Photo source: www.theautismhelper.com

Functional-

1. Of or having a special activity, purpose, or task.

2. Designed to be practical and useful.

In my Social Skills post I talked about how its important to remember to include social skills training in any ABA intervention. Teaching skills during ABA therapy isn't complete until the client can successfully navigate through social situations in their every day life.
In addition to social skill development, another instructional area that can be overlooked is Functional Skill Training. 

Functional skills are skills intended to be practical, useful, and helpful in a variety of real-world settings. Autistic individuals may need to be specifically taught functional skills that other people readily learn from their environment, or from social interactions. Functional skills should be age- appropriate goals that are personally relevant to the individual.

Some clients will present with minimal functional life skills, and usually this means day-to-day life requires heavy adult assistance and prompting. Think about a client you work with, and what their typical day looks like from waking up to bedtime: How much of that day is led by adults? How many meltdowns and behavioral episodes occur in a single day? How often do adults have to struggle to keep that client on a schedule, or flowing through daily activities?  How much stress does this put on the shoulders of caregivers or parents?
Its easy to see how a lack of appropriate functional life skills can have far reaching consequences across home, school, and community settings.

Functional skill goals are going to be very specific to the particular individual. Cookie-cutter interventions won't work.
The client's specific cognitive ability, environment, lifestyle, and the caregiver priorities will determine what goals to select. Its also important that treatment goals line up with what is important to the family, and how life happens for that particular family (as this will differ from one client to the next). 

 Without careful consideration of  these very personal client variables, treatment goals can be completely out of touch with what is best for the client. For example:

 -Functional goal: Teach a toddler to eat with utensils. I once worked with a Hispanic toddler who was being taught to grip and use a fork in the school setting. I saw this client at home, and only learned about this during an observation at school. I shared with the teachers that at home, this client's diet was pretty much all finger food (like tortillas, or pre-cut fruit). He rarely had opportunity to use utensils outside of school. This sparked a discussion with me, the school team, and the family, about the functionality of teaching utensil use. Would this skill be maintained outside of the school setting, and if not, then why teach it?  

When correctly implemented into an ABA program, functional skill training of age appropriate goals can benefit the individual in several ways:

Reduce social stigma

Can counteract bullying/teasing

Higher quality of life, and access to reinforcing life events or situations (such as hobbies, leisure activities, friends with shared interests, ability to live alone, etc.) 

Reduces daily burden and stress on parents or caregivers

Makes integrating into the community easier

Can reveal personal skills and strengths, which could lead to job placement/work opportunities (e.g. a love of cooking and a knack for it could lead to working in a restaurant)

Functional skills are skills or behaviors that are either done by the individual, or will need to be done FOR the individual. For example: brushing teeth. I can either brush my own teeth, or someone will have to do that for me. There is no "just skip it" option, as it would negatively impact my health and body to never brush my teeth.

Individuals of all ages need appropriate functional skill training; this isn’t just for adolescent and adult clients. Suggested skills to target include cooking, hygiene, grooming (including teaching adolescent females about makeup and hairstyling, if they have interest), emergency situations, puberty changes/dating/sexuality, Stranger Danger/sexual predators, street safety, laundry, finance/bills/purchasing items, etc. Depending on the age and ability of the client, some goals may be more or less appropriate, but the goal can always be modified and broken down to help the client understand it at an age-appropriate level. For example, a 4-year-old doesn't need to learn to cook a steak. BUT, how about make their own sandwich?

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Tameika Meadows, BCBA, Blog Author

Early intervention is key…… Early intervention is key…… Early intervention is key…

How many times have you heard that? Parents of children newly diagnosed with Autism are immediately told to get their child into intensive treatment. There is a sense of urgency to this recommendation, and if you are lucky you are handed a list of agencies to contact. If you’re not so lucky you get to research, locate, and narrow down agencies on your own.

But what if you dont know who to contact? Or you dont know which treatment to select? Or you contact several agencies and none of them have openings?

