‘Tis the season for joy and excitement. Perhaps a bit of stress and chaos too. October through December can be exhausting for many families. With holidays back to back, it can be challenging to maintain a comfortable routine. Children with autism tend to thrive on structure and routine, making these months particularly challenging. Rest assured, there are strategies you can take to prepare your child and your family for these major upcoming changes.
Plan ahead
Sudden or unexpected changes are often the most difficult for children with autism to cope with. When children are primed in advance for the upcoming holidays, this can greatly improve their response when the holiday events come along.
Holiday preparation strategies might include any number of the following:
Talk to your child often about the holidays and specifically what activities you all will be doing. For example, you might focus on Thanksgiving, discussing how you’ll be going to dinner at Grandma and Grandpa’s house that day.
Read social stories and/or books about the holiday and associated events. Social stories are great for outlining and reviewing exactly what the plans and expectations are.
Create a visual countdown or a calendar that shows when the holidays are to serve as a visual reminder of the upcoming events. Prompt your child to reference this visual each day as you discuss the upcoming holiday.
Make backup plans in case things don’t go quite as planned.
Prepare a holiday bag with any supports your child might need. Depending on what their individual needs are, this bag might include things such as noise-reducing headphones, fidgets, or weighted vests.
Ensure your child has a way to safely escape if the setting becomes too overwhelming. For example, establish a dedicated location where they can go to calm down at each holiday event.
Maintain consistency where possible
With so much out of the ordinary during the holidays, it’s a good idea to try to avoid unnecessary major changes during these times. This isn’t always possible as life can be unpredictable. However, to whatever degree possible, maintain a consistent routine for your family.
Prioritize activities
With each holiday, there is an abundance of possible ways to celebrate, from large family gatherings and public outings to independent activities. The ways we celebrate holidays are often tied to sentimental family traditions. As such, it can be challenging to branch off from those activities that are special to us. It may, however, be helpful to prioritize the activities that are most important and most enjoyable to you and your family. If a particular holiday tradition historically causes more stress than enjoyment, consider alternative activities you can try that may be just as special to your family. Take your child’s preferences into consideration when planning events as well.
Be flexible
Sometimes our best-laid plans simply don’t work out. We might think our child can handle a new activity this year, but it still turns out to be overstimulating for them. Try to go into the holidays with a flexible mindset. If things don’t go quite as planned, have a backup plan prepared for alternative activities.
Recognize the progress, no matter how small
Focus on the victories, whether great or small. Holidays can be both magical and taxing on the whole family. Don’t forget to take the time to acknowledge the growth that your child has made. Happy holidays to all!
About the Author
Ashleigh Evans, MS, is a Board Certified Behavior Analyst. She has been practicing in the behavior analysis field for over 13 years and opened her own independent practice in early 2022. Her experience has been vast across different age groups, diagnoses, and needs. She is passionate about improving the field through education, reformative action, and better supervisory practices, leading her to create content and resources for families and ABA professionals which can be found on her website, www.evansbehavioralservices.com/.
Originally published November 11, 2022 by Different Roads to Learning.
This month’s ASAT feature comes to us from Lisa Tereshko, Ph.D., BCBA-D, Endicott College. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!
Everyday all individuals complete a variety of sequences of behaviors that were taught to them at some point in their lives. Some of these sequences include getting dressed, packing a lunch for school or work, and cooking dinner. Independently completing these sequences are essential for one to have independence throughout their day. One way of teaching sequences of behavior is using visual activity schedules. Visual activity schedules are an arrangement of pictures or words used to display a sequence of upcoming events. For example, when teaching getting dressed, a visual activity schedule might include a picture of under garments that signals the individual to put those on first, then a picture of a shirt signaling the next item to put on, and so on until the individual is completely dressed. This visual activity schedule could be posted on the side of the dresser of clothes or on the closet door.
Visual activity schedules encompass three evidence-based strategies: antecedent interventions, prompting, and visual supports (Hume et al., 2021). They are antecedent interventions in that they are presented prior to the initiation of the task as a cue to help the individual understand what is expected of them. The presentation of the visual activity schedule before the activity may also reduce the likelihood of challenging or interfering behaviors that could occur if the individual is frustrated because they do not understand the expectations or are disinclined to do the activity. Visual activity schedules also serve as a prompt, or support, that can increase the individual’s success completing the activity or task. Finally, visual activity schedules are a visual support as they are an additional visual stimulus that can support an individual’s increased independence and decrease their reliance on others for assistance.
The use of visual activity schedules can benefit all individuals to increase productivity and success across the day. People use various forms of visual activity schedules to complete a variety of activities throughout their day (e.g., to-do lists, daily planners, and following written directions). For individuals with autism/autistic individuals, visual activity schedules can be further beneficial by increasing independence. Individuals with autism/autistic individuals frequently display prompt dependency on another individual (Koyama & Wang, 2011). The use of visual activity schedules as a visual prompt can allow the individual to prompt themselves or rely on environmental cues rather than other people. The addition of visual activity schedules can additionally benefit individuals with autism/autistic individuals by reducing the auditory information they need to process. Previous research has shown that auditory information can be difficult for individuals with autism/autistic individuals to interpret (Knight et al., 2015); therefore, strategies relying on visual input may be more beneficial.
Visual activity schedules can take many forms (Koyama & Wang, 2011; Knight et al., 2015). The presentation of pictures can be displayed either in a linear (vertical or horizontal) pattern or within a small book (with one picture per page) where the individual engages with the schedule by moving the icon to a “done” column, checking it off a list, sliding a bar to indicate completion, or turning a page. It can also be modified to include actual objects to cue the activity for individuals who may have more difficulty identifying pictures (Hugh et al., 2018). For individuals who have word identification skills, visual activity schedules may also be presented in a narrative format where words replace pictures. Furthermore, technological advances have led to many options for the presentation of visual activity schedules as pictures or videos, and in the context of apps on tablets or other electronic devices.
Research Summary
There is a growing body of research that supports the use of visual activity schedules to increase a variety of skills and to assist with the reduction of interfering behaviors for individuals with autism/autistic individuals. According to the National Standards Project: Phase 2 (2015), the use of schedules with children with autism/autistic individuals is an established intervention that has been shown to increase their independence and their ability to plan for events that are upcoming. Furthermore, in a review by Hume et al. (2021) that evaluated evidence-based treatments for individuals with autism/autistic individuals, the authors provided additional support for visual activity schedules by identifying visual supports as an evidence-based practice.
Two systematic literature reviews have provided further support for the use of visual activity schedules as an evidence-based intervention. The review conducted by Koyama and Wang (2011) identified 23 peer reviewed studies that evaluated the use of visual activity schedules. They found that visual activity schedules had been effectively used to teach individuals with autism and intellectual disabilities to engage in a variety of activities, including on-task behavior. Knight et al. (2014) conducted another comprehensive review of the literature to expand the findings of past reviews and to determine if the use of visual activity schedules continued to be an evidence-based procedure. Their review identified 31 articles that targeted the use of visual activity schedules with individuals with autism/autistic individuals. The researchers found that visual activity schedules were effective for teaching a variety of skills across the lifespan of individuals with autism/autistic individuals. Furthermore, they found that the use of visual activity schedules was a low-effort intervention that provided individuals with consistent cues about upcoming events.
The use of visual activity schedules has been successful in teaching individuals with autism/autistic individuals across ages a variety of skills and activities such as completing the steps of toothbrushing (Moran et al., 2022), completing medical exams (Chebuhar et al., 2013), getting ready for bed (Hart Barnett et al., 2022),and leisure or play skills (Koyama & Wang, 2011). Furthermore, in the articles reviewed by Koyama and Wang (2011), there were 69 total participants including preschool students (24.6%), school-aged students (30.4%), and adults (23.2%) and more than half of those individuals had a diagnosis of autism (59.4%). Some recent literature supports the use of visual activity schedules with individuals with autism/autistic individuals to increase compliance during physical activity (Becerra et al., 2021), appropriate feeding behavior (Kirkpatrick et al., 2019), engagement in academic tasks while maintaining low rates of interfering behavior (Boyle et al, 2021), choice-making (Deel et al., 2021), completion of job-related tasks (Lora et al., 2020; Sances et al., 2019), completion of less preferred tasks without interfering behavior (Lory et al., 2020), successful transitions (Pierce et al., 2013), and social skills (Osos et al., 2021).
