“Touch Your Head” Or “Make Your Bed”? Staying True To The Applied Dimension Of ABA When Creating Program Goals For Students With Profound Cognitive Impairment

This article originally appeared at www.bsci21.org. 

Nearly six months had gone by since we began Lily’s home-based ABA program, and she had not mastered a single target of a single program. Not one. I stared blankly at my own furrowed reflection through the graph on my computer screen. What was I doing wrong? Why couldn’t I get her to learn? Why was ABA failing me?

Prior to taking on Lily’s case, I had worked almost exclusively with early intervention and preschool children; kids who came to me with limited or nonexistent foundational skills, but who responded to ABA like a dream and whose graphs were magnificent; a baseline of 0% with a quick and steady climb to mastery. Over and over again, like behavioral clockwork. My work with early intervention kids is what got me hooked on ABA and convinced me that it could work for everything and everyone. “It’s a science!” I once exclaimed over-zealously to the thrilled parents of a toddler who was finally talking after only 30 days of treatment. I had become superbly confident in my niche.

But Lily’s graphs were a nightmare. Like the jagged teeth of an orthodontically-challenged dinosaur, and always below the 50% line. Identifying Body Parts, Matching Identical Pictures, Sorting Objects by Color, Requesting – the quintessential programs that I had come to rely on as instantaneously acquired were just not working. I had tried everything – switching back and forth from errorless teaching, using prompting strategies up the wazoo, working in different environments and at different times of the day; every new approach led to the same low, variable results. She couldn’t label. She couldn’t identify. She couldn’t imitate. She had one self-created sign that she used to universally indicate that she wanted something, but it was up to us to figure out what that something was. Her data book was a nasty, inflamed pimple on the otherwise flawless complexion of my career as a behavior analyst.

I considered talking to my supervisor and requesting that another BCBA take over the case. Someone with more experience, someone who knew more about non-verbal kids, someone who had tricks up their sleeve that I clearly didn’t. Before I made that call, I went back through her file one last time. She was 10-years-old and entirely nonverbal. She was not reliably toilet trained. A recent medical report indicated that her cognitive functioning level was similar to that of a 6-month-old child, and likely always would be. And then it hit me.

She didn’t need my programs. She didn’t need Imitating Actions with Objects. She didn’t need to meet criteria on “Answering ‘Who’ Questions or “Identifying Parts of a Picture.” Sure, those skills would be great to have, but they weren’t her most pressing needs. This child needed to learn to bathe herself. She needed to learn how to make a snack. She needed to brush her teeth and make her bed and use the bathroom independently. These were the skills that might one day mean the difference between a group home and an institution – not whether she could identify 15 exemplars of a school-bus from a larger array. I suddenly felt silly and almost angry at myself that I had spent so many months trying to jam the concept of pronoun-specific body part identification down her throat when there had been such an obvious deficit in actual living. I understood for a moment why we as behavior analysts sometimes get flak from the general population for being hard-headed and data-obsessed.

I scratched her entire program. I bought a copy of the AFLS (Assessment of Functional Living Skills) and started probing that week. Her scores were low, but we had a starting point. We implemented 10 functional programs and began fully prompting backward-chains of each. Her therapists relied on muscle memory and consistency, since she could not comprehend visual cues or task analysis pictures. We worked untiringly after school and on weekends to commit these sequences to memory and reach independence. And 30 data points later, she had mastered her first program: Making a Snack. She could find the cabinet where the cheese puffs were, twist off the top, pour some into a bowl, replace the top, replace the puffs, walk to the table, sit down and eat them. Without a single prompt. When the therapist called me to tell me, I welled up.

In the end, it wasn’t ABA that failed me. It was my own limited application of ABA, and the fact that I lost sight of perhaps the most important dimension of our science –that it’s meant to be applied.After working with Lily, I threw out my grand idea that I held the secret recipe for the “Fix-all Cookie Cutter ABA Program for Children Everywhere.” Now, every time I begin an initial assessment for a new client, I start the recipe from scratch. The first question I ask myself is, “What is the most significant, functional, real-life challenge for them?” instead of asking whether or not they can tell me the functions of 10 community helpers within 60 seconds over 3 consecutive sessions.

The content of this article is not based on any specific person. Certain incidents, characters, and timelines have been changed for creative purposes and may be composites or entirely fictitious.

Katherine DeCotiis Wiedemann, M.A., BCBA had her very own behavior intervention plan as a kindergartner in 1989. She had to earn five smurf stickers every morning in order to go to recess. Katherine eventually graduated from kindergarten and beyond, and after a false start as a comedic actress (she dropped out of NYU’s Tisch School of the Arts) she found herself very at home in special education and behavior analysis.

After 10 years in the field, she founded Every Child Behavior Solutions, a NJ-based consulting practice that provides behavior-analytic services to school districts, families and anyone else who asks. She loves public speaking, and has done countless school in-service presentations about ABA, as well as for pediatric groups and medical students at the top hospitals in the state.

Although the first chapter of her career focused mostly on children with autism spectrum disorders, she has also spent a good deal of time in general education and specializes in the school-based treatment of ODD, ADHD, OCD and anxiety disorders. One of her short-term goals is to convince the world that ABA is not just a teaching tool for autism (although it does that well), and that behavior analysts are not all condescending blockheads (although some may be). You can learn more at Katherine’s website, or contact her at katherine@everychildnj.com. 

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