The process of locating and then enrolling your child into early intervention services isn’t as simple as it sounds. The idea that you can get a diagnosis, enter into early and intensive treatment, and voila...everything works out great is more fantasy than reality for some families. 

The early intervention process can be a chaotic and frustrating series of misadventures that include  false starts, mounds and mounds of paperwork, a parade of professionals and therapists coming into your home, funding issues, and waiting lists. In addition to being a complicated process its also very stressful due to pressure parents feel to pick the best treatment at the best time, and the stakes are high.

Below is some information about what to expect from the early intervention process, based on what parents have told me about their experiences. Early intervention services will vary greatly from state to state, so some of this information might not be applicable for your area:

-          Document Everything: From the time you get a diagnosis for your child (or even before) start keeping a record of all doctors visits, evaluations, medications, etc. Keep a journal of behavioral notes about your child including a brief summary of pre or post-natal abnormalities. Your journal should include information about the pregnancy experience, birth, and developmental milestones leading up to the actual diagnosis. If you can include actual dates with your notes, that’s even better. This is helpful for a few reasons- - As you start seeing various doctors and professionals you will notice that many ask the same questions over and over. If you have a journal of your child’s history, then its a much easier process to give background information about your child to each professional. Keeping documentation is also helpful because it gives you a record to refer back to later. When your child ages out of early intervention and enters school, the school system will find a record of your child’s development and therapy history very helpful.

-          Require Documentation from Professionals: As you start the early intervention process you will talk to or receive services from many different individuals. ST’s, OT’s, pediatricians, doctors, psychologists, behavior specialists, etc. Each new professional may tell you they need to do an assessment and evaluation of your child. What they might not tell you is that sometimes they can use prior assessments instead of doing a brand new assessment. In other words, instead of paying 4 people to assess your child you can use 1 assessment 4 times. Every professional who observes, assesses, or evaluates your child should be able to provide a written report of their findings. Keep these reports, as you will need them again later.

-          Ask Questions!: This one is so important. In order to get the most out of early intervention services you need to understand what's going on. If a professional tells you that your child has “Global Receptive Language Deficits”, do you know what that means? If the doctor recommends a biomedical protocol, do you know what that is? If your insurance company denies ABA coverage because they state Autism is an educational diagnosis, do you understand what they are saying? Ask questions until you understand what a professional is saying, and if they make you feel stupid or uncomfortable for asking questions then find a new professional immediately. The professional should explain their services, their findings, and their recommendations in clear and simple terms that are easily understood.

-          Be Prepared for Service Transitions: Children with special needs have access to free early intervention services from birth to age 3, at which point the school system is responsible for providing services. That means if you don’t receive a diagnosis of Autism for your child until they are 2 years old, then you will only receive 1 year of early intervention services. Or if your child received a diagnosis at 15 months old and then sat on a waiting list for 13 months, the cut off is still age 3. Even as you begin using early intervention services, it’s important to plan ahead for what the next step is once the services end. Will you place your child in a preschool environment? If yes, at a special needs school or no? Will your child receive therapy services in the home? If yes, what kind of therapy and how will you fund services?

-          Quality May Vary: I have heard many stories from parents about rude, unreliable, or unprofessional early intervention specialists who worked with their child. The therapist might show up late for each session and then leave early. Or the therapist never returns your phone calls. Or maybe the therapist has been promising to get that evaluation report to you for over 5 months. Just because a service is free does not mean poor quality is acceptable. Speak up about rude and unprofessional treatment, and contact management of the organization to resolve the issue. Parents sometimes say things to me like “Well, my child only sees this person once a month. I don’t want to make a big deal about it”.  The point of early intervention is to get your child school ready and to address as many deficits as possible in a limited amount of time. In order for that to happen the quality of treatment is very important.

-          Beware of Ridiculous Waiting Lists: 6 months, 9 months, 1 year, even 3 years. These are all pretty standard amounts of time to be placed on a waiting list to receive Autism services. The reality is the number of children needing treatment is exploding, and the number of professionals in the field isn’t keeping up. So rather than being surprised by severe waiting lists, you should expect it.

