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*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

Photo source: www.hamermetalart.com, www.393communications.com

What’s “NR” you ask? A common way to collect data after a trial in which the learner not only did not give a correct response, but didn’t respond at all, is to score “no response” (NR).

While motor actions can be prompted if the learner does not do anything, vocal responses cannot. I say to my staff all the time, “we can’t reach into his/her throat and pull out words”. So if you say to your client “What color is the sun? YELLOW” and they just stare at you, then that was a “no response” trial.

I can absolutely relate to how it feels to bring your A-game, put on your animated face, and get a lot of nothing in return. It’s frustrating, and makes you doubt your clinical skills.

When correct responding disappears from the session, some clients may turn super silly and distracted, or some may have a spike in aggression. Just between you and me, I would much rather deal with one of those scenarios. It’s the completely non-responsive individual that I find to be the most challenging…..it is kind of like your clients body remained in the chair, but the rest of them got up, walked out of the building, and is headed somewhere FAR more exciting.

Here are a few things that definitely do not work, are ineffective, and should be avoided:

·         *Waiting the client out – I have seen a few therapists try this one, and usually the client is perfectly content to keep staring into space as you wait them out. And lets be real, your session is only so long. The client is quite aware that you will tire of this game before they do :-)

·        * Continue teaching/Keep up the status quo – Think of it like this, if your client has completely stopped any correct responding and you just keep plugging away: Is learning happening?

·       *  Speak louder – Sound silly? I see it a lot.

·       *  “Saaaam…..Sam!....Helloooooo, Sam?” – If your client is not responding to task demands or any of your instructions, odds are they also will not respond to their name being called.

Now that we got all the stuff that does not work out of the way, I really only have one suggestion for what you SHOULD try when those NR blues kick in. It may be just one suggestion, but it can look about 900 different ways depending on the learner. 

Change something about YOU.

What my staff usually say to me (and how I used to look at this back in the day) is: “I tried this, and that, and this, and Sam just won’t attend/listen/respond! I don’t know what else to do to get him to (insert whatever response the therapist is expecting)”.

What I am suggesting, is flip that statement on its head and instead ask yourself: “What can I do differently that will motivate Sam to respond? Am I interesting? Am I reinforcing? Would I want to attend to me? Is this program interesting? Are these materials engaging? When did I last reinforce any of his behavior? Is my frustration/annoyance showing on my face? Does my voice sound irritated? Am I moving through targets too quickly? Too slowly? How can I be more fun?”.

See the difference? Instead of unintentionally blaming Sam for his lack of responding, first blame yourself. Then, look at your options and start trying them out to see what is effective.  I am a big fan of “Let’s try this and see what happens”. Even if you try something and it fails, you just learned 1 thing that does NOT work. Which is still progress.

** Recommended Reading: 

ICEL

ABA is FUN!

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Tameika Meadows, BCBA, Blog Author

Chaining is a way to teach a multi-step or complex skill. While often used as a component of ABA instruction, chaining can be used to teach anyone a complex skill. A complex skill is a skill that really consists of several small behaviors that are linked or chained together, to accomplish a terminal goal. An example of a skill consisting of several discrete behaviors is wiping a table.

Teaching a skill using chaining is commonly recommended if the child can only perform some of the steps, consistently misses/skips steps, or is completing steps incorrectly. For example, on a daily basis the child throws their wet toothbrush in the sink instead of putting it in the toothbrush holder. That would be a good situation to introduce chaining into. Another issue I see commonly is the child who independently uses the bathroom, and then consistently fails to button/zip their pants back up. That is a child who could benefit from a chaining program.

A way I like to explain chaining is by comparing it to cooking. I am a recipe person. Even if I have made something multiple times, I still like to have the recipe in front of me. Imagine I asked you to make me some oatmeal raisin cookies, but I gave you no recipe to follow and no expectations of exactly what to do. What kind of raisins do I like? Do I like cinnamon in my cookies or vanilla extract? Do I prefer chewy or crisp cookies? You would likely start or finish the cooking chain successfully, but have errors or missed steps in the middle. This is why using chaining to teach a skill can be so helpful. For a child with Autism, hearing a demand like “make your bed” may not mean anything. They may need a recipe to follow, which clearly states my expectations of how to complete the task.

