Category Archives: From the Experts

Can the principles of ABA be used to toilet train a child with an autism spectrum disorder?

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This month’s ASAT feature comes to us from Dr. Frank Cicero, Ph.D., BCBA, LBA. 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!

Here is the good news…children with autism can be toilet trained through the exact same methods that are used with typically-developing children. And what are these methods? Applied behavior analysis! If you have ever toilet trained a typically-developing child, you probably used a combination of praise and rewards for going on the toilet, explaining your expectations, removing the child‘s diaper, prompting to the toilet on some type of schedule, rushing him or her to the toilet when they seemed like they needed to go, and teaching how to notify you that he or she needs to use the bathroom. You might or might not have added in some form of punishment or verbal reprimand for accidents. Well…here is my advice for toilet training a child on the spectrum…use exactly the strategies that I just described.

So then, why does it seem so much more difficult? One of the biggest obstacles is simply getting started. Because parents think that toilet training will be very difficult, and something so different than anything else they have taught their child in the past, they delay training. Toilet training for a girl typically is recommended to begin at around two years of age. For a boy it is a little later (about two and a half). When it comes to a child with a developmental disability it is difficult to use these age guidelines. Instead, a child is ready to begin training when they can hold urine in the bladder for at least 1 hour, can remain seated on a toilet for at least three minutes, have an awareness of the relationship between following instructions and getting rewarded, and do not have significantly interfering problem behavior. Another challenge with toilet training a child on the spectrum is the absolute need for consistency and intensity of training once you begin. The more intense you implement a plan, the quicker you will see results. For the most intense procedure, I recommended toilet training for at least 6-8 hours per day. I also usually implement the training directly in a bathroom with the child wearing the least amount of clothing possible (usually underwear, shirt and socks). In this way, he or she can easily get to the toilet when needed and also you, as the trainer, can easily and quickly see when they are beginning to have an accident.

Toilet training consists of four main components: prompting to the toilet on a schedule, rewarding success, teaching how to request, and quickly prompting to the toilet at the start of an accident. For the schedule, I usually recommend starting with 30 minutes. The child sits on the toilet and tries to urinate for 1 minute. If the child is successful, immediately provide him/her with a very powerful reward with verbal praise. If the child is not successful, simply prompt him/her to try again in 30 minutes. In order to teach requests, prompt the child to request the bathroom each time you are about to prompt him/her to the toilet. You can use whatever communication system (i.e., verbal speech, picture exchange, signs, etc.) your child is used to and does best with.

Now, what to do with the accidents? Accidents in toilet training are a good thing. In fact, without accidents, you will only be reinforcing prompted trips to the toilet, thereby resulting in a child that is schedule trained instead of independent. You have two choices here, prompting/reinforcement or punishment. I usually recommend the first choice, prompting/reinforcement instead of punishment, at least in the beginning of training. Try encouraging a lot of drinking during training hours. Within the first second of the child having an accident, produce a loud verbal startle such as “HURRY, HURRY, HURRY.” This is not a reprimand but should be stated in a very loud, surprising, urgent tone of voice. The idea is to temporarily produce a startle response in the child so that urination is reflexively held for a brief moment. In that moment, you physically prompt the child to the toilet, where you instruct him or her (now in a very calm voice) to continue their urination. If they continue (which is likely), you reward the behavior with a reward and verbal praise. In this way, you turned an accident into a positive teachable moment. Continue with these strategies until the child begins to show fewer accidents, goes more on the schedule and begins to independently request. Throughout training it is very important to collect data on accidents and successes, so that you can make data-based decisions along the way. Fade the intensity of the schedule, fade out of the bathroom and ultimately fade the tangible rewards. With this intensive treatment program, I have seen complete training in as little as 1 week; however do not get discouraged if your child takes longer. What about training for bowel movements? Good news….you often get bowel training along with urination training without doing any additional procedures. Bad news…this is not always the case. When a child is trained for urination, but continues to have bowel accidents, you need to figure out the reason behind the problem before you can treat it. Is it simply a lack of knowledge? An ingrained ritual or routine? Noncompliance? A medical problem such as constipation? The nature of the accidents will guide your treatment. Very briefly, if the problem is a lack of knowledge, a reinforcement / punishment procedure should work. This procedure is similar to the procedure that I described for urination training, except that it is rarely implemented for 6-8 hours per day. Instead, you bowel train only when the child is likely to need to have a bowel movement. If the problem is more consistent with a ritual or noncompliance, you need a traditional behavior plan more than a toilet training intervention. And finally, if the problem is medical in nature, follow the recommendations of a physician or dietician.

Please use the following format to cite this article:

Cicero, F. (2009). Clinical corner: Toilet training. Science in Autism Treatment, 6(1), 3-4.

About The Author

Dr. Frank Cicero, Ph.D., BCBA, LBA is a New York State licensed psychologist, licensed behavior analyst and board certified behavior analyst with over 20 experience working in the fields of applied behavior analysis and autism spectrum disorders. He received his master’s degree in school psychology from St. John’s University and his doctoral degree in educational psychology from the City University of New York Graduate Center. Dr. Cicero is currently an assistant professor and aba program director for Seton Hall University, New Jersey. Prior to this position, he served as the Director of Psychological Services for the Eden II Programs, an applied behavior analysis agency in the New York City area serving children and adults on the autism spectrum. Dr. Cicero continues a private practice for child/adolescent psychology and aba as well as conducts program consultations in best practice treatment for autism, developmental disabilities and problem behavior. Dr. Cicero frequently conducts workshops and trainings nationally on a variety of topics within his fields of expertise. He also has several publications including peer reviewed articles, book chapters and a training book titled “Toilet Training Success.”

Ten tips to prevent autism-related shopping meltdowns

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This week’s blog comes to us from Lucia Murillo, Autism Speaks’ assistant director of education research. and was originally posted on Autism Speaks as part of their Got Questions? series.

“How can I help my child avoid meltdowns at the store? Everything is okay with him until he gets into the store.”

Thanks so much for your question. You are far from alone in this challenge. For good reason, outings such as shopping can be particularly challenging for families who have children with autism.

