Friday, March 29, 2013

The Art of Redirection







Redirection – An ABA behavior reduction technique used to distract the child from a problem behavior, or lead them to engage in a more appropriate behavior than the one they are currently engaging in. Redirection isn’t intended to replace the need for a FBA  and Behavior Plan to extinguish a problem behavior.


I have stated previously on my blog that ABA therapists are not magicians and we don’t carry magic wands, but there is one thing that ABA therapists have in common with magicians: When we are doing our REALLY well, an onlooker has no idea what we just did. :-)

Redirection is a technique that most educators, therapists, and caregivers know all about. Great teachers and great ABA therapists are masters at the art of redirection. When done correctly, to the naked eye it isn’t clear that the therapist is using redirection and it sometimes might not be clear what the inappropriate behavior was.  Particularly if the therapist has known the child for some time, they are already aware of triggers or cues that precede problem behaviors and they move with precision timing to get the child engaged in something else that is more appropriate.
 It’s always easier to prevent a problem behavior than to react to one. So many times, parents will ask me “What do I do when my son/daughter does (problem behavior)?”, and my response to that is why wait until they are already engaged in the behavior?? Change your mindset about problem behaviors, and start focusing on how to prevent them before they even kick off.

Let’s make this more everyday and less clinical: You have been waiting all day for an important phone call, so you decide to relax a bit in the meantime. You have a steaming bubble bath ready to go in your candle lit bathroom. Which of the following scenarios would be more frustrating and/or annoying:

1) You step into the nice, warm bubble bath and sigh happily. Then the phone rings, and you have to get out of the tub to go answer it.
2) Before you can step into the nice, warm bubble bath the phone rings. You head towards the living room to answer the phone.

See the difference? It is more difficult to stop a problem behavior and redirect a child to a new behavior, because the behavior is already happening. From the child’s point of view, the problem behavior could be just as enjoyable (if not more enjoyable) than a warm bubble bath, and our therapist voice saying “Do NOT climb that!” is like the shrill, ringing telephone making them get out of the bathtub.

When done artfully, redirection is a way to distract the child from the problem behavior they want to engage in, remind the child they can make better choices, or present alternative ways to meet the same function of the problem behavior. I have seen some really creative ways to redirect, both in homes and in classrooms. Successful redirection requires consistently being 1 step ahead of the child. It requires putting on the eagle “therapist” eyes, scanning the environment for any behavioral triggers, and keeping a close eye on the child’s affect and mood particularly in new social situations, during transitions, and during downtimes.

I have also seen redirection done poorly. That usually looks something like a teacher or therapist who notices the child is engaged in a problem behavior, and then may say something like “Get down” or “Stop running”. The first issue is the therapist wasn’t attending to the child properly, and allowed the child to begin engaging in the problem behavior. The second issue is the therapist gives a “Stop” statement instead of a “Go” statement, so now the child is given the power to decide what replacement behavior to use. Most of the time, it wont be anything appropriate. I’m sure many teachers can relate to telling a child running down the hallway to “stop running” so then the child begins to skip…..or walk quickly…….or gallop. This is why “Go” statements are preferred, where the therapist or teacher tells the child what the replacement behavior should be (e.g. “Show me walking feet please”).

 The better you know the child, the easier it will be to redirect them successfully because you will know their interests and likes/dislikes. When I see the masters of redirection at work, there are certain things they do and don’t do that cause their redirection technique to be so successful. 

Wishing I would tell you what those things are?



Your wish is granted!