 I'm not saying you shouldn’t place your child on a waiting list to receive an evaluation or treatment from a reputable agency or professional. My question is, while you are on this waiting list what are you doing in the meantime? If you can afford to, hire a private therapist while you are waiting for a spot to open up for a free early intervention agency. Enroll your child in a playgroup or social skills program until that spot becomes available. At the very least you can read books, do some research, and start working with your child yourself. What’s most important is that you take advantage of the time you spend on waiting lists, because you cant get that time back.

Research and best practices consistently recommend early intervention services for children with Autism. However, for many different reasons it wont always be possible to secure quality early intervention for your child. Some parents don’t get an official diagnosis until their child enters the school system, and is way past the cutoff age for early intervention services. Or you might live in an area where there are no early intervention agencies or services. Don’t think of early intervention as only meaning “Birth to age 3”. Once you become aware that your child has Autism or some type of developmental delay, as early as you can begin intervening with quality treatments or therapies. 

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Tameika Meadows, BCBA, Blog Author

Most people think what I do is about using rewards and incentive to get children to stop inappropriate behaviors. That's not really what ABA is about.

I like to describe what I do as manipulating the environment in such a way that the child has no reason to maintain challenging, aggressive behaviors and every reason to adapt appropriate social behaviors.
Or put another way:

"If you wish to modify your child's behavior, you have to change yours".

Your behavior is what will ultimately determine the success of your child's ABA program.

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Tameika Meadows, BCBA, Blog Author

* Highly recommended book: Teaching Language to Children with Autism

 Many individuals with Autism can have impairments or difficulties with functional communication. Sometimes this is due to medical conditions, such as tongue abnormalities or Apraxia. Or it can be due to severe deficits in the areas of motivation, typical language development, and social interaction skills. Speech delays can also be linked with excessive ear infections, which can lead to hearing loss or impair speech processing during times of critical brain development.

 The majority of the children I have worked with were non- vocal when I first met them. This means they did not consistently communicate vocally. Maybe they had some babble, or would say a few word approximations, but they were unable to reliably communicate their wants and needs to other people.
 I intentionally used the word "non- verbal" in the title of this post, because communication is not just words. A child can be "verbal" and communicate using pictures, sign language, an iPad device, etc. But if I say a child is "vocal", I am specifically saying they can communicate with words or they can talk.
Confused yet? I hope not :-)

Non- verbal individuals often communicate by pointing, leading, or the majority of the time: through their behavior. I have observed quite a few clients who without saying a word had an entire household catering to their every desire. The parents knew that 2 screams meant “turn the TV on”, a crying fit meant “pick me up”, pushing a sibling meant “I don’t want to play”, and so on.

The goal when working with individuals who have communication difficulties should be broader than just expressive language.....the child may never gain vocal speech. That doesn't mean they can't ever learn to Communicate.

The goal should be teaching the child a functional, effective, system of communication. If I teach a 5 year old to label colors and body parts but she can't tell me when she is hungry, that's a good example of a child who can talk but isn't using language to communicate.

 From my experiences, positive indicators for developing vocal communication include vocal sterotypy (particularly with various intonations and pitches), frequent babble or echolalia, and demonstrating social awareness or alertness (e.g. child stares intently at your face when you sing to them). A young child who will echo, sing wordless songs, or babble, often can be quite successful with intensive language intervention.
The behavioral piece of communication is HUGE. It can't be stated enough: Children who cannot communicate have some of the most persistent and challenging problem behaviors. Why? Well, just imagine that you are placed in an environment where no one speaks your language. If you speak English, everyone else speaks French.  Now imagine that you are hungry and must convince these people to feed you. How long would you try pointing and gesturing, before you started pushing people and throwing things?