A variety of methods to implement visual activities is also supported in research. For some students, the use of video technology can be beneficial. Kirkpatrick et al. (2019) used video-enhanced activity schedules to reduce food stuffing (rapid eating), which resulted in a reduction of food stuffing and an increase in appropriate pacing of the meal for the participant. Brodhead et al. (2018) successfully increased the variety of games played on a tablet using an activity schedule on the tablet. Burckley et al. (2015) used a tablet to implement a video activity schedule in the community to increase the shopping skills of a young adult with autism. In only three lessons, the video activity schedule substantially helped to increase the young adults’ shopping skills.
Similar results were found when a visual activity schedule delivered via a smartphone was implemented in the community to teach an individual with autism to order items from a bakery (Cheung et al., 2016). Even a smart watch can be used to implement visual activity schedules, as shown by Jimenez-Gomez et al. (2021) when they increased the independence of play skills for three young children with autism/autistic children. The use of technology, such as tablets, smartphones, and smartwatches, may help to enhance the reach of visual activity schedules by increasing their portability and reducing the social stigma that may be associated with carrying a visual activity schedule into the community.
Though there is much research supporting the use of visual activity schedules. There are some cautions to note when examining their use. Knight et al. (2014) found that all but three studies used visual activity schedules in combination with other systematic instruction (e.g., graduated guidance, reinforcement, and prompting), which could have enhanced the effects. The maintenance and generalization of the use of visual activity schedules have limited research and represent an important direction for future research. With that said, the limited research that has been conducted appears promising. For example, MacDuff et al. (1993) successfully used visual activity schedules to teach on-task behavior that then generalized to novel pictures and activities in the schedule. Furthermore, Koyama and Wang (2011) noted that those studies that included maintenance information were able to successfully maintain the use of the visual activity schedule and those that did include generalization were successful with generalizing to novel activities or settings.
Recommendations
The application of visual activity schedules has been well documented in the research to be a successful intervention to increase a variety of skills across a variety of ages of individuals with autism/autistic individuals. This literature review is aligned with the National Standards Project: Phase 2 and other systematic literature reviews (e.g., Knight et al., 2014; Koyama and Wang, 2011) that support the recommendation to use visual activity schedules as an intervention for increasing skills and independence for individuals with autism/autistic individuals. Although research supports the success of visual activity schedules with individuals with autism/autistic individuals, the determination of appropriate intervention techniques for everyone should be decided by the team directly involved with that individual.
When using activity schedules with an individual with autism/autistic individual, it is important to consider the individual’s skills associated with symbolic representations, receptive language, and reading and comprehension when determining the mode of implementation (Hugh et al., 2018). Additionally, individual preference should be considered when determining the modality of the visual activity schedule (Knight et al., 2015). Giles et al. (2017) found similar acquisition rates when comparing static pictures to tablet-based modalities and preference for the different formats was idiosyncratic across participants. Additional clinical considerations include attention to assent and to the development of component skills. Specifically, learner assent should be assessed and regularly revisited; intervention should continue in the context of willingness and engagement (Morris et al., 2021). Component skills that can be built incidentally include choice-making, stamina for independent tasks, appropriate social engagement during activities, and self-monitoring. Many work-relevant skills can be shaped through the use of activity schedules.
Continued research should continue to explore the long-term effects of visual activity schedules and their ability to generalize effects across environments. The use of technology with visual activity schedules may help reduce the social stigma of some modalities of visual activity schedules and should continue to be explored to assist individuals in increasing their independence. While we await additional research, visual activity schedules remain an evidence-based intervention that can be valuable in increasing sequences of behavior for individuals with autism/autistic individuals.
Selected References
Systematic Reviews and Task Forces
Hume, K., Steinbrenner, J. R., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yücesoy-Özkan, S., & Savage, M. N. (2021). Evidence-based practices for children, youth, and young adults with autism: Third generation review. Journal of Autism and Developmental Disorders 51, 4013-4031. https://doi.org/10.1007/s10803-020-04844-2
Knight, V., Sartini, E., & Spriggs, A. D. (2015). Evaluating visual activity schedules as evidence-based practice for individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 45, 157-178. https://doi.org/10.1007/s10803-014-2201-z
Koyama, T., & Wang, H. T. (2011). Use of activity schedule to promote independent performance of individuals with autism and other intellectual disabilities: A review. Research in Developmental Disabilities, 32, 2235-2242. https://doi.org/10.1016/j.ridd.2011.05.003
National Autism Center. (2015). Findings and conclusions: National Standards Project, Phase 2. Author.
Selected Scientific Studies
Becerra, L. A., Higbee, T. S., Vieira, M. C., Pellegrino, A. J., Hobson, K. (2021). The effects of photographic activity schedules on moderate-to-vigorous physical activity in children with autism spectrum disorder. Journal of Applied Behavior Analysis, 54(2), 744-759. https://doi.org/10.1002/jaba.796
Boyle, M. A., Bacon, M. T., Sharp, D. S., Mills, N. D., & Janota, T. A. (2021). Incorporating an activity schedule during schedule thinning in treatment of problem behavior. Behavioral Interventions, 36, 1052-1064. https://doi.org/10.1002/bin.1813
Brodhead, M. T., Courtney, W. T., & Thaxton, J. R. (2018). Using activity schedules to promote varied application use in children with autism. Journal of Applied Behavior Analysis, 51(1), 80-86. https://doi.org/10.1002/jaba.435
Burckley, E., Tincani, M., & Fisher, A. G. (2015). An iPad-based picture and video activity schedule increases community shopping skills of a young adult with autism spectrum disorder and intellectual disability. Developmental Neurorehabilitation, 18(2), 131-136. https://doi.org/10.3109/17518423.2014.945045
Chebuhar, A., McCarthy, A. M., Bosch, J., & Baker, S. (2013). Using picture schedules in medical settings for patients with autism spectrum disorder. Journal of Pediatric Nursing, 28, 125-134. https://doi.org/10.1016/j.pedn.2012.05.004
Cheung, Y., Schulze, Leaf, J. B., & Rudrud, E. (2016). Teaching community skills to two young children with autism using a digital self-managed activity schedule. Exceptionality, 24(4), 241-250. https://dx.doi.org/10.1080/09362835.2016.1215654
Deel, N. M., Brodhead, M. T., Akers, J. S., White, A. N., & Miranda, D. R. G. (2021). Teaching choice-making within activity schedules to children with autism. Behavioral Interventions, 36, 731-744. https://doi.org/10.1002/bin.1816
Giles, A., & Markham, V. (2017). Comparing book- and tablet- based picture activity schedules: Acquisition and preference. Behavior Modification, 41(5), 647-664. https://doi.org/10.1177/0145445517700817
Hart Barnett, J. E., Zucker, S. H., & More, C. M. (2022). Visual schedule to promote compliance with bedtime routine in a child with autism spectrum disorder. Education and Training in Autism and Developmental Disabilities, 57(2), 196-203.
Jimenez-Gomez, C., Haggerty, K., & Topcuoglu, B. (2021). Wearable activity schedules to promote independence in young children. Journal of Applied Behavior Analysis, 54(1), 197-216. https://doi.org/10.1002/jaba.756
Lora, C. C., Kisamore, A. N., Reeve, K. F., & Townsend, D. B. (2020). Effects of a problem-solving strategy on the independent completion of vocational tasks by adolescents with autism spectrum disorder. Journal of Applied Behavior Analysis, 53(1), 175-187. https://doi.org/10.1002/jaba.558
Lory, C., Rispoli, M., Gregori, E., Kim, S. Y., & David, M. (2020). Reducing escape-maintained challenging behavior in children with autism spectrum disorder through visual activity schedule and instructional choice. Education and Treatment of Children, 43, 201-217. https://doi.org/10.1007/s43494-020-00019-x
Kirkpatrick, M., Lang, R., Lee, A., & Ledbetter-Cho, K. (2019). A video-enhanced activity schedule reduces food stuffing in child with pervasive developmental disability: A single subject design case study. Advances in Neurodevelopment Disorders, 3, 281-286. https://doi.org/10.1007/s41252-019-00100-6
Moran, K., Reeve, S. A., Reeve, K. F., DeBar, R. M., & Somers, K. (2022). Using a picture activity schedule treatment package to teach toothbrushing to children with autism spectrum disorder. Education and Treatment of Children, 45, 145-156. https://doi.org/10.1007/s4349-022-00074-6
Osos, J. A., Plavnick, J. B., & Avendaño, S. M. (2021). Assessing video enhanced activity schedules to teach social skills to children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 51, 3235-3244. https://doi.org/10.1007/s10803-020-04784-x
Pierce, J. M., Spriggs, A. D., Gast, D. L., & Luscre, D. (2013). Effects of visual activity schedules on independent classroom transitions for students with autism. International Journal of Disability, Development and Education, 60(3), 253-269. http://dx.doi.org/10.1080/1034912X.2013.812191
Sances, J., Day-Watkins, J., & Connell, J. E. (2019). Teaching an adult with autism spectrum disorder to use an activity schedule during a vocational beekeeping task. Behavior Analysis in Practice, 12, 435-439. https://doi.org/10.1007/s40617-018-00306-5
Other Works Cited Above
Hugh, M. L., Conner, C., & Stewart, J. (2018). Intensive intervention practice guide: Using visual activity schedules to intensify academic interventions for young children with autism spectrum disorder. National Center for Leadership in Intensive Intervention. https://files.eric.ed.gov/fulltext/ED591075.pdf
Morris, C., Detrick, J. J., & Peterson, S. M. (2021). Participant assent in behavior analytic research: Considerations for participants with autism and developmental disabilities. Journal of Applied Behavior Analysis, 54(4), 1300-1316. https://doi.org/10.1002/jaba.859
Dr. Lisa Tereshko, Ph.D., BCBA-D, LABA is the Director of Quality Assurance and Research for the Institute of Applied Behavioral Science at Endicott College. Lisa has over 20 years of experience working with individuals with autism and other behavioral disorders in schools, homes, and residential settings. Her research interests include: the effectiveness and efficiency of functional analyses, ethical and compassionate feeding interventions, increasing cultural competency in higher education, and identifying best pedagogical practices within higher education in which she has published peer-reviewed articles, books, and chapters. She has presented locally, nationally, and internationally on many topics, serves on committees at BABAT and at ASAT, and is on the editorial board of Behavior Analysis in Practice.