  • It’s good use of ABA methodology to always reinforce the redirection. The redirected item or activity is always something more appropriate than what the child was currently doing, or was about to do, so we would like the child to engage in the redirected behavior again in the future. Lets say a child is inappropriate when meeting new adults and just lunges into peoples personal space because it gets a big attention response. Redirect that problem behavior into a cool dance move. Teach the child to greet a new adult and then show off their cool dance move. Then be sure to reinforce the redirected behavior (the dance move) with applause and tons of praise (tell the new adult to clap with you!) so that the more appropriate behavior will be reinforced and continue to happen.
  • Try to redirect to something similar. I like to explain this by saying don’t take away an orange, and give a shoe. If you need to take an orange, give an apple. If your client enjoys visually stimming with mirrors by staring at mirrors and laughing hysterically, or putting his face directly against the glass, don’t take that behavior away by saying “Let’s go play with some blocks”. You just took away an orange, and handed the child a shoe. Pick a redirection behavior that is similar to the problem behavior, but more appropriate. In this example you could stand between the child and the mirror and hold out a pinwheel and a kaleidoscope. Tell the child to choose one to play with, and then reinforce their choice. Prompt the child to hold the toy close to their eyes, stare at the toy, and show them how to move the toy to make it visually exciting.
  • If you are trying to redirect the child to an activity, try hopping into the activity with the child. This is something I see many parents do who are amazing at redirection. If their child is being crabby and aggressive with their siblings while playing a board game, the parent will join the game and change the way it is being played.  Instead of the parent stopping the play, they will join the children and suggest a new game, or make up crazy rules that get everyone laughing and competing to think up the silliest way to play the game. Remember, redirection can sometimes be as simple as distracting the child out of the problem behavior.
  • Be quick on the draw! I dare any cowboy from an old black and white western to be quicker on the draw than an excellent ABA therapist. When redirection is an art, it happens so quickly that if you blink you might miss it. I have observed therapists prevent a child from aggressing at a peer with songs, one step instructions, or by asking questions. I have observed therapists redirect a tantrum into a silly dance, or an imitation game. Arrived to a home for a session and the child is clinging to Mom and wants no part of you or your therapy? Tell the child to race you to the therapy room, and have Mom give the countdown (Ready…Set…Go!). Let the child win, and then give them a reward for winning 1st place in the race, as you walk them to the therapy table.
Wednesday, March 20, 2013

Quote of The Day


Today's QOTD isn't a quote, its more of a "Did You Know"......


When teaching a child with Autism, so many painstaking baby steps of progress can happen when teaching language that its easy to forget what language looks like with a "normal" (that dreaded word) child.

When teaching language to a child with Autism, the child may initially just have a handful of words. Then they can say 15 words....then 30.....then 42! The progress is so exciting and therapists and parents are so happy to be able to communicate with the child that everyone can forget that typically developing children have vocabularies that are large, varied, and complex.

When I spend time with typically developing young children, it amazes me sometimes to watch things they can do that my much older clients still cannot do. Spent time with a 2 year old lately? They will talk your head off! :-)
 It is important as therapists and parents to remember to set high goals. Don't compare your child or your client to other kids with Autism. Set high goals, and work diligently to help the child meet the goals.

I found the above photo on Pinterest (do you know about Pinterest?? Its awesome!), and I immediately thought of Manding trials and pulling language out of my clients, often over weeks or months.
 Does your verbal child with Autism chatter as much as a typical child of the same age? If not, I challenge you to set higher goals for that child. Can your child engage in conversation, answer novel questions, or describe things? Or does their language consist only of mands ("I want juice") or tacts (child points to car driving by, "Car") ?

 I challenge you to spend some time with a typical child the same age as your child, and then go back and take an honest look at your child's ABA progress and language goals.


Tuesday, March 12, 2013

Generalization: Teaching Loosely






Teaching loosely is a term that most educators are probably familiar with, but it’s a concept that can also be very helpful to ABA therapists. Teaching loosely is a way of intentionally teaching content to promote generalization for the learner. Instead of the typical way of teaching where a child learns a skill and then learns to generalize the skill and maintain it across environments, with teaching loosely generalization is an integral part of the lesson right from the start. Teaching loosely is about randomly and intentionally varying parts of your teaching, including materials, tone of voice, words, facial expressions, seating, room/location, time of day, etc.

Generalization is so important! If you can teach a child or student to say “Hi” to you, but they never greet peers or unknown adults then what is the point of that? How does the skill of saying “Hi” benefit that child? Teaching children with Autism should never happen within a vacuum. The skills learned should be intentionally applied across settings and individuals, to help the child interact meaningfully with their environment.

 There are many ways to generalize, including across time, across settings, and across stimuli.

  • Time- Michael learned to read 15 sight words last October. Today he can still easily read those 15 sight words.
  • Settings- Michael learned to read 15 sight words off index cards in Mrs. McDougal’s 1st grade classroom. Michael can still read those 15 sight words off an index card regardless of the environment (at home, on the playground, during an ABA therapy session, etc.).
  • Behaviors- Michael learned to read 15 three letter sight words. Now Michael is easily reading other sight words that have three and sometimes four letters, and he has started showing an interest in storybooks.

When initially teaching a skill using DTT or VB methodology, it is important to remove unnecessary stimuli, use a clear and simple SD, provide strong reinforcement quickly, and minimize error. What can happen in an ABA program is the instructor or therapist doesn’t fade this intensive teaching style, and doesn’t remember to plan for generalization.  When teaching students with Autism, it is imperative to help the child generalize the material they have learned. If a child is taught to say the word “Mommy” because a therapist holds up a photo of his mother, that doesn’t mean the child will say “Mommy” when his mother walks into the room. Parents often ask me why their child doesn’t display skills outside of the therapy room, or why will they only do XYZ skill with the therapist. The reason why is usually a failure to teach for generalization.

Teaching loosely takes work and planning, and forethought. It would be pretty difficult to properly plan for generalization without a clear terminal goal. Teachers or ABA therapists often make long term and short term goals, but not a terminal goal. A terminal goal answers the question “What do I want it to ultimately look like when the student has mastered this skill”. A long term goal might be to get a child to sit quietly at their desk during transitions, instead of bothering peers, walking around the classroom, or engaging in stims. A terminal goal would be much broader than that, such as expecting the child to choose an appropriate activity to engage in during down time or transitions that doesn’t require adult help. For example, writing sentences in a journal book, reading quietly, or drawing a picture. 

As a professional, any skill that you teach to a child with Autism should be done with a terminal goal in mind. Think bigger than teaching a child to talk, potty training a child, or reducing a behavior. Aim for helping that child become as independent, successful, and productive as they can in a variety of real-world environments.

If you are wondering if your student or client may need more generalization intentionally embedded into instruction, ask yourself: If you removed yourself and someone else taught the student, would learning suffer? If you change the reinforcement, does learning suffer? If you move to a new classroom/setting, does learning suffer? If you change your wording (“Come here” vs. “Hey, stand by me”) does learning suffer? If you find yourself answering yes to these questions, it’s likely there isn’t enough generalization of skills happening.

Cooper, Heron, & Heward have some amazing tips and recommendations for teaching loosely. These strategies would be helpful in a classroom setting, as well as in any quality ABA program (I have implemented many of these strategies over the years, and they are great at promoting generalization):


Choose behaviors to change that will contact reinforcement in the natural environment (such as praise, positive feedback or attention, social approval, etc).

When writing programs or creating goals, think of all situations/settings where the behavior should and should NOT occur.
Teach sufficient examples (don’t just use one photo of “bird”. Use multiple photos, a video clip, and a bird stuffed animal).

Use 1 or more teachers (this is why most ABA programs use 2-3 therapists per case).
Teach from a variety of positions (do you always sit next to the child?? Switch it up!).
Regularly and consistently do “maintenance checks”, where you bring out old material and make sure the child can still perform the skill.


Use an intermittent schedule of reinforcement (start to thin the reinforcement schedule so the student isn’t sure exactly when reinforcement will be delivered).
Ask other people to help you reinforce the targeted behavior(s).
Vary the smells, sounds, and decorations in the training environment (for a child with Autism, they are absolutely learning not just you but also the environment).
Teach at various times of day.



*Recommended Resources:

Lots of specific tips about generalizing skills and concepts- From A to Z: Teaching Skills to Children with Autism by Tameika Meadows

The “White” Book- Applied Behavior Analysis by Cooper, Heron, & Heward

Wednesday, March 6, 2013

Initiators vs. Responders







For the parent of a child with special needs, you learn to become many things. The child’s translator, the child’s safe haven, the one who “explains” the things the child does, a short order cook, etc. When children with special needs are young and pre-verbal, they do require lots of assistance and help and someone who knows the child very well is usually the mediator for that child to communicate with anyone. Mom and Dad are the only ones who know that the child disrobing in public means “I need to go potty” or that throwing their bottle out of the crib means “More, please”. This is a natural and important step in the relationship between parent and child.
At some point this natural tendency for loving parents to step in and make things easier for the child can actually become a hindrance to learning and development. Similar to prompting, constantly stepping in to read your child’s mind and give them what they want can kill any motivation the child may have to communicate. That’s how behavior works. As humans, we tend to reach for the easiest option.

