Today's QOTD is a bit different. Its not a quote or inspirational saying, its a helpful tip.

Parents, did you know.....

.....about the Disneyland Autism Pass? If you go to Disneyland with paperwork verifying your child's diagnosis you can get a special badge that gets you to the front of every line in the park. The badge can be used by a group, as long as the child is in the group. No more waiting in line for an hour as your child with Autism melts down.
Many parents of children with Autism think that because their child doesn't have a physical disability that they can't ask for special services or privileges at public places or tourist attractions. Well, you can! Many movie theaters now offer Sensory Friendly Films, which includes leaving the lights on, playing the movie at a lower volume, AND you can bring your child's favorite snacks into the movie with you.
The next time you take your child with Autism to an amusement park, festival, movie theater, restaurant, or tourist attraction, be sure to ask what accomodations are available for children with disabilities.

Here is a guide to how to obtain the Autism Pass at Disneyland, written by the mother of a child with Autism.

Today’s post is a bit technical, but if you hang in there I guarantee it will be worth it.

I already wrote a post about Differential Reinforcement, which is helpful for trying to understand DRA. DRA, or Differential Reinforcement of Alternative Behavior, is an ABA technique used to reduce problem behaviors. ABA professionals always seek to accomplish behavior reduction through ethical, reinforcement based methods first. In other words we don’t just seek to make a problem behavior stop. We ask ourselves “What can I teach this child to do instead of this problem behavior?”
DRA is a great technique (when part of a comprehensive behavior plan) to intervene on behaviors such as aggression, self-stimulatory behaviors, perseveration, or tantrumming. It is typical that a DRA is combined with Extinction. Anyone who wants to reduce or eliminate problem behavior can benefit from an understanding of DRA.

So what is DRA?

DRA- Reinforcement of an alternative behavior while withholding reinforcement for the inappropriate behavior.

This basically means that you put an undesired behavior on extinction, while simultaneously giving reinforcement to an appropriate behavior.

Here are a few examples:

  • Child A has a problem behavior of mouthing non-food items (toys, pennies, fingers, etc) to gain sensory stimulation. Every time child A attempts to place a non-food item in her mouth, you block this behavior and redirect her to a sensory chewie toy. As child A places the chewie in her mouth, you provide verbal praise.
  • Child B has a problem behavior of elopement from the work table to escape a demand. When child B attempts to stand up at the work table, you physically prompt her to sit down and immediately hand her an “I want a break” card. When child B gives the card back to you, you provide  praise and allow child B a short break.

You may have already noticed two important factors when implementing a DRA:
    1. You need to know the function of the problem behavior
    2. You need to reinforce the alternative behavior

 It isn’t enough to simply redirect the child to a different behavior at random. That is not implementing a DRA technique. If the child is mouthing toys and pennies to get sensory stimulation and you block the mouthing and give the child a book to read, how does that address their sensory need? It doesn’t. What will happen is the child will try to mouth the book, or they will engage with it for a few seconds and then throw it down.
It also isn’t enough to redirect the child to a functionally similar alternative behavior with no reinforcement. While the behavior is inappropriate or maladaptive from our point of view, to the child the behavior they are engaging in works, it’s effective, and it’s efficient. It is only to us, as clinicians and parents, that the behavior is deemed unacceptable. To bring about lasting behavior change you must reinforce the alternative behavior and make it more appealing than the inappropriate behavior. You always want to create motivation for the child to engage in the behavior that is more appropriate.

Other important terms to know include DRO, Differential Reinforcement of Other Behavior, and DRI, Differential Reinforcement of Incompatible Behavior. Put simply, DRO means you give reinforcement to behaviors other than the problem behavior. DRI means you reinforce appropriate behaviors that are incompatible with the problem behavior, or you reinforce an appropriate behavior that cannot be done at the same time as the problem behavior.
 It isn’t always easy to implement Differential Reinforcement, because sometimes it is hard to "catch the child being good" or because it may be difficult to identify an alternative behavior that is functionally similar. 
For example, it can be challenging to find a functionally similar replacement behavior for masturbation. A better strategy is to teach the individual about public vs. private behavior, and redirect them away from sexual stimulation in front of others (exercise, go for a walk, excuse themselves to their room, etc.). 

