Thursday, May 23, 2013

Promoting Independence: Self-Help Skills







Self-help skills are those functional skills or tasks that build independence, self esteem, and increase the likelihood that a child will be successful across multiple environments. I think teaching self help skills is incredibly important, yet I often see these programs being skipped or left out of a treatment plan.

For parents of a child with Autism, they are typically very used to helping their child be successful. From an early age Mom or Dad have been prompting their child (even if they don’t know the term “prompting”, they have probably been doing it for years), modifying the environment to help their child, calming emotional outbursts/being a safe haven, etc. So by the time you meet a family, the parents have probably fallen into a habit of doing whatever they can to help their child get through each day. Problems can arise when this loving and caring help goes on for too long, across too many environments, and hinders development. 
Here is a very typical experience for me: During intake, I ask parents lots of questions about what their child can and cannot do. When I get to self help skills (can your child independently brush teeth, bathe, prepare a snack, etc) I usually hear "I dont know...I'm not sure...I do it for him". That is a big red flag for me that the child has little to no independence skills.

Part of typical childhood development includes a separation from Mom and Dad and learning to care for yourself, learning to calm yourself, and problem solving, e.g. “I’m in a new public setting and I have to use the bathroom. What do I do?” Emotionally, it can be difficult for a parent to start to separate from a special needs child, and to begin teaching the child skills that will lead to independence. It can be difficult for parents to let their “baby” start learning big girl/big boy skills. So understand that even if you have sound and reasonable reasons for wanting to teach self-help skills to a client, the parents may push back a little bit.

When first meeting a new client, problem behaviors and lack of language can overshadow any other goals. Parents usually express frustration and fear over their child’s lack of communication, or aggressive outbursts occurring multiple times a day. As the professional, even if the parent does not express a concern about self-help skills you should be the one to address it.
Don’t think teaching self-help skills is that big of a deal? If a child is lacking self-help skills they can have a developmental age that is years below their chronological age. Just think about a 9 year old who yells “Wipe me!” from the bathroom, because he still can’t wipe himself after bowel movements. Or a 4 year old who is still spoon fed by Mom. Or an 11 year old who cannot button or zip up his clothing.

The VB-MAPP, Vineland, and ABLLS-R assessments all include some type of self-help/adaptive skill domain. This is an important area of teaching; don’t skip it.

The first step in determining self-help deficits will be the assessment process, and observation. I wouldn’t advise just asking the parents about self-help skills, because parents can over or under estimate the independence level of their child. Always observe the child in the natural environment to make sure the information you were given about their level of independence was correct. 

Think about self-help skills that are developmentally appropriate, will make the child more successful in social settings or across environments (the biggest example of this is Toilet Training), and any self-help deficits that are placing undue burden on the parents. For example, do the parents have to bathe their 13 year old son each night because he is incapable of taking a bath? If so, that is a self-help deficit that should be targeted for intervention. Think about how much it will help that family, and empower that child, if he can start to bathe himself.

If you still are doubting the importance of self-help skills, here is my advice for you: Spend some time with a typically developing toddler. Toddlers are standing right in the gap of “babydom” and being a big girl/big boy. They typically want to do things independently even if they don’t have the skill yet. They don’t want you to pour their cereal or pick them up and put them on the couch: they want to do it by themselves. Compare a typical toddler to the child or client you care for, and prepare to be amazed at the difference in independence. Just because a child has Autism does not mean they don’t need to learn independence. I’m not going to wipe the nose of a typically developing 3 year old, and I’m not going to wipe the nose of a 7 year old client just because he has Autism. Hand him a tissue, and tell him to blow! :-)

I have never met a parent who told me their goal for their child was to be as dependent as possible. So help these kiddos be more independent, by deciding today to stop doing things for them that they can do themselves.


Self-Help Skills Checklist


  • Dressing Skills (tying shoes, putting on shirt, matching tops to pants, etc)
  •  Bathing Skills (washes face, uses soap, dries with towel, etc)
  • Grooming Skills (uses comb or brush, brushes teeth, can apply Chapstick, etc)
  •  Feeding Skills (uses utensils, sucks using a straw, chews with mouth closed, etc)
  •  Toileting Skills (wipes after BM’s, stays dry through the night, requests toilet if in a new public setting)
  • Independence/Autonomy Skills (chores, making choices, polite refusal, e.g. "No Thanks")




Friday, May 17, 2013

Quote of The Day

Ahhh, the timeless wisdom of Dr. Seuss.
Fantasy, sillyness, and whimsy are necessary ingredients when caring for children in any capacity, especially as a therapist. In some ways working with my kiddos can be like stepping into a Dr Seuss book, where up is down and fish can fly.

If you haven't lately, try to change your perspective about the "odd things" your clients do, and see things from their perspective. Similar to reading a Dr Seuss book, it could be an out of this world experience.

“Fantasy is a necessary ingredient in living, it's a way of looking at life through the wrong end of a telescope.” 

Dr Seuss, Writer/Cartoonist, March 1904 - September 1991


Saturday, May 11, 2013

Pairing & Developing Rapport




Pairing” is a common term that ABA professionals often use to describe the process of building or maintaining rapport with a client. Therapy often begins with intentional and thorough pairing, where its ALL about what the client loves or enjoys and making that available to them on a non-contingent basis (jargon defined: for FREE). Basically, the therapeutic relationship should start off with low demand, and high reward.


