh, you just went on vacation didn't you?" when one of my clients starts engaging in repetitive behaviors and trying to tune me out.

Not all individuals on the ASD spectrum have repetitive behavior to the degree that it interferes with learning. However, many do.
 If your child is engaging in sterotypy during social or instructional times these behaviors can be very persistent, and difficult to decrease. Some examples of these types of behaviors can include:

  • Rocking, spinning, hand flapping, mouthing items/objects, lining items up, spinning items, dropping items to watch them fall, verbal stims such as squeals, shrieks, or scripting scenes from favorite TV shows, visual stims such as staring closely at objects or flicking eyelashes, saliva play, tearing or ripping paper into tiny pieces

Many parents feel they don't want their child to "stim" at all. Other parents feel they want their child to know when to engage in sterotypy and when not to, and for some of the families I consult with this isn't even an issue (they do not want sterotypy reduced).

Just imagine that your way of de-stressing after a long day is to have a warm bath and listen to music and everyday a therapist stops you right as you go to turn on the bathtub faucet and says "No. Hands Down". How would you react to that??

I don't recommend simply removing a behavior. You must remember, there is a function (need) involved. It would be better to teach a replacement behavior that is less disruptive and does not prevent learning/social interaction. To put it simply, teach the child what TO do instead of just focusing on what you DON'T want them to do. Consider redirection, Differential Reinforcement, or teaching toy play/hobbies.

Yes, I understand sterotypy can be very trying on a parent and also difficult to handle in public.
A large step towards viewing "stims" as commonplace and not an annoying habit to extinguish is to realize that everybody engages in repetitive behaviors! Really, they do. The next time you are standing in line at the bank, or waiting at a stoplight, look at the people around you. Do you see someone twirling their hair? (I do that one). Do you see someone tapping their foot? What about humming to themselves? So if you and I engage in repetitive behaviors at times, then what is the difference between that and your child engaging in repetitive behavior? Well usually, it is the frequency/intensity (especially if the behavior causes harm), and the inability to interact/learn/engage in any other activity while the sterotypy is occurring. THAT is the difference.

*UPDATE: After reading this post, a very sweet young lady contacted me to share her opinion. Her name is Tracy, and she has ASD.  I think her words really put some perspective to this issue:

"I enjoyed your post on stimming. I like so much how you tell how everyone does it, and the analogy of a neurotypical person not being allowed a hot bath at the end of the day. Not being allowed to stim would sometimes be very much like this. Other times, it would be more like not being allowed to smile when I am happy. It's interesting to hear a neurotypical perspective: when we stim you feel we're in our own world. This is sometimes true....sometimes stimming helps me concentrate. Actually, stimming almost always helps me concentrate, just not always on the thing I am supposed to be concentrating on! :) When I spin around and flap, though, I don't feel like I'm in my own world. I feel like the I am surrounded by the world, held by the world, and my hands are moved up and down by what is the rhythm, the essence of the world. I stim to get the magical feeling of connection you might feel in the redwoods. True, this does sometimes require less being-with-people, but the world is just so magical and so wonderful and whole that- I don't know. As a spur of the moment choice, and as a conscious choice, I think my limited time is better spent spinning than small-talking. Stimming is also catharsis. You're right, it can be used when bored...... and it is a wonderful way to order the world in the midst of sensory overload."
Sunday, October 2, 2011

Program: Toy Play

From time to time I will do a post about a specific ABA program. This post is about teaching children with Autism to play with toys appropriately.

Toy Play is a program I typically write for children with minimal to no play and/or social skills, children who spend their down time engaged in stimming only, or children who are consistently inappropriate with toys (chew on the toy, throw the toy, etc). The goal of Toy Play is to teach the child to use different types of play skills to interact with objects as designed, and eventually to add other people into this play behavior.

Your child/client could benefit from a Toy Play program if:

They mouth or stim off of any object or toy you hand them
When given a toy they quickly drop it or throw it (no interest)
They ignore toys or objects in their environment and instead engage with random materials such as carpet lint, pebbles or rocks, doorknobs, etc.
They do not interact with other children and often ignore other children
You find yourself having to constantly keep the child engaged because if left alone they wander around stimming, or engaging in problem behavior

Many people think that "play is play" and that there is nothing about play that a child needs to learn.....Just hand them a toy and step back. However, all children go through stages in the development of play skills that range from playing with simple toys alone, to playing with more complex toys alone, to playing games with other children. Children with autism may have a very difficult time learning to play. In fact, it may be easier for a child with Autism to work successfully than to play successfully. Motor skills and imitation skills are important prerequisites before beginning to target toy play skills.

When first beginning to teach Toy Play, observe how long the child will interact with a toy without your interference. Give them a simple toy, and step back and observe. Once they disengage from the toy (push it away, drop it, walk away, etc.), determine how long they played with it. If it was 15 seconds, start your teaching at 10 seconds. Always start a little bit below where the child currently is to encourage success. Initially all you are doing is requiring the child to interact with the toy for a set amount of time. Interacting with the toy can be as simple as looking at and touching the toy. If the child attempts to get up, push the toy away, throw the toy, etc., you would block that and redirect them back to the toy. Praise and reinforce appropriate interaction with the toy, and keep the play fun and animated. Keep the toys simple at first. A good choice would be a Mr Potato Head toy, where it is clear what body parts go where. A poor choice would be a pile of Lego's where there isn't a clear "way" to play with the item, and the child would likely be inappropriate with the pieces.

Over time, you increase the time intervals that the child must interact with the toy. Then you start to work on how they play with the toy such as requiring the child play with it correctly versus just touching it. Then you would increase the complexity of the toys, add yourself into the toy play, and ultimately add other children into the toy play. Part of working on this skill is teaching the child different types of play. Anyone with child development knowledge knows that children typically learn to play in certain phases.  Examples include:

1) parallel play- playing near others, but not with others
 2)cooperative play- playing with others towards a common goal, such as building a tower
 3) imaginative play- playing alone or with others in a creative, free flow game of pretend, such as making an imaginary cake.

Toy Play is a fun program to teach, and it is also important. A child who has the been taught the skill of toy play can easily learn other important skills such as social interaction, joining play, Task Completion, and even transitioning. Children who do not know how to be appropriate with toys are at a disadvantage when placed in a group of peers. Especially for young children, play skills are a form of communication. Children walk up to one another and invite each other to join games, to play with a toy together, or to make up a game. Appropriate toy play skills can also decrease self stimulatory behaviors, because for some children with Autism their stereotypy is how they play. Teaching these children how to appropriately engage with an object can eventually replace the stims, which can be very socially stigmatizing.

 Children who lack toy play skills wont know what to do in social situations, which over time will delay social skill growth. Many times in classrooms the children are expected to attend to a toy or object while the teacher prepares for a transition. Children without the ability to play with toys are at a distinct disadvantage during transitions, because they tend to wander around the room stimming or being  inappropriate.

For more information about teaching play skills please see the following link: