If you care about someone with Autism and you've never heard of a "Meltdown", then this post is for you.

Meltdowns are often viewed/discussed as being a typical tantrum times 50.

To most of us, a tantrum is about a power struggle. You tell the child “No” when they expected to hear “Yes”. Or you gave them milk, when they wanted juice. Crying, whining, throwing things, stomping feet, and collapsing to the ground begin to occur. If you have ever witnessed a 2 year old having a tantrum, that seems to be the prototype. Despite the age of the child a tantrum usually looks like a 2 year old who didn’t get their way.

Meltdowns are often defined as when a typical tantrum goes off the deep end, and starts including property destruction, aggressive acts, maybe self-injurious acts,  and extended yelling/screaming that can go on and on.

What is important to know about the "tantrum" vs "meltdown" discussion is that they are both behaviors. Thats the good news. ABA provides a vast array of strategies for reducing or extinguishing behaviors. So why are tantrums and meltdowns often discussed as if they are 2 completely separate events? It seems like most people think a tantrum is something that can be dealt with but a meltdown is out of everyone's control.

I think one reason can be the varied use of terminology when describing what is really a group of behaviors. If I say to you that an individual is "crying, rolling around on the floor, and screaming", you could decide that I am describing a "tantrum" or you may decide I am describing a "meltdown". It just depends on your interpretation, and your opinions. The problem with that is the consequence you come up with may vary depending on if you think the individual is having a meltdown or not.....but it shouldn't. Why would the consequence change? Behavior is behavior. Once the function of a behavior is determined, you as the parent or caregiver are now equipped to intervene on the behavior. You could call it a "tantrum", "meltdown", or "outburst", and that wouldnt necessarily mean the function of the behavior is any different. Make sense?

This is similar to the conversation around "sensory" vs "behavior". If someone decides a child is let's say...... climbing furniture for "sensory reasons" and not to do a "behavior", then maybe things like a sensory diet, weighted vests, or time in a sensory room may be given to that child every time they start to climb furniture. Here's a  few problem that this viewpoint can lead to:
- A "behavior" is what you can observe and measure, which means that if you are looking at your child exhibit "sensory issues" such as toe walking or vocal stims, you are looking at a behavior.
-Since you are dealing with a behavior, the most effective way to reduce or change it requires first determining the function. What I usually see to be true is that people don't try to determine the function of "sensory issues". I am usually told "oh we know WHY she does it, its sensory!"
-This is when it gets a bit tricky...another problem that can happen when multiple behaviors get lumped together and called something is this: How do you know if the behaviors all have the same function? Maybe the child began crying to gain mom's attention, but maybe they then started trying to climb onto the coffee table to escape dad (who is now walking over). If we call the entire episode a "meltdown" or a "tantrum" and lump all the behaviors together, the intervention we come up with might not work.
-Probably the biggest problem I see is when people think a behavior is really "sensory", they tend to only use reactive strategies. This means that when little Alice begins to headbang in the classroom she's quickly put in a quiet hallway with a helmet to wear, or sometimes taken straight to a sensory room. Unfortunately, this often ends up increasing the behavior because from Alice's perspective she just left boring math class to go to Disneyland. 

See, this terminology stuff is actually pretty important :-) When it comes to ABA, you have to be realllllly clear on what you are targeting.


 So now that its clear the best way to manage the behavior is by not getting hung up on terminolgoy or labels, and instead putting on your trusty Behavioral Cap, then what do you do next?

Glad you asked!

1. Determine why the target behaviors are happening (the function).
2. Using the function, create an intervention (I recommend consulting a professional)
3. When designing the intervention,  be sure to think about what to do both BEFORE and AFTER the behavior occurs. You dont always want to be just reacting to behavioral episodes, you want to also be preventing them. Also, teaching replacement behaviors is important too. A good way I focus on this is by asking parents "Okay, what do you WANT him/her to do". For example, if a parent says to me "He gets angry and starts breaking things and slamming his bedroom door" I then respond with "What do you WANT him to do". Have you thought about that? Many times, the parents I consult with have not. Dont focus on just stopping behaviors, also think about what behaviors need to be taught/are currently lacking. 
4. Putting the intervention in place is not the last step. It will be important to track the behavior (to determine if the intervention is working) and to "feed" or reinforce the appropriate behaviors. "Feeding" the behaviors you want to see will make them happen more frequently. 

The following are some general tips I have found to be successful with previous clients, when it comes to managing what some may call "tantrums" and some may call "meltdowns". Keep in mind, ABA is not paint-by-numbers. For best results, an intervention needs to be individualized to your child.

Helpful Parent Tips

•       First, check-in with yourself-- are you calm?  Have you lowered your voice?  Are you remembering to breathe slowly?  Allow yourself to pause and not be in a rush. The more upset the child is, the more calm you should be. Minimize direct eye contact and remove any expression from your face (your feelings should not be flickering across your face).
•    Count & Mand Procedure can be very helpful for managing behavioral episodes, particularly in public. Avoid things like bargaining, pleading, begging the child to behave, making threats, or bribery. 
• Each time a behavioral episode kicks off, remind yourself that learning is occurring. Your child is taking note of what happens when they do a particular behavior, and determining if the behavior is a "keeper" or not (from the child's perspective). 
•    Harmful behaviors are not ignored. If your child begins to hit, headbang, bite, kick, etc., block these attempts and use restraint if necessary to maintain safety (if this is an ongoing issue, please seek professional help).

•  Look for opportunities to provide reinforcement, also known as "Catch 'em being good". If you are using hand over hand prompting to get the child to finish making the bed, step back every minute or so and see if he will comply independently. If he does, provide specific praise such as “Awesome making the bed!".
• Pay close attention to what is usually happening before these episodes happen--Is the child being told to do a task? Is no one interacting with them?, and what is happening when these episodes stop--- Does the child get attention? Hugs? Quiet time in their room? This is key information that will help determine possible triggers and motivation for the behavior, from the child's perspective.

**Tip: For more information on this topic, I recommend the book "No More Meltdowns" by Jed Baker.

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Tameika Meadows, BCBA

“Optimism is the faith that leads to achievement. Nothing can be done without hope and confidence.”

– Helen Keller, 1880-1968

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Tameika Meadows, BCBA

I loooove teaching Task Completion, it’s such a great skill to give to individuals with Autism.
Task Completion is a program that teaches a child to complete tasks independently for a specified amount of time. Beyond that, Task Completion teaches these kiddos appropriate leisure skills. When left to their own devices many children with Autism will spend their down time inappropriately. They may stim, have repetitive play, or engage in disruptive behaviors such as climbing onto cabinets or furniture. Once taught to mastery, Task Completion is a great tool that can be used by parents for when they need their child independently engaged in an appropriate activity. Such as when Dad is on the phone, when Mom needs to do the laundry, when big brother has friends over and doesn’t want his baby brother interrupting, during transition times, during down times, in the classroom, etc. This program also teaches children to follow a timed schedule, follow directions, complete tasks in serial order, attending skills, appropriate waiting, etc.

 I will recommend Task Completion as a program for children who:

 -Already have some toy play skills, but very few leisure skills

-Have difficulty with transitions or unstructured times in the home or classroom

-Need someone to engage with them in order for them to attend to a toy or object

-Have many attention seeking behaviors/Seek attention in inappropriate ways

Task Completion does have a few prerequisites. The child needs to be able to wait, must already have some toy play skills, must understand delayed reinforcement, must have a good number of mastered skills, and the parents need to be on board with this program. The way I write this program, in order for the child to master the skill (and for the program to be closed) each parent must be able to run Task Completion by themselves. So this particular program requires significant parental involvement.

Here is how a visual of what Task Completion looks like:

The therapist places tasks into a set of clear shelves, and sets a timer for a specific amount of time. Next the therapist gives the SD and starts the timer. The child should pull out the 1^st drawer, take it to the table and sit down, empty the drawer, complete the task, put the task back in the drawer, and return the drawer to the shelves. At that point the child either continues moving through drawers, or goes and sits back down until the timer goes off. Task Completion is not finished until the timer goes off. 

*Task Completion Tips:

•  Materials Needed: Clear plastic shelves, a variety of mastered tasks, a variety of reinforcers, a timer, a desk or table where the child completes the task.I usually get these clear shelves from Wal-Mart, they're around $8.You can buy them with or without wheels, it doesnt matter.

• The tasks placed in the drawer need to be mastered tasks that the child can complete independently. Pick tasks that have a clear start and stop, and don’t need instructions. A lump of Play Dough would be a poor choice, because it isn’t explicitly clear what to do with it. A string and beads are a better choice, because its clear the child is supposed to place the beads on the string.

• When first teaching this program, you can reinforce the child after they are completely finished or you can reinforce at the end and the beginning. What that usually looks like is I will place a small edible reinforcer on top of the drawers, and the child can grab the reinforcer before they pull out the 1^st drawer. This also works well for children who delay beginning Task Completion, and you have to physically guide them to start working.

• After you have been teaching the program for a while and have a few drawers, you can place reinforcers directly in the drawers. The 1^st drawer could be a task, 2^nd drawer is a reinforcer, and 3^rd drawer is a task. This builds reinforcement into the program. You could even place a child's favorite stim object or a sensory box in a drawer, and use that as a reinforcer.

• After you give the SD and start the timer, do not say anything to the child until the program is completely finished. The child may cry, tantrum, flop to the ground, ask you questions, etc. Do not respond verbally. Use nonverbal prompting as necessary. The reason for this is so the child learns they are expected to do the program independently.