The abundance of sights, sounds, crowds and other sensory stimuli can easily trigger challenging behaviors that seem near-impossible to handle in a public place. Unfortunately, this prompts many families to avoid taking children with autism to public places unless absolutely necessary. This, in turn, can contribute to isolation for the whole family.

So I’m so pleased for this opportunity to share a few meltdown-prevention strategies that, when practiced ahead of time, can help promote a calmer shopping experience.

But when I say “ahead of time,” I don’t mean right before you head to the store. These strategies involve time and patience. Ideally, you’ll also have the guidance of a behavioral therapist skilled in working with children who have autism.

#1 Give fair warning
Research and experience tells us that “knowing what to expect” helps children with autism cope with potentially stressful situations. This means resisting the understandable temptation to try to sneak a quick shopping trip into your son’s day. Whenever possible, I strongly recommend letting him know ahead of time where he is going and what he can expect.

#2 Take a virtual tour 
You and your son may be able to take a virtual tour of the store on the store’s website. If that’s not available, consider visiting the store on your own to take pictures and/or a cell-phone video.

This approach is particularly useful for preparing your child to accompany you to a new store. Sit down and look at the pictures and/or watch the video together so your son can become familiar with the new environment.

You might even take a virtual drive to the store using Google Maps.

#3 Practice and build tolerance

When you feel your child is ready to make an actual trip to the store, I suggest starting with a short trip and small purchase. Reward any degree of success with praise and perhaps a small prize or favorite activity.

As you sense your child is getting more comfortable with the short trips, gradually increase the length of time that the two of you are in the store. At this point, try to incorporate these trips into a regular routine – but always with fair warning – so your child can learn to expect them.

Repetition is important. And occasional reversals are likely. So don’t give up!

#4 Prepare a schedule 
Many children – and adults – on the autism spectrum greatly benefit from having a clear schedule for the day ahead. Visual schedules are particularly helpful, and the Autism Speaks visual supports guide can help you make one.

A morning review of the day’s activities can help your child gain a sense of where he’s going and what he’ll be doing. So on the morning of a shopping trip – or even the night before – sit down with your child as you add a shopping trip to the schedule. Or invite him to add it at the specified time.

It can help to schedule one of your child’s favorite activities following the shopping trip and together enter it on the day’s schedule. This can be as simple as time to play with a favorite toy or game with you.

#5 Remember: Rest is best
It can greatly increase your son’s chances of success if you make sure he’s well rested before the outing. In fact, the same goes for you! Being tired tends to shorten everyone’s tolerance.

#6 Identify triggers 
You know your child best. Are there certain sights, sounds or situations that tend to produce to a meltdown? You might try visiting the store without your son with an eye for such triggers. For some people with autism, fluorescent lighting is a trigger. Others are bothered by the loud hum of air conditioners or the blare of clerks calling to each other over the intercom.

#7 Provide personalized “armor”
Identifying triggers enables you to provide personalized support. For example, if loud sounds provoke anxiety in your son, he might be helped by headphones. If overhead lighting is a problem, he might be willing to wear sunglasses or a baseball cap. Many parents find these strategies make a world of difference for their kids.

#8 Getting ready to shop …
Before leaving the house, consider prompting your son with a finer breakdown of what you’re going to do on this shopping trip. For instance:

* We will drive to the store.

* We will park in the lot.

* We will walk into the store.

* We will find the items we want.

* We will pay for them at the register.

* We will walk back to the car.

* We will drive home.

* And we will play a game of Uno.

If, like many people with autism, your child responds best to visual information, try making a personalized story with pictures about the above steps. Autism Speaks has partnered with the University of Washington READI Lab to provide a series of personalized story templates that include Going to the Store. Learn more and download them for free here.

#9 Have a signal
Make sure there’s a way for your child to communicate to you when he begins to feel overwhelmed. We know that children who have autism vary widely in their ability to communicate. So one child might be able to simply say “I need a break.” Another might need to learn a sign – such as hands over ears. Picture communication systems are yet another option. (See the Autism Speaks visual supports guide mentioned above.)

Even if you child can’t reliably communicate when he’s getting overwhelmed, there are often behavioral cues that you can learn to recognize in time to leave the store or otherwise provide support before the meltdown.

#10 Bring “cool down” items
Meltdowns happen. Sometimes, having a favorite comfort item on hand can help ease the crisis.Despite all the best plans, meltdowns happen. You can ease the crisis by bringing an object or activity that you know will soothe. This could be a favorite toy or blanket. It could be a special little song.

All these strategies have the same goal: To provide optimal conditions for your child when taking him into an overly stimulating environment. By preparing ahead of time, you can increase the chances that the shopping trip – or any outing – will be more tolerable for your child and entire family.

 

Teaching Safety Skills to Adolescents

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This month’s ASAT feature comes to us from Shannon Wilkinson, M.ADS, BCBA. 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!

I am a Special Education Teacher at the high school level. A young man with autism is transitioning to my caseload from our middle school. Although there is much talk about “safety skills” amongst my colleagues, I would like to target this skill area effectively and comprehensively. Any suggestions?

Safety skills are important for learners with autism and should be addressed comprehensively over the course of the learner’s schooling and across the lifespan. The type of safety skills taught at any given time will vary depending on the learner’s age and functioning level. For example, younger learners can be taught to walk appropriately with an adult so they do not run into the street while older learners can be taught to cross the street independently. Regardless of age, safety skills should be included on the learner’s Individualized Education Plan (IEP) and reflect the goals of the individual and their families. In addition, data collection on the targeted skills is essential to ensure the learner is acquiring the skill and that the skill maintains over time.

An effective method to teach safety skills is Behavioral Skills Training (BST). BST is a comprehensive teaching method which includes delivering instructions to the learner, modeling the correct response, rehearsing the correct response in both pretend and more naturalistic environments, and delivering feedback to the participant regarding their actions. If the learner is having difficulty acquiring the skill, an additional teaching component known as In Situ Training (IST) can be added. In IST, the trainer provides immediate and direct training in the learner’s environment and allows for additional practice of the skill. Within the literature, BST and IST have been shown to be effective for teaching a wide range of safety skills such as abduction prevention skills (Beck & Miltenberger, 2009; Gunby, Carr & LeBlanc, 2010; Johnson et al., 2006) and how to seek assistance when lost (Pan-Skadden et al., 2009).

