Sunday, February 26, 2012

Addressing Social Deficits

The following is from the DSM –V and describes the social deficits necessary to receive a diagnosis of Autism Spectrum Disorder:

A) Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:
1.deficits in social-emotional reciprocity
2. deficits in nonverbal communicative behaviors used for social interaction
3.deficits in developing and maintaining relationships

 ABA therapy seeks to strengthen a child’s deficits so children can function better at home, at school, and in the community. There is an emphasis on intensive instruction and teaching (direct or incidental), and unfortunately social skills can sometimes be placed on the backburner or viewed as not as important. Actually social skills are quite important. Communication and social skills are closely linked, in that a child who cannot communicate and has limited receptive language will have little interest in socializing. Also typical peers will have little interest in interacting with a child who communicates mainly through problem behaviors. Communication deficits can dramatically affect social performance.

For most of us, developing skills such as eye contact, parallel play, and social gaze didn’t need to be explicitly taught. We picked them up from our environment and learning occurred when these behaviors were socially reinforced. Social Learning Theory explains that behaviors are learned through observation, imitation, and modeling. For a child with Autism social learning will either be minimal or nonexistent. I could visit a client every week and smile and wave at her when I arrive, but that does not mean she will imitate my behavior and  greet me. It may take repeated instruction and reinforcement to get that child to smile  back at me and wave.  Just like academic skills, social skills need to be part of an instructional plan when you are dealing with children who have Autism. If you want to see improvement in the area of socialization, then teach it.

For some reason there's a misconception that if a child with Autism just spends time with NT peers that they will “catch” appropriate behaviors. The problem with that belief is part of being Autistic means having a diminished ability to learn from social cues. Therefore it doesn’t make sense to expect an inclusive environment to solve all social deficit problems.

Social skills are much more than being able to play with peers. Social skills can include:

  • Eye contact, reading facial expressions, smiling, knowing and using good manners, appropriate physical touch, proximity to others/personal space, hygiene, profane language, attending, listening skills, waiting, requesting or accepting help, story telling, humor/sarcasm, group instruction, asking questions and answering questions, sexually aggressive behaviors, lack of empathy, public speaking, sharing, emotion regulation, voice modulation, public masturbation, and joint attending.

Social skills are a broad concept that basically covers any skill or behavior that involves others or affects others. When you think of it in those terms it’s easy to see how critical social skill deficits are.

So how do you teach social skills?

There are many curriculum guides, computer software programs, and books out there that describe exactly how to teach social skills. Two teaching tools I personally find very helpful are Social Stories  developed by Carol Gray, and Social Skill Builder a computer software program.  However it isn’t necessary to buy a specific book or software program to begin teaching social skills to your child. Below are a few recommendations:

  1. If the child is pre-school age: Create situations where you can observe the child around other children. It is often easier for an adult to get a child to engage than for another child to do so. For this reason, you cant assume that because the child will share with you that they would share with another child. Watch them with their peers  as well as children much younger and older than them. This is important because sometimes a child will completely ignore peers, but will interact with children much younger in age. You are looking to see how the child interacts socially compared to other children. Pay attention to eye contact, attending, initiating play or communication, sharing, and proximity to others. Once you have identified the social deficits, that is your starting point to begin teaching.
  2. If the child is school age: In addition to observing the child with other children, you need to observe  in the classroom setting. Pay attention to off- task behaviors, transitions, down time, independent and group instruction times, and attending to the teacher. Much of classroom instruction requires good social skills. Even a very bright child who does well academically will face serious social disapproval if they exhibit incorrect or odd social behaviors. Think about the Aspergers teenager who stares intently at peers in the classroom, and follows children around that he wants to befriend. That child will face ridicule and possibly bullying if that inappropriate behavior isn't corrected. Once you have identified the social deficits, that is your starting point to begin teaching.
  3. From the selected deficits create clear and measurable goals: If you observe that the child avoids being near other children and reacts with anger  if touched by another child, a great social goal would be “When given the opportunity, Stacie will sit appropriately with the class during Circle Time for 15 seconds”. A poor choice for a social goal would be “When given the opportunity, Stacie will play nice with her sister and not hit”. The second one is a poor goal because its not clear what "play nice" means.
  4. Work closely with your BCBA or Lead Therapist to write programs to address the social skill deficits: If you do not have a Consultant or Lead Therapist who is writing the ABA programs, ask one of your child’s teachers for help. The curriculum planning and objective writing that teachers do is very similar to the program writing that ABA therapists do.
  5. Understand that most social skill goals are taught using an adult model first: This is because typically it is hard to get a child to participate for the necessary repeated trials of learning, and also children are usually less aggressive with adults than peers. In other words, your child may find it easier to learn to share with you first, than with another child. Once you have some success teaching the social skill using an adult, at that point you can introduce a peer. Once you have success with a peer, then you can teach the social skill in a group of peers.
  6. Stay true to ABA methodology: Use positive reinforcement to teach and strengthen social skills, collect and analyze data to track progress, and plan for generalization of the social skills that have been taught. For example, if you teach the child to make eye contact and say “Hello” to people who visit the house, you also need to teach the child to exhibit these skills at the park, at Uncle David’s house, at daycare, etc.
  7. Do not expect a child to exhibit a skill they have not learned yet:  I usually explain that to parents by saying “If the behavior is inconsistent, or consistently poor, then we have to believe the child doesn’t know what to do”. If you know your child has poor social skills don’t be surprised if she hits her brother because she doesn’t want to share. Don’t be surprised when she refuses to give Grandma a hug, and don’t be surprised if her teacher complains to you about excessive tantrums during recess. Expect that your child will need help being appropriate in social situations in addition to structured ABA instruction.

