Saturday, July 30, 2016

Simplifying the Morning Routine

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ABA therapy can be used to teach/increase a variety of adaptive skills, such as tooth brushing, toileting, hair brushing, shoe tying, making a bed, etc. My favorite definition of an adaptive skill is anything that will have to be done for the learner, if the learner does not learn the skill. So if I don’t teach my child how to dress him/herself, then I will have to dress my child.

A common concern many of my clients have around adaptive functioning is the dreaded Morning Routine. Since my clients are usually school age, I have ample opportunity to help families target issues that regularly pop up during that frenzied time in the morning of trying to get the child out of the door on time. Issues like: task refusal, off task behavior, prompt dependency, skipping steps of the routine/completing the routine out of order, etc.

ABA interventions should always be individualized, but some of my most effective strategies for simplifying the morning routine include:
-          Visuals! Visuals are your friend :-)
-          Use of auditory cues (timers)

 With some simple tweaks here and there and adding in more supports, the morning routine can be less stressful, more efficient, and require less intrusive prompting which equals more independence for your child.

Let’s jump in:

-          Add visuals: I say “add visuals” and not “add more visuals”, because usually what I see is that families who struggle the most with the morning routine are not using any visual supports. If you are regularly struggling during the morning routine but you already have visual supports in place, then that’s a gold star for you. You are ahead of the game. If you are new to visual supports, just keep reading. Think of a visual support as a way to minimize prompting or assistance. If you have to stand in the bathroom doorway, physically assist your child, or keep giving the same demand over and over (“Make up your bed Evan ……. Evan, did you make your bed?”), then you definitely need to add some visuals. It is much easier to fade the prompt of a visual, then to fade your voice, or your presence. Or to put it another way, do you want to have to stand in the doorway to make sure tooth brushing happens when your child is 25? Here are some awesome examples of visual supports, all were found on Pinterest.

-          Auditory cues: The use of a timer can be such a helpful addition to the morning routine because time is usually of the essence. We have to go, and we have to go now. For many of my defiant kiddos, those with attention issues, or those with lots of escape maintained behaviors, the simplest demand  (e.g. “Put your socks on”) can take ages and ages to actually happen. Decide on a specific amount of time for the skill to occur, and then set a timer. If the child can beat the timer, then allow them to contact reinforcement. Depending on the child, this could mean a treat, getting to pick what they wear that day, 2 minutes of TV time, etc. Make the concept of “hurry up” more concrete by helping the child understand how quickly tasks needs to be completed.
-          Organization: This tip is more for you than the child. Organization or proper set up for the morning routine does not begin that morning, it begins the night before. Part of the bedtime routine can include setting up items for the next day. This could mean lining up the soap, facetowel, toothpaste, and toothbrush by the bathroom sink. Or this could mean putting the backpack by the front door, so there is no frantic search for it in the morning. How you organize will depend on the specific issues you are having in your home. The point is to set the child up for success. For younger children (especially if you want to increase independence) line up needed items/materials in their correct order so your assistance is not needed. For example, in the bedroom line up underwear, socks, pants, shirt, and shoes. In the kitchen, line up the bowl, spoon, and cereal box. For some children you may need to put number cards on each item (e.g. put a "1" card on the underwear). Any step you can do the night before will save precious time the next morning, and the materials being visible helps serve as a prompt of what to do next.

*Bonus Tip: A good way to practice the skills required for a successful morning routine is to incorporate weekend practice. If these skills are only performed M-F with a time crunch, then you’re setting yourself up for lots of frustration. On the weekends, still have your child go through the morning routine. Use this to fine- tune skills, or provide more repetition than is possible on a Monday morning. If tooth brushing is always a struggle, consider modifying the visuals or making them larger/more detailed. Try removing yourself, and only checking on your child periodically. If the child is older or needs less support, try implementing a checklist that the child completes. As they perform each skill, they check a box. When all the boxes are checked they bring the checklist to you for review.
Friday, July 15, 2016

Mand Training

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When teaching or providing intervention to young children with Autism, communication impairments are often pretty high on the list of priorities. This can include issues such as echolalia, poor articulation, syntax difficulties, or the child may be nonverbal (remember, nonverbal does not mean “no talking”. That would be “non vocal”. Nonverbal would indicate a lack of a consistent means to communicate).