There are a number of safety skills that that could be targeted for an adolescent with autism. Targeting those that also increase independence should be a priority if appropriate, based on the adolescent’s level of functioning. Teaching him to use a cell phone is one such skill, as it can be used to improve his safety and overall independence (Hoch, Taylor, & Rodriguez, 2009; Taber, Alberto, Seltzer & Hughes, 2003). First, you will want to ensure the learner has the basic skills associated with cell phone use including: answering the phone, following directions on the phone, answering questions on the phone and negotiating all of the mechanisms associated with initiating a call. Once these basic skills are mastered, specific safety skills involving the phone can be taught. For example, a learner can be taught to answer his cell phone and provide a description of his location in the event he is separated from his caregiver or group. He could also be taught to follow instructions to seek assistance from a community member if lost (Hoch, Taylor, & Rodriguez, 2009; Taylor, Hughes, Richard, Hoch & Coello, 2004) or to call a trusted adult.

A major safety concern for most parents is abduction. Although abduction may be more likely with a young child, adolescents with autism should still be taught to identify “safe people” such as police officers, fire fighters and security guards, in the community. Many learners with autism are not able to distinguish safe or familiar people from unsafe or unfamiliar people. As a result, they cannot determine whom they can speak to or make a request for help. Learners can first learn to identify safe people, such as those noted above, in pictures. Once they can reliably do so, they should be taught what to do if a stranger approaches them. Multiple scenarios should be practiced so the learner becomes familiar with potential lures such as a stranger offering candy to get in a car or telling the student that his mom told the stranger to pick him up. Behavioral skills training and In Situ Training may be beneficial in teaching these skills (Beck & Miltenberger, 2009; Gunby, Carr & Leblanc, 2010; Mechling, 2008). In this scenario, the learner would first be provided instructions on what to do in each stranger situation. The learner should then model the correct response. If he does so successfully, a mock scenario can then be set up whereby a confederate approaches the learner and the learner has the opportunity to demonstrate the skills he has learned (i.e., do not go with the stranger, run away and tell an adult). If the learner performs the correct actions, he receives praise. If the learner does not demonstrate the correct response, the instructor immediately provides him with additional training.

Additional safety skills to target could include:

  • navigating and using community resources appropriately and independently;
  • exiting a car and crossing a parking lot or busy street safely;
  • responding appropriately in emergency situations such as a fire or earthquake;
  • addressing potential household hazards such as responding safely to cleaning chemicals, using appliances properly, or answering the doorbell when it rings;
  • identifying a need to dial 911;
  • using basic first aid procedures;
  • interacting appropriately with pets and other animals;
  • using the internet safely; and
  • managing teasing and bullying

 

There are many others that can be addressed based on the learner, his individualized goals and his future educational, vocational and residential placements. Involving the learner’s parents in the planning process will help you to identify which safety skills are most important and relevant for the individual to learn, particularly if the parents have specific concerns or if there has been a history of unsafe behavior. Finally, as you go through this program planning process, it’s helpful to keep in mind that the essential goal in teaching these skills is to promote greater independence by ensuring the learner has the tools he needs to be safe and to protect himself in his environment.

References

Beck, K. V., & Miltenberger, R. (2009). Evaluation of a commercially available program and in situ training by parents to teach abduction-prevention skills to children. Journal of Applied Behavior Analysis, 42, 761-772.

Gunby, K. V., Carr, J. E., & Leblanc, L. A. (2010). Teaching abduction-prevention skills to children with autism. Journal of Applied Behavior Analysis, 43, 107-112.

Hoch, H., Taylor, B. A., & Rodriguez, A. (2009). Teaching teenagers with autism to answer cell phones and seek assistance when lost. Behavior Analysis in Practice, 2, 14-20.

Mechling, L. C. (2008). Thirty year review of safety skill instruction for persons with intellectual disabilities. Education and Training in Developmental Disabilities, 43, 311-323.

Pan-Skadden, J., Wilder, D. A., Sparling, J., Stevenson, E., Donaldson, J., Postma, N., et al.(2009). The use of behavioral skills training and in-situ training to teach children to solicit help when lost: A preliminary investigation. Education and Treatment of Children, 32, 359-370.

Taber, T. A., Alberto, P. A., Seltzer, A., & Hughes, M. (2003). Obtaining assistance when lost in the community using cell phones. Research and Practice for Persons with Severe Disabilities, 28, 105-116.

Taylor, B. A., Hughes, C. E., Richard, E., Hoch, H., & Rodriquez-Coello, A. (2004). Teaching teenagers with autism to seek assistance when lost. Journal of Applied Behavior Analysis, 37, 79-82.

About The Author 

Shannon Wilkinson, M.ADS, BCBA is a Supervising Therapist with TRE-ADD program at Surrey Place Centre in Toronto, which is a comprehensive day treatment program that provides services for children and youth with autism and related developmental disorders and their families. Shannon has worked in the field of autism for 13 years, starting as an Instructor Therapist. She is particularly passionate about working with adolescents and has taught many vocational and life skills over the years. Shannon has a Masters in Applied Disability Studies from Brock University and is a Board Certified Behaviour Analyst.

How Can Parents Find Effective Reinforcers?

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This week, Leanne Page M.Ed, BCBA, answers a parent’s question on creating effective token economies.  

This piece originally appeared on bsci21.org.

“Dear Behavior BFF, I’ve tried using a token economy and it helped for a little while. But lately my son has told me that he doesn’t want to earn stickers and he doesn’t care about the new toy he can get from his sticker chart. What do I do?”

First of all- good job using some behavior analysis to help increase desired behaviors in your family! A token economy is a great tool.

Now- a token economy is a great tool when it is combined with great positive reinforcement. What your message is telling me is that it’s not the token economy that is the problem. The rewards you are offering your son are not reinforcing. It sounds like they were super reinforcing and effective for a while, but your son is just not that into these rewards anymore.