Applied Behavior Analysis (ABA) therapy is an evidence-based approach to treating children with Autism Spectrum Disorder (ASD). When ABA therapy is implemented in a center-based environment, it takes place in a clinical or therapy center to provide structure. This allows for the environment to be controlled. It involves a consistent approach to therapy, provided by a team of trained professionals like Board Certified Behavior Analysts (BCBA) and Registered Behavior Technicians (RBT).
The goal of center-based ABA therapy is to teach children on the autism spectrum new skills and behaviors while reducing unwanted behaviors. This is accomplished through a process of breaking down complex skills into smaller, more manageable steps and using positive reinforcement to motivate and encourage progress. At Action Behavior Centers, center-based ABA therapy sessions run from Monday to Friday at 8AM to 5PM. During each therapy session, the child may engage in a variety of activities designed by our therapist to help them develop new skills and behaviors. This form of therapy includes a variety of activities, such as play-based activities, structured teaching activities, and social skills training. For example, they may work on communication skills, social skills, and daily living skills. While working on a one-to-one therapist to child ratio, our therapist will evaluate each autistic child to implement a specific treatment plan. These plans will be designed to address the individual’s unique needs and goals.
Center-based ABA therapy offers several advantages over the at-home alternative. Therapy centers offer an environment that is designed to be structured and predictable to allow ABA therapists the ability to conduct in a consistent and supportive manner. However, the benefits of center-based ABA therapy go beyond a controlled environment. Benefits of center-based Applied Behavior Analysis (ABA) therapy for children with autism include:
Peer Play, Social Imitation, and Social Interaction: One of the most significant benefits to in-center ABA therapy is the opportunity for children to connect with others their age. At Action Behavior Centers, our compassionate therapists supervise and guide child-to-child engagement. This gives ABA therapists the opportunity to teach children social skills such as how to greet others, initiate conversations, and join in on activities. This then translates into the development of other important skills like sharing and turn-taking. These skills can help children feel more comfortable and confident when interacting with peers and most importantly, it allows for peers to build friendships.
Increased Supervision: Being in a center-based ABA therapy program allows for your child’s therapist to connect to a larger body of professionals, ensuring your child is getting the best possible care and attention. Not only will your child be surrounded by a team of experts, but they’ll have access to more resources as well. Having a consistent team of clinical experts nearby creates a safe space for your child to explore and interact with their environment. At Action Behavior Centers, we employ trained professionals who have experience in working with children with autism. These professionals can provide individualized treatment plans and tailor therapy to the specific needs of the child. We make sure that our Board Certified Behavior Analysts (BCBAs), Registered Behavior Technicians (RBTs), and other therapists have had specialized training and experience in working with children with autism so that they can provide the most up-to-date form of ABA therapy possible.
School Readiness: Children who attend ABA therapy in-center will be practicing school-readiness skills such as participating in group activities, imitation, matching, and categorizing. Children will begin to familiarize themselves with the drop-off and pick-up process, alleviating some of the transitional stress associated with entering the school environment. ABA therapists help autistic children develop communication skills such as expressing themselves effectively, asking for help, and following directions as these skills are essential for effective communication with teachers and classmates.
State of the Art Facilities: Each of our ABA therapy centers is created with your child’s specific needs in mind. From the big-picture ideas to the minute details, our New Center’s Team focuses on creating the perfect place for children to learn & grow – while making our therapists feel relaxed, happy, and engaged. The village build-outs are perfect for pretend play – creating a unique, imaginative experience for our children to engage with. Our centers have a variety of therapy spaces to accommodate different activities and interventions, such as individual therapy rooms, group therapy spaces, and play areas. With safety in mind, our autism clinics are accessible for all clients, including those with physical disabilities or mobility impairments.
Structured Learning Environment: As previously stated, center-based settings provide a structured and controlled environment for ABA therapy to be implemented. This allows therapists to create a consistent and predictable routine for the child, which can aid in the child’s learning and behavioral management. Center-based ABA therapy provides a structured and consistent environment that is designed to support the learning and development of children with autism. This can be especially important for children who struggle with routine and structure in other areas of their lives.
Specialized Equipment: Centers often have specialized equipment and resources that can be used to aid in the therapy process. For example, therapy rooms may be equipped with toys and other materials that are specifically designed to help with skill development. For example, our ABC centers have access to specialized resources and materials, such as sensory equipment, communication devices, and other technology that is used to support learning and development. Our centers even have access to a wide range of resources that include educational resources. This can help to support the learning and development of children with autism.
Overall, center-based ABA therapy can provide the structure needed for a child with autism to learn and grow. It is important to note that while center-based ABA therapy can be beneficial for many children with autism, it may not be the best fit for every child. Center-based ABA therapy can provide valuable resources and support for parents and other caregivers that In-home ABA therapy can lack in. Each child has unique needs, strengths, and challenges, and families should work with their healthcare providers to determine the best approach for their child’s individual needs.
About Action Behavior Centers
Action Behavior Centers (ABC) is an organization committed to the treatment of children using empirically validated methods and strategies to assist each child in reaching his or her greatest potential and improving their quality of life.
This month’s ASAT feature comes to us from Kate McKenna, MEd, MSEd, MS, BCBA,and Kristina Gasiewski, MEd, MOTR/L, BCBA,Association for Science in Autism Treatment. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!
Occupational therapy (OT) was established in 1917 by six founders of the National Society for the Promotion of Occupational Therapy (NSPOT). This Society was later renamed in 1923 and is currently known as the American Occupational Therapy Association (AOTA) (Paterson, 2011). The founders were from a variety of professional backgrounds and disciplines (i.e., psychiatrists, architects, welfare workers, teachers, nurses, and medical doctors) who came together with one strong belief that occupations hold a therapeutic value. The values and beliefs that most OTs hold today were created and shaped by the 19th and early 20th-century historical events such as industrialization, women’s rights, World War I, healthcare legislation, and technology (Christiansen & Haertl, 2019).
As a discipline, OT rose to prominence following WW1 as the medical professionals working with shell-shocked and wounded veterans. In their efforts to rehabilitate those suffering the effects of combat, the original practitioners of OT based their profession on the idea that real work would aid in creating a healthy body and mind (Christiansen & Haertl, 2019). As a result of their success, OT came to be recognized as a medical discipline in its own right.
By the 1960s, there were two distinct practice areas including treating those with physical disabilities and those with psychological dysfunction. Some key events that influenced the OT profession stemmed from the civil rights movement and its influence on health care and social justice, and large mental institutions closing (which affected the number of OT professionals working in longer-term mental health settings). The American Occupational Therapy Foundation (AOTF) was founded in 1965 to promote scientific development in the field of OT. At this time, there was also increased emphasis on sensorimotor therapies and neurodevelopmental theories (Christiansen & Haertl, 2019).