A highly effective method for teaching a child with communication deficits to communicate is: Mand Training. If you read my Verbal Behavior post then you know that “mand” just means request.
Notice I said Mand Training is about teaching an individual to communicate, not “talk”. Communication is far more than being able to speak. I have clients who can talk, but aren’t communicators. I also have clients who communicate all the time, but do not talk. Some of my previous clients never reached a point of producing vocalizations (talking), and that does not mean treatment failed. They made amazing gains, they just developed other means of communicating.
Since Mand Training is far more than just talking, this means that communicating can be taught via sign language, picture communication (photos or iPad), use of an assistive device, etc. While many parents often want to target vocalizations, manding does not have to be vocal.

So WHY teach manding? What is so important about being able to communicate with others?
-A child who cannot request wants and needs, is (very often) a child who will use problem behavior to communicate: aggression, tantrums, property destruction, etc.
-A child who cannot request wants and needs is a child who will bewilder and frustrate caregivers on a regular basis: “What do you want? Are you sick? Are you hungry? Are you tired? Does something hurt?”. I work with many parents who often have to guess if their child is hungry, guess what their child wants to eat, guess when their child is full, etc. It’s a very difficult and challenging way to live. Not just for the parent of course, but for the child as well.
-A child who cannot request wants and needs is a child who may struggle with social interaction. How will the child let other children know they want to play? How will the child let other children know they are tired of playing? For a nonverbal child this can often happen through exhibiting problem behavior (such as pushing a peer down who stands too close, or snatching an interesting looking toy from a peer).

Before learning more about Mand Training my biggest tip would be NOT to read this post and then try to implement a mand training procedure on your own. It’s important to work with a BCBA to accurately design and implement a manding intervention. This is one of those skill areas where you definitely want the assistance of a qualified professional.

Okay, so here is a basic outline of how Mand Training occurs. At the end of the post I will include a clip of some actual mand training (taken from an episode of Supernanny) because I think seeing how the procedures are implemented could really be helpful.

  • Mand Training kicks off with a good amount of highly preferred items/reinforcers. You need to know what the learner is MOST interested in, because those are the mands you will want to teach first. You teach reinforcers first -- before general nouns (“school”), before generalized mands (“more”), and before manners (“please”) --- because motivation is key. If I love my talking Elmo doll more than anything in the world, I will be ridiculously motivated to mand for my talking Elmo doll.
  • Next, you will start requiring a mand in order to access the highly preferred items. No mand= No access. I suggest watching the video clip below to see examples of what this looks like, and what often happens at this part. If you’re a professional you probably already know what I am hinting at: Behavior City. From the perspective of the learner, they are used to getting what they want, when they want it, without having to mand. So once you start to require communication, expect to get some pushback.
  • Be knowledgeable about vocal shaping, if you are targeting vocalizations. When the learner begins to vocally communicate the speech may be unclear, garbled, or otherwise fractured. It is important to work with a professional who understands shaping procedures and how to accept closer and closer approximations to clear speech. This means that initially, “BUH” may be acceptable to request “Bubbles”.
  • Consistency will lead to success. Mand training can take literally hundreds of trials per target, or per item. In a typical therapy session, I can incorporate mand training into nearly every few minutes of work. This repetition can be extremely necessary for some children with Autism. Be prepared to work on mands all throughout the day, across environments, and across caregivers.
  • Mand training gets increasingly more complex. I may start out with a client by having them mand for a reinforcer that is present, and accept any vocalization as a correct response. From there, the item may be hidden from view, the learner may have to accurately state the name of the item, the learner may have to request using a full sentence, etc. Skipping over this step can lead to learners who can only speak in short phrases (“want chips”), can only mand for a few items, or mands for categories and not items (can say "eat", but no one knows what they want to eat). Once the learner can successfully mand for something, increase the response requirement.  