Wednesday, February 22, 2012

Quote of the Day

“I need to see something to learn it, not just hear it. Words are frequently like steam to me; I know they are there but they evaporate before I have a chance to make sense of them. I need more time to process information than typical children. Information delivered in words comes and goes in an instant…when information in presented to me visually, it can stay in front of me for as long as it takes to decode.” 

From the book "Ten Things Your Student With Autism Wishes You Knew" by Ellen Notbohm 

Friday, February 17, 2012

How To Select Reinforcers

Which of the items pictured above would be reinforcing to you?
It would probably depend on what I asked you to do, the time of day, if you were hungry, sleepy, tired, sad, etc. You probably wouldn’t wash my car if I offered to give you $1. But you might wash my car if I offered to give you $100 (…or maybe not, if you really hate washing cars).

ABA therapists use reinforcers to get the learner to comply, to sit, to attend, to transition, and many more various behaviors. It took me a while to learn that just because child A will work for something that doesn’t mean child B will. It seems like such an obvious thing to know, but as therapists we do tend to make sweeping generalizations about the kiddos we work with. Such as:
"All kids will work for candy… All kids will work to avoid a reprimand.....All kids like attention… All kids know who Dora or Spongebob is... All kids like tickles" 
Every one of those statements is wrong, because they assume all kids are the same.

Choosing, selecting, and testing reinforcers takes skill and patience but the payoff is huge. Instead of being in a session with a child who is bored or defiant,  you now are approaching the child with the knowledge of what they like and what they will work for…..because there is a difference.

 I really like chocolate cupcakes, but I will not paint your house to get paid in chocolate cupcakes. There is a difference between your client liking something, and your client working for something. If you have been working with a client on a skill or set of skills for a long time without seeing progress, try changing your reinforcement. The child may have gotten bored with the reinforcement. Or maybe they like the item but not enough to do a difficult skill for it. They could have become satiated on the reinforcement (this happens very often with edible reinforcers).

A big issue I see happen frequently is someone else in the child’s life is giving them a similar reinforcer and the therapist doesn’t know. For example, the teacher at school keeps a candy dish full of Skittles in the room that the children have free access to. Its highly unlikely that you will be able to get your client to do challenging tasks to earn a Skittle, if they spent all day freely munching on Skittles. In behavior analytic terms this is called Bootleg Reinforcement. This can happen pretty often, so its important to make sure the reinforcement you are using is unique and the child doesn't have free access to it.
 If you had just finished a big seafood platter and I offered you a hamburger, the hamburger probably wouldn’t seem too appetizing. Even if you love hamburgers I have to offer it to you at the right moment. To understand effective reinforcement, you have to understand how to manipulate M.O. (Motivating Operations). Once you can do that you are on your way to being an awesome therapist!