In the 1970s, OT was again influenced by the medical rehabilitation and treatment of war veterans. This created a shift from a holistic and occupation-based approach to a more medical, bottom-up approach with an emphasis on the source of the problem. This was a shift from the root of OT as of a top-down approach and utilizing occupations and crafts in a therapeutic manner. OT practitioners began focusing more on theory and research. Mechanical approaches were being applied to interventions such as the neuromotor and musculoskeletal systems and their relation to occupational function (Christiansen & Haertl, 2019).
With advances in science, technology, education, and health care during the 1980s and 1990s, the OT profession continued to evolve. There was a greater emphasis on research, efficacy, and defining the scope of practice. In 1986, AOTA created the American Occupational Therapy Certification Board (AOTCB), which, in 1996, was later named the National Board for Certification in Occupational Therapy (NBCOT) (Christiansen & Haertl, 2019). Regulations requiring licensure for OT became effective on July 1, 1998. Additionally, in 1999, the first edition of the American Journal of Occupational Therapy (AJOT) was published. Also, in 1997, the Individuals with Disabilities Education Act (IDEA) was passed, which ensures specialized services, including OT, are provided for children with disabilities in schools in order to improve education. This led to an increase in the number of OT practitioners working in school systems increased (Christiansen & Haertl, 2019).
Legislation and policies continue to change and heavily influence the OT profession such as increasing the quality of practice through measurable outcomes, creating goals that contain cost, and providing evidence-based research that demonstrates the effectiveness and efficacy of OT practice (Christiansen & Haertl, 2019).
Education
Occupational Therapy professionals acquire their degrees from an ACOTE (Accreditation Council for Occupational Therapy Education) accredited occupational therapy program. There are two degrees: occupational therapy assistant (OTA) and occupational therapist (OT).
An OTA may practice with an associates degree under the supervision of a licensed OT. An OT must obtain a Masters level degree to practice. However, those who acquired and have been practicing prior to 1990 may continue to practice with a bachelor’s degree. There are both post-professional master’s programs for those that hold an approved bachelor’s degree in a related field, and entry-level master’s degree programs. Additionally, there are entry-level occupational therapy doctorate (OTD) programs. At this time, the profession runs under a dual-entry point. There was a proposal to mandate a doctorate-level requirement; however, in 2019, after much debate, AOTA, who presides over ACOTE, upheld the dual point of entry policy.
Some typical courses of study may include anatomy and physiology, kinesiology, movement analysis, neuroscience, adult rehabilitation, assistive technology, occupations across the lifespan, and assessing occupational performance. Additionally, OTA and OT students must complete fieldwork consisting of two levels. Level I fieldwork typically consists of observations and shadowing OTs in multiple settings; however, there has been a bigger push to allow more hands-on opportunities during these practicums. Level II fieldwork requires a minimum of 16 weeks for OTA students and at least 24 weeks for OT students. This must occur across two different settings and requires the OT student to work directly with clients under the supervision of a licensed OT.
Standards of Practice & Guiding Documents
Once graduated, OTs and OTAs must pass the National Board for Certification in Occupational Therapy (NBCOT) exam in order to practice. Currently, all 50 states, Guam, Puerto Rico, and the District of Columbia require the NBCOT initial certification. For OTs, this test is comprised of 3 clinical simulation test items and 170 multiple-choice single-response questions. The OTA exam consists of 200 questions of both multiple-choice, single-response questions and six option multi-select questions. Passing the exam, therapists become certified and assume the following credential: OTR – Occupational Therapist Registered, or COTA – Certified Occupational Therapy Assistant. The NBCOT requires 36 units of continuing education during a three-year renewal cycle to be in good standing with the OTR NBCOT Practice Standards, the COTA NBCOT Practice Standards, and the NBCOT Code of Conduct. A list of renewal activities can be found here: NBCOT® Certification Renewal Activities.
OT professionals must be licensed per the state they work in, and state licensing requirements vary per state. It should be noted that while each state requires the initial passing of the NBCOT exam and to be registered with NBCOT, it may not be a requirement to continue this certification. Therefore, you may see two different credentials: Occupational Therapist Registered/Licensed (OTR/L) or Occupational Therapist/Licensed (OT/L).
Additionally, COTAs practice under the ongoing supervision of a licensed OT. The amount and level of supervision is guided per state regulations as well as the type of setting and insurance protocols.
A glance through the titles of some of the peer-reviewed journals published in the field of OT gives us a sense of the areas in which OTs practice. The specificity makes clear that OT is a broad field that impacts the lives of people with a range of support needs, in a variety of settings.
Areas of focus in OT can be categorized into two domains: Activities of Daily Living (ADLs), which include supporting competency and independence in areas such as feeding, dressing, and grooming, and Instrumental Activities of Daily Living (IADLs). IADLs are activities that bring people in contact with their environments such as shopping, managing money, traveling, work, and leisure activities. Other activities that come under the heading of IADLs revolve around independent living. Meal preparation, household chores, health management, education, and personal safety are examples (OT Scope of Practice, 2021; OTPF-4, 2020). Supporting progress in these activities may involve adapting or modifying the environment and conducting an activity analysis to pinpoint the specific skills that require work.
OTs are employed in a variety of settings such as schools, hospitals, both long-term care facilities for those with memory loss or extensive care needs and outpatient clinics, and in the home or other community settings. OT practitioners work on refining fine motor manipulation (i.e., finger dexterity, in-hand manipulation, bilateral coordination, etc.) in order to improve the overall function of skill (i.e., self-care skill, handwriting, keyboarding, etc.). OTs also have the expertise to assess core strength and develop an intervention plan for postural control that may include providing adaptive seating equipment. OT practitioners may work with an individual to improve processing skills such as organizational skills and work on improving visual perceptual and motor planning skills (Schell & Gillen, 2019).
“Occupational Therapy has a long history that is steeped in cultural and historical events. Professionals who practice OT engage in rigorous coursework and clinical practice prior to passing a certification exam and have established many professional organizations and peer-reviewed journals to form a solid foundation of scientific evidence regarding their treatments. At the heart of OT is the goal of promoting participation in meaningful occupations, which are defined by OT practitioners as any activity in which an individual engages throughout their day. The field of OT focuses on teaching individuals, across the lifespan, the skills needed to promote independence and participation in daily life activities. (Schell & Gillen, 2019).
References
American Occupational Therapy Association (2021). Occupational Therapy Scope [KG1] of Practice. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 75(Supplement_3), 7513410020. https://doi.org/10.5014/ajot.2021.75S3005
American Occupational Therapy Association. (2020). AOTA 2020 occupational therapy code of ethics. American Journal of Occupational Therapy, 74(Suppl. 3), 7413410005. https://doi.org/10.5014/ajot.2020.74S3006
American Occupational Therapy Association. (2021). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 75(Suppl. 3), 7513410030. https://doi.org/10.5014/ajot.2021.75S3004
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001
Christiansen, C. H., & Haertl, K. L. (2019). A contextual history of occupational therapy. In Schell, B. A. & Gillen, G. (Eds.), Willard & Spackman’s Occupational Therapy (13th ed.). Williams & Wilkins.
Paterson, C. F. (2011). A short history of occupational therapy in psychiatry. In Cree, J. & Lougher, L. (Eds.), Occupational Therapy and Mental Health (4th ed.). Elsevier Health Sciences UK.
Schell, B. A., & Gillen, G. (2019). Willard & Spackman’s Occupational Therapy (13th ed.). Williams & Wilkins.
Citation for this article:
McKenna, K., & Gasiewski, K. (2022). Focus on the treatment team: Occupational therapy. Science in Autism Treatment, 19(12).
Kate McKenna, MEd, MSEd, MS, BCBA, LBA, received a Masters in Child Study from the Eliot-Pearson Department of Child Study at Tufts University, a Masters in Special Education from Pace University, and a Masters in ABA from Hunter College. In addition to New York state certifications in general and special education from Birth to Grade 2 and Grades 1-6, she holds a New York State Annotated Certification in Severe/Multiple Disabilities. Kate is currently completing a Masters degree in Children’s Literature at Eastern Michigan University. She was an extern at the Association for Science in Autism Treatment before joining the Board of Directors in 2020.
Kristina Gasiewski, MOTR/L, MEd, BCBA received her Bachelor of Science in psychology and her Master of Occupational Therapy from University of the Sciences in Philadelphia. She went on to receive her Master of Education in autism and applied behavior analysis from Endicott College. Kristina works at Melmark PA, and recently has transitioned into her new role as the behavior analysist/QIDP in adult clinical services. Previously she worked as a school-based occupational therapist. Being dually credentialed, her research interests include collaboration between occupational therapists and behavior analysts and bridging the gap in order to best serve individuals with autism and developmental disabilities. Kristina is a member of the American Occupational Therapy Association (AOTA) as well as the Association for Behavior Analysis International (ABAI), and has had the opportunity to present at both organizations’ annual conferences. Additionally, Kristina is a Board member of the Association for Science in Autism Treatment (ASAT).
