Photo source: www.traditionoflondonshop.com, broedor10.wordpress.com

In the military, the frontline are the first ones to go into the heat of the battle. 

On my blog I try to share helpful information for all "levels of defense" : ABA staff and related professionals, teachers, and parents. It was during a conversation with a colleague last week that I realized I am forgetting a pretty important section of the "levels of defense". I would actually consider them to be the frontline, as they often are the first ones to realize a child is not meeting milestones and may need help. These would be the day care workers/preschool staff/Sunday school teachers.

For preschool age children, they are usually spending all day at home with parents or at a daycare/preschool. Due to the age of children served, day care staff (and related professionals) tend to work with many special needs children--whether they realize it or not. 

Not all needs are "visible", especially for children under the age of 3. A diagnosis at that age may just look like persistent, daily behavioral challenges.

The parents are not always the first recognize signs of Autism....sometimes it isn't until the child is placed in a group of their peers, or a structured setting, that deficits and impairments become obvious.

For many of my clients, it was through a bad experience with a day care or preschool that the diagnosis process began. The child was kicked out of a day care (or multiple day cares), or the parent was constantly called about behaviors issues.  I often hear one of two complaints: "That super expensive and upscale preschool wouldn't let my child stay because of his behaviors" or "That super affordable and welcoming preschool had NO idea how to handle my child's behavior".


Just like I have a helpful Top 10 list for parents who are seeing issues/problems at home but don't have the benefit of a team of therapists, I think its important to have a similar list of tips for day care workers.

Please share this information with anyone who could benefit from it, as I strongly believe that highly trained day care workers can be KEY in early diagnosis and early treatment. I mean, they're the frontline staff! They need proper training and support to perform their job, and they need to be trained on Developmental Delays in order to clearly communicate any indicators to parents and caregivers.

Tips for Frontline Staff

• Screening Tools - The very first thing a day care or preschool should look at improving is the intake process for enrolling a child. I have worked in preschools, so I know that often this process is basically a quick interview and completing a few forms. This just isn't thorough enough. Proper intake needs to gather family background, include observation of the child/interaction with the child, ask about developmental milestones, determine child strengths and deficits, and I recommend including a brief screening. Screening tools are intentionally easy to administer, quick, and can be administered by pediatric/healthcare providers. I am not saying diagnose every child that comes through the door of the day care. Screenings are about catching red flags, not diagnosing. With the information gained from a screening checklist, the day care provider can now alert the parent to seek further evaluation, modify instruction, and be prepared that there may be behavioral challenges. Here is a great link for various screening tools.

•  Amp up the structure - Typical day care classrooms have a schedule that is followed and taught to the children. For young children with Autism, this may need to be much more concrete and visible. I suggest a visual schedule clearly posted in the classroom, along with "schedule checks" throughout the day where the children are reminded what is coming next as well as "transition warnings", where the children are given verbal reminders that an activity is ending. What workers may notice is that unstructured times or days (such as a party the last day before a long break) are the WORST behavioral days for some of the children. This is likely due to an unwanted or confusing change in schedule/consistency, from the perspective of the child.

• Toss chronological age out the window - Conducting proper intake will help to determine a child's developmental age, but its important that day care workers understand that just because a child is "4" that may not mean anything. That child may not communicate, eat, play, or use a toilet like a typical 4 year old. So if the child is 4 with a developmental age of 18 months, some decisions will have to be made about placement. What classroom is best suited for this child? Will staff toilet train the child? Are there enough staff in the classroom to help the child perform self help tasks (such as eating lunch)? How will staff communicate with the child?

• Incorporate multi-sensory experiences - The preschools I have worked with always had a "sensory area" of the room, such as a popcorn tub, water table, clay table, tactile wall, etc. Usually the workers will observe that certain children gravitate to these areas, all throughout the day......they just seem to want lots of time to manipulate these objects. In addition to an area of the room, I suggest adding a sensory component to teaching times (this will keep you from constantly pulling Edward away from the tactile wall). During Circle Time, make sure the children have objects to hold, shake, or bounce. On the playground, use trampolines, swings, or huge yoga balls. 