Here are a few procedures to select powerful, effective reinforcers:

  • Start by observing the child in a variety of settings- When I say “observe the child”, most therapists think I mean follow the child around the house. Observation is much bigger than that. Observe the child at the park, the grocery store, grandma’s house, in the classroom, at a birthday party, etc. Notice what the child gravitates to, what they touch, what they stare at, what they smile at, and what objects they pick up. Over time you will likely start to see patterns emerge that tell you what that child likes. A favorite observation tool of mine is to take a client to a toy store like Toys R Us. I just let them wander freely and I pay attention to what they look at, touch, or engage with. That gives me a great source of ideas as to what kind of items/toys that child likes.
  • Talk to caregivers and others- Talk to the child’s parents, teachers, other therapists, siblings, etc. Ask questions about what kind of toys/items your client likes. Try to use open ended questions, such as “What kind of movies does Tanisha like” versus a closed ended question like “Does Tanisha like movies”. Make sure you ask sensory related questions so you can learn what the child likes to see/hear/smell/touch. If appropriate, you can also just interview the child.
  • Test your ideas- Once you have an idea of what the child likes gather a few reinforcers together. Present the reinforcers to the child and pay attention to what they engage with longest. I am basically describing a Preference Assessment.
  • The only constant is change- This is probably the most important thing to remember: Your client’s interests and likes will change over time. Don't your interests change with time?? With some of my clients I change the toys in my goodie bag every few days because I know those children get bored quickly. On the other hand, I have one client I have been seeing over 2 years on a consultative basis. Every time I visit, she immediately requests that I play Hide & Seek with her which is a game she finds highly reinforcing. She never gets tired of it. Let the child indicate to you when its time to change your reinforcers. If they want to work for the trampoline every day, that’s great. However if one day they don’t want the trampoline you need to be ready to use another reinforcer. Keep a supply of reinforcing items with you that are interesting and vary in size, texture, color, etc. Don’t just show up to a session and grab what is in the home, and try and use that as a reinforcer. The items in the home are things that child sees everyday. You may be able to get the child to do easy tasks for the teddy bear you grab off their bed. But once you move to more difficult tasks, or once that child has a bad day, that teddy bear just isn’t going to cut it.
  • Have a stash of 24 Karat Gold reinforcers- That is just my own nickname for my super powerful reinforcers. I call them my “24 Karats”. As you spend time with your clients you get to know their personalities, and what they like. You learn what items they go insane over. Instead of mixing those items in with your other reinforcers, put them aside. Save them for really difficult sessions, like if the child is getting over a cold, didn’t get enough sleep, or you are teaching a very hard skill. Bring these items out sparingly. You want to keep the interest in these items high so when you bring them out the child is really excited. How do you know if a reinforcer is a “24 Karat”? Here are a few signs to look for:
    1. You bring the item out of your goodie bag or your car, and the child immediately makes a beeline over to you and tries to take the item.
    2. The child mands for the item when it is out of sight.
    3. Watch facial expression: the child smiles, their eyes widen, or they give intense eye contact to the item. Here is a very simple trick: Place the reinforcer/random goodie on your palm so the child can see, and then close your palm tightly. If the child comes over to you and tries prying your hand open you are holding a 24 Karat!
    4. When its time to put the reinforcer away the child resists giving the item up, cries, tantrums, or may even become aggressive. Therapists, be happy when you see this reaction because it tells you that the child really wants that item.
    5. The child will drop an item they really like, in order to approach you when you are holding the 24 Karat.

Thursday, February 16, 2012

Quote of the Day

"We learn more by looking for the answer to a question and not finding it than we do from learning the answer itself".

“At the end of knowledge, wisdom begins, and at the end of wisdom, there is not grief...but hope”.

Lloyd Alexander, (1924-2007)

Saturday, February 11, 2012

Everyday FBA: Functional Behavior Assessment

Isn't Giada great? 
I am a fan of her cooking shows "Everyday Italian" and "Giada At Home". She makes preparing elegant Italian dishes seem quite simple and easy to accomplish for amateur cooks like myself. 

So what in the world does Giada have to do with FBA’s & behavior?