So what do you do? Throw out the whole token economy system? No! Let’s find some more effective reinforcers to help you be successful again.

As parents, we assume we know what our kiddos like. We know what they are into, what they want, and what their preferred items are. But sometimes the things they will work to earn may surprise us.

Our kids may become satiated or habituated to the rewards we are offering them. This means they have had enough and it’s no longer piquing their interest. No matter what the cause, what we do know is that our children’s preferences change. To use effective positive reinforcement, we must identify what is reinforcing to our child at this point in time.

Enter preference assessments.

A preference assessment encapsultes “a variety of procedures used to determine the stimuli that the person prefers, the relative preference values of those stimuli, and the conditions under which those preference values change when task demands, deprivation states, or schedules of reinforcement are modified” (Cooper, Heron, & Heward, 2014).

As parents, we can do this in a number of ways.

  1. Observe your child and see what they choose to play with. This can take place at home but also outside your home. If you go to a friend or family member’s house, what things does your child choose to interact with? If you go to a museum, bookstore, other outings, what interests does your child show?
  2. Make a list of things/activities you think would be good reinforcers and ask your child how he feels about them. Depending on age and ability you could have him rate them on a scale of 1-10 or have them choose a happy face for each one. You could read each item and have your child give thumbs up, thumb sideways, or thumbs down to indicate preference. If you can’t think of ideas, google it. There are many reinforcer surveys or preference assessment checklists floating around on the internet.
  3. Let your child generate the list. Ask “What do you want to earn?” Let them say the big things that are unlikely and help to identify ones that are reasonable.
  4. If you are going to use new items- let your son choose. Take your child shopping. I let me daughter pick one or two things from the dollar spot every time we go to Target. She doesn’t get to keep them that day. She puts them in her prize bag to earn with good behavior or reaching goals on a token economy.

Any time we have a valid system of positive behavior supports in place, such as your token economy, and it stops working- it’s not the system. It’s the reinforcement. The reinforcement you are offering is simply not strong enough.

Up the ante. Give better options for rewards. Identify potential reinforcers by conducting a preference assessment. Let your son choose his reinforcer.

Whenever there is a new problem behavior, or a behavior management system not working- my first response is increase the positive reinforcement for appropriate behaviors.

Be prepared to continue to do preference assessments every once in a while. Our children’s interests and preferences change, so if we stay in the know we can have effective reinforcers at hand.

References

Carr, J. E., Nicolson, A. C., & Higbee, T. S. (2000). Evaluation of a brief multiple‐stimulus preference assessment in a naturalistic context. Journal of Applied Behavior Analysis, 33(3), 353-357.

Cooper, J.O, Heron, T.E., & Heward, W. L. (2014). Applied behavior analysis. Pearson Education International.

DeLeon, I. G., Fisher, W. W., Rodriguez‐Catter, V., Maglieri, K., Herman, K., & Marhefka, J. M. (2001). Examination of relative reinforcement effects of stimuli identified through pretreatment and daily brief preference assessments. Journal of Applied Behavior Analysis, 34(4), 463-473.

Leanne Page, MEd, BCBA, is the author of Parenting with Science: Behavior Analysis Saves Mom’s Sanity. As a Behavior Analyst and a mom of two little girls, she wanted to share behavior analysis with a population who could really use it- parents!

Leanne’s writing can be found in Parenting with Science and Parenting with ABA as well as a few other sites. She is a monthly contributor to bSci21.com , guest host for the Dr. Kim Live show, and has contributed to other websites as well.

Leanne has worked with children with disabilities for over 10 years. She earned both her Bachelor’s and Master’s degrees from Texas A&M University.  She also completed ABA coursework through the University of North Texas before earning her BCBA certification in 2011. Leanne has worked as a special educator of both elementary and high school self-contained, inclusion, general education, and resource settings.

Leanne also has managed a center providing ABA services to children in 1:1 and small group settings. She has  extensive experience in school and teacher training, therapist training, parent training, and providing direct services to children and families in a center-based or in-home therapy setting.

Leanne is now located in Dallas, Texas and is available for: distance BCBA and BCaBA supervision, parent training, speaking opportunities, and consultation. She can be reached via Facebook or at Lpagebcba@gmail.com.

10 Common Mistakes Parents Make In Playing With Their Children With ASD

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This week’s post comes to us from Stephanny Freeman, PhD and Kristen Hayashida, MEd, BCBA, and Dr. Tanya Paparella, our partners on the Play Idea Cards app. Play Idea Cards is a full curriculum on teaching play – right in the palm of your hand! Check it out on the Apple App Store! 

Parents of young children with developmental disabilities are truly tireless. At times when one would think a break could be had – the time when they get to enjoy watching their children play, enjoy a conversation with another adult while their children play, or even relaxing by playing and having fun with their children – instead they are working with and teaching their children…and rightly so!

 
I’ve spent a good part of my career watching parents play with their young children with a variety of developmental disabilities (severe intellectual delay, Down syndrome, and autism spectrum disorder). Across the board, parents are remarkable. In a beautiful coordination of grace and direction, they work on controlling behavior, developing language, teaching concepts, maintaining attention, and building fun and relationships. Parents of children with disabilities are more directive and more instructional – yielding evidence of tremendous benefits for their children’s development as a result of these tireless warriors.

 
Children with autism in particular, have a significant and very specialized deficit in their ability to play with toys. Sometimes it can be in the functional domain but it is always difficult for them to think symbolically and abstractly about play. Teaching play to children with ASD is incredibly important and parents know this – they try!
For parents of children with ASD, here are 10 mistakes that are commonly made during play that can really disrupt their child’s growth in play.

 
1. Thinking that play develops on its own and randomly. Play in neurotypical children develops generally in a sequence and children with ASD do not naturally follow or progress through that sequence. Most books you find on children’s play show a fairly consistent developmental pathway for play. Skills build upon skills. Children start with very functional and constructional acts and develop into symbolic and creative play.

 
2. Forgetting to use play to actually teach play. Parents often use play to teach other skills (e.g. language or early concepts). Children with ASD have a core deficit in play so take time during your play with your child to actually teach them how to play with the toys regularly.

