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*Note: This post is Part I of a Two Part series.

I have hinted at and made quick reference to Early Learners before on my blog, but this post is all about designing intervention for early learners.

First, another lovely disclaimer :-)

ABA treatments or interventions are not one size fits all, and should never follow a generic formula across individuals. The specific needs and strengths of the individual receiving services will always guide treatment planning and intervention choices. This post is meant to be a helpful guide, not a guaranteed "recipe" to designing intervention.

End of disclaimer.

So if you haven't seen my other posts about early learners, allow me to quickly bring you up to speed:
  • Typically younger, or if older this is an individual who is very impacted by their diagnosis
  • Typically in a self -contained classroom, or attending a school for special needs children
  • Deficits are pervasive; there are significant difficulties with communication, social interaction, repetitive behaviors, toileting, etc.
  • Typically this individual has no means to communicate, other than through problem behavior
  • Interest in peers, age appropriate toys, or social interaction is typically low
  • Problem behavior rate and severity are typically high (if given lots of "free time" this individual would likely fill it with problem behavior)
So now that we all know what I mean when I say "early learner", what are The Basics for intervention?

A problem I see a lot when it comes to non - ABA interventions (special needs schools, the "Autism" classroom at a public school, related therapies) is a lack of starting with The Basics. A BCBA would be able to tell you that when working with an early learner, you won't get very far until you start by helping that individual "learn how to learn". This is often lacking from the various school intervention programs that I visit. For example, having an IEP goal of sitting in Circle Time for 10 minutes, yet the child sits there engaging in sterotypy the entire time. Or, having an IEP goal of reading a short story in Language Arts, yet the child cannot identify letters. I think the main problem is sometimes non-ABA professionals think they are starting at Level 1/Ground Floor, but they really are not.

Regardless of client age, the developmental ability and overall functioning must take priority. I find that specialized programs often overlook this. Just because the child is 9, the best placement may not be the classroom filled with 7-9 year olds. Maybe that child's chronological age is 9, but their developmental age could be 24 months. If that is the case, any goal/target created based on chronological age will be highly inappropriate, and most likely the treatment will be ineffective.

The reinforcement system, communication system, teaching format, and goals selected all need to be particularly modified for early learners. Failure to do this often leads to the child making erratic progress (which to me, is a way of saying "the child learned this, but we don't think it was due to our intervention efforts"), having a "swiss cheese" learning profile, being consistently stuck in one or more areas ("flatline data"), OR a child who is completely checked out of the intervention process.
I recently had the very unfortunate experience of conducting a school observation where my client was physically prompted to complete every single academic task placed before her.....all math tasks, all reading tasks, all matching tasks, all writing tasks, etc.
What is being taught in that scenario? Not much more than prompt dependency.

 I once had a supervisor who used to say early learners are unaccustomed to contacting success in a learning scenario.
Just think for a second about your early learner clients: how often do they come home from school with an "A" grade, a sticker on their behavior chart, or a ribbon they earned for super attending? The answer is probably never, as these individuals are usually the ones in the classroom who are constantly engaged in problem behavior, or completely checked out.

Below is a sample of the intervention package for one of my early learner clients, including typical (see disclaimer) program goals.
Keep in mind that these recommendations are not setting specific. In other words, early learners need these structures in place whether intervention takes place at home, at an ABA clinic, at daycare, or in a classroom. Changing the setting does not change what these children need to be successful.

Sample Intervention Package 

Teacher to Student Staffing Ratio:
1:1 (if highly aggressive, 2:1)
Teaching Format:
Recommended Intensity:
30+ hours per week
Reinforcement Schedule:
Initially 1:1 dense schedule may be necessary, thin this as appropriate
Types of Reinforcement:
Likely tangibles or edibles (cookie, candy, juice, favorite toy car, etc.)
 Intervention Goals:
Parent Training, Manding/Requesting, Toilet Training, Motor Skills, Imitation, Compliance/Cooperation, One Step Directions, Toy Play, Puzzles, Matching, Receptive Identification, Dressing, Tooth Brushing, Waiting
Watch Out For These:
Failure to generalize or retain learned skills, rote responding, school readiness (don’t forget to program for this), high resistance to behavior change, consistency across environments (everyone has to be on same page)

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Have you ever heard the phrase "Praise publicly, Criticize privately"?

I used to work at a facility that had this posted on the wall in the employee break area. It sounds very cute and fluffy, right? It's actually more insightful than you may think.

 I think the meaning behind "criticize privately" is so you can take your time and incorporate modeling, role play, and active discussion when giving corrective feedback. In other words: view deficits as areas where further teaching is needed, rather than an attack on the person.