Some professionals in the field of ABA do clients a disservice when they cannot break down complicated, jargon- filled terminology to explain behavior in such a way that a busy parent with 3 kids or a stressed out 2nd grade teacher can apply these techniques. If you are a professional reading this blog, understand that much of what you think up/write as an ABA professional will be implemented by someone other than you. You can spend hours writing an amazing intervention, but if you can't get the family members or teachers to carry out your intervention then what's the point?

Part of my responsibility as an ABA professional is to teach and train people at a level that makes ABA seem easy to understand and carry out. That is part of providing effective treatment to clients. A FBA, or a Functional Behavior Assessment is a behavior analytic tool that I will explain in this post (A FA, or Functional Analysis, is a more complex way to determine the function of a behavior by manipulating the environment. A full FA should always be conducted by an experienced ABA professional). Understanding an FBA is critical to any ABA program.

Now for the disclaimer:
A FBA is a tool used to determine the function of a behavior, and then design a function based intervention.  This post is intended to be a brief introduction to the FBA process. If you are having behavioral issues with your child/client, it is always  recommend you contact a Behavior Analyst to conduct a  comprehensive FBA and design a behavioral intervention, rather than try to create an intervention yourself. To put it another way, watching “Everyday Italian” does not qualify me to open an Italian restaurant. It’s a basic understanding at a limited knowledge level.

To understand what an FBA is, first lets define behavior: A behavior is anything an organism does in response to a stimulus. To put it simply, behaviors are observable and/or measurable activities. By this definition, talking is a behavior and thinking is not because I can't observe someones thoughts.
All behavior occurs for a reason and the goal of an FBA is to discover that reason. Once the reason is discovered then  an intervention, or plan of action, can be created. A FBA is needed anytime behavior reduction is desired.

 A common question I get asked is “Do I have to get a FBA done in order to intervene on a behavior?" The answer is no, you do not.  However, understand that without first doing a FBA to discover what is maintaining the behavior you are just guessing. You are then creating an intervention based on a guess.
In addition, research has shown that when people intervene on a behavior without first doing a FBA the focus tends to be on punishment. In other words the parent or professional is only focusing on stopping the behavior, and there is no emphasis on teaching replacement behaviors. A real life example of this I see all the time would be a parent who dislikes their child's self stimulatory behavior, such as repetitively sticking fingers into the mouth. Every time the parent sees the behavior, they pull the child's fingers out of the mouth. What is missing from this strategy is teaching the child what you want them to do instead of sucking on their fingers.

A FBA is conducted in order to reduce or extinguish challenging behaviors. Challenging behaviors can include aggression, tantrumming, noncompliance, self injurious behaviors (SIB's), elopement, self harm, cursing, skipping school, etc.  In an ideal situation a qualified BCBA would be the person conducting the entire FBA process. Unfortunately that isn’t always possible. Some school districts or families cannot afford to hire a BCBA, or you might live in an area without access to BCBA's. BCBA's can be quite difficult to find depending on where you live.

A FBA has 3 basic steps: 
  • Gather information, Consultation
  •  Direct observation, Develop a hypothesis
  •  Create plan of action, Consultation

Step 1: There are many ways to gather information about the child, the problem behaviors, the environment, and the possible function(s) of the behavior. I will typically conduct 1-2 interviews with the parents (or teacher, if a school requested a FBA), review the child's records (educational records, IEP, recent reports from a psychologist, physician, SLP, etc), and collect information from the parents about possible replacement behaviors. Its important to involve the parents in every step of the FBA process, as it helps ensure that the parents are active participants in the intervention. The goal at this point is to gather information about the problem behavior, when it occurs, how long it lasts, what does it look like, has it recently gotten worse, what tends to make it occur, and how do the parents react to the problem behavior. It can also be helpful to ask what strategies the parents have already tried to eliminate the behavior. To assist with the parent interview, I recommend using the FAST form (Functional Analysis Screening Tool), or the MAS (Motivation Assessment Scale).

