Photo source: www.peacefulplaygrounds.com, www.speechbuddy.com

 Here is a scenario I encounter on a regular basis with the clients I serve:

After receiving a diagnosis of ASD the parents receive a list of recommendations about what to do next. Things like speech therapy, occupational therapy, special needs school settings, and early intervention/ABA therapy are almost always on that list.

Invariably, there is a small problem. Due to the intensive nature of ABA therapy (especially if its provided in an early intervention context) the parent soon realizes they have to make a choice. Should the child be enrolled in a local preschool? Or should the child receive several hours of therapy per day? Which one is “best”?

I see so many parents facing this dilemma, without the needed information to make a decision. Obviously no matter what they choose there will be pros and cons, but I like to help people make informed decisions as much as possible. So if you were my client, what follows is what I would typically say:

1. Is it really Either/Or? – I have worked with families who were able to enroll their child into a part time preschool setting, which allowed for plenty of time each week for therapy. I have also seen many scenarios where the preschool/daycare allowed the therapists to enter the classroom, to fully maximize therapy hours. So before moving straight to making a choice, find out if a compromise is possible.
2. Pros of preschool/daycare option- The main benefit of placing a child with a developmental delay in a setting with their peers, is socio-emotional development. The child is learning to socialize with peers, seeing how typically developing children play/talk/behave, and learning to receive instruction from adults other than mom and dad. For many of my clients, the daycare/preschool setting is also their first experience with following a schedule/having routine in their day. However, the biggest issue I see is the appropriateness of the preschool setting. If the setting is not conducive to catching the child up developmentally, then it’s pretty similar to just sticking a plant in a room full of toddlers. 
3. Pros of intensive therapy option- The main benefit of pursuing intensive therapy  is overall development and skill acquisition. Pursuing a rigorous therapy schedule means that the core deficits the child is exhibiting will be clinically evaluated and treated, as well as reducing or replacing problem behaviors that impede learning. Also, part of intensive therapy is parent training, which is priceless for most families. Having a team of professionals help you learn how to better engage, teach, or correct the behavior of your child can be life- changing. However, working with a therapist 1:1 cannot compare with the social opportunities provided in a classroom. While social opportunities can be embedded into treatment, often it’s not as varied or frequent as what the child would get at school. Add to that, many of my clients just feel very strongly that they want their child to have the same option of a school experience as any other child.

Clearly, this isn’t a decision to make lightly. 

With different clients, I give different recommendations about which option would be “best”. There is no way to make a blanket statement about what all young children with Autism need the most, as far as treatment.

Making this decision should involve the child’s treatment team, include observation of the classroom the child would be placed in, as well as careful review of the yearly learning objectives for that classroom. 

By the end of the year, what skills will the child have gained? How will skills be taught? Does the classroom teacher have experience/training on ASD or behavior management? What is the school policy on addressing challenging behavior? These are just a few examples of the kind of questions the preschool/daycare should be able to answer.

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Tameika Meadows, BCBA, Blog Author

Photo source: www.pinterest.com, http://blog.kevineikenberry.com

*Recommended Post: 3 Step Prompting

This post is really about 2 issues, but I almost always see them done at the same time: stating instructions over and over, and delivering utterly non-concise instructions.

There is almost a quizzical cause and effect thing going on, where the more times the parent delivers the instruction to the child the more and more unclear the instruction becomes. I’ll give you an example:

(parent is trying to get child to touch a flashcard)“Okay Nicholas, touch the frog…..Come on, touch the frog….Hey—are you looking? Nicholas……Nicholas?....Nicholas!.....Nicholas, touch the frog…..Look, the green FROG right here……Just touch it…..” etc., etc.

I promise I am not exaggerating, I saw an exchange very similar to this just this week. These 2 issues that I will really boil down to 1 issue (stating non-concise instructions over and over), are extremely non- helpful whether your child has Autism or not.

An individual with communication delays (receptive or expressive) is not likely to respond well when instructions come at them too quickly, in a jumble of other words, or without any prompting to help them understand what they are supposed to do. Children with communication delays or impairments can struggle to comprehend language spoken to them, understand abstract words/terms, make inferences, read facial expressions, and respond appropriately to spoken language.