A healthy child with autism often has a harder time developing self-esteem than their typical peers. They struggle to find their value and self-identity and may have a hard time understanding their own internal worth, especially when they don’t always understand their own emotions.
Here are a few tips for helping your child on this journey to self-esteem.
Find Their Passion
Help your child find something that catches their interest and have the whole family support it. This can be a great help when they are feeling down about something they aren’t good at or have failed at and you can shift their focus to something they are great at and enjoy
It should help them identify things about themselves to be proud of and things they can share with other members of their family and peers to start conversations and develop a feeling of importance in their social space. Whether it’s a love of space and playing chess or an affinity for dinosaurs and facts about past presidents, let them find their niche and shine!
Remind Them That Bad Days Happen to Everyone
Having a bad day doesn’t mean you’re a bad person. It’s important to remind your child that even though they will have days they are struggling, those days are only 24 hours long and the next day is a chance to start over.
This will also help them learn forgiveness of other people’s bad days – when mom is yelling for seemingly no reason and grandpa is grumpy at dinner – those people deserve their bad days too and it doesn’t mean they aren’t as valuable a person because of it.
Point Out Differences in Others and Celebrate Them
Talk about how some of the best people in their lives are different and how those differences help make them who they are. Celebrate the little quirks in each person in your family and focus on how being different is something to be proud of.
Talk about people’s unique personality traits and compare them to their own. Have each family member describe their favorite things about others. Write them down and review them when your child is having a bad day or feeling low. Different does not mean less!
Model Healthy Self Esteem
If your child constantly hears you down on yourself, they will think this is normal behavior and follow suit. You want to show your child that while it is important to set goals and work towards them, failure is a part of life and it does not change who you are as a person.
Express your disappointment in a healthy way by verbalizing it but also focusing on how you will try something different next time or change your goals to something else you want to accomplish. Show pride for trying and the important thing is not to give up.
About BlueSprig
BlueSprig is on a mission to change the world for children with autism.
BlueSprig Is the Premier Provider with the Highest Standards in ABA Therapy Our mission is simple: we are focused on changing the world for children with autism.
The main question we seek the answer to is “what if?”
What if we focus on quality services? What if we are a leader in ABA research? What if we are strong advocates for the rights of all children with autism? Instead of choosing, we’re pursuing all three together – that’s the BlueSprig difference.
If you’re a helping professional working with kids, such as a child psychologist, clinical counselor, behavior analyst, occupational therapist, or speech and language pathologist, you may find yourself working with your client’s teacher. Learning to effectively collaborate with teachers is a critical skill to have.
Teacher collaboration can be an important part of your job if you’re a helping professional working with kids.
Sometimes this relationship may be a brief interaction, and others it might be frequent contact, depending on the situation.
Ideally, you’re able to build a relationship with a teacher you’re working with in which you can share ideas, collaborate on interventions, and truly feel like team members. After all, the goal of effective collaboration with teachers and outside professionals is better student outcomes.
As a teacher and behavior analyst, I’ve been on both sides of this relationship. As school starts back this fall, I’ve been reflecting on my experiences over the years and thinking about lessons learned. I wanted to share it with other helping professionals who find themselves going into schools to support clients this year.
Here are some things I think all professionals collaborating with school teams can consider going into this school year, boiled down from my personal experience.
The purpose is to share some ideas that can help build a foundation for deeply effective collaborative work.
Teachers have REALLY hard jobs
Communication is key
Teachers are professionals
Schools and school boards have policies and procedures. There’s no way around this.
A little kindness can go a long way
A classroom is like a teacher’s home
Going out of your way to help can make all the difference.
Teachers Have REALLY Hard Jobs
It is no easy task to be the one responsible for planning, implementing, teaching, evaluating, and reporting on the learning, development and overall student achievement of anywhere from 20-40 children with very little paid planning time.
Furthermore, there are few breaks. During instructional time, you’re on. Time between lessons is usually spent going to the bathroom, eating a snack since you coached a team or hosted a club at lunch, and tidying in the classroom before the kids return and you move on with your lesson.
Teachers just never have enough time in the day to get done what they need to get done. Not to mention, they often put in a lot of unpaid time for professional development, trying to stay on top of best practices.
Teachers put an incredible amount of unpaid time into their jobs to see their students succeed. I highlight this because I remember the times that a helping professional would show up in my room and then want to chat with me during my preparation time which I had planned to use to get my next class ready.
If you’re working in schools as an OT, SLP, PT, BCBA, psychologist or counselor, consider this harried context when scheduling time to work with teachers.
Always let them know you are coming and, if possible, coordinate a time convenient for them. You may even consider requesting from school leaders that coverage be provided for the teacher should you need to meet outside of the classroom during instructional time.
You will learn that school culture and school leadership have a lot to do with whether teachers are released for meetings with outside professionals. Sometimes teacher teams may provide coverage for each other
Lastly, even just a simple recognition of the work they’re doing, the effort they’re putting in, and thanking them for having you into their classroom can really help build rapport. Building this rapport through empathy of the position they are in can build a solid foundation to effectively collaborate with teachers.
Communication Is Key
As a teacher, I always appreciated when outside professionals were open with communication, being ready and willing to provide updates, reach out with questions, and check in with the school team. It really felt like we were creating strong partnerships.
Try starting out by giving them the benefit of the doubt that they want to work with you and are capable and willing partners. Sometimes this will not be the case and the administrator has asked you as an outside professional to come in, resulting in a less-than-willing colleague. However, beginning with the benefit of the doubt until proven otherwise is a great place to start.
It only serves your client better to be open and transparent with the school team, sharing things that have worked for you, offering help and communicating and changes on your end.
However, the tone of your communication is also really important. Recognizing the challenges and constraints of the school environment and getting their input on a client sets a respectful tone.
One key area for this is with observations. If you’re asked to go observe a student, discuss ahead of time with the classroom teacher about how they should introduce you and what they would prefer from you during the observation. For example, do they want to you interact with students or not?
Some will want you to sit quietly in one spot and observe. Others may prefer you to mingle in the classroom and interact with students as you observe your client.
Discussing these details before the observation helps avoid awkward or frustrating situations during the observation. This may differ based on grade-level or whether this is a high school or elementary classroom.
The bottom line is, simply asking the teacher about their preferences is a great starting point. Taking the time to communicate can be a great way to set a positive and respectful tone and effectively collaborate with teachers.
Teachers Are Professionals
Regardless of whether teachers have completed a degree beyond their teacher training and undergraduate degree, teachers are professionals and should be treated as such.
They’re experts in their curriculum, assessment and, most importantly, their students. Teachers work incredibly hard to do well for their students and (in my opinion) are the backbone of our society, so should be treated with a commensurate level of respect.
Teachers participate in professional learning communities (PLCs) that involve professional development around specific topics.
This can mean delving into best teaching practices as found in educational research, problem-solving current issues in education, using educational research to plan for student success or school improvement, giving feedback to each other on lesson plans, or other learning experiences based on relevant educational topics.
PLCs are ways for teachers to stay current in best practices and improve their pedagogy and instructional practices through teamwork in a small group setting.
Teachers want to see their students do well, and are always looking for ways to improve students learning and overall well-being at school. The job of a teacher is never done.
There is constant reflection and response to student learning that drives teachers to seek out ways to be an increasingly effective teacher. Teachers are lifelong learners and try to instill the same in their students.
To effectively collaborate with teachers, come in with a respectful tone that shows admiration for the work they do, listen to their insights, and actually integrate this into your work. This builds a successful collaborative relationship.
Schools And Boards Have Policies That Can’t Be Avoided
Part of being respectful when entering a school as an invited professional is adhering to school (and classroom) rules. Knowing what policies are relevant to you ahead of time is best. An initial call to the Office Administrator or Principal can help set common expectations at the outset.
My recommendation is to not try to haggle for exceptions, instead be flexible and work around their policies and procedures. Being accommodating and toeing the line can help you effectively collaborate with teachers becuase it shows respect and doesn’t ruffle any feathers before you even set foot in the school.
Examples of policies to be aware of are:
Forms to be signed ahead of time
Certain school staff being notified of your visit
Not wearing scented products
Adhering to set times for visiting the school
Signing in upon arrival
Wearing a ‘Visitor’ tag and signing out when you leave.
Covid pandemic-related protocols.
Asking about school policies at the outset can help show respect without having to be asked.