 
3. Thinking that your child will love play right away. For children with ASD, symbolic play is very difficult and likely your child would rather do other things than play. For example, a child with ASD may rather roll a car down a ramp repetitively then have the car “feel hungry” and go to the gas station for some “food.” It actually falls on the parent, at first, to convince the child that play is fun! This means you must have high positive affect (e.g., show excitement in your body language and in your words), work through difficulties with a huge smile, and laugh and enjoy using positive language.

 
4. Playing at a level that is way too difficult. Knowing what your child can do will help you teach them what comes next. If you child is just starting to put puzzles together, asking them to pretend to be Buzz Lightyear and talk like him is much too difficult.
5. Forgetting to imitate. It is critical for engagement building to imitate your child’s appropriate play behavior. Directiveness is still great but integrate imitation in your play. You should have a good balance of both. If your child is building blocks, grab a few and copy your child.

 
6. Constantly shifting your child’s attention. Sometimes it is necessary to move your child away from something that is a perseveration or a repetitive interest but in general, try to stick with what your child is doing. Sustained engagement with toys and people in coordination is a great skill and something children with ASD need to work on. It’s not a race to see how many different things you can do during a play time. Be patient and tolerant and build off of their interests rather than shifting their attention. Enjoy playing similar routines every time you play – just slowly build off of them.

 
7. Prompting intrusively. Starting off by hand-over-hand prompting or being very verbally directive (“put that block here and the train here”) your child is forced to shifts their attention without their own consideration. Instead, focus on what they pick up or are interested in, then move them forward by showing them something related to what they are doing, or general verbal comments (“Boy, that doll is super hungry!” as your child is holding a piece of play food).

 
8. Being concrete. If your child wants to do something a little imaginative, don’t bring them back to the concrete. If a child grabs a block and starts to eat it like a burger, please don’t tell them “It’s not food it’s a block!” Instead, imitate and say, “You have a burger, I have a hot dog!”

 
9. Missing the surprise factor. Every play session, even if it’s pretty routine and organized, should include something surprising by the parent. Parents should throw in a fun “wrench” and make a huge facial expression that indicates surprise. It’s called “violating” a routine or a play scheme. So if Mickey Mouse always goes to his top bunk in the play house, make sure one day the top bunk has cats in it! Your child will laugh and you can laugh too. This makes for enjoyment and further eye contact and engagement. It also facilitates problems solving.

 
10. Allowing your child to get away from play. Although the prior points suggest to following your child’s lead and imitate, the line should be drawn when your child doesn’t follow through with play. So if you are playing with your child’s interest (e.g. play food) and you make the suggestion of showing him dolls or plates or cups, then you verbally request his participation, he must follow through. Don’t allow your child to not follow through on play. Remember it’s a core problem for them so it’s hard!

 
Although play is still a “work” time for parents, hopefully these tips will help make it smoother and more enjoyable for everyone. This builds interest, sustained engagement, longer schemes and ideas for play, and positive practice of play skills. Ready Set PLAY!

About The Authors

Dr. Stephanny Freeman is a clinical professor at UCLA, a licensed clinical psychologist, and Co-Directs the Early Childhood Partial Hospitalization Program (ECPHP).  For 20 years, she has educated children with ASD and other exceptionalities as a teacher, studied interventions for social emotional development, and designed curriculum and behavior plans in school and clinic settings.

Kristen Hayashida is a Board Certified Behavior Analyst at the UCLA Early Childhood Partial Hospitalization Program (ECPHP).  For the last 10 years she has served as a therapist, researcher and educator of children and families living with autism spectrum disorder through the treatment of problem behavior.

Dr. Tanya Paparella is a specialist in the field of autism having spent more than 20 years in intervention and research in autism. She is an Associate Clinical Professor in the Division of Child Psychiatry at UCLA, a licensed clinical psychologist, and Co-Director of UCLA’s Early Childhood Partial Hospitalization Program (ECPHP), an internationally recognized model treatment program for young children on the autism spectrum.

Ethics Part Two: More on the Right to Effective Treatment

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This is part two in a series on ethics and effective treatment. Part one can be found here.

 

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In Part One, I discussed the right to effective treatment as detailed by the Professional and Ethical Compliance Code for Behavior Analysts. An essential part of effective treatment is providing, as the code specifies, “scientifically supported, most-effective treatment procedures” (BACB, 2014). In order to do this, behavior analysts must contact the research literature to fully understand scientifically supported treatments. They should do this through reading journal articles, but also through attending workshops, trainings, and local conferences.
Reading journal articles should be a regular activity for behavior analysts. It is suggested that behavior analysts set aside two to four hours per week to read recent journals (Bailey & Burch, 2016, p. 24). This may seem like a lot of time, especially if you aren’t currently doing it. But this practice allows you to stay abreast of current research and have access to a broader range of possible interventions. You may also find it easier to follow through if you participate in a journal club (click here to see suggestions for that.).
Most of the behavior analytic research you’ll find is comprised of single-subject studies. You may get pushback from professionals or parents who are accustomed to seeing research with very large numbers of participants and an explanation of average results. It’s important to understand how to address those concerns in an accessible and accurate way. Here are some things to consider:
• Behavior analytic research does not utilize averages. Therefore, we learn a lot about the specific individuals who responded to an intervention, and can make a more accurate hypothesis about whether or not that intervention will work for a particular client. Furthermore, research based on averages doesn’t provide any information on the percentage of individuals who did not respond to the intervention and WHY they did not respond to the intervention. This is important information that we’re missing out on!
• Behavior analysis is focused on creating individualized interventions. We do not believe in a one-size-fits-all approach, but rather in a set of principles of behavior. Individualizing treatment means that we are looking at the environment, the basic characteristics of the individual, the motivations of the individual, and the functions of a behavior when creating an intervention. When you familiarize yourself with behavior analytic research, you are able to identify interventions that worked with individuals who similar characteristics to that of your particular client.
• Though behavior analysts utilize single subject research, we are fully aware that this does not mean an intervention that worked for a few subjects will work for everyone. This is why there is an important stress on replication of research. (Chiesa, 1994). This is also why it’s important to read several journal articles on the same subject, rather than simply reading one and considering yourself up to date.