• As the child begins to learn the program, the therapist should fade further and further into the background. On drawer 1, you may need to be right by the child to ensure compliance. By drawer 3, you should be standing across the room and by drawer 5 or 6 you should be able to move freely in and out of the room as the child stays engaged with the Task Completion program.

• There are SO many creative ways my kiddos have of being defiant during Task Completion. Sometimes the child will move very slowly to try and “ride out the clock”. Other times, as soon I give the SD the child drops to the floor and refuses to move. Some children are perfectionists, and get upset if the timer goes off before they have finished their task. They may scream and then throw the drawer across the room. Be aware in advance that you may see all kinds of new behaviors pop-up during Task Completion. What is most important is that you do not speak, prompt full compliance, and take a look at your reinforcement to make sure it is strong enough.

Once taught to mastery, Task Completion can consist of anywhere from 1 drawer to 12 drawers…or even more.  It just depends on the setting. Most homes end up using 8-12 drawers, which is about 15-25 minutes of time where the child is independently engaged in a leisure activity. That’s a lot of extra time in the day for busy and stressed parents to get things done, knowing that their child is engaged in something appropriate.

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Tameika Meadows, BCBA

If you have a money tree in your backyard this post isn’t for you. Also, please drop me an email and let me know where you found a money tree.

Thanks.

In my Frequently Asked Questions post, I briefly touched on different ways families can pay for ABA. If you are a regular reader of my blog then by now you know that an ABA program needs at a minimum:

-Staff/Therapists
-Consultant/BCBA
-Supplies (table and chair, paper, pens,binders, etc)
-Teaching Materials (reinforcers, flashcards, data sheets, timers, clipboards, etc).

Everything on that list has recurring cost. For example, supplies aren’t purchased one time, and then you’re done. Some of the best clinical programs I have seen are SUPER materials heavy, with hundreds of flashcards, visuals, etc.
 Let’s look at that list again for a typical month:

 *(Estimated for a 20 hour per week in-home ABA program with 2 therapists and 1 Consultant)

-Staff $2400

-Consultant $4000

-Supplies $400

-Materials $600

Monthly Cost: $7400

For one year, a basic ABA program could cost somewhere around $80K. That doesn’t include additional costs like medications/supplements, other therapies, private school, etc. I don't know about you, but the families I know simply cannot afford that.

As an ABA professional there are many aspects of my job that can just be heartbreaking. It’s very difficult to see a child who desperately needs therapy go without services because of cost, or to work with a family who must suddenly stop therapy because of cost. In this country we have a long way to go in terms of understanding the critical need for Autism services. Although it is statistically clear that Autism rates have risen, the treatment accessibility has remained mainly open to the financially well-off. Not helping matters any is the reality that the pool of professionals available to offer ABA therapy is quite small compared to the demand (and that small pool gets reduced as the child ages). Add to all of this a seriously hurting economy and parents are left to wonder who exactly is going to pay for this much needed therapy. 

This is such an important topic that I want to be very careful in saying that I am NOT an insurance coverage expert. I'm not the final word on financial resources for ABA therapy. I am happy to share the information that I have but be sure to research what is available in your area, as much of this information differs from state to state.

 For the international readers of my blog I do not know much about financial resources for ABA Therapy outside of the US. I would suggest you talk with other parents in your area, do research online, and check with your insurance company and see what options you have. If you are financially able, you may want to consider moving to a country that has mandated laws regarding Autism and Autism therapies.

Financial Options

• Private Pay- Private pay means paying out of pocket for therapy. Be sure to ask the provider if they use a sliding scale for private pay clients. Also, please note that if you are wanting to receive private pay services from a company/provider who normally only works with insurance clients, they may expect you to pay what the insurance company pays. The reason why being, if they charge you a lower rate then they would have to reduce what they pay the staff and Consultant who work on your case. With private pay, your payment may be due at the end of the month, or even per session. Also, some individual providers do not accept check payment. Keep in mind that if you pay for therapists to provide therapy in your home some of that cost may be tax deductible. Contact your tax preparer to find out if you can claim any costs of ABA therapy, including staff salaries or therapy materials.
• Scholarships/Grants/Waivers- These are funding sources available from the state, Autism agencies, or non profits that give stipends or grants to families for ABA therapy (such as Easter Seals). There is usually a precise paperwork process to request these monies, and typically a waiting list. If you live in GA, there is a link below to funding sources available for parents of varying income levels. Even if these stipend amounts are small, trust me: every little bit helps! Sometimes multiple grants or waivers can be applied for by the same family, each year.Also, sometimes ABA companies will reserve a "scholarship" spot for needy families. It may only cover limited services, but still ask about this option.
• Loans- Some families secure loans from banks, organizations, or family members to cover the cost of therapy. When considering loan options always look for low interest rates and know the details of the re-payment plan.
• School Funding – Many families have children who receive free ABA therapy at school, although usually this does not include wrap around services (meaning they will not come into the home to help you). You also need to know who is supervising and managing the ABA program at the school. Is it a teacher? A BCBA? The Special Education Director? Be sure to ask how that person is qualified to manage an ABA program. If your child’s school does not provide ABA therapy, they might have an Autism program or Autism classrooms. In some instances, parents have been able to successfully petition the school system to pay for ABA therapy in the home. This was no easy accomplishment and in some cases took litigation, but I have seen it happen.
• Respite Providers/Students – You can minimize salary cost by hiring college students or respite providers to provide therapy. Many states have respite agencies that will send individuals to your home to provide respite care at low cost, or no cost. These respite providers may have an ABA background, in which case they could work with your child. Another option is to use the providers sent out by early intervention agencies in your state. In GA, the early intervention agency is called Babies Cant Wait. If your child is not meeting developmental milestones and is under age 3, they are eligible to receive services in the home from a Special Instructor at no cost to you. Some of these Instructors may provide ABA therapy and some may not. If you decide to hire college students they may get course/internship credit for working with your child, and you wouldn’t have to pay them. I would suggest contacting the Education, Social Work, and Psychology departments of college campuses near you to gather a pool of students. With all of these options you would still need a Consultant to oversee the quality of the program and provide training.
•   Insurance – This refers to private insurance or employer provided insurance and is the most common funding source today, yet its also the most difficult to obtain. Take a look at this map: 

