Friday, November 22, 2013

My Top Ten List





Lately I have been starting lots of new cases, which means I am doing the intake process over and over again. I’ve been noticing similarities and patterns in what each client needs that cuts across age, level of functioning, and even abilities.  It seems there are certain key strategies or interventions that many homes need, but do not have in place. I will call these strategies:  “The Essentials”.

There are certain things that should just be common practice and implemented in the home of every child with Autism. Now of course I am generalizing a bit in this post, so if something doesn’t apply to you or your child’s needs feel free to skip it, but in my experience these things do apply the majority of the time. The main deficits of Autism mean that there will be similarities of needs and/or problem behaviors across individuals (e.g. wandering away from home, little to no communication, not toilet trained, etc.). However, there are always individual differences to be considered.

If you can already have these things in place before you start ABA services (whether you use a company, or do your own in home program) you will be SO far ahead of the pack. …and your Consultant will greatly appreciate having less to do :-)

The main reason for implementing these strategies is to make your own life, and the life of your child easier, decrease stress, teach skills, and reduce problem behaviors. Just putting these systems in place in your home, even if you do not currently receive ABA  services, could make a dramatic difference in your childs ability to successfully manage their day, transitions, know expectations of behavior, and communicate their wants and needs.
  I guarantee you if you look around any quality ABA classroom you will see some, or all, of these systems in place. So pop quiz time: if the school needs these systems in place to successfully teach and care for children with Autism, then don’t you think you need them in place at home too? (The answer is Yes!)

I recommend implementing these strategies as soon as possible, the younger the better. However, if you have an older child or care for an adult with Autism, these strategies would still be very helpful.

So, drum roll please……




My Top 10 List of “The Essentials”!