• Function based behavior management - This is SO important!!! The #1 reason I get called in to day cares or preschool settings is problem behavior. Almost without exception, when I go in to observe what I see is that everyone around that child is reinforcing the problem behavior. The child runs around the room during Circle Time, so they get sent to the Directors office. The child screams during nap time, so the teacher lies down on their mat with them. The child refuses to share toys from home, so the other children are told to not touch their toys. It is important to take a good look at the current behavior management system used at the day care, and evaluate its effectiveness. Be knowledgeable about the FBA process, as well as proactive behavior strategies that prevent behavioral blow ups in the first place. Daycares: train your staff so they know how to address challenging behaviors!

• Don't be afraid to call in the Calvary - Do not be hesitant to seek outside help when needed. For the parents, did you know most day cares set aside funds for outside trainings or consultations with professionals? For the day cares, did you know you can work with contract BCBA's both locally and remotely? A typical day care won't have Autism or behavior experts on staff. So consider working with local professionals to create trainings, put together workshops for staff, or as a part time Consultant.

• Expect to deal with this - As I already said, whether preschools/day cares are aware or not, there are likely already multiple children present on the Spectrum (or with other developmental delays). When a child is that young, it is very likely they don't have a diagnosis yet. Even if the parents have noticed concerning symptoms, they might not know the seriousness of what they are seeing. Or, there's always denial....denial is very real. So my last tip to day care workers is approach your classroom each day with a watchful, intentional eye, and be on the lookout for red flags in the children you serve. You can help point a parent towards much needed professional help. Also, please clearly state limits of competency to the families you serve. I have worked with multiple families who were told by XYZ daycare "Oh we have staff trained to work with Autistic kids, your child will do just fine here!".....cut to a few weeks later and my client has been kicked out of the daycare. :-( If the facility/day care is not properly trained or set up to serve kids with behavior issues or delays in language, toileting, self-help skills, etc., clearly explain that to parents (refer out) or seek out a professional to help the staff get trained (equip the team).

*Recommended Resources:

Autism & Child Care - How a Lack of Quality Programs Hurts Families

Finding the Right Daycare

Teaching Children with Autism (NAEYC)

Lushin V, Marcus S, Gaston D, et al. The role of staffing and classroom characteristics on preschool teachers’ use of one-to-one intervention with children with autism. Autism. 2020;24(8)

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Tameika Meadows, BCBA, Blog Author

Photo source: www.forbes.com, www.rompa.com

If you have spent any time with ABA people you may have picked up on the fact that we're all about data. We collect data, analyze data to make decisions, and look for the evidence, or data, behind strategies or techniques before we implement them.

 

So where do we stand on the issue of “sensory diets/sensory protocols/sensory interventions”? Well, many items or activities often included in a “sensory intervention” (I keep placing that in quotation marks because one of the problems is there is no set definition of this term. It means many things, to many different people), such as koosh balls, massage, tickles, dark lighting, aromatherapy, scented oils, pillows, etc., are quite enjoyable and can be very reinforcing.

Did you catch that?

Okay, I’ll say it again: Many items or activities often included in a “sensory intervention” such as koosh balls, massage, tickles, dark lighting, aromatherapy, scented oils, pillows, etc., are quite enjoyable and can be very reinforcing.

And there is the problem. “Sensory protocols” are often implemented as a response to problem behavior, in order to quickly remove the agitated child, let them de-stress, and to give them a quiet and relaxing space to gradually de-escalate. So what happens if you apply an enjoyable and possibly reinforcing activity after problem behavior has occurred? You inadvertently reinforce, or strengthen, that problem behavior.

Many center programs or schools are now setting up separate cool down areas where some type of “sensory protocol” is applied, such as the child sits on a beanbag and listens to soft music while a teacher or aide gives them deep pressure and firm touch.

These professionals often are unaware that the very protocol designed to reduce or prevent problem behavior is actually causing problem behavior to increase. Here’s a sample scenario to show you what I mean:

Child in math class.....hates math class.....child throws book across room, yells, and stands on desk...immediately removed from math class (yay!)...taken to the cool down room...now laying on a soft  blanket, sipping water, and holding a koosh ball...awesome!