      The green states have enacted laws to require insurance companies to pay for ABA therapy. The red and yellow states are working towards laws but are currently only at a bill level regarding legislation, and the blue states are not pursuing legislation at all. As you can see, depending on where you live insurance coverage might be a great option or a nonexistent option. Further complicating matters is even if you live in a green state you still may be unable to get insurance to cover your child’s therapy. This is because of something called “Self Funded Insurance Plans”. A self funded insurance plan is when the company you work for pools their own money together to pay claims rather than contracting with an insurance company. That means it is up to individual companies to offer ABA therapy on their insurance plan or not. The only way to know whether your insurance is self-funded is to ask your employer.  The insurance issue is much more complicated and complex than I can explain here. If you live in a state that does not mandate insurance companies cover ABA, know that this issue is currently being lobbied for around the country.  Even for families who can get insurance to pay for ABA therapy, there are still many flaws in the system. Some insurance companies will only pay for services provided by a licensed Psychologist, only pay for a minimal amount of therapy each month, or  make it extremely difficult for BCBA's to get reimbursed for services rendered ...thats another thing, if you want insurance funding you typically have to hire a BCBA. Many insurance companies are new to working with ABA providers and don't quite know how to categorize us, so they routinely deny our claims. That means the BCBA may regularly wait 45-90 days to get paid for their services. That can really deter a BCBA from accepting insurance clients, and you may be responsible for payment of the claim if the insurance company refuses to pay.

• Run a Program Yourself! – I always present this option to parents, because you are in the best position to take the reins of your child's therapy. Especially with the economy crisis right now and the insurance mess; this is the most realistic option for many parents. In my post on How To Start An ABA Program I described the steps parents can take to run an ABA program. For many reasons families cannot always hire staff  to  provide in-home therapy. For the international readers of my blog, this option may be the best pick for you. I have a client located outside of the US and they live in an area where there are no Autism schools, services, or professionals. Where they live, information and knowledge about Autism is extremely minimal. What this family chose to do was run an in-home therapy program themselves, to fight for advocacy in their country, and to hold seminars open to the public to raise awareness. The mother provides her own son with intensive ABA therapy per week, and also trains individuals (relatives, babysitters, etc.) as needed on basic ABA knowledge. The out of pocket costs for this family includes consultation, supplies, and materials. They make much of the materials and supplies they use, so that also brings costs down. Is it difficult for a parent to be their own child’s therapist? Absolutely. But is it possible? Definitely. I hope the example of this family can be a source of inspiration. If you live in an area where ABA resources don't exist,  please don’t think all hope is lost. If no funding options are available to you, I encourage you to get on the floor, pull out those flashcards, and start teaching your child yourself. 

Helpful Links:

• http://www.autismvotes.org/site/c.frKNI3PCImE/b.3909853/k.BE44/Home.htm
• http://www.wrightslaw.com/info/ei.index.htm
•  http://www.tricare.mil/ - For military families only
•  http://www.autismhealthinsurance.org/
• http://www.tacanow.org/family-resources/start-an-in-home-therapy-program/
• http://www.autismspeaks.org/family-services/grants
• Who Pays for ABA Programs?
• http://p2pga.org/roadmap/insurance/insurancemedicalinsurance.htm
  
  CARD Resource: Insurance Funding & Autism
   
  
  
  
  

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Tameika Meadows, BCBA

"The whole purpose of education is to turn mirrors into windows".

Sydney J. Harris, 1917-1986

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Tameika Meadows, BCBA

After my post about How to Interview ABA Therapists, I started receiving questions from ABA professionals about what they should be asking during an interview.

