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Medication Considerations

What do you do when your doctor recommends medication? In this month’s ASAT feature, Megan Atthowe, RN, MSN, BCBA, offers insight on a variety of approaches parents can take when medication is recommended for children exhibiting aggressive behaviors. 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!


My son with autism has developed aggressive behavior, and his doctor is considering whether medication could help. What can I do to prepare for this conversation?
Answered by Megan Atthowe, RN, MSN, BCBA

doctor-563428_960_720First, you should know that there is no medication that specifically treats autism. Medications approved by the United States Food and Drug Administration (FDA) for other conditions can be useful only to lessen symptoms. That said, off-label use of pharmaceuticals is by no means unique to autism and is common practice for many health conditions. So while research on the use of particular psychotropic medications in the autistic population is growing, our body of knowledge is still limited. In addition, medications can and do affect every individual differently, and children can respond differently as they develop, so it is likely to take time to find the best medication at the appropriate dose. Medication management, in other words, is a complex and an ongoing process and one that is highly individualized. It is a good idea, then, to be prepared with the right information before every visit to your health care provider.

Do you know how often the aggression actually occurs? Bringing data like this to the visit can be very helpful. You may want to ask your son’s teachers to share any information they have about the aggression with your health care provider, too. (They would need your consent to talk with him/her or to share any confidential information such as behavior data.) If you have not been keeping track of the aggression, now is a good time to start, even if there are only a few days until your visit. An easy way to do this is to use a calendar. Record specifics about when the aggression happens, what the behavior is like, how long it lasts, and whether you have noticed any recent changes. It is difficult for anyone to recall these details accurately, especially if the behaviors happen frequently, so writing them down will help you to share the most meaningful information you can with your health care provider. If your son’s school team is not already collecting data, perhaps they should start as well.

In addition to information about the current levels of the behavior, be prepared to describe how the school and your family are addressing the behavior and how long that plan has been in place. Has your son’s team considered or tried Applied Behavior Analysis (ABA) to treat the behavior? Research supports ABA as an effective intervention for decreasing problem behaviors such as aggression as well as for teaching children with autism new skills. It is important to be sure that a qualified behavior analyst is supervising any ABA interventions, as they must be implemented correctly to be effective. Your health care provider may be able to refer you to a local ABA provider, or you can find a list of board certified behavior analysts at the Behavior Analysis Certification Board’s website.

Before your visit, prepare a list of the names and doses of any medications your son takes, as well as any over-the-counter medications, vitamins, or other supplements. If your son receives other therapies, share what they are with your health care provider. He or she will want to ensure that any new medication is safe to take and will not interact with other medications.

If you and your health care provider decide to start your son on a medication, decide what the goal is. How will you know when the medication has been effective? How will you know if it is ineffective? Be specific and write the goal down. Schedule a date when you will check in with your health care provider on your son’s progress. He or she may have specific suggestions about what type of data to keep.
Finally, there are some important questions that you should have the answers to before you leave. Make sure that you ask any questions you have—a responsible health care provider will want to know that you understand how to use the new medication correctly. If you think of questions later, do not hesitate to call and ask your physician, nurse, or pharmacist.

Key Questions:

  • What is the name of the medication?
  • What is the medication used for?
  • When and how should I give it to my son, and how much do I give?
  • Should I give this medication with food?
  • What effects should I expect to see?
  • What are common side effects?
  • How long will it be until I notice the desired effects and side effects
  • What side effects are serious, and what should I do if I notice them?
  • Will side effects lessen over time?
  • Is there anything I should avoid giving my son while he is on this medication?
  • If I decide that I would like to stop giving him the medication, what should I do?
  • What should I do if I miss a dose?

Please note that there is information about research related to medications elsewhere on the ASAT website.

ABOUT THE AUTHOR

Megan Atthowe, MSN, RN, BCBA, LBA, is a registered nurse and behavior analyst who has worked with people with autism and other special needs in educational, home, and healthcare settings for over 15 years. Currently she consults to educational teams who serve students with autism in public schools.

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Tip of the Week: Teaching Language—Focus on the Stage, Not the Age

CHILD IN SPEECH THERAPYTeaching language skills is one of the most frequent needs for children with autism, but also one of the most misunderstood skillsets amongst both parents and practitioners. The desire to hear your learner speak in full sentences can be overwhelming, making it especially difficult to take a step back and consider what it means to communicate and how communication skills develop in neurotypical children. Many times we get hung up on what a child should be capable of communicating at a certain age, rather than focusing on what they are capable of communicating at this stage of development.

Many practitioners and curricula utilize Brown’s Stages of Language Development.* Brown described the first five stages of language development in terms of the child’s “mean length of utterance” (or MLU) as well as the structure of their utterances.