 

The main takeaway here is that being familiar with the research is important in order to maintain an ethical practice. Supervisors should support this by providing suggestions for readings and modeling these behaviors. Organizations can support this by subscribing to journals and maintaining a small library for employees. You can support it by subscribing to journals, setting aside time to spend time reading journals, and participating in a journal club. It is incredibly important to our field, and to your practice.

 
Bailey, J. S., & Burch, M. R. (2016). Ethics for behavior analysts: 3rd edition. New York: Routledge.
Behavior Analyst Certification Board. (2014). Professional and ethical compliance code for behavior analysts.
Chiesa, M. (1994). Radical behaviorism: The philosophy and the science. Authors Cooperative.

WRITTEN BY SAM BLANCO, PhD, LBA, BCBA

Sam is an ABA provider for students ages 3-15 in NYC. Working in education for twelve years with students with Autism Spectrum Disorders and other developmental delays, Sam utilizes strategies for achieving a multitude of academic, behavior, and social goals. She is also an assistant professor in the ABA program at The Sage Colleges.

Building Variability Into The Routine

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Several years ago, I was working with a 6-year-old boy we’ll call Terrence. Terrence was diagnosed with autism. He was a very playful child who was generally good-tempered, enjoyed playing with trains and watching TV, and posed few difficult behavior issues for his parents…until the day there was construction on their walk from the grocery store to their apartment and they decided to take a different route home. What happened next is what most people would call a full-blown meltdown: Terrence dropped to the ground, screaming and crying, and refused to move.

Many of the parents I work with have a similar story when it comes to their child with autism and an unexpected change in the routine. The change varies: the favorite flavor of fruit snacks is out of stock at the store or the babysitter greeted the child at the bus instead of the parent or they grew out of the coat they wore the past two winters… In fact, it can be difficult to anticipate exactly what specific routine may be a trigger for your learner. This is precisely why building variability into the routine can be helpful.

Here are a few things to consider:

First, think about the routines that are the most likely to be interrupted. Make a list of these so you can begin thinking about how to address those issues.
Second, work with your team (whether that means family or practitioners that work with your learner) to select 2-3 routines to focus on first.
Discuss how those routines would most likely be interrupted. For instance, a favorite TV show may be interrupted during election season or you may have a family function when the TV show is aired. In teaching your learner to be flexible with changes in routine, you will contrive changes that are likely to occur to give your learner quality practice.
Plan to vary the routine. Essentially, you are setting up the change in routine, but you will be prepared in advance to help your learner behave appropriately. (You’re much more likely to experience some success in this scenario than you would be if a change in routine occurs unexpectedly and/or last minute.)
Give your learner a vocabulary for what is happening. I teach many of my students the term “flexible.” I might say, “I appreciate how you’re being flexible right now” or “Sometimes when plans change we have to be flexible. This means…”
Reinforce appropriate behaviors related to flexibility! You want to be clear when they’ve made an appropriate, flexible response. In the planning phase, you can discuss what appropriate reinforcers might be for the routines you are targeting.
If you build in variations in routine and teach your learner some strategies for being flexible, you and your learner are much more likely to be successful in navigating unexpected changes.

WRITTEN BY SAM BLANCO, PhD, LBA, BCBA

Sam is an ABA provider for students ages 3-15 in NYC. Working in education for twelve years with students with Autism Spectrum Disorders and other developmental delays, Sam utilizes strategies for achieving a multitude of academic, behavior, and social goals. She is also an assistant professor in the ABA program at The Sage Colleges.

Go Play! The Importance of Symbolic Play in Early Childhood

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This week’s post comes to us from Stephanny Freeman, PhD and Kristen Hayashida, MEd, BCBA, and Dr. Tanya Paparella, our partners on the Play Idea Cards app. Play Idea Cards is a full curriculum on teaching play – right in the palm of your hand! Check it out on the Apple App Store! 

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Most adults think of toy play as a natural part of childhood.  When my daughter was born, we were showered with plush animals, tea sets, and dress up clothes for her to use in play.  But what happens when the child does not find toy play to be natural?

Many children on the autism spectrum use toys non-functionally or repetitively.  When I ask parents of children with ASD to tell me about their child’s play they often say “he doesn’t know how to use toys appropriately!”  They then tell me about how the child may spin the wheels on the car while staring at the rotating objects.  They tell me about the specific scripts the child uses to carry out a routine with their toys and subsequent tantrums if the routine is disrupted.  Parents notice how this deficit in play impacts their ability to engage with peers or occupy their free time appropriately.

Symbolic play occurs when the child uses objects or actions to represent other objects or actions.  For example, a child using a doll as their baby and rocking the doll to sleep is an act of symbolic play.  The doll is not alive, but the child is representing a baby.  This skill is a core deficit in children with ASD.  This means that they do not “naturally” or “easily” acquire the ability to use toys to represent other things.  Development of symbolic play is crucial in early development and is tied to numerous subsequent skills:

Language: symbolic play is highly correlated to language development.  This means that the better the child’s ability to play representationally, the better the child’s language skills.  There is also emerging evidence to support symbolic play as having a causal relationship to language.  [Explanation].

Social Development: as neurotypical children continue their learning about symbolic play and through symbolic play, children with ASD often struggle to relate to their peers and understand their play schemes.  Some children with ASD may only engage peers in physical play (instead of symbolic play) or they may end up playing alone using their familiar play scripts.

Perspective-taking: symbolic play allows the child early opportunities to take on the perspective of another being.  If a child pretends to be a pirate, they being to talk and think of things a pirate might want/do.  This early practice with perspective-taking allows the child to use this skill when interacting with peers and adults.

Meta-cognition and Problem Solving Skills: meta-cognition is the ability to think about one’s own thinking.  This is an essential skill when solving problems and planning one’s time.  During play kids plan, organize and cognitively process through obstacles and mishaps with their toys.

Emotional Development: through symbolic play, children can practice expressing emotion through the scenes they create.  There is also some evidence suggesting that this early practice contributes to emotion understanding and empathy.