The 3 types of chaining are: Backward chaining, Forward chaining, and Total Task chaining.

Backward Chaining- Backward chaining refers to teaching a behavioral chain beginning with the last step: you would completely prompt the entire chain of behaviors except the last step. Using the tooth brushing example, the child would be prompted to do every single step and then would independently put the toothbrush in the toothbrush holder. Backward chaining is recommended if the child can successfully complete more steps at the end of the behavior chain. Backward chaining also has the advantage of creating a link between the most work and the biggest reinforcer. If I am using backward chaining to teach a child to make French toast, then I would prompt every step and have the child independently use a spatula to move the toast from the pan to a plate. Then we get to eat! So the most work (independent step) led to the biggest reinforcement (consuming the food). Once the last step is mastered at an independent level, then move to the last 2 steps, then the last 3 steps, etc.

Forward chaining- Forward chaining refers to teaching a behavioral chain beginning with the first step: have the child complete the first step independently and then prompt all remaining steps. Using the tooth brushing example, the child would independently pick up their toothbrush out of the toothbrush holder, and then all remaining steps are prompted. Forward chaining is recommended if the child can successfully complete more steps at the start of the behavior chain. Forward chaining has the advantage of using behavior momentum, as the 1^st step is often the simplest, easiest step. If I am using forward chaining to teach a child to make French toast, then I would have the child get the bread out of the refrigerator independently, and prompt every other step. Once the first step is mastered at an independent level, then move to the first 2 steps, then the first 3 steps, etc.

Total task chaining- As the name implies, total task chaining is when you teach the complete behavior chain one step after another. Total task is what most teachers or parents naturally use to teach a skill. E.g. "Okay turn the water on...now soap up your hands....good, now scrub your hands together", etc. The adult walks the child through each step, prompting as necessary. For a child with Autism, this may still be too complex of a teaching style. For that reason, backward or forward chaining is usually more commonly used for kiddos with Autism. 

 Lastly, to create a chaining program you will need a Task Analysis. A task analysis isn’t as complicated as it might sound. It is basically the GPS step- by- step directions to completing the skill. A task analysis is typically created by completing the skill yourself or watching someone else complete the skill. It’s very important not to just write up a task analysis based on your memory. Even simple tasks, like making a sandwich, can have small important steps that you may inadvertently skip. If you don’t teach the step, then you really can’t blame the child for not completing the step. You could also consult with a professional or do some research on how to perform a specific task. I could easily create a task analysis for tooth brushing, but if I had to teach an older client to change the oil on a car, I definitely could not easily write a task analysis for that. I would need to do some research, perhaps talk with a mechanic, etc.

 Here’s a tip: after you create a task analysis, complete the behavior chain yourself to make sure you haven’t skipped any steps or placed steps out of order. It happens more often than you might think.

*Resource:

- How to use Chaining to teach skills

-A solid understanding of Reinforcement and Prompting is necessary to teach using chaining.

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Tameika Meadows, BCBA, Blog Author

For the parent of a child with special needs, you learn to become many things. The child’s translator, the child’s safe haven, the one who “explains” the things the child does, a short order cook, etc. When children with special needs are young and pre-verbal, they do require lots of assistance and help and someone who knows the child very well is usually the mediator for that child to communicate with anyone. Mom and Dad are the only ones who know that the child disrobing in public means “I need to go potty” or that throwing their bottle out of the crib means “More, please”. This is a natural and important step in the relationship between parent and child.

At some point this natural tendency for loving parents to step in and make things easier for the child can actually become a hindrance to learning and development. Similar to prompting, constantly stepping in to read your child’s mind and give them what they want can kill any motivation the child may have to communicate. That’s how behavior works. As humans, we tend to reach for the easiest option.

When working with my clients, I often walk into situations where it’s glaringly obvious that while the parents adore and love their child, they have made life for the child WAY too easy. For example, a parent telling me how she wants her child to be more independent as I watch her spoon feed her 4 year old. Things that make you go, "Hmmmmm......"

I do understand that all of this care and involvement comes from a place of love, and likely started as a necessary response to a child with many serious deficits. However at some point as parents and professionals, we have to start taking steps back and expecting the child to be more independent. I haven’t met many parents who tell me they want their child to be more dependent..….its usually the exact opposite. If you want your child to be more independent, then first examine if you are helping the child depend on you too much.