 When done correctly, the client will see the ABA professional walk through the door and connect that to receiving good things/having fun.




I have mentioned pairing before on my blog, but this is the first full post all about pairing. Pairing is one of those ABA activities that some therapists just LOVE to do, and some therapists find challenging. I can't tell you how many times a therapist has said to me "...But, I don't know how to pair with him".
 I think this is because so much of pairing can be unstructured, client-led, and loose, that for some individuals it feels like doing nothing. Or it feels like wasted time. I have even had parents complain to me that the staff is "just playing" with their child and need to get to work already. 

I have also worked with ABA therapists who are amazing at pairing and building rapport. One of my previous staff referred to herself as "Mary Poppins on crack". :-) Correctly so, I would say.

Pairing in its simplest terms is just being the embodiment of a toy. When I am successfully paired with a child, I feel like a gigantic toy. The child is pushing and pulling on me to get me to engage with them, ordering me around (“No, sit with me Ms Tameika!”), excited to see me arrive and bummed to see me leave, responsive and cooperative during work tasks, and and any activity is more exciting if I do it too.


The therapeutic process should begin with intentional pairing. Even if you already know the child, you shouldn’t immediately jump into presenting demands. Pairing is how therapists establish instructional control, build trust, connect themselves to reinforcement (eventually becoming a reinforcer), and get to know the child’s interests. Skipping the pairing process can cause problem behaviors to increase, kill instructional control, and impair the therapist-child relationship. If I am not properly paired with a new client and I just walk in and start giving orders, what is motivating the child to do what I say? What is motivating the child to want to come and play with me? 
What you could unintentionally do is create a situation where the child is doing things you ask to get away from you. So you place a demand, the child answers, you provide reinforcement, and the child walks away/leaves the room/elopes. That is definitely NOT a situation you want. It’s no fun for you or the child to have to chase them around the home. 

You will know pairing has been successful when the child is consistently coming toward you, or approaching, and not walking away from you, or escaping. The whole "Im-going-to-play-alone-with-my-back-turned-to-you" thing is like a red flag that you have more pairing to do.


Pairing is all about social reinforcement and enthusiastic engagement, which is often hard for the children I work with. They just don't find social interaction all that interesting.

Pairing is not something you do for a few days with a new client and then never do again. I have worked places that taught us pairing rules like: pair for the first 5 sessions, or the first 2 weeks, and then transition to placing demands. Research does not support these kind of blanket rules. 

Think of pairing as something to be implemented prior to task demands, not just when starting with a new client. I actually teach my staff to briefly pair at the top of all therapy sessions, and to continually conduct brief reinforcer preference assessments to make sure they are approaching the client with what that client wants, in that moment. This is a far more effective way to think about pairing......it is not something to check off a list and then never do again. Its a way of embedding client interest and just good ol' FUN into your sessions, so that work is gradually embedded into play, rather than being a jarring transition.


There is one last benefit of the pairing process that I feel is sometimes overlooked. Successful pairing teaches the child that I am fun and when I show up at the house good things happen. So in the future if we have a bad session or the child hates a program I am trying to teach, they can separate the task I am asking them to do from who I am. In other words, they can dislike what I want them to do and still like working with me.

Here is a simple mock up of the first few days of pairing with a new client, and what that progression could look like. 
This is not a template that has to be followed, remember pairing is NOT a dry recipe to follow! Rather this is a sample of how task demands can be gradually increased over time:

PAIRING PROGRESSION

Day 1: Introduce myself to child. Observe the flow of the day and how the child spends their day. Act more as an observer than an active participant. Shadow the parents as they engage with the child so I am connected to reinforcing people (the parents). Place 0 demands on the child.
Day 2: Greet the child. Begin to connect myself to known reinforcers. If child loves to swing, push the child on a swing. If child loves going to the park, take the child to the park. Praise appropriate independent behaviors, such as eye contact or sharing (“Thanks for sharing with me!”), and have lots of playful interactions doing what the child wants to do. Do lots of narrating or mimicking during the play. Follow the child’s lead. Introduce some task demands in the work area.
Day 3: Greet the child and begin to prompt a response. Restrict access to reinforcers by being the one in control of reinforcing items. Spend more time in the work area, or increase ratio of demands to breaks. Begin to incorporate social reinforcers into play such as having a babydoll give the child kisses. Praise appropriate independent behaviors, such as eye contact or sharing, and have lots of playful interactions doing what the child wants to do.
Day 4: Greet the child and wait for them to respond. Arrive to the home with a Grab Bag of reinforcing items to introduce during the session. Restrict access to the reinforcers by placing demands on the items. For example if the child wants a pinwheel out of the Grab Bag require them to spin the pinwheel once (prompt if needed), then immediately praise the spinning and give the pinwheel to the child. If the child is vocal begin to require they label reinforcers to get them (hand the child a ball but don't release it until they say “Ball”). Increase amount of social reinforcers used during the session to a few each hour; label the name of the activities as you do them. For example, lift the child into the air and say “You’re an airplane!” Begin to have the child follow your lead, e.g. As you are playing with the child on the floor stand up and yell “Chase me!” and then run into another room. Reward the child following your lead with tickles.


*Quick Tip: Here’s a link to a massive variety of social reinforcers. Try to mix in 5-7 different ideas into each ABA pairing session.

*Awesome article explaining the process of Pairing: http://www.bsci21.org/how-to-get-your-client-to-listen-to-you/