For both parents and the therapists the interview process is a time to discuss details of the position, pay and benefits, expectations, qualifications and background, etc. Just as parents are responsible for making expectations clear during the interview process, therapists are responsible for evaluating these expectations and determining if they can meet them. This post is specifically for ABA professionals who work in the home with clients.

There are basically two different roles an ABA therapist can inhabit: an Employee or an Independent Contractor. If you have a supervisor or work for a company you are an employee. If you work for yourself, you are independent.

 (You can work for a company or agency and be considered an independent contractor. To reduce confusion, in this post the term "independent contractor" refers only to people who work directly for families)

When I started in this field I was an independent. I worked directly for families and I didn’t have a direct supervisor. That means I was responsible for finding work, setting pay criteria, marketing myself, and creating my own employment contract.

There are pros and cons to either role; it just depends on what works for you. Some therapists prefer working for themselves, and others like the advantages of being under a company. It’s a personal decision.

The interview/hiring process looks a little different depending on if you are an employee or an independent. Employees typically are given policies to adhere to; they don’t get to create them. So I will move straight to talking about independents. 

For independents, your role and the responsibilities of your position should be clear before you ever begin working with the family. I talk to many therapists who work in the home and are dissatisfied with pay, hours, communication, etc. If these issues are discussed before you ever begin work, it is much easier to find areas of compromise. For example, if you are going on vacation for 2 weeks who will cover your sessions? Have you discussed that with the family? The day before your vacation starts is not the ideal time to have that discussion. Some families are not used to having employees working for them in their home, so they may not know how to interview you. They may not know what issues need to be discussed, or what needs to be put in writing. As an ABA professional it is your responsibility to inform and educate the family during this process. You are not just the more knowledgeable one when it comes to behavior and ABA, you are probably the more knowledgeable one about the hiring process. Below are some hiring/interview tips for both employees and independents:

Independents

• The most important part of the interview is finding out from the family exactly what the position entails. What are the hours, what is the pay rate, what are the job responsibilities, what expectations does the family have of you, what programs does the child have, how many therapists are on the team, is there a Lead therapist, who writes/creates the programs, who writes/creates the behavior interventions, what ABA methodology is the family using, how is training provided to you (if it is provided at all), etc. I suggest arriving to the interview with a list of questions to ask the family about the position.
• Directly after discussing the position, it is important to talk about policies. Think of policies as “The Rules”. You and the family together need to create policies that are satisfactory to both of you. Examples of important policies to discuss include: Sick days, vacation pay (if either you or the family go on vacation), cancelling sessions, pay raises, benefits, audio/video recording of sessions, mileage reimbursement, can you administer medications, etc. As awkward as it may be to discuss these issues with a family you may have just met, imagine how much more awkward it is to talk about overtime pay after you stay an extra 2 hours at the home one night. Take any anxiety or nervousness out of it and make sure to discuss these issues before you accept the position. I also suggest you get these policies in writing.
• The next area of importance includes several things which can all be lumped together under “Boundaries”. It is important, from day one, to establish clear boundaries with the family. It is unfair to work with a family for several months and then suddenly inform them you aren’t comfortable with something. If you know there are duties you are not willing to do make that clear from the beginning. That is what creating boundaries is all about. It tells the parents when something is outside of your comfort zone. If you are a new therapist you may not know what your boundaries are yet. Even if you don’t know what they are you can inform families during the hiring process that if something makes you feel uncomfortable/ is outside of your job description, you wont do it. A boundary of mine is I don’t babysit siblings while I am working with my client. I have had negative experiences in the past where a parent has left me home alone with all their children, and was it awkward to ask them not to do that? Yes! However, it isnt fair for my client to receive 10-15% of my attention and focus because I'm busy babysitting their siblings.

Employees

• If you are an employee, there isn’t really an interview process with your clients. You are assigned a caseload and you go out and start seeing clients.  It can still be helpful to discuss with your company or supervisor what the policies are, get a full job description in writing, and discuss how clients are declined. Declining a client is basically when you decide for whatever reason that you no longer want to work with a family. Usually if you make the decision before you ever meet the family, it’s a very easy process to decline a client. However once you start working on the case some companies make it very difficult for you to be removed from it. The emphasis can be on what works best for the company, and not for you, the actual therapist. Changing a caseload is typically a decision made by your supervisor(s), not you. In addition to asking about these issues you should also find out how conflicts are handled. Conflict can come in the form of therapist/therapist, supervisor/therapist, or family/therapist. Whichever type of relationship the conflict occurs in, it can seriously affect your ability to do your job and decrease your job satisfaction. As a professional it is always your responsibility to try and repair any difficult relationships and resolve conflict on your own first. Sometimes that isn’t enough to defuse a negative situation, especially if your conflict is with a parent or therapist you see regularly. At that point, what is the protocol for handling conflict? Can you ask to be removed from a case, and if so, will you receive a replacement case? Can you request a different supervisor without being penalized? These are all important questions you need to ask.