DRA is a wonderful ABA tool that can produce quick and significant changes in behavior. In my opinion, it is also easy for most parents to implement. For example:

  •  Nick has a perseveration behavior of excessively talking about dinosaurs. Anytime Nick wants to initiate a social interaction, he walks up to someone and begins a monologue all about dinosaurs. Nick’s parents place the dinosaur perseveration on extinction, and reinforce Nick for appropriately initiating a conversation by asking social questions such as “What did you do today?”

Play skills can sometimes be seen as unimportant, or delegated to the bottom of the list of important skills to teach to a child with Autism. I often observe many play skill deficits in my clients during the assessment or initial interview, such as the child shoves every toy I hand them into their mouth, the child doesn’t play with toys as designed, the child refuses to share, the child can only attend to a toy for a few seconds, etc. I do understand why for most parents skills such as language, toilet training, and appropriate behaviors are deemed the most important skills to teach. However, I would advise being sure to teach your child how to play.

 Play skills affect a variety of learning situations, and a child who cannot play appropriately will have a very hard time making social connections with other kids. This is because for children, much of their communication and interaction occurs through play. Small children don’t introduce themselves, shake hands, exchange business cards, and begin to debate the state of the economy. A child walks up to another child, starts to play with them, and a friendship is born. If your child lacks appropriate play skills they might be at a social disadvantage, as well as have difficulty with basic concepts such as: sharing/negotiation, conflict resolution, turn taking/reciprocity, manners/rules, etc. Small children often learn these basic concepts through the intricate complexities of play. 
See, play is important!

There is a basic hierarchy of play skills, based on developmental levels:

  • Solitary play- Carrie will play or engage with a toy, as long as no one sits next to her or tries to interact with her. If someone tries to sit down with Carrie, she turns her back to the person or scoots away. If the person tries to touch her toy, she gets up and walks away.
  • Parallel play- Carrie will play or engage with a toy while in close proximity to other children or adults, and sometimes she will look at how the other child is engaging with their own toy. Mainly, Carrie focuses on her own toy and does not interact with the peer or adult.
  • Interactive play- Carrie will share a toy with a peer or adult, and will take turns appropriately. This could include passing a toy back and forth, or imitating each others play. Carrie may still play silently, or avoid eye contact with the other person.
  • Cooperative play- Carrie will play and engage with another person, while playing with separate toys or sharing one toy. Carrie will look at the other person and make eye contact. This could include building a block tower together, or working together to solve a puzzle.
  • Pretend play- Carrie will engage in imaginative play (either alone or with others) that involves elements of pretend. This could include cuddling a doll and pretending the doll is crying, cooking a pretend meal using Play-Dough, or playing dress up (Dress up play should include an understanding of the character. Such as putting on a fireman hat and pretending to be a fireman).
  • Rule based play- Carrie will play highly social and competitive games with other persons, such as sports, board games, card games, and video games. Carrie can also play games that other children make up on the spot and can easily adhere to rules of the game that constantly change.

You can likely view these basic definitions and already see where your child is in their play skill development. Depending on the specific deficits your child has, they may move through the play levels easily. For other children, they stall at certain play levels or skip some play levels altogether. What is most important is to look at children the same age as your child, and closely observe their play and compare it to how your child plays.

When teaching play skills it’s helpful to create a plan of implementation. Approach play skills just like any other skill you would teach. Set concrete, small goals, determine how you will measure progress, and embed reinforcement into the task. Yes, you may need to contrive motivation for play. 

Here are some general guidelines for teaching play skills. These tips can be helpful for parents or professionals:

  • It is typically easier to teach play skills with an adult first, before bringing in peers. Adults are more predictable and less demanding than children, and for this reason children with Autism may easily play or interact with adults but avoid, hit, or refuse to play with other children.
  • It is best to start teaching play skills with simple cause-and-effect toys, such as a Jack in The Box or a keyboard. Avoid imaginative, work based, or complex toys, such as puzzles, figurines, dolls, or Play Dough. If you hand a child with no play skills a lump of Play Dough, they will likely try to eat or lick it.
  • Many people don’t realize it, but strong imitation skills are a pre-requisite of pretend play. A child who cooks a pretend meal, or comforts a “crying” baby doll, is a child who has observed someone else perform these actions.
  • In order to teach play skills, you should model a happy and excited affect. The child is observing not just the play skill, but your face, voice tone, and mannerisms. Make sound effects, clap, laugh, smile, look at the child's face frequently, speak in funny voices, yell, and cheer as you play with the child.
  • It is so important to minimize problem behaviors during play. If the child is engaging in vocal or motor stereotypy, crying, trying to escape, or being aggressive when you are trying to teach play skills then that could stall progress. Conduct a FBA to determine the function of the problem behavior and create a behavior plan. Work on these behaviors in the bud before introducing peers into the play sessions.
  • Talk during play. Children typically talk while they are playing (even if they play alone, they still narrate what's happening).
  • Have F-U-N!