Clearly, children need play for growth and development.   However, for children with ASD the development of symbolic play may be difficult and, even thought of as WORK!

Given the numerous skills that come out of symbolic play, we urge parents of children with ASD to consider the importance of toy play.  Dedicate time and effort to engage your child in symbolic play.  It is usually not easy at first!  It might have been decades since you picked up an action figure and used him to fight off bad guys, but practice with your child.

Parents know that it is part of their job to help their child learn to read and do basic math.  They would not let their child escape those tasks because they are hard.  Please consider PLAY to be just as important and necessary for the child’s development.  Even if it is work at first, insist the child play with you and in time, improvements may come not only in toy play but also in so many other key areas of development.

Jarrold, C., Boucher, J., & Smith, P. (1993). Symbolic play in autism: A review. Journal of

Autism and Developmental Disorders, 23(2), 281-307.

Ungerer, J.A. & Sigman, M. (1981). Symbolic play and language comprehension in autistic

children. Journal of the American Academy of Child Psychiatry, 20, 318-337.

About The Authors

Dr. Stephanny Freeman is a clinical professor at UCLA, a licensed clinical psychologist, and Co-Directs the Early Childhood Partial Hospitalization Program (ECPHP).  For 20 years, she has educated children with ASD and other exceptionalities as a teacher, studied interventions for social emotional development, and designed curriculum and behavior plans in school and clinic settings.

Kristen Hayashida is a Board Certified Behavior Analyst at the UCLA Early Childhood Partial Hospitalization Program (ECPHP).  For the last 10 years she has served as a therapist, researcher and educator of children and families living with autism spectrum disorder through the treatment of problem behavior.

Dr. Tanya Paparella is a specialist in the field of autism having spent more than 20 years in intervention and research in autism. She is an Associate Clinical Professor in the Division of Child Psychiatry at UCLA, a licensed clinical psychologist, and Co-Director of UCLA’s Early Childhood Partial Hospitalization Program (ECPHP), an internationally recognized model treatment program for young children on the autism spectrum.

 

 

 

Discussing Autism with Newly Diagnosed 9 Year Old

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This week’s blog comes to us from clinical psychologist Lauren Elder and was originally posted on Autism Speaks as part of their Got Questions? series.

“Our son, age 9, was recently diagnosed with autism. He knows something’s up, but we’re not sure how to explain. Advice?”

Yours is a difficult situation shared by many parents. Children need to understand what’s going on, but the discussion needs to be appropriate for their age and level of development. Your openness will help your child feel comfortable coming to you with questions.

I recommend a series of ongoing conversations rather than a one-time discussion. Here are some tips for starting the conversation and preparing some answers for questions that your son may ask:

Explain autism in terms of your child’s strengths and weaknesses
You may want to focus on what he’s good at, and then discuss what’s difficult for him. You can explain that his diagnostic evaluation provided important information on how to use his strengths to meet his challenges. Focus on how everyone has strengths as well as weaknesses. Give some examples for yourself, his siblings and other people he knows.

Provide basic information about autism 
Depending on your son’s maturity and understanding, you may want to continue by talking about what autism means. (See our “What Is Autism?” webpage.) You want to give your child a positive but realistic picture.

It may help your son to hear that autism is common and that there are many children like him. This can open a discussion about the strengths and challenges that many children with autism share. You might likewise discuss how individuals with autism tend to differ from other children.

For instance, you might explain that many children with autism are very good at remembering things. Some excel at building things or at math. Also explain that many children with autism have difficulty making friends and communicating with other people.

Don’t make everything about autism
It’s important to emphasize that your son’s autism-related strengths and challenges are just part of who he is and why you love him. Be sure to point out some of those special qualities that have nothing to do with his autism. This will help your child understand that autism is something that he has, not the sum total of who he is.

Assure your child of support 
Explain to your son why he’s receiving the services he’s getting. For instance, you could tell him that he sees a speech therapist to help him communicate more clearly, or that he’s seeing a behavioral therapist to improve how he makes friends. Help him understand how you, his therapists and his teachers all want to help him. You can point out that we all need some help to become the best we can be. Some children need extra help learning to read. Some get very sad and need help in that department, etc.

Expect to repeat these conversations!
All children – and especially those with autism – need to hear some information multiple times. This doesn’t mean he doesn’t understand. what you’ve told him. Rather, revisiting these topics can be an important part of his processing the information.

Find role models and peers
It’s important for children with autism to spend time with typically developing peers. However, for children your son’s age and older, it can be a wonderful experience to spend time with other children on the autism spectrum. Consider enrolling your son in a play group or social skills group specifically for children with autism.

 

Discussing Concerns With Family Members

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This month’s ASAT feature comes to us from Peggy Halliday, MEd, BCBA and David Celiberti, PhD, BCBA-D. 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!

I am concerned that my two year old grandson may have signs of autism, but I am uncomfortable bringing this up with my son and daughter-in-law. Do you have any suggestions about how best to approach them?

 

It is natural to be unsure of how to share your concerns with your grandson’s parents. As is the case with many concerned family members, you may worry that such a discussion will not be well received or may cause some discomfort or tension in your relationship. If autism is a possibility, you would not want to delay screening and referral for possible evaluation and services because this may waste valuable time during which intervention can be most beneficial for your grandson. Even knowing that the best outcomes are associated with early diagnosis and intensive intervention, it still may be difficult to talk to your son and daughter-in-law if they have not expressed their concerns to you.

As a grandparent, you have already raised at least one child, so you probably have a good sense of what is typical in child development, and what is not. You may feel that your grandson is not making expected gains or may appear delayed in some areas such as communication or play relative to other children his age. Also, you may not have day to day contact so slower development of skills may be more apparent to you. This may create a sense of urgency in you that should be balanced with the need to support your son and daughter-in-law.

There are several important considerations. The way in which you approach your son and daughter-in-law will depend in large part on the quality of your pre-existing relationship and on the nature of how you communicate with one another. You may possess a relationship where difficult issues are frequently and easily discussed. On the other hand, this may not typify the type of relationship that you have. Regardless of your relationship, it is important that you bring this up from a place of love and concern, rather than judgment and blame. Many parents who have been carefully and respectfully approached by a relative later admit that they already had concerns of their own, and it was a relief to discuss them with someone else close to the child.