Whether you work independently for 1 family, or for a large company with a caseload of 10 clients, it is your responsibility to know the specific duties of your position, and all policies and regulations. The client-therapist relationship is only improved by open and ongoing communication from day one.

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Tameika Meadows, BCBA

If just hearing the words "potty training" makes you tense and nervous,  then you probably are currently struggling with the toilet training process, or you have a child who will begin the process soon. Teaching any child to move from freely voiding in a diaper or pull-up to using a toilet is a difficult process. Now toss into that situation a child who has Autism, and potty training can go from being challenging to being a severely frustrating and stressful experience for the entire household.

Children with Autism may have challenges in the areas of language/communication, sensory processing, social skills/social thinking, and behavior control that need to be taken into consideration when formulating a potty training program. Other issues such as motor planning, sensory needs (feeling a full bladder or a wet diaper), communication abilities, and preference for predictability and routine may make potty training more difficult. It is also common to see an increase in problem behaviors during potty training, or to see an emergence of new behaviors at this time.

It is hard to predict which kids will struggle with potty training and which will not. I have potty trained some clients in days. Other clients it took years before they were consistently successful. The amount of time needed to teach this skill to a point of independence will vary. Before you actually start potty training your child with Autism, you can’t know with certainty what the process will be like. So the best approach is to be prepared and informed before you ever begin.

First, it’s important to redefine the potty training process. You may have other children you have successfully potty trained, you may have potty trained nieces or nephews, or maybe you have friends who have told you exactly what to expect. Throw all of those expectations out the window. 
Realize that your child with Autism is unique, and the techniques that worked for your 3 year old nephew may not work for your 3 year old child with Autism. Here are a few things that I have learned over the years about potty training & Autism:

• Children with Autism may take much longer to show interest in the potty or display signs of readiness than typical children
• Children with Autism may have fear or anxiety about using a toilet which could be exhibited through severe behaviors
• Children with Autism may need a visual schedule to remember the steps for using the bathroom
• Children with Autism may need to be separately trained to stay dry through the night, even after they are potty trained
• Children with Autism may need to be separately trained to defecate in a toilet, even after they are potty trained to urinate in a toilet
• Children with Autism may need to be separately trained to request the bathroom
• Children with Autism may refuse to use unknown toilets, such as public bathrooms
• It is critical to rule out medical issues as a reason for difficulties with bowel training. If the child has intestinal issues, chronic diarrhea or constipation, or is compacted with fecal matter, they are not “choosing” to have messy bowel accidents. They are not in control of their bowels, and any punishment or consequences will simply confuse or anger the child. A sign of underlying medical issues is a child with loose, watery stools, a child who does not defecate often (defecates 1-3 times per week), a child with a hard, distended belly, or a child with allergies. If any of these issues are going on, seek medical treatment before continuing.

This post is not going to be a step-by-step guide to potty training a child with Autism.  Just like when teaching any other skill, the approach must be individualized to the child and to their needs.

What this post is intended to be is an overview of two of the main approaches to potty training your child with Autism.

Technique #1: ITT (Intensive Toilet Training), also called "In The Bathroom" Training

• Q: What is it?
• A: The ITT method requires a dedicated time and place to do nothing else but potty training. It is helpful to have two or even three people available to work in shifts. Your child should be in regular underwear with no pants for easy access and so you can clearly see if they have had an accident. Give your child plenty of liquids, which will encourage urination and increase the opportunities to reward successful attempts. Place him on the potty from his first waking moment for 3-5 minutes, then use a data chart to gauge how frequently to put him back on the potty (5- 10 minutes before the next regular voiding time). If he is staying dry between sittings on the potty, expand the time gradually by a set increment of minutes. If there is an accident, lessen the time between potty sittings to the previous length. If the child voids in the toilet, heap on the praise and rewards. If the child doesn’t pee in the toilet, instruct him to stand up, and get dressed (with assistance if needed). Sitting on the potty needs to be a fun time, with games, puzzles or social interaction. Blow bubbles, bring a TV and DVD player into the bathroom, sing songs, give the child candy, etc. Make sure the child cannot access any of these items outside of the bathroom.
• Q: How long does it take?
• A: The amount of time will vary from child to child. Generally, the ITT method is done over 2-4 consecutive days, where the child spends the majority of their time on the toilet.
• Q: Why should I pick this method?
• A: The biggest benefit of this method is the intensity. It’s a very quick approach, where the child pretty much spends all of their time in the bathroom. If you can stick to it and dedicate the time to being this intensive then the child could possibly be potty trained in a few days.
• Q: What would I need to get started?
• A: To get started you would need a large supply of 24 Karat gold reinforcers, a way for the child to communicate a need to go potty (could be a PECS card, or sign language), underwear, data sheets, timers, a clipboard, strength, and patience!
• Q: Any quick tips?
• A: When the child is sleeping, or anytime the child will not be around a bathroom (such as if the child rides the bus home), then it is ok for them to wear a diaper or pull up. Place the child in the diaper or pull up and put the underwear on top of it, so that they still are wearing the big kid underwear. As the child becomes more able to use the potty, phase out the diapers or pull ups completely.  