*More information about Mand Training:

Wednesday, July 6, 2016

Supervisor Tips: Good Staff?

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Suggested post: ABA Staff training

How is “Good” evaluated? Better than bad? Almost great? Without further definition of the word “good”, valid measurement is pretty impossible.

ABA people are big on defining things. We like to break abstract concepts down, get an operational definition, make sure everyone agrees on the definition (and what the definition excludes), and ONLY then go about measuring the concept. It's super common to hear ABA people say things like “What does that look like?”, “Give me an example”, or “What do you mean by tantrum?”. If we can’t agree on what we are measuring, then how can we accurately measure?

Staff evaluations and staff feedback are two areas where all of these same skills come into play: being able to break concepts down, defining what you want to measure, and then creating a system of measurement. For supervisors, at any given moment we are always shaping the behavior of at least 3 people: the client, the caregivers/parents, and the staff. Everyone wants excellent and well-trained staff, but I have often observed few want to do the work necessary to transform staff from "good enough" to "excellent".

The reality is regardless of experience or education you may find that the direct staff need remediation in various skill competencies in order to perform their role with excellence. Years and years of experience does not mean it was quality experience. Or, months and months working for “prestigious Dr. so- and- so” does not necessarily translate into a great clinician. Sometimes book smarts does not equal bedside manner, and vice versa.

Staff evaluation is basically about making sure the staff are meeting the demands of their role, but it’s also about seeing staff improve over time. Of those two concepts, I have encountered the most staff opposition with the 2nd one. Particularly for highly experienced staff, there can be a bit of a “I know what I’m doing, so there’s nothing I can improve” kind of attitude, which may need to be addressed before accurate evaluation can occur. I’m pretty sure you don’t know any perfect people (because I sure don’t), so that means staff can always improve upon their skillset or knowledge base.

An approach I like to use is to provide overall performance evaluation (long term/every 6 months) combined with more frequent and specific feedback (every supervision session). I like to focus on a combination of content areas, as well as more indirect skills or capabilities that are an important part of this kind of work. What’s that, you’d like to see an example? Sure, I can do that :-)

For the specific staff feedback, it’s good to include specific skillsets that should be demonstrated each session. I suggest starting with the staff job description and building from there when creating your feedback forms. For example, typical direct staff job duties can include implementing the treatment plan, accurate data collection, and appropriately conducting reinforcer preference assessments. For those indirect areas, I like to include areas such as professionalism (e.g. appropriate work attire, cell phone used only for emergencies), initiative (e.g. asking for supervisor help when needed, promptly updating the supervisor on client changes), and personal goals. I like to have the staff select a few goals for themselves that they want to be held accountable for, and that I will assess as part of their feedback forms (e.g. increase fluency with using ABA jargon when describing client progress, teach a parent to collect ABC data, etc.)

For the long term evaluations, this is where I am more interested in improved performance over time. I focus on areas such as Teaching/Instructional Control, Time Management/Organization, Behavior Reduction, Prompting & Prompt Fading, etc. A good tip is to incorporate content areas from the current BACB task list. This will help guide your understanding of what behavior analytic skills and concepts you should be teaching to your staff. I’m big on teaching…probably the #1 thing I do during supervision sessions is on the spot staff training, or teaching.

Lastly, part of helping your staff reach excellence means you need to intentionally hop in the passenger seat and let them drive sometimes. What I mean by that is allowing opportunities for more of a leadership role, such as having the staff create program visuals, help you update the client’s VB-MAPP, co-lead a parent training session with you, or give input on skill acquisition goals. Giving the direct staff opportunities to learn about your role and what you do as the supervisor enhances their skillset, and I have found multiple times it can spark an interest in becoming certified/pursuing a career in this field.