Since most of my client base consists of children with pervasive communication deficits, one of the first things I work on teaching parents is how to deliver a concise instruction. This seems like something that should be common knowledge, right? I disagree. I think most of what ABA professionals do is not common knowledge to the average parent, so it’s important to take the time to explain these concepts and strategies that we love to implement.

There are a few common objections that I almost always hear from a parent when we start working on this issue:

Objection #1- “But what if s/he didn’t hear me the first time?”

Objection #2-“But I KNOW s/he can do this, so I just keep asking”

Objection #3- “S/he doesn’t respond unless I yell/get “firm”.

My lovely rebuttals to these objections:

Rebuttal #1- Many of the families I work with tell me during our first meeting that they actually had their child’s hearing evaluated, because it truly seemed that the child had hearing loss. Definitely, make sure your child’s hearing is working normally. But lots of my clients can ignore people so well that it seems like something must be wrong with their ears (their ears are fine).

Rebuttal #2- How do I know what you know? By what you show me. If you show me inconsistent behavior, then I cannot say with certainty what you know. In the absence of consistency, I have to treat the behavior like an unlearned skill.

Rebuttal #3- I usually respond to this by reminding the parent that I don’t have to yell, get aggressive, or anything else like that to get their child to comply (and if I did, they should fire me immediately!). Do you think the child’s teacher has to yell? What about their nanny? What about their speech therapist? I hope not, because that’s a lot of yelling. What this objection is actually saying, is that the child has been conditioned over time to know that mom/dad are not serious, and do not mean business unless they get angry and threatening. The goal is for the child to know you mean business wayyy before that point.

Now that you thoroughly understand how NOT to give instructions, let’s jump into what I mean by Show & Not Tell.

A little trick I like to teach to parents is that when they give an instruction, start a mental countdown clock. Example: “Tameika, go brush your teeth (1….2….3)”. Once the clock in your head has counted to 3, this means it’s time to move from Telling to Showing. Does that sound radical, impatient, or worse? How long do you think teachers give your child to respond? Or a friend on the playground? You don’t want to unrealistically teach your child that its ok to respond to a question the 4^th or 5^th time the person asks it.

Let me back up just a bit, and repeat the original instruction: “Tameika, go brush your teeth”. This is a concise instruction. It tells the child what to do using simple and clear words. Now that a full concise instruction has been given, there is no need to repeat it. That’s right, once you have given the concise instruction you want to only use less language. Why? You want to make it clear to the child that you do not have to repeat yourself, you know they heard you, and that ignoring instructions does not gain more of your attention. I know parents don’t intend to do this, but amping up your reaction after your child starts ignoring you is actually giving them WAY more attention for ignoring you, than for listening to you.

The next (and shorter) instruction should be combined with some type of prompt. Remember, inconsistently correct behavior is still inconsistent behavior. Show the child what they need to do, and don’t assume they already know.

You may have noticed something else about the Show & Not Tell: it’s faster. Have you ever used a timer or stopwatch to see how much of your day you spend telling your child to do something over and over? Well, I have. I do it at work all the time.

Most parents don’t realize how much time is wasted when each instruction is given 5 or 6 times before the child responds. Buckets and buckets of time. Do you have buckets and buckets of time to waste? I doubt it.

Want a handy -dandy example of all of this in motion? Here you go:

“Tameika, clean up these blocks”	Clear, simple language. Use the fewest words necessary for the child to understand. Gain their attention before you give the instruction. Once you say the instruction, start your mental clock.
(Approach the child and use some level of prompting to SHOW them what to do) “Clean up”	Remain cool and calm. Use less words than you did the first time. Move in quickly to provide assistance/a prompt. Assistance does not equal completely allowing the child to get out of following the instruction.
(Move quickly through the prompting to get the task completed. Make a brief and neutral statement at the end) “You cleaned up/This is cleaning up/All done with blocks”	Continue to remain cool and calm. Avoid lectures or reprimands about how the child does not listen. Use short, simple words. IF the child had complied right away they would have received praise and/or reinforcement, so at this point provide neither.

*Resources:

Kennedy Krieger Institute article about teaching ASD children

Research article “Verbal Expression and Comprehension Deficits in Young Children with Autism”

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Tameika Meadows, BCBA, Blog Author