More Tips:
Keep reinforcers available in the bathroom so you don’t have to hunt to find them “in the moment.”
 Use simple, concrete directives that tell the child what to do. Rather than “Don’t pee on the floor,” say “Pee in the potty.” Speak slowly, clearly, and specifically. Remember that persons with autism may have difficulty with auditory directions. Most will need more time to process your words and form a response.
 Teach boys to use the potty sitting down, until they are completely toilet trained. There are 2 reasons for this: the child may accidentally have a BM while standing and urinating, and if the child always stands to use the potty then sitting to have a BM may feel strange and awkward for them and as a result they may choose to just not do BM's in a toilet. 
 Dress the child in easy on/easy off clothes during the potty training program, avoid pants that snap, button, or buckle. Potty training is often easier in the summer, when children wear less clothing.

Technique #2: Trip Training, also called "Schedule Training"

• Q: What is it?
• A: Trip Training is putting the child on a toileting schedule based on how often they void, such as every 15 minutes. Throughout the day at specific time intervals, the child is taken to the toilet. You prompt the child that it is time for the toilet, such as by holding up a picture of the potty and saying “Its time to go potty”. Take the child to the bathroom, help them pull down their pants, and sit on the toilet. The child must sit on the toilet at least 5 minutes. Block any attempts made by the child to get up, and ignore any behaviors. Every 45 seconds or so prompt the child by saying “Go potty”. If the child voids in the toilet give HUGE praise and reinforcement. If you get to the toilet and you see the child has had an accident, they still go through the whole toileting process. If the child consistently is already wet or soiled when they get to the toilet, then the time intervals are too long. Praise and reward if the child is dry (dry pants check) before they sit on the toilet. Once the child gets off the toilet, prompt them to wash and dry their hands.
• Q: How long does it take?
• A: The amount of time will vary from child to child. Generally, the Trip Training method takes several weeks to several months to teach. There usually is a learning curve as you discover what time intervals are best to avoid accidents.
• Q: Why should I pick this method?
• A: This method isn’t as time and labor intensive as ITT, and it is also much easier to use if the child cannot be kept at home for a few days. Trip Training works better for parents or teachers who do not have access to a staff of behavior therapists who can help you implement the ITT technique.
• Q: What would I need to get started?
• A: To get started you would need a record of when your child typically voids, a clipboard, timer, a large supply of 24 Karat gold reinforcers, a way for the child to communicate a need to go potty (could be a PECS card, or sign language), underwear, data sheets, strength, and patience!
• Q: Any quick tips?
• A: If you cannot avoid taking the child to a public bathroom while they are being toilet trained then plan ahead. Carry a small tote bag with you filled with the child’s favorite juice, cookies, chips, toys, etc. Take this bag with you into public bathrooms and try to mimic the home environment as much as you can.

More Tips:
  It can be helpful to use a small step stool for the child to rest their feet on. Some children with Autism do not like their feet dangling in space, and having both feet planted on a frim surface can help with BM's.
 Try not to let the child undress completely before getting on the toilet, this can be a hard habit to break.
 The reinforcement for defecation may need to be 3x as powerful as the one for urination.
 Having a consistent bedtime and wake up time will also help with night time training. If the child goes to bed at varying hours, and wakes up at varying hours it can be very difficult to see patterns of behavior and predict when they are most likely to void.

The most important things you can do before you begin potty training your child with Autism is decide on the approach you want to use and stick to it.

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Tameika Meadows, BCBA

"Train up a child in the way he should go, and when he is old he will not depart from it". Proverbs 22:6

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Tameika Meadows, BCBA

ABA programming refers to skill acquisition. The priority skills to teach should focus on the core deficits of Autism: communication, social interaction, and widening narrow interests and activities. The programs selected for instruction should answer the question "What does this individual need to know in order to be as independent and successful as possible?".

ABA therapists aren’t the only ones who need to know how to write programs. Parents also can benefit from this knowledge, especially if you are a parent providing ABA therapy to your child. Programs can be written for all kinds of skills: brushing teeth, greeting people, table manners, potty training, sharing, counting, reading, one step instruction, etc.

 I typically use the ABLLS-R assessment tool, which then guides my program writing. I will refer to the ABLLS-R in this post simply because it is the tool I use the most. Some people use other assessment tools, such as the VB-MAPP, or the Vineland. If you are unfamiliar with the assessment process, check out my post about the ABLLS-R which gives a general overview. I have my own program writing style that has evolved over the years. It isn’t unusual for 2 different professionals to take the same goal and teach it in two different ways. For every goal you can think of, there are multiple ways to take the child from not knowing the skill, to knowing the skill. Program writing is definitely a skill that takes time to learn, but understanding the basic steps makes the process much easier.