When working with my kiddos, I often walk into situations where it’s glaringly obvious that while the parents adore and love their child, they have made life for the child WAY too easy. For example, a parent telling me how she wants her child to be more independent as I watch her spoon feed her 4 year old.
I do understand that all of this care and involvement comes from a place of love, and likely started as a necessary response to a child with many serious deficits. However at some point as parents and professionals, we have to start taking steps back and forcing the child to be more independent. I haven’t met many parents who tell me they want their child to be more dependent..….its usually the exact opposite. If you want your child to be more independent, then first examine if you are helping the child depend on you too much.

The goal is to help the child move towards being an Initiator, and away from being a Responder. Here are a few examples of what that would look like:

  
INITIATOR CHILD
RESPONDER CHILD
The child is hungry, so they seek out an adult and mand for food (e.g. “Cookies please”).
The child is hungry, so they begin to whine and display irritable behaviors. After some time has passed, someone figures out that the child may be hungry.
The child is bored, so they turn on the TV and sit down to watch.
The child is bored, so they follow Mom or Dad around the house begging to be picked up. It is then up to Mom or Dad to entertain the child.
Dad forgets to give the child juice with their snack. The child makes eye contact with Dad and points to the refrigerator, to request juice.
Dad forgets to give the child juice with their snack. The child bursts into tears and refuses to eat.


A child who is a responder will depend on others to get needs met, or they will use behavior to communicate a need. These children rely on adults to read their mind and determine what they need. This often leads to a lovely game that I like to call “Guess what I want!”, as Mom or Dad frantically try to figure out how to get the child to stop crying, or engaging in some other problem behavior. 

 A child who is an initiator will either attempt to meet needs themselves, or they will use communication to request an adult help them.  The child is able to use communication (either vocal or nonvocal) to express what they want in a way that multiple people can understand.
The goal when teaching a child with Autism is always to strive for more than what the child is currently doing. Depending on what a child is currently able to do, there is always a way to help the child gain more independence with that skill.

A very common example of initiators vs. responders that I see often deals with toilet training. I have had parents tell me that their child is completely toilet trained. Then I ask how the child indicates they need to use the toilet. If the parent answers “I don’t know” or “We can just tell”, then no….that child is not fully toilet trained. If your child just gets up and silently goes to a bathroom, then what happens when you are in public? If you are in a crowded mall, how does your child let you know they have to go potty? If you left your child with a babysitter, would that person be able to tell that your child needs to use the bathroom? Being fully toilet trained means being able to inform adults of the need to use the bathroom, as well as being able to request the bathroom in an unknown place.

Helping your child move from being a responder to an initiator will help them become more independent, and initiation is a critical life skill for success in school, with peer groups, and many other important domains. Here are some helpful tips for making life just a little bit harder for your child with Autism :-)