If a child lacks motivation to communicate, and isn’t externally required to communicate, then from the child’s perspective its much easier to engage in behaviors. A child who is allowed to fling their plate to the floor during dinner to signify “I'm done” has zero incentive to think up words, form them with their lips, and then speak.
Reinforcement is also huge. For a child with Autism to learn to communicate, reinforcement must be present. You might be wondering, “Why do I have to reinforce my child to talk? My other children just started talking, they didn’t require M&M’s to do so”. A characteristic of Autistic Disorder is qualitative impairments in communication. This can mean the child has no language, exhibits speech delays, or lacks motivation to use the language they do have.


There are  many options for teaching functional communication (and often a BCBA/Consultant will recommend multiple options at once, I know I often do). Remember, communication is far broader than just the ability to talk:

Various Communication Methods

•      Verbal Behavior Approach (ABA) – There are many different ways to do ABA, and VB is a branch on the ABA therapy tree. VB has a functional language focus. VB captures and builds upon motivation, and uses rewards to reinforce communication across verbal operants (requesting, labeling, echoics, etc). Language is taught as a behavior and each component is broken down. If the child likes ice cream, one of the first things they learn to say is “ice cream”. This way, the child’s motivation to get a desired item is used to pull language out of the child: You say ice cream, you get ice cream. The VB approach also uses repetition, prompting, and shaping to get desired responses. Initially, “buh” is acceptable to request the ball. Over time (and with careful data analysis), the criteria become more demanding until the child can say “BALL”. For a detailed description of VB, see my Verbal Behavior post. 

•    Speech Therapy- For every 10 clients I see, probably 6 are also receiving speech therapy.  SLP's often work with conditions such as stuttering, language impairment, feeding/swallowing, etc. (for more information see www.asha.org). I have worked with kids who made huge gains from ST, and I have also worked with kids who did not, even after months and months of ST.  Its important as a consumer to pursue speech and language professionals who have experience with Autism and behavior management. I have certain clients who lost their speech services due to behavior issues. Meaning, they were so aggressive during speech sessions that services could not continue. Its also important to look at the intensity of services being offered. Many of my clients who get speech therapy only receive one session per week. For a child with Autism, that may not be enough therapy.  I  also highly suggest encouraging collaboration between the ABA team and the SLP. Its so important that we all collaborate with each other and train the parents/caregivers on what we are doing!

•  Sign Language- Always combine labeling with sign language so the child hears the correct word, as well as learns the sign. When considering sign language you want to think about the child’s age and fine motor skills. If a child has poor fine motor abilities and cannot make multiple, intricate signs to communicate then sign language may not be a good choice (although you can always teach approximations to signs). Age is important because you want to think about how big that child’s world is. If the child is only 2 and spends all day at home with Mom or Dad, then sign language is probably a good choice. However if the child is 11 and goes to school, after school care, karate practice, and then home, then all of the people the child has regular contact with must know the child’s signs. If the child walks up to a teacher on the playground and signs for her “red notebook”, will the teacher understand? If the child doesn’t get a prompt response to their sign language, they may stop signing. Also a very common error I see with clients who have learned ASL is getting stuck on the sign "more". Many professionals and parents teach the child to sign "more", and unfortunately the sign then gets generalized. The child will randomly walk up to people and sign for more, and no one knows what they want. More of what?? Imagine how frustrating this must be to the child. Its best to begin teaching signs with simple, clear mands that are highly preferred by the child ("book", "chips", "juice", etc), also be sure to avoid teaching signs that are very topographically similar when first starting out.

 

•  Picture Communication Systems- This would include the PECS system, touching or pointing to photos to communicate, or use of an electronic picture system such as the iPad app Proloquo2Go. The child learns to communicate by exchanging, touching, or pointing to photos of items, activities, individuals, etc. Systems such as these can be ideal for an individual who can match picture to sample, or demonstrates the ability to scan and select. Other advantages to these systems is that they are simple to use (and for others to understand), can be transported across environments, and can eventually be very elaborate.  Disadvantages of picture systems can include: difficult to keep up with all the various photos/pictures, and the child's interests change so frequently it may require changing the cards very often. There are also assisted communication devices that will create speech for the individual by speaking in a simulated voice (which is often programmable). The learner inserts a card, or types/pushes a button and the machine speaks for them. Since these are technological devices the cognitive level of the learner should be considered (do they have the muscle control to push or swipe? do they understand the 2D photo connects to a 3D item or activity?).