Whether you found your way to this blog as a parent, teacher, or ABA professional, you need to know how to motivate individuals, as well as how to improve performance.
 If I always gave my staff glowing reports, how could they grow? How could they ever sharpen their skill set unless I help them identify the dull areas?
What about if I constantly gave them corrective feedback? How would they know their strengths and where they shine (I regularly interview/meet new staff who cannot identify their own strengths, and its usually because they have had experiences with really poor leadership). Also, think about how aversive I would become to staff if I only said things like "Here's whats wrong with what you just did........".

So its necessary to give both the sweet and the sour, in order to teach and in order to have excellent staff.

This article gives some solid tips on ways to make the most out of your criticism, I also recommend reading this post.

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Case conceptualization basically describes outlining treatment goals.

Think of this as getting into a car, and then deciding where to go. Once you have decided where you want to go, you need directions. So the goal of case conceptualization is basically to answer 2 questions:
  1. Where am I going?
  2. How do I get there?

With each client you serve, it is imperative to conduct thorough case conceptualization or your case will quickly dissolve into chaos, frustration, or poor quality treatment (the dreaded “cookie cutter” treatment).

I often find that newer staff/ newly certified staff struggle in this area, and have many questions about properly designing treatment. When supervising individuals for the BCBA exam, I love to give many opportunities to practice case conceptualization because it ties together so many important behavior analytic skills. It’s like reading a well written report from a clinician; when it’s done right, you feel as if you know everything vital about the client, their needs, their history, and their environment.

I see case conceptualization as more art than science, because 2 clinicians could have the same information from the same client, and “create” two completely different “treatment recipes”. Very similar to making a meal, two cooks could receive identical ingredients and yet create two separate, and amazing, dishes. It doesn’t mean one dish is wrong and one dish is right.
 I seek out and give feedback to colleagues all the time, mainly as just good clinical practice, but also because it’s fascinating and a learning experience to see how someone else would approach my clients…. Where would they begin with instruction? What barriers to parent involvement do they see? Am I missing any key setting events for problem behavior? If you don’t regularly have your work reviewed by colleagues, I highly recommend it. Its super helpful.

So here are some key points/tips that should have you conceptualizing treatment like a pro in no time!

  •         Conceptualization begins with a solid understanding of your client, their environment and/or the family system. Have you conducted a complete intake? Have you observed across settings for differences in behavior? Have you completed an appropriate assessment (which assessment to use will vary based on client functioning)? Have you conducted record review of the evaluation report, current IEP, any current or former Behavior Intervention Plans, etc.?
  •  Clearly identify the “problem”: WHY is the family/caregiver seeking services? What do they see as the main concerns? What specific changes do they expect ABA treatment to bring about. Do not skip this step, it is super important. I spend a lot of time during intake revealing misconceptions people have about ABA and explaining what they can expect from treatment, and what is unrealistic to expect from treatment. If you and the family (or whoever is hiring you) are not clear on the purpose of treatment, you'll end up just spinning in circles. 
  •  Please don’t forget client strengths! I was just talking to a colleague about this, but I regularly review/read over reports from various clinicians (the client’s OT, SLP, Psychiatrist, etc.) and sometimes I am blown away by how negative these reports can read. I can’t imagine as a parent what it would feel like to read report after report of your child’s lacks, deficits, and limitations. Accurate case conceptualization includes knowing your client’s deficits, of course, but what are they good at? What strengths do they bring to the table? Where can you highlight something positive? Treatment isn’t just about correcting deficits-- you can also build on strengths. 
  •   Be shortsighted and longsighted all at the same time. You will get your big, long term goals during intake (parent/caregiver input combined with clinician recommendations). But you can’t stop with just long term goals. For example, it is typical a parent will say something like “I want David to talk”. That’s great, but I can’t write a program that says “Within 6 months, David will talk”. Ummm, how will David learn to talk? How many words do I expect him to say? What function of communication am I focusing on (manding, labeling, etc.)? Answering these questions will lead you directly to your short term goals for treatment.
  •  Consider Treatment Mapping. I once worked for a company that required BCBA's submit treatment maps for 6 months out. If you are unfamiliar with these, it’s basically a way to visually outline where treatment is going. To me, it was like doing brainstorming in middle school. Remember that? You would write a topic, like “rainbows”, and then draw little lines out from the topic to start generating supporting ideas. Here is a very basic example of a treatment map, they usually are much larger than this. The cool thing about it is it basically takes everything out of your head, and gives you a concrete reference you can refer back to months down the line. If you are new to conceptualizing treatment, this is a tool that will take you some time, but could be very helpful for learning purposes.

*Recommended Reading:

Ingram, B. L. (2006). Behavioral and learning models. In B. L. Ingram, Ed., Clinical case formulations: Matching the integrative treatment plan to the client (pp. 157-190). Hoboken, NJ: John Wiley & Sons, Inc.
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