The goal is to help the child move towards being an Initiator, and away from being a Responder. Here are a few examples of what that would look like:

  

INITIATOR CHILD	RESPONDER CHILD
The child is hungry, so they seek out an adult and mand for food (e.g. “Cookies please”).	The child is hungry, so they begin to whine and display irritable behaviors. After some time has passed, someone figures out that the child may be hungry.
The child is bored, so they turn on the TV and sit down to watch.	The child is bored, so they follow Mom or Dad around the house begging to be picked up. It is then up to Mom or Dad to entertain the child.
Dad forgets to give the child juice with their snack. The child makes eye contact with Dad and points to the refrigerator, to request juice.	Dad forgets to give the child juice with their snack. The child bursts into tears and refuses to eat.

A child who is a responder will depend on others to get needs met, or they will use behavior to communicate a need. These children rely on adults to read their mind and determine what they need. This often leads to a lovely game that I like to call “Guess what I want!”, as Mom or Dad frantically try to figure out how to get the child to stop crying, or engaging in some other problem behavior. 

 A child who is an initiator will either attempt to meet needs themselves, or they will use communication to request an adult help them.  The child is able to use communication (either vocal or nonvocal) to express what they want in a way that multiple people can understand.

The goal when teaching a child with Autism is always to strive for more than what the child is currently doing. Depending on what a child is currently able to do, there is always a way to help the child gain more independence with that skill.

A very common example of initiators vs. responders that I see often deals with toilet training. I have had parents tell me that their child is completely toilet trained. Then I ask how the child indicates they need to use the toilet. If the parent answers “I don’t know” or “We can just tell”, then no….that child is not fully toilet trained. If your child just gets up and silently goes to a bathroom, then what happens when you are in public? If you are in a crowded mall, how does your child let you know they have to go potty? If you left your child with a babysitter, would that person be able to tell that your child needs to use the bathroom? Being fully toilet trained means being able to inform adults of the need to use the bathroom, as well as being able to request the bathroom in an unknown place.

Helping your child move from being a responder to an initiator will help them become more independent, and initiation is a critical life skill for success in school, with peer groups, and many other important domains. Here are some helpful tips for making life just a little bit harder for your child with Autism.

• Don’t be afraid of independence: I know it might be hard to let your 3 year old use a knife to cut his hot dog, or to teach your 6 year old how to unbuckle his seatbelt. You can encourage independence in a safe way and within boundaries. Just because your son can unbuckle his seatbelt doesn’t mean its okay to do so as you are driving down the highway. Teach boundaries and limits, even as you increase your child’s independence.
• Play dumb: This is the simplest way to start slowly decreasing the amount of assistance or prompting you provide. When your child comes up to you whining or crying with outstretched arms, look at them quizzically and act as if you don’t understand what they want. Depending on the ability of the child, prompt them to communicate via language, PECS, pointing, etc. For example, require the child to say “Up” before you will pick them up. Crying, pulling on your pants, or kicking your leg, should not be reinforced. Stop anticipating your child’s needs and acting on it, and instead pretend as if you don’t understand what they want so they will be motivated to try something else.
• Slow down: Parents often tell me it’s easier to just dress the child, wash the child’s face, or feed the child breakfast. I know it’s easier and saves time, but in the long run it is making the child too dependent on you. Accept that sometimes you will be late. Yes, you might have to wait 15 minutes for your child to put on their shirt, or it may take a full tantrum to get your child to brush his teeth. Sometimes you have to make immediate sacrifices in order to reach a long term goal. Start small, such as giving your child a bowl, spoon, and no cereal. Using communication at the level of the child, prompt them to request the cereal. Even if this takes 10 minutes out of your morning routine, in the long run you are teaching your child to be an initiator. Tell the child’s teacher that you are working on independence in the morning routine, and your child may be late to school for a few days. I’m sure if you explain it the teacher will understand, and possibly even help you reinforce the skill in the classroom.
• Wait: This isn’t just difficult for parents; I am guilty of this too. Sometimes we want to help the child be successful so much, that we are too quick to provide prompting or assistance. We give a demand, the child doesn’t respond, and we immediately jump in to provide a prompt. The problem with this is over time it can cause the child to become prompt-dependent, and to remain a responder instead of being an initiator. The next time you give a demand to your child, try waiting 10 seconds for them to respond. I know that sounds like a lifetime, but some children with Autism have auditory processing issues, so they need to process what you said and select a response before they can begin to comply. I wouldn’t suggest doing this all of the time, but it’s important not to make a habit out of jumping in and helping your child. If you have just told your daughter to tie her shoes, sit down next to her and wait a full 10 seconds before giving any prompts. See what the child does with that time. Does she just sit and stare at her shoes, or does she start attempting to put them on? You might even see the child look over at you, and reach for your hand for help. That’s great! That is an opportunity to teach a type of request, such as “Help”. It’s important to let the child try before hastily jumping in to help.