For all the parents and educators: there is NOTHING wrong with using preferred items to bring about behavior change. Just pay attention to WHEN you present these items/activities. 

Preferred, enjoyable items and activities should be presented when desired behaviors occur and not when problem behaviors occur. When problem behaviors repeatedly occur, your best plan of action is to conduct a FBA, and create a Behavior Plan.  

So why do “sensory protocols” or other interventions without empirical support persist, or even gain traction among professionals and educators? What is the lure? Well, Lilienfield et al (2015) provide a few answers to that question:

• Parents are often desperate for Autism treatment options
• Behaviors often wax and wane naturally as children age and mature, so it can seem that sudden short term improvements are due to a particular treatment or intervention
• The internet and technology brings a mass of information to people quickly, and most people would rather read something online than in a research article
• At a psychological level, once someone believes in something it can be quite difficult to convince them otherwise

I absolutely agree that fad treatments can be very alluring. It’s like that fast food place that you know you shouldn’t eat at, but the food is cheap, fast, and convenient. 

Based on my experiences with this issue, here are the main captivating lures I see when it comes to “sensory protocols”:

The Lure	The Truth
Typically easy or quick to come up with, can be implemented or created by anyone	Most quality, evidence based interventions require the use of credentialed or licensed professionals who have specific expertise
Materials/objects are often cheap and readily available, some can even be made	Gather together all of these cheap and readily accessible items and use them as reinforcers, not as a “treat” that only comes out after the child has aggressed at someone. If the only time the child can access all these amazing items is after they have become severely disruptive, then Houston, we have a problem
Can appear to have an immediate effect, or in the short term can appear to be working	Especially for an escape maintained child, yes….these types of interventions will appear to work like magic! Unfortunately, that is only until the child gets sent back to class or a high demand situation. What I typically see is a high cycle of: behavior, calm down room, behavior, calm down room, etc. Another important point to consider is do you plan to create a sensory room in all environments? No? Then what happens when problem behaviors occur at the beach, the post office, or at Grandma's house?
A “sensory room”, particularly in a school, can serve as negative reinforcement for the teacher (escalated and disruptive student is quickly removed from their   classroom)	If at all possible, it’s best not to remove the child from the location where problem behavior began, or for another educator/professional to come to the “rescue” and remove the student. This sends a message to the child you don't want to send: that you cannot handle the child’s behaviors, and if they want to quickly leave a certain setting all they have to do is exhibit significant problem behavior
If the child enjoys it, what’s the harm?	Lemon treatments waste money, time, efforts, and energy that could be directed at effective interventions based on data. They can also shape up problem behaviors and make them far worse, or more entrenched over time. Lastly, during the time the child was engaged in the sensory intervention and removed from the learning setting, effective instruction was paused or delayed.

Reference: 

The persistence of fad interventions in the face of negative scientific evidence: Facilitated communication for autism as a case example

Lilienfeld SO, Marshalla J, Todd JT, Shane HC (2015) Evidence-Based Communication Assessment and Intervention

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Tameika Meadows, BCBA, Blog Author

Photo source: www.cyclingtips.com.au, www.crossfitdownunder.com

"Intensity"  is a term often used when describing very rigorous or challenging fitness programs, but did you know "intensity" is also how ABA treatment dosage is described? So when you wonder to yourself, or question the ABA team about "How much therapy does my child need? How much ABA is enough? Is this too much therapy? What if I can only afford a few hours a month?", what you are really asking about is intensity of treatment.

First, a little background information:

In 2014, the BACB published a helpful guide for insurance companies who must make decisions about how and when to fund ABA therapy. In this guide the ideal "magic number" of treatment intensity is described as an analysis of multiple variables, such as intensity of treatment goals, client needs & severity of deficits, and client response to treatment. A range of 10-25 hours/week for focused treatment and 30-40 hours/week for comprehensive treatment is recommended. It is important to note this recommendation does factor in instructional time outside of ABA intervention. For example, if the child participates in Special Olympics basketball 5 hours a month where they work on socialization, sportsmanship, gross motor skills, and more, that absolutely can be included as part of their intervention.

