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.

Building Variability Into The Routine

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.

Building Variability Into The Routine

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, 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.

How To Have A Successful School Experience

Every parent wants their child to succeed in school. The definition of success may differ from parent to parent, but most would agree that they want their child to get good grades, demonstrate good behavior and make friends. These desires are no different for parents who have children with developmental disabilities. So, how do you know if your child is ready and are there ways to predict how well they will do? Tools like the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP), which is one of the primary assessment tools used at the Behavior Analysis Center for Autism (BACA), can assist parents and professionals alike in assessing their child’s skills and providing them with valuable information as to what areas they can support their child to increase the chances of them doing well in whatever educational setting they may enter.

How To Have A Successful School Experience

General skill deficits will likely determine the educational placement of your child, but may not be the biggest issue at hand.

Behavior problems and problems with instructional control can cause significant barriers to achievement with grades, developing friendships and avoiding expulsion. Learned prompt dependency may make developing independence and responsibility more difficult. Failure to generalize already existing knowledge across multiple examples, people and environments will require more teaching time and may manifest inconsistent performance on tests and classroom work. If your child likes very few things, seemingly peculiar things, or has strong motivation for some things, but is unwilling to work to attain them, it may make it more difficult to motivate them to learn material that is presented. If your child is reliant on getting something for responding every time in order for learning to occur, the teaching process will likely remain a tedious one and decrease the likelihood that they will be able to maintain those responses when those incentives are not provided as frequently. Many children with developmental disabilities will rely on providing themselves with reinforcement in the form of self-stimulation when such dense access to preferred items or activities is not provided.

Overall skill level will undoubtedly increase the odds that your child will be able to manage good grades. However, their ability to acquire new material quickly and then retain that information for later use may play a more critical role in their long term accomplishment. Adapting to change quickly or ‘going with the flow’ will be critical when faced with day to day schedule changes that occur in classrooms or other instructional environments. General independence with functional skills such as toileting, eating and managing their personal items such as backpacks, folders, etc., will decrease the amount of time their teachers may need to focus on teaching these skills and allow more time for teaching other critical skills.

All of these things taken together can seem daunting, even for parents of typically developing children. The good news is that there are things that every parent can do to help. Perfect parenting is unattainable, but valiant and consistent attempts with certain things can go a long way. Allowing your child to experience the consequences of their behavior can be tough, but is central to ensuring that they will behave well when it counts. Having your child try things on their own before helping them and then only helping them as much as needed to get the job done whenever possible will foster independence. Exposing your child to new or different things within fun activities can increase the things they are interested in. Those things can then be used to motivate them to learn. Setting up opportunities for them to experience even small changes, modeling a calm demeanor and praising them for doing the same when unexpected things happen can also help.

Your child’s teacher or other professionals like Board Certified Behavior Analysts can aid you in thinking of other ways to enhance what you are already doing and assist in developing an individualized treatment plan to support you and your child.

WRITTEN BY MELANY SHAMPO, MA, BCBA

Melany Shampo is a clinical director at the Behavior Analysis Center for Autism in Fishers, IN.

This post first appeared on Indy’s Special Child. 

Tip of the Week: How to Implement a Successful Behavioral Intervention

Creating a successful behavior intervention is more challenging than it first appears. Below, I’ve listed four essential parts for changing maladaptive behaviors and increasing desired behaviors. Most of the time, when a behavior intervention is not working, one or more of these steps has been neglected.

1.  Find a BCBA or ABA provider who can guide you through the process. Getting help from someone with experience in addressing challenging behaviors is an essential first step. They should be a wealth of information about each of the following steps, provide check-ins and troubleshooting during the intervention process, and maintain data on the behavior to insure the intervention is working.

2.  Identify the function of the behavior. There are four reasons that any of us behave: attention, escape/avoidance, access to a tangible (such as chips or a toy train), and automatic reinforcement (meaning physical sensations that are not related to social interactions, including sound, taste, touch, or a response to movement). A BCBA can be especially useful in helping to identify the function of the behavior. They may utilize an ABC chart to determine the function, which means they observe the behavior and note it’s antecedent, what the behavior looks like, and the immediate consequence. If the ABC chart is not helpful, they may perform a more formal Functional Analysis. Before any intervention is put in place, all parties interacting with the child should understand the function (or reason) for the problematic behavior.