  • Don’t be afraid of independence: I know it might be hard to let your 3 year old use a knife to cut his hot dog, or to teach your 6 year old how to unbuckle his seatbelt. You can encourage independence in a safe way and within boundaries. Just because your son can unbuckle his seatbelt doesn’t mean its okay to do so as you are driving down the highway. Teach boundaries and limits, even as you increase your child’s independence.
  • Play dumb: This is the simplest way to start slowly decreasing the amount of assistance or prompting you provide. When your child comes up to you whining or crying with outstretched arms, look at them quizzically and act as if you don’t understand what they want. Depending on the ability of the child, prompt them to communicate via language, PECS, pointing, etc. For example, require the child to say “Up” before you will pick them up. Crying, pulling on your pants, or kicking your leg, should not be reinforced. Stop anticipating your child’s needs and acting on it, and instead pretend as if you don’t understand what they want so they will be motivated to try something else.
  • Slow down: Parents often tell me it’s easier to just dress the child, wash the child’s face, or feed the child breakfast. I know it’s easier and saves time, but in the long run it is making the child too dependent on you. Accept that sometimes you will be late. Yes, you might have to wait 35 minutes for your child to put on their shirt, or it may take a full tantrum to get your child to brush his teeth. Sometimes you have to make immediate sacrifices in order to reach a long term goal. Start small, such as giving your child a bowl, spoon, and no cereal. Using communication at the level of the child, prompt them to request the cereal. Even if this takes 15 minutes out of your morning routine, in the long run you are teaching your child to be an initiator. Tell the child’s teacher that you are working on independence in the morning routine, and your child may be late to school for a few days. I’m sure if you explain it the teacher will understand, and possibly even help you reinforce the skill in the classroom.
  • Wait: This isn’t just difficult for parents; I am guilty of this too. Sometimes we want to help the child be successful so much, that we are too quick to provide prompting or assistance. We give a demand, the child doesn’t respond, and we immediately jump in to provide a prompt. The problem with this is over time it can cause the child to become prompt-dependent, and to remain a responder instead of being an initiator. The next time you give a demand to your child, try waiting 10-20 seconds for them to respond. I know that sounds like a lifetime, but some children with Autism have auditory processing issues, so they need to process what you said and select a response before they can begin to comply. I wouldn’t suggest doing this all of the time, but it’s important not to make a habit out of jumping in and helping your child. If you have just told your daughter to tie her shoes, sit down next to her and wait a full 15 seconds before giving any prompts. See what the child does with that time. Doe she just sit and stare at her shoes, or does she start attempting to put them on? You might even see the child look over at you, and reach for your hand for help. That’s great! That is an opportunity to teach a type of request, such as “Help”. It’s important to let the child try before hastily jumping in to help.


* GREAT and very parent-friendly resource on this topic: Initiations and Interactions: Early Intervention Techniques by Teresa A. Cardon

Friday, March 1, 2013

How To: The ABA Program Binder







*This post is intended to be a guide to creating an ABA program book, also known as the skill book. The information in this post is not all-inclusive. The funding source and your employer may have their own requirements for what must be kept inside the program book.*


The program binder is an essential part of any ABA program, regardless of where therapy is conducted (home, at a center, inside a classroom). The programs tell you what skills to teach, and the programs are all compiled inside of the program book. The program book will remain a source of information, progress, goals, and data, throughout the duration of the therapeutic process. Many people may view or have regular access to the program book including all of the direct therapists, the Consultant, school staff, and the parents/family. Depending on the funding source, the information inside of the program book may be considered legal documents. For example, the data sheets could be used as evidence during an IEP due process, or submitted to insurance companies to receive reimbursement. It is important to keep the program book neat, organized, and accurate. As information becomes obsolete, it should be removed and securely stored elsewhere to keep the book neat and current. Old data sheets from 6 months ago shouldn’t be just jammed into the back of the program book.

The Consultant should be the only person removing programs or data from the program book after careful review, but sometimes the Consultant may share this responsibility with the Lead therapist or teacher. What’s important is that someone is in charge of the upkeep of the program book, and is reviewing the data regularly and closely. I have walked into some homes for consultation, and been handed huge, overflowing, program books and the reason why is usually because everybody helps to update and organize the program book. When its “everybody’s” job that usually means it’s “nobody’s” job. Everyone thinks someone else will clean it up, so one actually does.

For parents, it is important to store the program book (and all therapy materials) in a secure location, out of the reach of children. It wastes time and resources when a therapist arrives for a therapy session and finds that the children in the home have colored all over the data sheets, or spilled juice on the session notes.


To create a program book you will need:

Large 3-5 in. binder, with easy to open rings
Notebook paper
Dividers with multicolored tabs
Pencil pouch containing: pens, pencils, highlighters, hand sanitizer, paperclips, timer, calculator, Kleenex, etc. (never know what you will need in the middle of a session!)
Transparent sheet protectors (3 hole punched)
3 hole punched manila folders
Clipboard