So now that you have some background information, what does all of this mean?

Basically, determining the ideal treatment dosage of ABA therapy for your child is a complex decision. Many factors have to be considered. Added to this, is that funding source recommendations may not line up with what the clinical team is recommending. In other words, your insurance provider may approve 10 hours of therapy/month, but the BCBA may tell you at least 15 hours/week will be necessary. What I see happen very often, is that the families I work with receive the therapy amount they can afford and not the the therapy amount that is needed.  

I know this question of "How much therapy does my child need?" is confusing and frustrating for the average parent. So here are some takeaway tips to aid your understanding. When I am making a decision about how much therapy to recommend for a particular client, these are some of the points I consider :

•  What are the treatment goals? - The more intense the treatment goals, the more likely higher hours per week will be recommended. During a client intake, if the parents are telling me they want to work on feeding, toileting, language, severe behavior reduction, etc., what I am hearing them describe is an intensive and comprehensive ABA program. Think about it like this: for just one of those goals, literally hundreds of learning trials could be necessary for your child to master the skill. Its very unrealistic to ask for comprehensive treatment, but only request a few hours of therapy per week.
• What is the treatment setting?- Will therapy sessions occur at home, at school, in the community, or at a clinic/center program? This can impact how much therapy the child can receive. For example if you only want behavioral help at your child's karate class, that limits the frequency of therapy to when the karate class is held. Conversely, if the child is not in school and therapy will occur at home then treatment intensity should increase to maximize the availability.
• Can relevant stakeholders be considered on the "team"? - Buy In. Read it, learn it, live it. The less involved the parents, teacher, or related professionals with the ABA treatment plan, the more the weight of treatment integrity will fall on the ABA team. I see this all the time: a family is receiving ABA services, the ABA team expresses that the child is making huge gains, and the family disagrees. Why? Well, if the parents are not involved with treatment/not generalizing treatment then they likely won't see the gains that the therapists see. While your child will use words with me, when I leave your house they will go back to pulling you by the arm to indicate what they want. The more the ABA team can count on the family to reinforce the treatment plan, the more confidence they will have in decreasing therapy hours.
• How therapeutic are the child's non-ABA hours? - This is closely related to the previous point. How much of the child's non-ABA hours are contributing to or generalizing the skills and behaviors being addressed? Ideally, there would be generalization across individuals and settings. I recently had to discuss this with a client, whose son has in -home ABA and is in an inclusive classroom. Unfortunately, the classroom environment is such that it encourages and reinforces the very problem behavior the ABA team is working to reduce. So in that scenario, I could not count school hours as therapeutic or likely to promote skill acquisition... quite the opposite. So this would be a situation where I recommend increasing the intensity of ABA services.
• Are there any company policies/limitations to consider? -  Some companies won't staff a case for less than 5-10 hours a week of services. Another example is if your insurance provider will pay for 40 hrs of ABA a week, does the company have enough staff to cover that many hours? Sound like a silly question? Believe me, issues like this happen both with very low treatment intensity and very high treatment intensity.
• Where are we in the course of treatment? -  Is the client new to ABA and an early learner, or have they received therapy for years and are now close to terminating services? This also must be considered when deciding how much therapy the individual should receive. It is typical that the intensity of ABA begins high, and then is carefully reduced over time until services are no longer necessary. If therapy services will be fading soon, or the client needs focused/short term help, then a lower intensity of therapy may be most appropriate.

References:

BACB resource 

Eldevik, S., Hastings, R. P., Hughes, J. C., Jahr, E., Eikeseth, S., & Cross, S. (2010). Using participant data to extend the evidence for intensive behavioral intervention for children with autism. American Journal on Intellectual and Developmental Disabilities, 115, 381-405.

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Tameika Meadows, BCBA, Blog Author

Photo source: www.heatherwilsoninternational.com

Suggested Reading: Selecting Reinforcers

I once had a client who referred to things/activities/places that he really, realllllly, liked as his "favorite-favorite". As in, "French fries are my favorite- favorite". How cute is that??