3.  Provide a replacement behavior. As a part of the intervention, a replacement behavior should be provided. A BCBA or ABA provider should be able to help you find appropriate replacement behaviors for the problematic behavior. For example, with one student who was chewing his shirt, we introduced a replacement behavior of chewing gum. With another student who was throwing his iPad, we used tape to put an “X” on his desk and taught him to place it on the “X.” The idea is to provide an appropriate behavior that is incompatible with the problematic behavior. But that’s not always possible. For example, one of my former students was banging her head on the table during instruction. We taught her to request a break by touching a picture of a stop sign. Realistically, she was able to bang her head while simultaneously touching the stop sign, but once she learned that she got to escape the activity by touching the stop sign, she stopped banging her head in order to escape. It’s important to note that using the stop sign wouldn’t work for all head-banging behavior, but we had identified the function of the behavior and were able to introduce a replacement behavior that served the same function while meeting the skill level and needs of that individual student.

4.  Provide reinforcement for appropriate behavior. A specific plan for providing reinforcement for use of a replacement behavior and any other desired behaviors is essential. The reinforcement for the appropriate replacement behavior should serve the same function as the problematic behavior. This can sometimes be difficult to achieve, but without this aspect of intervention, you may see slow success, or no success at all.

Again, creating a multi-pronged intervention can be a challenge. It’s important to seek out help, and to take a look at research related to the problem behavior you are trying to address. It is possible to create a strong intervention that has a huge impact on your learner, but it must include the aspects listed above to have the highest potential for success.

WRITTEN BY SAM BLANCO, MSED, BCBA

Sam is an ABA provider for students ages 3-12 in NYC. Working in education for ten years with students with Autism Spectrum Disorders and other developmental delays, Sam has developed strategies for achieving a multitude of academic, behavior, and social goals.

Prompting Behavior Change: A Guest Post by Steve Levinson, PhD, Inventor of the MotivAider

We’re thrilled to bring you this exclusive article written by Steve Levinson, PhD, Inventor of the incredible MotivAider. We’re all familiar with the incredible versatility of the MotivAider in facilitating behavior changes and here, Dr. Levinson explains how behavior modification works. We’re so grateful to Dr. Levinson for this fantastic article. You can find more exclusive articles from leading experts in the field in our new catalog.

Prompting Behavior Change by Steve Levinson, PhD

If you’re a parent or a teacher who’s trying to change a child’s behavior, you’re probably frustrated. It’s not easy to change a child’s behavior. But before you blame the child, consider this: It’s not all that easy to change your own behavior either! Even when you have a good reason to make a particular change, and you’re really serious about doing it, changing your own behavior is rarely a snap.

Why it’s so hard to change behavior  So, what makes it so hard to change behavior? If you think it’s simply a matter of motivation, think again. Motivation is certainly important, but many behavior change attempts fail not because of insufficient motivation. They fail because of insufficient focus.

You can’t change your own behavior unless you can keep your attention focused on making the desired change. While it’s easy to do things the old way because the old way is automatic, doing things the new way requires focus.

Unfortunately, whether you’re a parent, a teacher or a child, it’s not easy to stay focused. That’s because, amazingly, the human mind has no built-in mechanism to keep our attention focused on making the changes we want to make. So it’s really no wonder that our good intentions keep getting lost in the shuffle.

If you’re not convinced that (1) focus is an essential ingredient in the recipe for behavior change and (2) we’re not well-equipped to stay focused on the changes we want to make, here’s an example that should help. Suppose you have a bad habit of slouching. You realize that slouching is not only bad for your back, it’s bad for your image. So you promise yourself that from now on that you’ll sit up straight and stand up tall. How hard could that be? Yet soon—very soon—after setting out to improve your posture, you’re right back to slouching.

So, what happened? Did you lose your motivation? No. You lost your focus! You failed to make a change you genuinely wanted to make because you simply couldn’t keep your attention focused on making it.Yes, it’s hard to change behavior because changing behavior requires focus, and none of us—not parents, not teachers and especially not children—are particularly well-equipped to stay focused.