* GREAT and very parent-friendly resource on this topic: Initiations and Interactions: Early Intervention Techniques by Teresa A. Cardon

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Tameika Meadows, BCBA, Blog Author

I had a supervision session yesterday with a new hire, that made me think of a topic for a blog post: Prompting!

Prompting in ABA is a method or tool used to move the learner from incorrect responding to correct responding. When done correctly, prompting increases the rate of responding, lowers frustration, and helps the individual learn more efficiently.
If I know you don't know how to bake a pie, I wouldn't say to you: "Make me a cherry pie" and then just stand back and watch you struggle. Practicing errors impedes learning. I would step in to provide you with prompting and guidance as much as you needed, in order to help you be successful.

There are many ways you can prompt:

Hierarchy

(Some prompts will be much more intrusive than other prompts. This is not an exhaustive list of ALL possible prompts. it is simply a way to understand types of prompting)

• Physical - Hand over Hand (HOH), leading a child by the hand, or physically moving a child
•  Verbal - Can be partial verbal or full verbal
•  Model - Demonstrating for the child what you want them to do
•  Gestural - Gesturing, pointing, making a non verbal motion to show the child what to do (*note: don’t combine with words, that’s actually 2 prompts) 
•  Visual - Larger stimuli, brightly colored stimuli
•  Spatial (proximity) - Putting the correct choice nearer to the child than the incorrect choice
•  Sequential (order in which things are presented) - Working on easy tasks first and building up to difficult tasks
•  Textual (written) - Writing out the steps of the task
•  Tactile - Using the actual stimuli as a prompt/reminder, such as placing a briefcase by the front door so you don’t forget it the next day

To increase prompting to improve learning, move UP the prompting hierarchy (from least to most intrusive).  To fade out prompts and prevent prompt dependency move DOWN the prompting hierarchy (from most to least). Generally, the most to least prompting hierarchy would be: Full physical, partial physical, full vocal, partial vocal, modeling, gestural. *This is a general guideline, and is leaving out many other types or prompts

During a therapy session you will use many different types of prompts at different times, usually when teaching a brand  new skill. The client shouldn't need much prompting for a known skill. If they do you may want to examine your teaching procedure and also make sure the client has the prerequisite skills needed for the current target.


The therapist I supervised yesterday was making a common error that can happen with new therapists and also with parents. She was over -prompting and then reinforcing those prompted responses.
I brought this to the therapists attention who was completely unaware of her error. She asked me, "How do I know if something I am doing is a prompt?"  There is an easy way to determine this. Ask yourself, "If I remove this step, would the client still be able to do the task?" If the answer is no then you are over -prompting and need to remember to fade prompts as rapidly as possible.


Something I used to do as a new therapist was arrange learning materials with the correct item closest to the client. There was no particular reason I did this other than a bad habit that went on for too long. During a training session with my supervisor, this was pointed out to me and then we did a few practice trials where the materials were arranged in a different way each time. My supervisor was able to demonstrate to me that the position of learning materials can absolutely serve as an inadvertent prompt, if I'm not careful. Lesson learned for me!

Sometimes you have to purposely change the way you do something to see if you are using a prompt.

If you remove a glance, a touch, a word, a facial expression, or a gesture, and the client "suddenly" can't perform the task anymore then you were likely over- prompting the task all along.

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Tameika Meadows, BCBA, Blog Author