"Time to Work": Transitioning the Child to the Table

Photo Source: www.magnoliabehaviortherapy.com

As an ABA Therapist, sometimes it can be difficult getting the child you are working with engaged in the therapy session. You may arrive at the house and the child starts crying and runs away from you. Or, you work with the child at school and when you arrive the child begins to tantrum and throw things. Sometimes the child is fine when you arrive to their house/classroom, but the second you try to get them to start working/present demands the behaviors begin.

There will be good days and bad days, and its normal that your client won't be excited to see you every single day. However, if you are finding that every time you arrive at the home the child runs from you, begins exhibiting behaviors, or you have to struggle to get them to sit down then something is definitely wrong and you need to take action. You don't want to be consistently starting off a session with an angry, overstimulated, crying child who is only thinking of escape.
This is important for several reasons. Firstly, much of what we do as ABA therapists relies on a reinforcing or "paired" relationship with the child. If the child is consistently trying to escape work/the table/you, then pairing becomes very difficult and you will become aversive to the child. Secondly, it's unlikely that after you spend several minutes physically guiding or prompting the child to the work area, that you will then be able to get a great session out of that child. That is the equivalent of your boss waking you up in the middle of the night to go to the office and do some work. You just aren't at your best. We definitely want to work with these children when they are at their best, or as close to that as we can get.  Lastly, successfully getting your client ready for a session teaches transitioning skills. Moving from pre-work mode (whatever the child was doing before you arrived) into work mode is a big transition, and if you can teach the child to transition appropriately into a session then it should be easier to make small transitions during therapy.

Usually if a therapist is consistently having difficulty getting a client to the table its for one of the following reasons: the therapist isn't properly paired with the child, the parents aren't properly preparing the child for a session, or  the therapist isn't using reinforcement properly during a session. 

  • Issues with PairingRapport Building, aka Pairing is a critical part of instruction. Pairing is an applied strategy based on reinforcement where the therapist pairs with whatever the child finds reinforcing so that over time, the actual therapist can serve as a signal of reinforcement (translation: fun things happen when Ms Tameika shows up). Don't think of pairing as something that is done once, and then never again. Effective pairing should occur regularly, or even be embedded at the start of all instruction. How long does it take to play a quick game with the child, or watch a few minutes of their favorite video? Not long at all, and the benefits of starting off the session that way are very much worth it. Taking the time to pair properly will ensure more success once demands are placed, as well as higher motivation for the client to interact with you. I can typically tell when pairing has been successful if I arrive at a house for a session and the child displays excitement or interest in me. This can mean the child grabs my hand and tries to lead me to the work area, the child immediately goes and sits down in the work area, or the child runs to the door to greet me when I arrive. These are all signs of successful pairing. 
  • Issues with Preparing the Child for A Session- Therapists, you may need to help the family understand how to get their child ready for a session. You can be the most fun and exciting therapist around, but if right before you arrive at the house the child is jumping on the couch, watching cartoons, and eating a Snickers bar, that child will likely get pretty upset when they hear that doorbell ring and see you walk into the house. Depending on the child, at least 15-20 minutes before the session the parents need to begin making transition statements. Something like, "Its almost time to turn the TV off, because Ms Jane will be here soon". Give the child ample warning that it is almost time for work. Another way the parents can help you is by using a visual schedule and showing the child on the schedule that after TV time it is time for Ms Jane. Parents can also make sure the child is fed, clean, and has been to the toilet before each ABA session. The therapist should not have to try to motivate a hungry, thirsty, or wet child to participate in a therapy session.
  • Issues with Reinforcement-  I could write an entire post on reinforcement alone, so I will just discuss a few points here. Its important to always keep a balance between reinforcement and demand. If demand is too high, the child may start exhibiting behaviors or try to escape the table. If demand is too low, the child may tune out, withdraw, or become silly/giggly to entertain themselves. Try switching up your reinforcers and see if that will get the child to willingly come to the worktable. Arrive at the house with a bag of reinforcers and toys and let the child carry your "goody bag" into the therapy room. Once you get into the room, let the child select 1 toy to take over to the work area. This is a painless and simple way to do several things: get the child into the therapy room, get the child in a happy and calm mood, and transition the child from break to work. 

Below is some information about Pairing that I usually give to new therapists.
  • As the therapist, you should identify what is reinforcing to the child, and associate yourself with these items. This may occur by simply handing the items to the child, sitting next to the child while they access the items, or engaging in play with the item together with the child. Slowly ease in demands and language, as the child begins to trust you and be more accepting of your presence. As you hand the child a cookie say “cookie”, before giving it to them. Over time, you can require the child echo the word cookie after you. Another way to ease in demands is to place the reinforcer farther and farther away from the child, or to require language before they can access the reinforcer. Place the cookie in a container the child cant open independently, and when they come to you for help, have them say or sign “open” before you will open the container.  This way the child learns that the therapist has access to the things he/she loves, and the therapist becomes paired with fun, reinforcing things.  The use of reinforcers and pairing is the essential first step before any program can be implemented. Pairing is an important skill that may be necessary to come back to as time passes. If a child has been ill a long time, missed a few weeks of therapy due to vacation, or has a new therapist, then the therapist needs to go back to pairing before beginning work. At the start of a session a child should approach the therapist eager and ready to learn, and pairing is the tool that helps accomplish that. When the child is consistently approaching you, attempting to engage with you, wants you to join in play with them (particularly if they are on a break), or happily greets you when you arrive at the house, then you know that pairing has been successful.

    **Quick Tip: You can also use the Demand & A Promise technique to successfully transition a child to the work area. 

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