We would like to offer some concrete suggestions that may increase the likelihood that your discussion will be positive and constructive.

Planning Ahead:

  1. Take some time to think about what you want to share and how you want to frame your concerns. You might begin by commenting on the child’s strengths and praising the parents’ love and dedication to their child. It is important not to appear judgmental or focused only on the concerns.
  2. Plan your discussion ahead of time. Find a time and place when you will not be interrupted. It may be best when the child is with another caregiver.
  3. The role you take in the child’s life depends, of course, on geographic proximity, but be poised to offer concrete, practical help whenever possible. For example, you might offer to babysit siblings while parents pursue evaluation of the child, or offer a respite weekend of childcare so that your son and daughter-in-law might have time to discuss the situation without interruption. Whatever assistance you offer, the important thing is that your grandson’s parents perceive it to be helpful, so try and gauge their reactions carefully.

Having the Conversation:

  1. Try to keep the conversation free flowing. You may want to ask a few questions that will allow the parents to express their own concerns, if they have them (e.g., “I noticed that Billy became very upset when the phone rang. Has that happened before?” or “Does he seek you out when he is upset?”).
  2. Avoid labels and technical terms, which may trigger fear or upset from the parents. Focus instead on discussing milestones, which are observable indicators of a child’s development and accomplishments.
  3. In some cases, it may be beneficial to think about the discussion as a series of tiny conversations. This would be more appropriate if you have frequent contact with your son or daughter-in-law. It may then be helpful to share some observations that may provide a backdrop for later discussion (e.g., “Little Peter seems overwhelmed by noise levels.” or “I have noticed that he does not seem to know how to use words to get his needs met.). It may also be helpful to discuss observations surrounding worrisome or absent peer or sibling interaction.
  4. Emphasize the need to simply get any concerns checked out in order to “rule out” anything serious or to get some guidance and support in how to promote skill development. You might follow this up by mentioning that the earlier a potential problem is recognized and addressed, the easier it is to help the child.

Other Considerations:

  1. Most parents begin to become concerned that something may be wrong when their child is between the ages of 12 and 18 months. If the parents are beginning to realize a potential problem exists, you want to gently urge them not to delay a preliminary assessment and evaluation.
  2. You should never take for granted that developmental concerns will automatically be addressed during routine visits to the pediatrician. Refer parents to resources such as good websites and resources they can explore on their own (we emphasize the word “good” as there is a tremendous amount of misinformation about autism both in the media and on the Internet, particularly many false promises about autism treatment). The most helpful websites at this stage are typically the ones that discuss developmental milestones. Parents often know when to expect their infant and toddler to sit up or take their first steps, but they do not know when they should begin to babble with inflection, point to things they notice or want, imitate gestures, or show interest in another child.
  3. If the child is in a daycare, speak to his or her teachers and directors about the child’s progress. They should be keeping records on how the child is developing in different areas such as social interaction, verbalization, etc. They are also a good resource to use to help evaluate your child in a school setting.

The following websites include milestones checklists, booklets, and charts, and a wealth of other helpful information.

  • Association for Science in Autism Treatment (ASAT): On the ASAT website, you will find extensive information about the scientific support (or lack thereof) behind the full array of treatments proposed for autism, research reviews, articles and guidelines on how to make informed choices, and weigh evidence in selecting treatment options, a section of frequently asked questions such as the one you asked, information about upcoming conferences of interest, and links to helpful sites and other science-based organizations.
  • Centers for Disease Control and Prevention: The Act Early website contains an interactive and easy- to-use milestones checklist you can create and periodically update for children ages three months through five years, tips on sharing concerns with the child’s doctor, and free materials you can order, including fact sheets, resource kits, and growth charts.
  • First Signs: The First Signs website contains a variety of helpful resources related to recognizing the first signs of autism spectrum disorder, and the screening and referral process. There is a directory of local resources for at least eight states and that number is likely to increase over time.
  • American Academy of Pediatrics (AAP): The AAP website contains information for families, links to many other web sites, information about pediatrician surveillance and screening, and early intervention. This site contains great tools for pediatricians, as well as parents.
  • Autism Speaks: The Autism Speaks website includes an Autism Spectrum Disorder Video Glossary of clips designed to help parents and professionals learn more about the early ‘red flags’ of autism, information about how autism is diagnosed, and a resource library. They also offer a free 100 Day Kit designed to help families of newly diagnosed children make the most of the first 100 days following a diagnosis of autism.

About The Authors

Peggy Halliday, MEd, BCBA, is a Board Member of ASAT, and serves as the JCH Director of School Consultation at the Virginia Institute of Autism (VIA) in Charlottesville, Virginia, where she has been a practitioner since 1998. Peggy oversees trainings for parents and professionals and provides consultation to public school divisions throughout Virginia. She also oversees BCBA and BCaBA training experiences. In addition to serving as a presenter at state and national conferences, including the Organization for Autism Research (OAR), Commonwealth Autism Service (CAS), and Association for Behavior Analysis International (ABAI) Peggy was selected as an autism expert for the “how-to” website monkeysee.com. Peggy has been on the board of ASAT since 2010 and serves on the Public Relations Committee.

David Celiberti, PhD, BCBA-D, is the part time Executive Director of ASAT and Past-President, a role he served from 2006 and 2012. He is the Co-Editor of ASAT’s newsletter, Science in Autism Treatment. He received his PhD in clinical psychology from Rutgers University in 1993. Dr. Celiberti has served on a number of advisory boards and special interest groups in the field of autism, applied behavior analysis, and early childhood education, and been an active participant in local fundraising initiatives to support after school programming for economically disadvantaged children. He works in private practice and provides consultation to public and private schools and agencies in underserved areas. He has authored several articles in professional journals and presents frequently at regional, national, and international conferences. In prior positions, Dr. Celiberti taught courses related to applied behavior analysis (ABA) at both the undergraduate and graduate levels, supervised individuals pursuing BCBA certifications, and conducted research in the areas of ABA, family intervention, and autism.