A Little Kindness Can Go A Long Way
This relates to point #1 about a teacher’s job being hard. After spending some time in the classroom, you’ll get a good idea of how you can help out and what the teacher might appreciate.
To effectively collaborate with the teachers you are working with, I guarantee extending some simple acts of kindness can really help.
Going out of your way to help a teacher by making materials for a strategy you’ve suggested, bringing a treat to a meeting, volunteering some time in the classroom, being really flexible to suit the teacher’s schedule, or helping to tidy the classroom at the end of the day are all ways that you can show kindness to a teacher you are working with.
A Classroom Is Much Like A Teacher’s Home
Most teachers spend a lot of time and effort intentionally designing their classroom environment. Respecting this by asking about classroom rules or procedures ahead of time can help start your relationship with the classroom teacher off on the right foot.
You are entering a teacher’s personal space that they have carefully curated. Take their cues, and show respect by treating it as if you are going into someone’s living room.
You never want it to seem like you’re coming into their space and critiquing their home. This is especially true as, when outside professionals are observing, it’s not your role to critique their teaching but rather just observe your client in the context of the classroom.
Be cognizant of not leaving any garbage in the classroom like empty coffee cups, tucking in your chair when you leave, or helping with other classroom chores.
Some special education classrooms have no-hot-drink policies due to risk of spilling. Consider not bringing any food or drink into the classroom just to be safe. The last thing you want is to be that person who spills something on student work!
Think about the little things like stacking your chair after an observation. All of this adds up.
Don’t Take Yourself Too Seriously
Schools are full of kids. Kids like fun. Teachers (generally speaking!) also are lighthearted and accustomed to having fun with their students. Being too serious can make it harder to build rapport.
That being said, read the room. You’ll get a good sense of classroom culture and teacher personality by spending some time in a classroom. If invited, participate in what the class is doing and have fun participating and interacting with students.
After spending some time in the school, you’ll also get an idea of its culture. Participating in activities, buying some cookies at a bake sale, or eating your lunch in the staff room (if welcome to do so) are all ways to get to know staff in a laid back manner.
The Bottom Line on How to Effectively Collaborate with Teachers
It’s common for outside professionals like psychologists, BCBAs, OT, PTs, SLPs or counselors to be invited into a classroom to collaborate with a school team.
There are some basic things to keep in mind about school culture and collaborative practices before heading in to help.
It’s a privilege to be invited into a teacher’s domain, their classroom. Keeping these few tips in mind can go a really long way to building rapport. If you start out on the right foot, you’re likely to get where you are going faster: better success for the client/learner you are both there to serve.
About Behavioral Collective
The Behavioral Health Collective is a multi-disciplinary behavioral health resource for clinicians, families and educators. We believe that only through working together, listening and learning from each other and our clients can behavioral health professionals truly create meaningful change.
This is a community for allied behavioral health professionals who are passionate about working together across disciplines to improve client outcomes by valuing collaboration, connection, humility and best-practices.
We want to empower caregivers and educators with the knowledge you need to make informed decisions around promoting behavioral health with the children and young people you work with.
As clinicians, it is our ethical responsibility to provide effective and culturally sensitive treatment for individuals with autism. Addressing diversity in treatment plans is essential to ensure that we meet the unique needs of each individual and create interventions that are respectful, inclusive, and meaningful. Cultural competence plays a crucial role in understanding the influence of culture, ethnicity, language, and other aspects of diversity on an individual’s development and behavior. By embracing diversity and actively incorporating cultural considerations into our treatment plans, we can enhance the effectiveness and social validity of our interventions. This post aims to provide practical strategies to use when creating treatment plans with a culturally sensitive approach. By doing so, we can foster better outcomes and promote equity, inclusion, and respect for all individuals and their families.
Addressing Diversity in Treatment Plans
When considering the social significance of behavior interventions, diversity and culture must be discussed. A comprehensive understanding of the individual’s culture allows us to make ethically sound decisions for treatment. By taking into account the cultural context, we can develop interventions that are relevant, meaningful, and promote the individual’s overall well-being.
Strategies to Incorporate Diversity and Culture when Creating your Treatment Goals
Culturally Relevant Materials: Incorporate materials, resources, and activities that reflect the diversity of the individual’s cultural background. For example, if the child comes from a bilingual or multilingual family, provide materials in their native language to promote engagement and understanding.
Collaborate with Families: Involve the family in the treatment planning process and seek their input regarding their cultural values, traditions, and goals for their child. Respect and incorporate their perspectives to create a collaborative and culturally responsive treatment plan.
Cultural Contextualization of Goals: Tailor behavior change goals to be culturally meaningful and relevant. For instance, if the child comes from a culture where extended family support is highly valued, consider incorporating goals that foster social interactions and connections with extended family members.
Understanding Social Norms: Familiarize yourself with the social norms, customs, and traditions of the individual’s culture. This knowledge can help guide treatment decisions and ensure that interventions align with the cultural expectations and values of the child and their family.
Culturally Responsive Strategies: Adapt behavior change strategies to accommodate cultural differences. For instance, if the child comes from a culture that values communal decision-making, involve the extended family or community members in the treatment process and decision-making.
Sensitivity to Religious Practices: Respect and accommodate religious practices within the treatment plan. Consider scheduling therapy sessions to avoid conflicts with religious obligations or incorporating religious rituals into the session if appropriate and desired by the family. You may even create goals on how to improve participation in religious environments that are significant to the child’s culture.
Training and Professional Development: Continuously engage in cultural competency training and professional development to enhance your understanding of diverse cultures and build your skills in providing culturally sensitive treatment. Stay informed about current research and best practices in the field of cultural competence. Most importantly, if you do not feel competent to serve the client and address your potential cultural biases, it is vital to recognize your own difficulties and provide the family with another clinician that can better suit their needs, whenever possible.
By actively addressing diversity in treatment plans, we can create interventions that are respectful, inclusive, and effective for children with autism from diverse cultural backgrounds. It is essential to approach each child as an individual and tailor treatment plans to their unique needs, cultural values, and experiences.
About the Author
Nicole Gorden, M.S., BCBA, LBA has over 14 years of experience implementing Applied Behavior Analysis principles with the Autism Population. She currently works for Comprehensive Behavior Supports in Brooklyn, NY.
As a black behavior analyst, I have personally witnessed how culture and diversity profoundly impact the effectiveness of treatment for children with autism. It is crucial for us, as professionals, to recognize the role of culture and be conscious of our own biases when creating behavior change programs. We will explore the importance of cultural sensitivity in creating treatment plans and discuss how being attentive to diversity can lead to more ethical and effective interventions. Whether you are a parent, clinician, or teacher, understanding the influence of culture is essential for providing the best support for children with autism.
The Impact of Culture on ABA Treatment
Culture plays a significant role in shaping an individual’s beliefs, values, and behaviors. It influences how we communicate, perceive the world, and respond to interventions. Recognizing and respecting the cultural backgrounds of children with autism is vital in tailoring treatment plans that are both effective and ethical.
Cultural Bias and Behavior Change Programs
As professionals, it is essential for us to examine our own cultural biases. Our biases can inadvertently influence the goals we set and the strategies we employ in behavior change programs. By being aware of our biases, we can ensure that treatment plans are culturally sensitive and respect the unique needs and values of each individual.
For example, a provider working with a child from a collectivist culture may set a goal to increase the child’s independent decision-making skills during play activities. However, in the child’s cultural context, interdependence and collaboration are highly valued, and decision-making is often a shared process among family members. By overlooking this cultural aspect, the clinician’s bias towards individualism may unintentionally disregard the importance of cooperative decision-making, potentially limiting the cultural relevance and effectiveness of the treatment goal.
Cultural Sensitivity and Ethical Considerations
Behavior-change interventions must meet the culturally sensitive needs of the client to be considered ethical. Cultural sensitivity requires us to be attentive and respectful of the individual’s culture, considering how cultural contingencies can support their behaviors and aligning treatment recommendations with the values of their culture. It is crucial to foster an inclusive and culturally responsive environment to promote positive outcomes.
Consider a therapist working with a child from a culturally diverse background who exhibits challenging behaviors during mealtime. The BCBA recognizes that the family’s cultural practices include communal eating, eating with their hands, and the preparation of traditional foods. In this case, an ethically sound intervention would involve understanding and respecting the family’s cultural practices while addressing the challenging behavior. Instead of imposing rigid expectations of eating independently, forcing the child to eat with utensils, or conforming to other Western mealtime norms, the therapist would collaborate with the family to develop strategies that promote positive mealtime experiences while honoring their cultural traditions. This approach ensures that the behavior-change intervention is culturally sensitive and respectful, promoting the client’s well-being while maintaining the integrity of their cultural background.