Step 2: The next step is to directly observe the child engaging in the problem behavior. This can sometimes be difficult to do. Since I am a professional unknown to the child and have no history with them of reinforcing their problem behaviors, its very common that I will go out for an observation and the child will be a perfect little saint during my entire observation. This often irritates parents immensely! :-) I like to explain this phenomenon to parents by comparing it to taking your car into the shop for auto repair. The mechanic will often say "I don't hear that noise you're talking about", and inevitably as you drive away from the auto shop your car begins making the noise again. If you are able to actually observe the problem behavior, be sure to closely watch for the Antecedent and Consequence to the behavior. You can always try and schedule more observation visits, or you can ask the parents to videotape the behavior the next time it occurs. At this point you should have some ideas of the hypothesis of the problem behavior, based on what you have seen and the data you have collected. There are 4 main functions for any behavior: Gain attention or a Tangible item, Automatic reinforcement (sensory), Avoid or escape a demand or situation, and To communicate wants/needs. It isn't unusual for a behavior to serve multiple functions, although there is typically a main function (primary) and a lesser function (secondary).

Step 3: After the FBA is completed your next step is creating a Behavior Plan.
The behavior plan is your "plan of action", or the intervention that will reduce or eliminate the problem behavior. The plan to reduce the problem behavior is 50% of the intervention, and the other 50% is the plan to teach replacement behaviors. In other words, when the child stops engaging in the problem behavior what do you want them to do instead? The intervention you create will be directly connected to the function of the problem behavior. If a child is engaging in screaming to gain sensory input, then ignoring the screaming is a poor choice of a replacement behavior. A better choice would be to teach the child songs to sing, to match the need for vocal sensory input. Consultation is listed again for step 3 because it is critical to involve the parents as you develop the behavior plan and replacement behaviors. It isn't uncommon to come up with great, research proven replacement behaviors that one or both parents don't like. If the parent seems unsure or hesitant about the intervention you are suggesting then you need to find out why. What is it about the intervention that one or both of the parents don't agree with? For example, I worked with a parent a few years ago who did not want to use any planned ignoring procedures where her child would cry for extended periods of time. I explained the difference between planned ignoring for problem behavior and ignoring the child, as well as cited research, but the parent still disliked the planned procedure. So I redesigned the intervention. The problem behavior did eventually improve, but it took a much longer period of time. However, as an ABA professional I don't write behavior plans for myself. I write them for the client, so its imperative that the client is on board with the treatment I am recommending.

**Quick Tip: Doing an FBA and creating interventions can be a challenging process. Do not be discouraged if it takes time and repeated attempts to learn this skill. If you look online or in books you may find resources to guide you in designing a FBA, but they are just examples. Tyler's FBA and behavior plan cannot be applied to Jared; these children are not identical and their behavior plans should not be identical.
 A FBA should be individualized to the child, as well as be viewed as acceptable by the people who must carry it out. The people closest to the child are the ones who ultimately determine the social validity and effectiveness of any behavioral intervention.

FBA: Function of Positive Reinforcement
FBA: Function of Negative Reinforcement
FBA: Function of Automatic Reinforcement

Tuesday, February 7, 2012

Quote of the Day

Parents and therapists, always remember to stay flexible and creative when trying to teach any skill. Dr. Ivar O. Lovaas, says it best:

“If they can't learn the way we teach, we teach the way they learn”.
 Dr. O. Ivar Lovaas, creator of DTT style of ABA
Saturday, February 4, 2012

The Mystery of Time Out

Time Out is a highly misunderstood and overused behavioral management technique. 
When I consult with  parents, therapists, or teachers and ask what behavior techniques they currently use, Time Out is usually stated pretty quickly. Then when I ask if Time Out is effective, I hear “no/sometimes/maybe”.  There seems to be this mysterious cloud surrounding time out that people cant break through in order to really understand the procedure. That is unfortunate because the very people who use Time Out the most tend to be the ones who don’t really understand it.
Time Out is a concept that seems to be very simple and straightforward, but if that were true it wouldn’t be  implemented incorrectly so often.

Time Out is a punishment technique, and punishment can be positive or negative. Time Out is a negative punishment because you are removing (not adding) something. Many people don’t know when they say the phrase "Time Out" they are using an abbreviation. The full name is Time Out from Reinforcing Activities. Once you understand that, then you can see how putting little David in Time Out during homework time because he refuses to do his homework will not be effective at all. You must be able to identify and then isolate the reinforcement embedded in an activity for Time Out to be effective. In other words, the “Time In” environment must be reinforcing to the child before you can implement “Time Out”.