Love this!

I would also add: "Said no ABA therapist ever"

Recently, there was an article published in the LA Times about racial disparities in Autism treatment. In California, ABA is paid for through either regional centers or insurance. At most parents pay a co-pay for treatment, similar to someone paying a small co-pay when visiting the dentist. So in such a progressive state where 40 hours of ABA per week can actually be prescribed like Tylenol or antibiotics, treatment should be equally accessible to all children right? Well, apparently not.

The article which was published this year basically revealed that there is a great disparity among racial groups between who receives access to ABA services. White and Asian children were shown to receive the most services, while African American and Latino children were severely under-served.  Here is an annual numbers breakdown for the state of CA:

White children- $11,723 per child
Asian children- $11,063 per child
Latino children- $7,634 per child
African American children- $6,593 per child

So, what is happening here? Why are some children more likely to receive access to quality ABA services than other children with the same diagnosis? The main reason set forth by the LA Times article indicated that “The squeaky wheel gets the oil”: Parents who scream the loudest for services tend to get them.

So, what is behind these racial disparities?
I don’t claim to have all the answers, but based on my experiences and observations in this field I would say a lack of Autism/ABA knowledge, and a lack of advocacy leads to under-served areas:

  • Little to no knowledge of Autism- I still meet families who think Autism is just for White children. Autism sees no color, and is not a respecter of differences. Autism crosses across racial groups, income levels, countries, and languages. A lack of knowledge about Autism can lead to a late, or no diagnosis.
  • Medical professionals or school systems don’t always recognize Autism- If the family doesn’t recognize the Autism when the child is young, then usually a doctor or teacher will notice something. This is usually what happens, but not always. Doctors sometimes mislabel children with Autism as having MR or ADD. Teachers sometimes label children as just badly behaved or stubborn, instead of recognizing that the child has a true disability. A lack of knowledge about the many shades of gray of Autism can lead to poor, or no services.
  • Low expectations of the child- Many parents might not know Autism treatment is available and possible. I have worked with families who were shocked to discover that kids with Autism can talk, read, have friends, or be toilet trained. If a parent lacks knowledge about what Autism treatment can do, then they won’t seek it out.
  • “A” is for Advocacy- I have worked with so many parents who were completely unprepared for the fight that is sometimes necessary to get services. It can be a fight to get a diagnosis. It can be a fight to get your child enrolled in school. If no one has told you today, let me be the first to do so: You are your child’s advocate.  If you don’t push for the services that you know your child needs, then who will?

A racial disparity among Autism treatment doesn’t have a simple answer, but I think advocacy and knowledge are key factors. Families who are new to this country, families with lower incomes, families living within poorly funded school districts...all of these families are more likely to be unaware of quality ABA treatment. It is so important to know what your rights are as a parent, and to fight to get the services you are supposed to get.

Many companies and agencies do communities a disservice by not going after the "non squeaky wheels". Here's an example: Lets say you are the owner of a small ABA agency located in Anytown, USA. The census statistics for Anytown say that its a community with 50% Caucasians, 20% African Americans, and 30% Latino or Hispanic. However, your client base are all Caucasian families. Clearly something is wrong with this picture. Where are the Hispanic or Latino families who live in the community? Where are the African American families who live in the community? It is a simple matter to use the rate of Autism in this country (1 in 88) to determine how many of the families in your community are likely impacted by Autism. Just because the consumers aren't coming in to your business or company, doesn't mean they don't need services.

I hope parents get from this post how desperately your child needs you to be an advocate for them. You could be the difference between your child receiving bare minimum services and amazing services.  I don’t say all of this to make burdened and stressed out parents feel worse. I say it because I have seen it happen. I have seen parents fight reluctant doctors, apathetic school districts, and unethical insurance companies to get quality services for their child.

Don’t give up, and don’t stop being that “squeaky wheel”.

Advocacy Resource: "The Everyday Advocate" by Areva Martin

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