Whether you are a parent or professional,  I am quite sure a question you are regularly asking yourself is how to identify and properly build upon the child's motivation in order to teach them. In other words: 1) what is it that the individual wants, 2) what is the individual willing to do, and NOT willing to do for what they want, and 3) how can I use this knowledge to teach?

And here I am to answer those questions for you. Aren't you lucky :-)

Say hello to Preference Assessments.

What is a Preference Assessment? Basically, conducting a preference assessment on an individual will equip you with valuable (highly valuable) information about what they like, what they find enjoyable, and how much they like something You may already know that your son Nicholas likes trains, Barney, and toy cars. But do you know which one he likes the most? Do you know which one he satiates on the fastest? Do you know which one he likes the least? Wouldn't you like to know these things?

Ultimately, we are all teachers. If you're a parent, then you may be teaching your children respect, manners, or household chores. If you are a professional, you may be teaching your client to count, ride a bike, or to have a conversation. As a teacher, it is essential that you approach instruction thinking about "what's in it for this kid?". As the adult we can often get caught in the trap of "do this because I say so", or its unfortunate cousin, "just doing this should be its own reward". No and no. 

When you approach instruction by first taking the time to determine what the learner is motivated for, and the degree of motivation (more on this in a sec), you win AND the learner wins. Obviously the learner wins because they are now highly motivated to comply with instruction in order to get what they want. You win because instead of an uphill battle with a child who just wants to get away from you, you now have an attentive and cooperative learner who is ready to be taught.

Now that you understand why preference assessments are so important, you may be thinking this is some magic technique that you do once, write the information down, and then you are free to get on with your teaching for the next few years.

No.

Proper use of preference assessments means you will conduct them regularly (interests will change!), you will be on the lookout for satiation (being "full" on the item), you will watch out for competing stimuli or items, you will make sure the response effort does not outweigh what is being offered, and you will understand that while a strong preference is usually an indicator of a potential reinforcer, this is not always the case. I have worked with clients who may LOVE to be praised, but no way are they going to work an entire therapy session just for praise. So once you have a list of highly preferred preferences (edibles, tangibles, activities, people, etc.) just know that not everything on that list may serve as a reinforcer.  Remember that by definition, the stimuli must increase the future likelihood of a behavior to be called a reinforcer. So if you regularly give your little learner a sticker after they exhibit a specific behavior, and the behavior does not increase over time then guess what? Those stickers are not reinforcers.  

I will often teach my staff to conduct brief preference assessments before each teaching block of  trials (not session, trial). That is how much I value preference assessments, and approaching the learner with what they want. If you find yourself approaching the learner for instruction, and just reaching out and grabbing an item as their "reinforcer"...stop.  Don't be a lazy instructor. Yes, preference assessments take time, they take practice to learn how to do them, and there is data collection involved. However, for your diligence and effort you get a super motivated and attentive learner to teach. I say that's a pretty good deal.

Here are your basic preference assessment options:

• Observe and/or Interview - This can be done by simply observing what the learner freely does in an environment, and what they choose to engage with or do. Or, you can prime the area with items you think the learner enjoys or have previously seen them interact with. Then stand back and observe what they go to, and how long they interact with each item. You can also interview the parents, teacher, or the learner (if appropriate) to find out information about likes/dislikes and get a rating scale of preference. I usually collect the interview information via a simple form or checklist.
• Structured presentation - Items are presented either in pairs or as a group, and the learner is told to "pick one". Items may or may not be replaced as the learner makes choices, depending on which type of preference assessment is being conducted: forced choice (paired method), multiple stimulus with replacement (MSW), or multiple stimulus without replacement (MSWO). Data is collected on how long the learner interacted with the item, as well as which item they selected  (they cannot select multiple items), in order to calculate a hierarchy of preference.

*Resources:  

Conducting Preference Assessments on Individuals with Developmental Disabilities

Increasing Accurate Preference Assessment Implementation

 Training Staff to Implement Stimulus Preference Assessments

 

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Tameika Meadows, BCBA, Blog Author