  1. Structure /Routine in the home: Consistency and knowing what to expect helps kiddos with Autism manage their day. Create a routine for your home, and stick to it. Bedtime should be the same every day. Dinner time should be the same every day. Outside play time should be the same every day. Big, sweeping, dramatic changes from day to day or moment to moment are a good way to cause your child with Autism to dissolve into behaviors or meltdown mode. Create a routine based on activities that happen daily, so your child can begin to learn it and feel more in control of their environment.
  2. Visual schedule/Daily schedule: See how impossible this strategy would be without a routine in the home?? A visual schedule is essential if you want to teach independence. How can your child learn to independently transition from morning routine, to breakfast, to the school bus? Simple: create a visual schedule. Do you find yourself having to give a demand 2, 3, or 85 times a day? Create a visual schedule. Does your child finish an activity or task, and then just wander around, filling their time with problem behaviors or self-stimulatory behavior? Create a visual schedule, and use it to redirect them to what they are supposed to be doing. Visual schedules help these kiddos know what they are supposed to be doing, what is coming up next, and what is after that. Heres a tip: please do not use written schedules with kiddos who cant read. That isn’t helpful at all. Use visuals instead.
  3. System of communication: I have a post about teaching communication skills, and this is something you want to begin working on as soon as possible. Maybe your child communicates with sign language, or an Ipad, or PECS, etc. What is important is that everyone in the home agrees to reinforce and only accept the system of communication. If the child is verbal, then reinforce and require words. If the child can sign, then reinforce and require signs. What I usually see in homes is the child has multiple ineffective or weak modes of communication, and that is a simple problem to fix. Start reinforcing one communication mode, and make sure everyone in the home is on the same page.
  4. Restricted access to reinforcers: No “free reign” or “grazing”. Free reign would look like a child who just “loves” Dora DVDs, and is allowed to sit and watch Dora for hours and hours each day. Grazing would look like a child who just “loves” pretzels, and when he wants some he climbs up onto the kitchen counter, opens the cabinet, and grabs a handful. If your child has free, no limit access to the things he/she enjoys the most, then what is left for you to use as a reinforcer? Reinforcement is critical for learning, and when I usually hear “She just doesn’t have any reinforcers!”, what that often means is the child has no reason to work for anything because they have free access to it all day.
  5. Elopement pro-active strategies: Elopement is a huge safety concern for many kiddos with Autism, especially those who are nonverbal. From a young age, you can teach your child that eloping is not ok. Along with the house routine (see how important that is?), there should be rules for the household. An elopement rule could be something like “Ask Mommy before going outside”. Create visuals and place them near all the doors, that say things like “Stop & Ask”. When the child gets to the door, they will be reminded that they cannot go outside alone. Teach them to come find you, and using their system of communication (PECS, sign, Ipad, etc) to request “outside”. I suggest covering up the visual at night, to indicate going outside is not an option. Or you could put up a different visual, such as “Wait”. Then explain to the child that they must wait until the sun wakes up to go outside. 
  6. Choice board: Making choices is a skill I always like to teach my kiddos. It’s such an important human right that is often forgotten about when it comes to kids with disabilities. Many problem behaviors can be reduced or completely extinguished if the child is simply given more opportunities to choose where they want to sit…..what movie they want to watch…..do they want juice or milk? To help kiddos make choices, I usually create a visual choice board of their preferred activities, foods, or items (this can also be done on an IPad if you have one). Then at multiple opportunities throughout the day I show them the choice board and have them pick what they want to do, eat, or play with. Depending on the child, the choice board may have to vary frequently if they get bored with reinforcers quickly. I also like using a choice board because it teaches scanning, and choosing from multiple items. Especially for a nonverbal child, instead of running around trying to figure out what they want as they tantrum and scream, they can be taught to request things using their Choice Board.
  7. Toileting pre-requisites: This is a big strategy, that so many homes need but I almost never see. Even if your child is too young to begin toilet training or isn’t ready yet, you can begin working on the prerequisite skills now. Only change your childs diaper or pull up in the bathroom, have them assist with dressing/undressing, throwing away the soiled diaper/pull up, and washing their hands. You are teaching the whole toileting routine, just without requiring the child to sit on the toilet. The child is becoming familiar with the bathroom, and learning multiple skills they will need later (e.g. unzipping pants). Use a visual to help with complex tasks, such as handwashing. When your child has accidents, they need to participate in the clean up, get a new diaper/pull up, and still go to the bathroom to wash hands/throw the diaper/pull up away.
  8. Multi-modal sensory items: This relates directly to reducing repetitive, self-stimulatory behaviors, or decreasing hyperactivity. For kiddos who spend their free time stimming, parents often ask me how to reduce that. Well, stimming serves a need for your child. So my suggestion is to redirect it, not to stop it. Place things in your home that your child can manipulate or interact with to gain sensory stimulation, so they do not have to walk around the house humming, handflapping, or pacing all day. Suggestions include yoga balls, trampolines, sensory boxes, fairy lights, sound machines, finger paints, etc.
  9. Independent activities/Work station: One of my favorite programs to teach is Task Completion. I love this program because it teaches leisure skills (my kiddos almost never have appropriate leisure skills when I meet them), and independence. Do you have to entertain your child all day long? If you need to take a phone call, do the laundry, or send emails on your computer, can your child keep themselves busy? If not, then I suggest teaching independent activities. Set up a small area, place a few activities in it, and set a timer. Direct the child to engage in the activities until the timer goes off, and provide huge praise and reinforcement for compliance. Over time, the work stations can be added to the daily schedule (see how important that is?) and the child will be able to independently have snack, clean up, do 2 work stations, start homework, etc.
  10.  Cool down area: This is another one that I wish I saw more, because it is often very much needed. Kiddos with Autism often become overwhelmed or overstimulated throughout their day, and dissolve into tantrumming, whining, meltdown mode, or self-injury. What I often see parents do is take responsibility for the childs emotions. This could look like picking the screaming child up and rocking or cuddling them until they calm down. For one, that could be reinforcing problem behavior. For two, we want to teach the child from an early age that they need to control their own emotions. Select a quiet area of your home and place calming items in the area (pillows, koosh balls, etc.). When your child becomes upset or overwhelmed, explain to them that they need to calm down, e.g. “You are crying and throwing toys. You need to go calm down”. Direct the child to the cool down area and silently prompt them to do calming strategies, such as taking deep, slow breaths, or counting to 5. Use visuals to help show them the steps they can complete to calm down.  Over time, you will be able to tell the child to go calm down, and they will be able to independently go to their cool down spot, practice their exercises, and come out on their own.  The calming strategies visuals can be taken anywhere, and used in any setting.  It isn’t the location that matters; its teaching the child the steps to self calm.

Monday, November 11, 2013

Quote Of The Day


"Violence is the language of the unheard"

Dr. Martin Luther King, Jr

I love this quote.

I recently participated in a physical management training for work, and we were talking about some of the reasons why nonverbal clients use aggression/hurting others as a way to communicate.
Aggressive or violent ASD individuals need a consistent way to communicate with others instead of resorting to hurting others. Beyond communication, I recommend putting yourself in that individuals shoes to consider factors that can make violence seem like a desirable option:

How often does that individual get to feel powerful?
How often is that individual offered choices vs. given demands?
Does the individuals communication, whether vocal, by Ipad, etc., contain more than just mands ("I want juice")?
How is personality, interests, and likes/dislikes incorporated into the individuals treatment? In other words, are we teaching what they want to learn, or only what we think they should know?
Is treatment provided in a way where the individual feels respected?
Does the individual feel heard?