Program Writing Steps

1. Prioritize what to teach first: After you assess the child you are left with an inventory of their strengths and deficits.  This large inventory is then narrowed down into specific skills to begin teaching. This process is child specific because it will vary depending on the child’s age, level of functioning, issues most important to the family, is the child in school or not, etc. The programs I write for a nonverbal 2 year old will be very different from the programs I write for a high functioning 7 year old. How many skills you select will also vary, but typically you want to consider the child’s ability to work for extended periods of time, and how many hours of therapy per week the child is receiving. If a child only gets 3 hours of ABA per week, they don’t have enough time to work on 25 programs. There also is somewhat of a hierarchy of needs to address. Its more critical that a child be able to communicate than play with a doll. When in doubt, make skill deficits that impact communication or inhibit learning the most important.
2. Write an objective for each program: Think of the objective as your long term goal and keep it broad. A good rule of thumb for the objective is to think about what the child would be able to learn in 6 months. “Child will be able to share with a peer for a minimum of 1 minute with only gestural prompting necessary” is a solid objective. You will then need to create mini goals to work up to the objective, such as teaching the child to tolerate being near peers, to share for 10 seconds, to share for 25 seconds, etc.
3. Each objective needs an active targets list: There are two types of targets: active and mastered. An active target is what you are currently working on, and includes skills the child does not know yet. A mastered target is a skill the child has been taught, or already knows at the time of assessment. If the objective is “Child will be able to share with peers”, then the active targets are the small steps towards that goal. Look at the objective you created, and then think of how you can break it down into small, discrete steps. If you are using the ABLLS-R it will actually list an objective and a few active targets for each skill. There are also appendices in the back of the ABLLS-R manual that list sample active targets.
4. Decide on your measurement of mastery: In order to get a child to a point of mastery, you need to decide how they will demonstrate to you that they are competent in a skill. Typically, most ABA programs use the standard of “80% or higher across 3-4 consecutive sessions”. However, sometimes you need to use a different measurement system. Nothing about ABA should be cookie-cutter, so dont feel stuck in that “80% or higher across 3-4 consecutive sessions” rut. For example if the child is being taught to safely cross the street, only 80% success could be extremely dangerous.
5. Plan for maintenance of mastered targets: It isn’t enough to write a program, teach a skill, and then move on to the next program. A common characteristic of Autism is difficulty generalizing skills, which over time can cause a learned skill to be lost. When writing a program you need to be thinking “How will I generalize this skill to various settings, materials, people, etc?” There are many ways to plan for generalization and maintenance. A way I regularly plan for generalization is to “Teach Loosely”. Teaching loosely means that I will intentionally vary where I teach, when I teach, the materials I use, and if possible who does the teaching.  A favorite technique I like to use for maintenance is: Get a small card filing box. Take a stack of index cards and write a mastered target on each card. During each session, grab a few cards out of the box and ask the child a mastered target. If they still have the skill,  move on to the next card. If they do not still have the skill, take the card out of the box as it may need to be taught again. At the end of the session put the cards you used in the back of the box so you will pull different cards the next day. The great thing about this technique is anyone can do it. I love using strategies that the whole household can implement. If the child gets a new babysitter who doesn’t know how to engage them, give the babysitter the box of mastered targets and a few reinforcers. This way anyone can target maintenance of skills.

This may seem like a LOT of work, and it is :-)

But trust me, it isn’t impossible to learn how to write ABA programs. There are resources out there for parents or inexperienced professionals to use that will guide program writing, or even write the programs for you. Two resources I can recommend are the Catherine Maurice guide, and the webABLLS. The webABLLS is a completely online version of the ABBLS-R assessment tool, and you plug in your child’s strengths and deficits and then print out pre-written programs. I know many parents who use this tool.
There are also companies that sell pre-written blank programs to be used in an ABA program. However, problems can arise when using “automated” tools like these if you don’t understand how to tweak or modify programs, such as unintentionally teaching skills out of order or not knowing what to do when progress stalls. Most of these program tools are just "program shells" that still need to be individualized and revised before they are ready to use. In other words: Don’t expect shortcuts.
It is fine to use software or books/manuals to help you write programs but be aware that you will still likely need professional assistance.

*Here is a helpful program writing visual aid-


A correctly written program goal should include:

Who	Will do “X”	Under what Conditions	Level of Proficiency	Measured by whom & measurement methods & Materials
Example: Tameika	will respond to 5 one-step instructions	when instructed by an adult in an home, school, or community setting	with 90% accuracy or higher, across three sessions	Measured by direct staff through frequency data collection

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Tameika Meadows, BCBA