Brown_Grammatical_Structures_ChartFrom aacinstitute.org

 

Sometimes it is necessary to compare a child to his or her same-age peers in order to receive services or measure progress, but it can be detrimental to focus on what a child should be doing at a specific age instead of supporting them and reinforcing them for progress within their current stage.

Research has suggested that teaching beyond the child’s current stage results in errors, lack of comprehension, and difficulty with retention. Here are some common errors you may have witnessed:

  • The child learns the phrase “I want _____ please.” This phrase is fine for “I want juice, please” or “I want Brobee, please,” but it loses meaning when overgeneralized to “I want jump, please” or “I want play, please.” It’s better to allow your learner to acquire hundreds of 1-2 word mands (or requests) before expecting them to speak in simple noun+verb mands.
  • The child learns to imitate only when the word “say” is used. Then the child makes statements such as “say how are you today,” as a greeting or “say I’m sorry,” when they bump into someone accidentally. Here, the child clearly has some understanding of when the phrases should be used without understanding the meanings of the individual words within each phrase.
  • The child learns easily overgeneralized words such as “more.” This is useful at times, but the child can start using it for everything. Instead of saying “cookie” he’ll say “more.” Instead of saying “train,” he’ll say “more.” And he may say “more” when the desired item is not present, leaving the caregiver frustrated as he/she tries to guess what the child is requesting. Moreover, as language begins to develop, he may misuse it by saying things such as “more up, please.”
  • The child learns to say “Hello, how are you today?” upon seeing a person entering a room. A child comes into the classroom and the learner looks up, says “Hello, how are you today?” The child responds, “Great! Look at the cool sticker I got!” Your learner then doesn’t respond at all, or may say “fine,” as he has practiced conversations of greeting.

These are only a few of the common language errors you may see. While you may want your learner to speak in longer sentences, your goal should be to have them communicate effectively. With this goal in mind, it becomes essential to support them at their current stage, which means it’s essential to assess them and understand how to help them make progress.

This is why I always use the VB-MAPP to assess each child and make decisions about language instruction. I need to have a full understanding of how the learner is using language, and then move them through each stage in a clear progression. I may want the child to say “Hello, how are you today?” But when I teach them that, do they understand those individual words? Do they comprehend what today means as opposed to yesterday or tomorrow? Do they generalize the use of “how” to other questions?

As you make treatment decisions for your learner, think about their current stage and talk about how to support your child with both a Speech Language Pathologist and an ABA therapist.

*Brown, R. (1973). A first language: The early stages. London: George Allen & Unwin Ltd.

WRITTEN BY SAM BLANCO, MSED, 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. Sam is currently a PhD candidate in Applied Behavior Analysis at Endicott College. She is also a lecturer in the ABA program at The Sage Colleges.

 

 

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Focus on Generalization and Maintenance

On more than one occasion, I’ve been in the situation that a student will only demonstrate a skill in my presence. And I’ve heard from other colleagues that they have had similar experiences. This is highly problematic. When it happens with one of my students, there is only one person I can blame: myself.  A skill that a student can only demonstrate in my presence is a pretty useless skill and does nothing to promote independence.

TeacherSo what do you do when you find yourself in this situation? You reteach, with a focus on generalization. This means that, from the very beginning, you are teaching with a wide variety of materials, varying your instructions, asking other adults to help teach the skill, and demonstrating its use in a variety of environments. Preparing activities takes more time on the front-end for the teacher, but saves a ton of time later because your student is more likely to actually master the skill. (Generalization, after all, does show true mastery.)

Hopefully, you don’t have to do this, though. Hopefully, you’ve focused on generalization from the first time you taught the skill. You may see generalization built into materials you already use, such as 300-Noun List at AVB press.

Another commonly cited issue teachers of children with autism encounter is failure to maintain a skill. In my mind, generalization and maintenance go hand-in-hand, in that they require you to plan ahead and consider how, when, and where you will practice acquired skills. Here are a few tips that may help you with maintenance of skills:

  • Create notecards of all mastered skills. During the course of a session, go through the notecards and set aside any missed questions or activities. You might need to do booster sessions on these. (This can also be an opportunity for extending generalization by presenting the questions with different materials, phrases, environments, or people.)
  • Set an alert on your phone to remind you to do a maintenance test two weeks, four weeks, and eight weeks after the student has mastered the skill.
  • Create a space on your data sheets for maintenance tasks to help you remember not only to build maintenance into your programs, but also to take data on maintenance.

Considering generalization and maintenance from the outset of any teaching procedure is incredibly important. Often, when working with students with special needs, we are working with students who are already one or more grade levels behind their typically developing peers. Failing to teach generalization and maintenance, then having to reteach, is a waste of your students’ time.