Promoting Diversity in the Field
As highlighted by Dubay, Watson, and Zhang (2018), “The lack of racial, ethnic, and linguistic diversity in service providers is an issue facing many clinical fields.” Increasing diversity within the field is essential for ensuring culturally competent and effective treatment for individuals from diverse backgrounds. By promoting diversity, we can enhance our understanding of different cultures and provide more inclusive and tailored interventions.
The Importance of Culture in Achieving Socially Meaningful Goals
Recognizing the influence of culture in behavior analysis allows us to design interventions that are relevant, respectful, and aligned with the values of the individual and their community. This leads to interventions that are more meaningful, promote independence, and improve the quality of life for individuals with autism. In addition, it allows our clients to access naturally occurring reinforcement within their own environment which is critical for generalization and maintenance of skills.
Incorporating cultural sensitivity into treatment plans is crucial for creating effective and ethical interventions for children with autism. Recognizing the influence of culture, addressing our own biases, and promoting diversity within the field are key steps toward providing inclusive and meaningful support. By embracing cultural awareness, we can develop interventions that respect and value the unique cultural backgrounds of individuals, leading to better outcomes and enhancing the overall well-being of children with autism.
References
DuBay, M., Watson, L. R., & Zhang, W. (2018). In search of culturally appropriate autism interventions: Perspectives of Latino caregivers. Journal of autism and developmental disorders, 48, 1623-1639.
Fong, E. H., Catagnus, R. M., Brodhead, M. T., Quigley, S., & Field, S. (2016). Developing the cultural awareness skills of behavior analysts. Behavior analysis in practice, 9, 84-94.
About the Author
Nicole Gorden, M.S., BCBA, LBA has over 14 years of experience implementing Applied Behavior Analysis principles with the Autism Population. She currently works for Comprehensive Behavior Supports in Brooklyn, NY.
This month’s ASAT feature comes to us from Kate McKenna, MEd, MSEd, MS, BCBA,and Lindsay Bly, MS, CCC-SLP, Melmark. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!
The science of speech-language pathology in the United States had its roots in the study of elocution, what we now call articulation, for rhetoric debate, and theatre, which had risen to prominence in 18th century England. Several clinicians of the era (e.g., Potter) that were considered legitimate came from the profession of education, medicine, and elocution. With the publication of Speech and its defects. Considered physiologically, pathologically, historically, and remedially (Potter, 1882), the field expanded to include speech and language disorders. Potter provided a taxonomy of all speech disorders and a definition and suggested treatments for each. This publication then became the model for the field of speech-pathology in the early period in its history. Speech production continued to be the primary focus of the field in the United States as reflected by the establishment of the American Academy of Speech Correction, in 1925 at a meeting of the National Association of Teachers of Speech (NATS), held in New York City, whose members wanted to promote “scientific, organized work in the field of speech correction.” (https://www.asha.org/about/history/) The establishment of the Academy was the birth of American Speech-Language Hearing Association (ASHA).
As an organization the Academy has gone through several name changes and in 1978 took its current title of the American Speech-Language Hearing Association (ASHA). The organization that began with 25 charter members now represents over 228,000 speech-language pathologists. Based in Rockville, Maryland, ASHA is committed to a mission of empowering and supporting audiologists, speech-language pathologists, and speech, language, and hearing scientists.
As with the professions of physical and occupational therapy, injuries in the World Wars also spurred growth and diversification in the field of speech and language therapy. Soldiers returning from the battlefields had suffered brain injuries that resulted in aphasia, a language disorder that involves loss of the ability to understand or express speech and language. Consequently, during the 1940’s and ’50s, as brain studies, technological advances, and the development of standardized testing procedures gave rise to more useful receptive and expressive language assessments and treatment techniques, speech therapists began to expand their focus into the treatment of language disorders. The field of speech pathology became speech-language pathology during this time.
Although speech and language disorders can occur by themselves, they often exist together, which is why speech-language pathology is a combined field of study. During the 1960’s through the ’80’s, advances in linguistic studies further enhanced the speech-language pathologist’s understanding and ability to treat a variety of language delays and disorders in persons of any age. In the 21st century, speech-language pathologists have begun to research and treat the pragmatic use of language along with the other areas of communication disorders.
Today’s speech-language pathologist is a professional whose professional practice and expertise is in diagnosis, screening, assessment, and treatment of challenges and difficulties, in the areas of communication, including speech, language, cognition, voice, fluency, resonance and hearing, and swallowing in people of all ages. Moreover, SLPs practice within eight domains of speech-language pathology service delivery: collaboration; counseling; prevention and wellness; screening; assessment; treatment; modalities, technology, and instrumentation; and population and systems. In addition, SLPs engage in five domains of professional practice including: advocacy and outreach, supervision, education, research, and administration/leadership. A speech disorder is identified as when someone has a hard time producing speech sounds and misarticulations, has a voice problem, or stutters when speaking. A language disorder is when an individual experiences difficulties understanding and using language to communicate, sharing their thoughts and emotions, and engaging in conversation with others as a conversational partner.
Education
The education and training of speech-language pathologists is overseen by the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA), which is an entity within the American Speech-Language-Hearing Association (ASHA). ASHA is the national professional, scientific, and credentialing association of speech-language pathologists and audiologists. According to ASHA, to practice as a speech-language pathologist (SLP), a masters, doctoral, or other recognized postbaccalaureate degree from a CAA accredited program is required along with completing 400 supervised clinical hours, with at least 25 hours spent in guided observation and at least 375 hours spent in direct client/patient contact, with 325 completed at the graduate level. Supervision is required in real time and never less than 25% of the student’s total contact with each client/patient. Aspiring speech-language therapists must also pass a Praxis Exam in Speech-Language Pathology and complete a clinical fellowship of at least 36 weeks and 1260 hours of full-time experience or its part-time equivalent. During the clinical fellowship applicants are rated by their mentor according to the Clinical Fellowship Skills Inventory (CFSI), which consists of 18 skill statements covering the areas of evaluation, treatment, management, and interaction. Mentees are judged on accuracy and consistency, which assesses the performance of a skill without error, consistently across cases, as well as independence and supervisory guidance, which measure both the level of independence and the ability to self-monitor skill level and request support as necessary. After being granted a Certificate of Clinical Competency (CCC) from ASHA, speech-language pathologists are required to complete 30 hours of professional development every three years. Other license requirements vary by state.
Speech-Language Pathology Assistants (SLPA) can become certified through three different educational pathways and must complete 100 hours of clinical field work under the supervision of an SLP. In addition, applicants take courses in ethics, universal safety precautions and complete the ASHA online SLPA education modules. As with SLPs, speech-language pathology assistants pass a certification exam and renew their certification every three years.
Standards of Practice and Guiding Documents
In their practice speech-language pathologists are guided by the ASHA Code of Ethics, which reflects the values and expectations for both research and clinical practice. The code is intended to provide a framework for ethical decision-making and professional conduct. Four Principles of Ethics form the philosophical base of the Code: 1) responsibility to persons served professionally and to research participants, 2) responsibility for one’s professional competence, 3) responsibility to the public, and 4) responsibility for professional relationships. The Scope of Practice in Speech-Language Pathology also governs the practice of speech-language pathologists. This document is a framework for practice and describes the domains of service delivery. The work of speech-language pathologists assistants is guided by similar documents, a Code of Conduct, and a Scope of Practice, that describe the limits of service delivery as they work under the supervision of SLPs. A goal of SLPs is to provide evidence-based treatment and interventions to clients. To this end, ASHA has created Evidence Maps, a searchable online tool designed to assist speech-language therapists in making evidence-based decisions in their practice.
Professional Organizations
The American Speech-Language Hearing Association (ASHA), is the professional and credentialing organization for audiologists, speech-language pathologists, scientists studying speech, language and hearing, and has 20 Special Interest Groups (SIG) that indicate the breadth and depth of study in the professions. Its mission is “Making effective communication, a human right, accessible and achievable for all.”
ASHA publishes five peer-reviewed journals. American Journal of Audiology (AJA) is an online only peer-reviewed journal that publishes research and other scholarly articles pertaining to clinical audiology methods and issues. American Journal of Speech-Language Pathology (AJSLP) is an international journal that publishes clinical research on diverse aspects of clinical practice in speech-language pathology, including screening, diagnosis, and treatment of communication and swallowing disorders. Articles in the Journal of Speech, Language, and Hearing Research (JSLHR) touch on speech, language, hearing, and related areas such as cognition, oral-motor function, and swallowing. Language, Speech, and Hearing Services in Schools (LSHSS) focuses on school age children and adolescents and audiological and communication disorders that impact full participation in the school setting. Perspectives of the ASHA Special Interest Groups, a bimonthly online peer-reviewed journal, publishes research related to the 20 SIGs. The ASHA Leader, which highlights the latest research and practice advances in communication sciences and disorders, is a bimonthly newsmagazine for and about audiologists, speech-language pathologists, and speech, language, and hearing scientists available to all ASHA members.