               ...Something to think about.
Saturday, November 2, 2013

Say It Nicely




Resource: Allen, R., Hastings, R.., McDermot, K., & Still, D. (2002). Factors Related to Positive Perceptions in Mothers of Children with Intellectual Disabilities. Journal of Applied Research in Intellectual Disabilities, 15(3), 269-275


Positive reframing is a psychological tool that can be implemented  within ABA strategies or treatment to make a decision to focus on positive aspects for intervention: what the learner should be able to DO, not what the learner should stop doing. The family is viewed as a necessary and integral piece of the treatment puzzle, and “barriers to treatment” are viewed as teaching opportunities. I am not a teacher, but as a BCBA much of my job involves teaching: teaching behaviors, teaching families, teaching kids.


The way you view your clients and their families will impact the services you provide to them. The way you speak to a resistant parent, or a smothering parent, will be shaped by how you view that parent. Words have power (Proverbs 18:21). Negativity breeds negativity, and a “Me vs. The Family” perspective will only lead to conflict, miscommunications, and hurt feelings. 


This isn’t some unusual or new concept, we all learn at an early age that the way someone says something to us is often more important than what they actually say.  However, does that impact the way you speak to your clients or their families? Imagine your supervisor says to you “Reports must be submitted to me every week by Friday, NO exceptions!!” vs. “You can submit reports on Monday, Tuesday, Wednesday, or Thursday…..your choice”. Wow, what a difference some positive reframing can make! :-)
 
  If we as adults want to be communicated with in a positive way, then imagine how your 6 year old nonverbal client feels when you take the time to offer choices to her (“Do you want juice or milk? Pick one”) vs. just giving orders (“Drink your juice”).

It is SO important to positively reframe your thoughts, expectations, and opinions about your clients so you can help them in a caring and professional manner. The individuals you work with as an ABA professional may exhibit challenging, frustrating, and exhausting problem behaviors. If you decide to view those behaviors in a negative way (“This kid is just being a brat”) then that will affect how you interact with that client. If you view problem behaviors in a positive way (“This child needs to learn new coping strategies”) it changes your interactions with the child…..it really does. 
Positive reframing helps ABA staff realize that the client really needs your help so they can have a better future. I suggest you do this today: think about what kind of life your client will have in 10 years if these problem behaviors are still happening. For some kiddos that may be a very sobering thing to think about.

It may be necessary to help the family or school staff use positive reframing techniques. Some people really don’t hear how negative their words are. I cringe when I walk into classrooms and see huge visuals with things like “NO hitting/We do not spit!/Stop running” or a color coded behavior system that lists out “red” or “bad” behaviors. That is all suuuuuper negative. Did that teacher intentionally mean to sound that negative? Probably not. As the ABA professional that is a great opportunity for you to help the teacher understand positive reframing.  You want the child to stop hitting? Teach them “nice hands”. You want the child to stop running in the hallways? Tell them to have “walking feet”. The teacher tells you about a challenging student with many attention seeking behaviors? Point out how the child is clearly socially motivated (that isn’t always the case!) and with redirection and reinforcement they can be taught to seek out attention appropriately.

This may sound like a super simple concept, but I interact with professionals and families quite often who don’t realize how negative they sound, or that they are interacting with the child based on  low expectations of behavior. Remember, reinforcement always increases what it directly follows. So what do you want to increase in the client/family: the positive or the negative?


Examples of Positive Reframing

Negative view
Positive view
Your clients mother is very demanding and critical of you and your treatment plan
The clients mother is engaged and wants to be involved with what is going on with treatment. This is an opportunity to really include the parent in your treatment design, gather their input, and work on conflict resolution
Your clients father states to you he doesn’t believe in this “ABA nonsense” and you find him to be very argumentative
The clients father is openly communicating to you his thoughts and concerns about the therapy process, and engaging you in a dialogue. This is an opportunity to work on communicating respectfully, and also to educate the father about exactly what ABA is
Your clients teacher is using a behavior support system in the classroom that is poorly written and not reinforcing to your client
The teacher wants to implement ABA strategies in the classroom to help the students…great! This is an opportunity to provide ABA training to the teacher, which will benefit your client
Your client has many problem behaviors that really frustrate you, such as aggression and noncompliance
Your clients behaviors are serving a need and a function for that child, and if faster, easier, or more functional options were available the child could easily learn to extinguish these problem behaviors. This is an opportunity to teach new skills
Your clients younger sibling constantly intrudes upon your ABA sessions, and gets into your toys and reinforcers

Your clients sibling is interested and fascinated with you, and the therapy process. They would likely LOVE to be asked to participate. This is an opportunity to work on social interaction, group responding, or even toy play with your client and their sibling