WRITTEN BY SAM BLANCO, MSED, 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. Sam is currently a PhD candidate in Applied Behavior Analysis at Endicott College. She is also a lecturer in the ABA program at The Sage Colleges.

 

 

Thinking Ahead: Self-Determination in the Elementary Years

Though I typically work with elementary-aged children, I’m consistently thinking about what skills the child needs in order to be independent and ready to transition out of the school setting as an adult.  Sometimes, it may seem that it is too early to be thinking about adulthood when the child is only 8 or 9, but there are things we can, and should, be doing to prepare our students from an early age.

One of my favorite articles addressing this issue is a 2015 article from Teaching Exceptional Children by Papay, Unger, Williams-Diehm, and Mitchell.  (The entire issue is about transition and is a fantastic read. You can view that issue here: http://journals.sagepub.com/toc/tcxa/47/6.) While the Individuals with Disabilities Education Act requires transition planning to begin at age 16, and some states require it to begin at age 14, if we want to provide more successful outcomes for individuals with special needs, we must begin thinking about the transition into adulthood at a younger age.

Papay et al., suggest focusing on self-determination. “Individuals who are self-determined have better knowledge of their own interests, strengths, and needs, and they carry out their own desires. Self-determined individuals make decisions, set goals, and carry out the necessary steps to ensure their goals are accomplished” (Papay, et al., p. 311, 2016). The authors then go on to suggest activities for incorporating self-determination at the elementary level, such as understanding grades, using responsibility charts, making choices, and problem solving. In the push to get students up to speed with academic skills, we may be leaving out these core skills that provide success in adulthood. And these skills, such as goal-setting and problem-solving are skills that typically developing children need years of practice to develop.

            So, how do you get started? Here are a few suggestions:

  • First, read the full article here: http://journals.sagepub.com/doi/pdf/10.1177/0040059915587901
  • Call a meeting of the adults in the child’s life and the child to talk about appropriate goals around these specific skill sets.
  • Write down the ways in which you can incorporate self-determination activities in your student’s daily life.
  • Identify short-term outcomes you would like to see in relation to the activities you’ve identified.
  • Share with your colleagues and other students what you are doing in relation to self-determination to help normalize this conversation on the elementary level.

In recent decades, we have come a long way in providing services for youth with special needs. At this point in time, it is becoming more and more clear that we need to be doing more for adults with special needs, but we can’t wait until the individual is well into their teenage years to begin thinking about it.

Papay, C., Unger, D. D., Williams-Diehm, K., & Mitchell, V. (2015). Begin With the End in Mind Infusing Transition Planning and Instruction Into Elementary Classrooms. Teaching Exceptional Children, 47(6), 310-318.

Focus on Reinforcement

Focus on Reinforcement

Teaching can be incredibly overwhelming, especially in a special education classroom. Between paperwork, lesson planning, updating bulletin boards, and actually teaching, the day can get pretty hairy. Sometimes, that stress leads to a short temper, which can lead to a punitive classroom environment.

If things seem to be going in the wrong direction in your classroom, the first thing you should do is focus on reinforcement. Here are a few steps to consider:

  1. Identify 1-3 behaviors you would like to see your students exhibiting. For instance, maybe you’d like to see an increase in hand-raising (as opposed to calling out.) Clearly define the behaviors you want to see.
  2. Set up a contingency for increasing those behaviors. Maybe you’ll wear a MotivAider to give yourself a reminder throughout the day to provide verbal praise to students exhibiting the target behavior. Maybe you’ll have students earn points that they can exchange for other things, such as a homework pass or lunch with the teacher. Maybe you’ll encourage students to recognize each other when they engage in the target behavior.
  3. Teach the students about the target behavior(s). Introduce the goals to the students. It’s helpful to create a sign or other visual to remind students about the new goals.

While these are simple steps, providing more verbal praise and other reinforcement can turn around a classroom with too much time spent on reprimands and punishments.

It’s also helpful to remember (especially for new teachers) that you can make changes at any time. One of my mentors in my first year of teaching told me to tell my class we had gotten off track, so we were having a brand new first day of school. (I was teaching fourth and fifth grade students with emotional behavioral disorders.) It was shocking how well that new first day of school went over. The students were excited about the idea of a “fresh start” in the middle of the school year, and it helped me get back on track with creating a more positive learning environment.

Ultimately, the goal is to teach students about appropriate behavior by spending more time showing them what they’re doing right than focusing on what they’re doing wrong.

 

WRITTEN BY SAM BLANCO, MSED, 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. Sam is currently a PhD candidate in Applied Behavior Analysis at Endicott College. She is also a lecturer in the ABA program at The Sage Colleges.