Scope of Practice
The SLP profession falls under the larger discipline of communication sciences and disorders, which also includes audiology. Speech-language pathology is focused on a range of human communication and swallowing disorders affecting people of all ages. The practice of speech-language pathology includes those who want to learn how to communicate more effectively, such as those who want to work on accent modification or improve their communication skills. It also includes the treatment of people with tracheostomies and ventilators and those who use Augmented and Alternative Communication such as manual signs, gestures, picture or letter communication boards, and speech generating devices.
Speech is a verbal form of communication that is comprised of articulation, how speech sounds are produced (e.g., manner, placement, and voicing), voice, the coordination of the breathing/respiratory apparatus and vocal cords to produce those sounds, and fluency, the rhythm of speech. Speech problems often occur because a person has difficulty producing sounds due to difficulties or incorrect movement or development of the lips, tongue, and mouth, and/or coordination of the speech motor and respiratory mechanism. Language consists of socially shared rules that govern what words mean, how new words are created, and how words are put together in sentences. It also includes what we call the pragmatics of language, the socially accepted rules for interacting in daily life. This includes non-verbal communication (eye contact, facial expressions, body language) as well as conversational skills such as turn taking, asking questions, appropriately maintaining conversations, and adjusting language and vocabulary based on the situation. Speech-language pathologists treat both receptive (difficulty understanding others) and expressive language disorders (difficulty communicating thoughts, ideas, and feelings).
Stuttering: Interruption in the flow of speaking characterized by specific types of disfluencies.
Cluttering: Characterized by a perceived rapid and/or irregular speech rate, atypical pauses, maze behaviors.
Speech Production Disorder:
Motor planning and execution disorders:
Childhood speech apraxia: Neurological childhood speech sound disorder resulting from neuromuscular difficulties, such as abnormal reflexes or abnormal tone.
Adult speech apraxia: Speech disorder caused by neuromuscular difficulties, such as abnormal reflexes or abnormal tone; usually because of stroke, traumatic brain injury, dementia, or other progressive neurological disorders.
Speech sound disorders:
Articulation: Errors (e.g., distortions and substitutions) in production of individual speech sound
Phonological: Predictable, rule-based errors (e.g., fronting, stopping, and final consonant deletion) that affect more than one sound.
Language Disorder:
Language disorder: A significant impairment in the acquisition and use of language across modalities due to deficits in comprehension and/or production across any of the five language domains (i.e., phonology, morphology, syntax, semantics, and pragmatics).
Written language disorder: A significant impairment in fluent word reading (i.e., reading decoding and sight word recognition), reading comprehension, written spelling, and/or written expression. Dyslexia – word reading disorder.
Areas of language include phonology, morphology, syntax, semantics, pragmatics (language use and social aspects of communication), prelinguistic communication (e.g., joint attention, intentionality, communicative signaling), paralinguistic communication (e.g., gestures, signs, body language), literacy (reading, writing, spelling)
Cognition:
Cognitive-Communication Disorders: Difficulties paying attention, planning, problem-solving, or organizing their thoughts. Many times, these disorders occur because of a traumatic brain injury, stroke, or dementia.
Voice:
Voice disorders: Includes vocal cord nodules and polyps, vocal cord paralysis, spasmodic dysphonia, and paradoxical vocal fold movement.
Dysarthria: Impaired movement of the muscles used for speech production, including the vocal cords, tongue, lips, and/or diaphragm.
Resonance Disorder:
Resonance disorders: Too much or too little nasal and/or oral sound energy in the speech signal.
Feeding and Swallowing:
Swallowing Disorders: Difficulty eating and swallowing. Swallowing disorders are often a result of an illness, injury, or stroke.
Speech, language, communication, and listening skills impacted by hearing loss, deafness.
Auditory processing
SLPs practice in many settings including schools, homes, and hospitals. They also provide services to those in outpatient clinics or in long-term care facilities. In addition to working with adults with persistent speech/language needs who were diagnosed with developmental disabilities from a young age, SLPs work with people across the lifespan, providing care and treatment in early intervention to working with adults with whom a major medical event may have caused a speech or language disorder. They also work in mental and behavioral health settings. SLPs are also involved in academia and research advancing the knowledge base of the field. Given the various settings that SLPs work in, overlapping scopes of practice across health care, educational and other settings is a reality. As such, SLPs engaged in interprofessional collaborative practice to ensure that individuals served will benefit from the collaborative comprehensive approach, receive effective interventions that lead to meaningful and best health and educational outcome.
Speech-language pathologists are health care professionals who identify, assess, and treat speech, language and swallowing disorders, preventing, and treating communication disorders in people of all ages. The principles and code of ethics that guide members of the profession highlight safeguarding human dignity, protecting the rights of individuals seeking treatment, celebrating diversity, and embracing collaboration in their efforts to ensure that the individuals with whom they work can communicate effectively.
We would like to thank Dr. Lina Slim for her contributions to this article. We appreciate her insight and expertise.
References
American Speech-Language-Hearing Association. (1970, January 1). Assistants code of conduct. American Speech-Language-Hearing Association. Retrieved February 24, 2023, from https://www.asha.org/policy/assistants-code-of-conduct/.
American Speech-Language-Hearing Association. (1970, January 1). Scope of practice in speech-language pathology. American Speech-Language-Hearing Association. Retrieved February 17, 2023, from https://www.asha.org/policy/sp2016-00343/.
American Speech-Language-Hearing Association. (n.d.). History of Asha. American Speech-Language-Hearing Association. Retrieved February 24, 2023, from https://www.asha.org/about/history/.
American Speech-Language-Hearing Association. (n.d.). National Outcomes Measurement System (NOMS). American Speech-Language-Hearing Association. Retrieved February 24, 2023, from https://www.asha.org/noms/.
A Brief History of SPEECH-LANGUAGE PATHOLOGY. History of the Professions – Health Sciences Library – University of North Carolina at Chapel Hill. (n.d.). Retrieved February 24, 2023, from https://hsl.lib.unc.edu/speechandhearing/professionshistory.
Bullett, M. S. (1985). Certification Requirements for Public School speech-language pathologists in the United States. Language, Speech, and Hearing Services in Schools, 16(2), 124-128. https://doi.org/10.1044/0161-1461.1602.124
McKenna, K., & Bly, L. (2023). Focus on the treatment team: Speech-Language Therapy. Science in Autism Treatment, 20(5).
About the Authors
Kate McKenna, MEd, MSEd, MS, BCBA, LBA, received a Masters in Child Study from the Eliot-Pearson Department of Child Study at Tufts University, a Masters in Special Education from Pace University, and a Masters in ABA from Hunter College. In addition to New York state certifications in general and special education from Birth to Grade 2 and Grades 1-6, she holds a New York State Annotated Certification in Severe/Multiple Disabilities. Kate is currently completing a Masters degree in Children’s Literature at Eastern Michigan University. She was an extern at the Association for Science in Autism Treatment before joining the Board of Directors in 2020.
Lindsay Bly, MS, CCC-SLP, is an ASHA certified speech language pathologist. After receiving her master’s degree at Clarion University of Pennsylvania, she began specializing in dysphagia management and augmentative and alternative communication (AAC) evaluation and implementation. In 2018, Lindsay assumed a newly created speech language pathologist position in the intermediate care facility (ICF) at Melmark. Lindsay develops, creates, and collaborates on protocols to minimize the risk of aspiration in medically complex patients with significant and multiple disabilities including a rigorous evaluation schedule and maintenance treatment for all at risk patients. Lindsay has a passion for management of oropharyngeal dysphagia and maximizing quality of life through least restrictive and safest diets.
Reposted with permission from Action Behavior Centers
Applied Behavior Analysis therapy, most commonly known as ABA therapy, has grown to become the leading therapy for children with autism. Board Certified Behavior Analysts (BCBAs) primarily work with children on the autism spectrum and their families. As the field continues to grow, it is important to identify potential variables that will lead to a family choosing behavioral therapy (in this case ABA therapy) for their autistic child.
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Action Behavior Centers (ABC) is an organization committed to the treatment of children using empirically validated methods and strategies to assist each child in reaching his or her greatest potential and improving their quality of life.