Order of Program Book

  • Sign In Sheet –The sign-in sheet is where anyone who will be running a session needs to record the time, date, and duration of the session. This could be the therapist team, or maybe Mom or Dad decide to do a Saturday morning session. Keeping a record of who worked with the child and when, is important for knowing how many hours of therapy the child is receiving. If the Consultant asks “How many hours of therapy did Lisa get last week”, can you answer that question? The sign-in sheet can also help to reveal concerning patterns, such as a line therapist who regularly leaves sessions 30 minutes early.
  • Preference Assessment, ABLLS/ VB-MAPP Assessments/Behavior Checklists – During the intake process, an observation and assessment should have been completed. The results of this information should be kept in the program book to be easily accessible. Typically as the Consultant, I am the one to conduct the initial assessment and not the direct staff. However, the direct staff will be working with the child daily and the information contained in the assessment can be valuable to them. I also like putting the initial assessment and intake form inside the program book because it helps the direct staff know what the initial goals were, or why the parents sought treatment. This helps to remind all staff involved of the goals that are most important to the parents. The preference assessment is important to keep in the program book because it will tell the direct staff what is motivating to the child, what the child likes to touch, see, taste, etc.
  • Current BIP, FBA, Protocols – The initial Behavior Plan or Functional Behavior Assessment should be kept in the program book, to be easily accessible. Any current protocols, should be kept in the book. The people who will be working with the child daily need to know what problem behaviors are being targeted, and what procedures to use. Everyone on the team needs to know how to handle (and collect data on) challenging behaviors.
  • Data Sheets – The data sheets should be kept near the front of the book for easy access, and so they can be grabbed quickly at the start of the session. This could include trial by trial data sheets, Cold Probe data sheets, NET data sheets, behavior frequency data sheets, etc. Typically, the first therapist to work with the child at the start of the week should look over the program book and clean it up as necessary (print out more data sheets, replace pens, etc.)
  • Manding/ NET Data Sheets – If Manding trials or NET sessions are being done, the data sheets should be stored inside of the program book. These sheets should be reviewed regularly by the Consultant, both to track progress and make programming changes as necessary.
  • Graphs – If the data is being graphed either during sessions or after sessions, the graphs should be stored directly after the data sheets. Graphing helps to visually see progress and enables quick decision making. Downward trend graphs, or "flatline data" (that would look like 40%, 40%, 40%) need to be evaluated, so a determination can be made if the program needs to be changed or if teaching error is happening.
  • Active Programs – The active, or current, programs are the meat of the program book. I typically will give a client more programs than they need, with most being active and some being put on “hold”. This way as the child begins mastering programs, the therapists can quickly move to a new program. The therapists should be keeping track of when a program begins, when it ends, and maintenance trial data. Sometimes the Consultant is the only one who can master or remove a program, and sometimes this task is shared with a Lead therapist or teacher. What is important is that anyone who is mastering out a program or choosing what to teach next is trained to do so. Selecting which programs to teach should not be an arbitrary process.
  • Mastered Programs – As programs are mastered, or “closed out”, the active programs should be moved into the mastered programs section of the book. This way the therapists can easily go back and revisit old programs, as well as look and see what the child has recently mastered. The mastered programs are also necessary to fill out the ABLLS or VB-MAPP skill grid.
  • Daily Session Notes – The direct staff should be taking session notes after each session, or however often the parents request. Daily session notes should include a brief summary of the child’s mood, behavior, and attending, as well as any particular areas of strength or deficit. It is important to use professional, objective language when writing session notes. Trust me when I say: you never know who will read the session notes. Avoid overly negative statements like, “He was so whiny today”. Focus on objective statements, and try to frame them positively. This is also where you can leave notes/suggestions for the next therapist, such as “Zoey may be getting a cold, appeared drowsy today and sneezed several times”.
  • Supervision Notes – The Consultant should be writing supervision notes when they are on-site for supervision visits. This could include information about the programs, the data sheets, the staff schedule, etc. The Consultant should avoid using these notes to write specific comments or disparaging remarks about a therapist, such as “Carrie was 25 minutes late for the session today”.  Again, try to use objective, positive language when writing notes, such as “Therapists: please be sure to arrive on time for sessions, and immediately notify the parents if you will be late”. When each therapist arrives for a therapy session they should review the daily notes from the last session, data sheets, and the supervision notes to see if any changes have been made to programs.


During the team meetings, the entire team should review the program book together looking over the data, programs, and session notes to discuss if any changes need to be made. Also, I suggest taking turns implementing programs and watching each therapist work 1:1 with the child. In a group setting, this can provide extremely valuable feedback and tips on how to improve. Team meetings are also a great time to get the parents involved and give them 1 or 2 programs to try with the child, so they can receive instant feedback from the professionals present. If you take notes during team meetings, those notes can also be stored inside of the program book for future review or as a record of what was discussed.