So what can we do to stay more focused on the positive changes we want to make? And what can we do to help our children or our students stay focused on the positive changes they want to make?

Prompting: A simple way to facilitate behavior change  One solution is to use “prompting.” Prompting is a simple behavior change method that uses frequently repeated signals to keep your attention focused on making a desired change.

To illustrate how and why prompting works, let’s return to the posture example we used earlier. Only this time, after you promise yourself that you’ll sit up straight and stand up tall from now on, I’m going to follow you around and every few minutes—whether you’re slouching or not—tap you on the shoulder and whisper in your ear, “You’re no slouch.”

With me reminding you frequently, I guarantee that you’ll stay focused on improving your posture. What’s more, soon I’ll be able to stop whispering because just feeling the tap on your shoulder will be all it takes to send you the associated message, “Yes, I’m no slouch.” Sometimes when you feel the tap, you’ll find yourself slouching, and you’ll straighten up right away. Other times when you feel the tap, you’ll notice that your posture is already fine. It doesn’t matter whether you catch yourself slouching or you catch yourself with perfect posture. Either way, you’ll be making progress in replacing your bad posture habit with a good posture habit. Before long, you’ll automatically be sitting up straight and standing up tall.

Fortunately, there’s a more practical and even more effective way to use prompting. Instead of relying on a dedicated person to follow you around and keep tapping you on the shoulder, all you really need to implement basic prompting is a timer or other mechanical or electronic means that’s capable of sending you frequent private signals automatically. The process is simple. First, you devise a brief personal message that urges you to make the change you want to make. Then, you associate the personal message with the signal—the same way we associated “You’re no slouch” with a tap on the shoulder in the example above. The result is that whenever you receive the signal, you’ll focus your attention on making the change you want to make. And by making certain that you receive signals often enough, you’ll stay focused.

Prompting isn’t magic, but it can do amazing things. What’s more, because it allows us to overcome an obstacle that all of us—parents, teachers and children—share, it’s remarkably versatile. The same simple method that can be used to help a young child do a better job of staying on task can also be used to help parents and teachers consistently stick to an effective technique they forget to use when they’re busy or frustrated. The same simple method that can be used to help a child make a constructive keystone change in her social behavior can also be used to help parents and teachers stay cool, calm, collected, and constructive when interacting with a defiant child.

How Do I Get My Kid To Eat?!

I couldn’t even begin to count how many times I’ve been asked this question. It is an issue that I love to tackle in collaboration with the families that I work with mostly because when progress is made, it makes such a dramatic difference in the well-being of the entire family.

Behavioral and sensory issues of a child with special needs can further complicate the ordinary mealtime struggles of a parent of a small child. Parents are often torn between the interventions outlined for them by therapists and the reality of everyday life. This usually means that at the end of the day, just getting the child to eat anything and by any means necessary. No one is happy when mealtime becomes a battle zone. Use of a token economy or escape extinction is most common and can work if implemented consistently. However, I am always impressed when I come across new and creative approaches to food and feeding issues.
One such example of creativity comes from my experience with a great family and their two young boys that I worked with for several years. Their mother was a force to be reckoned with when it came to approaching the introduction of new foods and organizing play dates. I don’t remember how it started, or if it was a conscious plan but the weekly play dates she organized for socialization quickly evolved into preschool foodie events. The children were much more likely to try new foods and like them when their peers were trying them too. It was also a great opportunity to work through sensory aversions and begin to enjoy getting messy. I was recently reminded about these special food play dates when I came across a post on http://special-needs.families.com about a food centric play group started by some parents in Texas.
Currently I am experimenting with new ways to expand the diets of the children on my caseload as well as improving my own health through my food choices. My own mantra for health is to “Eat the Rainbow” so that I make sure I get a nice mix of fruits and vegetables. In my research I came across a great book for one child who has a strong interest in letters. The book is “Eating the Alphabet” by Lois Ehlert and it has inspired a new token economy type system for him and his siblings. Check out the template for the chart in the DRL Downloads! All you have to do is add your child’s picture and a picture of anyone else in the family wanting to participate, laminate, start checking off new foods with a dry erase marker and let the eating begin!
What have you tried?