Make sense? Good :-)

Another cloud of mystery around Time Out is regarding the rules of how to do it. I have been in a variety of settings and seen Time Out done many different ways, and often the parents or teachers will report confusion about the "rules" of Time Out. People describe some very creative Time Out rules to me, that range from odd to confusing. Not surprisingly, many of these rules have no merit. These rules are not based in research, and are not written in stone anywhere. They are just passed from person to person, spreading incorrect information. The biggest guidelines to remember about Time Out are:

-Time Out is not supposed to be humiliating, or degrading to the child
-Time Out is not supposed to be excessive, overly punitive, or cruel ( see Hancock v. Avery, 1969)
-The child cannot leave Time Out if they are still engaging in the inappropriate behavior
-It should be clear to the child why they are in Time Out
-Time Out (like any punishment technique) is not a replacement for teaching skills

All of that describes what Time Out is not. So what is Time Out supposed to be?
The goal of Time Out is to decrease the future occurrence of a specific behavior. The child should learn over time that engaging in a specific behavior  leads to a removal of reinforcement. All punishment techniques should result in the target behavior going down. If the target behavior does not go down, then what you are doing is not punishing to the child. There are two main categories of Time Out: Exclusionary & Non-Exclusionary.
  • Exclusionary is when the child is removed from the environment and the reinforcement. This is the most common type of Time Out I see, where the child is sent out to the hallway (if in school), or sent to a certain chair (if in the home) for a period of time.
  • Non- Exclusionary is when the child remains in the environment, and only the reinforcement is removed. I don’t see this kind of Time Out as often. This would be things like planned ignoring, or taking a reinforcer away.

Now that you know what Time Out is, here are some examples of correct implementations:

    1. During a session with a client you bring out some toys to play with. The child immediately reaches for the Play-Dough, so you open up the Play-Dough and start playing. The child begins mouthing the Play-Dough. You give the child a reprimand to stop eating the Play-Dough. The child continues to try and eat it, so you close the Play-Dough and place it out of reach. You then direct the child to help you put a puzzle together. Once the puzzle is done, you bring the Play-Dough back out and remind the child “No mouth” before letting them play with the Play-Dough again.
    2. Some of the children in your 1st grade class are being disruptive and off task during art time. You remove your attention from those children and start giving eye contact and compliments only to the children who are doing their art project (e.g. “Lisa I love the circle you made! Very nice”). As the other children stop being disruptive and start doing their art project, you give eye contact, praise, and smiles to them too.
    3. You are in the backyard with your children, swimming together in the pool. Your son begins to play too roughly with his sister, and won’t stop splashing water in her eyes. You tell your son to leave the pool and go sit on the grass. Your son starts crying and stomps over to the grass and sits down. Once he is calm and quiet, you tell him he can get back in the pool and remind him to play nicely.
    4. Setting a partition in the classroom and when a child misbehaves they must go sit behind the partition. They are still in the classroom, but they cannot participate in or see what is going on.
    5. The “sit and watch” technique. I see teachers do this one a lot. The teacher is outside on the playground with his class, and one child begins to become aggressive with his peers. The teacher tells the student to come sit near him, and take a break from playing. The child sits down near the teacher and watches the other children play. After some time, the teacher lets the child get up and re-join his peers.
    6. A dad is playing Monopoly with his kids. His son is caught cheating and not playing fairly. The dad tells his son he will miss his next 2 turns, because he was cheating. After his son has sat out for 2 turns, the dad tells him he can start playing again.

These are all different ways to do Time Out, none of which might fit what most people think Time Out is. Time out is much more than just a timer and a “Naughty Chair”. If you have been consistently using a Time Out technique and aren't seeing a behavior change, its possible the "Time In" environment isn't reinforcing enough.


**Quick Tip:
Understand that you may have to do Time Out with the child. In other words, if the child will not stay in Time Out, or becomes aggressive when you put them in Time Out, you may need to stay with the child to restrain them or block them from leaving Time Out. So in a way, every time you send the child to time out you are putting yourself in Time Out as well.
It is not uncommon for punishment techniques to lead to anger, retaliation, or aggression. Be aware of that in advance and decide if that is something you are able to handle. Remember, the Time Out can not end if the child is engaging in inappropriate behaviors (hitting, spitting, screaming, etc.). Please refer to my punishment post for more information about possible side effects of punishment techniques.