•  Language Immersion- This is a method typically seen in preschools or daycares that accept very young children with special needs. The classroom immerses the children in language throughout the day with the intention of creating a stimulating environment conducive to speech. Items are clearly labeled with photos and words, children are engaged in conversation even if they cant talk (“David, is my coat blue? Nod if my coat is blue”), and the teachers spend time working 1:1 with each child on turntaking, eye contact, and joint attention. To me, these classrooms look similar to the Koegel method, or Pivotal Response Training. Often these types of techniques are implemented by early childhood education teachers, or parents. An advantage of language immersion, or focusing on pivotal skills to enhance communication, is this method can be easy for a parent to implement with their own child. These types of techniques focus on developmental milestones leading to first words, such as babbling, recognizing distinct sounds, imitating actions, responding to receptive commands, and communicating using gestures. Working with the child 1:1 will include lots of intrinsic rewards, and naturally occurring interactions. For example: treat the child’s babble as if they are words, and carry on a conversation with them. Narrate your actions and the child's actions, even if the child doesn't respond to you ("We're walking upstairs now. Lets count the stairs: 1,2,3,4....."). While you are narrating try to make eye contact with the child, build upon shared interests, have an animated facial expression, and make learning fun.

 
The wide array of programs, books, resources, and clinics out there that promise to get children with Autism to talk can be very intimidating and confusing for consumers. Be a critical consumer and look for research proven methods that clearly explain how the treatment works, and what is involved.
Ask lots of questions! If you have to buy the treatment or purchase a book before anyone will explain exactly how it works, be suspicious.

 No matter which option you select to teach communication, in order for it to be effective and consistent across settings and people you will likely need to incorporate behavior management.
The child must also learn that communicating with people leads to good things. If they just learned to request “juice”, then initially every time the child says juice they should get a sip of juice. The child needs to see that communicating with people promptly gets needs and wants met.



**Quick Tip: Early intervention is critical when it comes to targeting speech production and development. You want to start working with the child from a very young age to ensure the best results. However, research shows that all hope is not lost for older individuals with Autism who have no consistent system of communication. It may be more challenging for an older child to learn to talk, but it is by no means impossible. The most promising methods for children over the age of 5 include speech generating devices (which do not inhibit language) and developmental approaches that facilitate joint attention.



References:

Kaiser, A. P., Hancock, T. B., & Nietfeld, J. P. (2000). The effects of parent-implemented enhanced milieu teaching on the social communication of children who have autism. Journal of Early Education and Development [Special Issue], 11(4), 423-446.

Kasari, C., Paparella, T, Freeman, S.N., & Jahromi, L (2008).  Language outcome in autism: Randomized comparison of joint attention and play interventions.  Journal of Consulting and Clinical Psychology, 76, 125-137.

Murphy SA. (2005) An Experimental Design for the Development of Adaptive Treatment Strategies. Statistics in Medicine. 24:1455-1481.

Pickett, E., Pullara, O, O’Grady, J., & Gordon, B. (2009).  Speech acquisition in older nonverbal individuals with autism: A review of features, methods and prognosis. Cognitive Behavior Neurology, 22 1-21.

Schlosser, RW, & Wendt O (2008).  Effects of augmentative and alternative communication intervention on speech production in children with autism: A systematic review. American Journal of Speech-Language Pathology • Vol. 17 • 212–230.

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Tameika Meadows, BCBA, Blog Author

Waiting can be a hard skill to learn. Individuals with Autism may have difficulty with abstract thought, and the concept of time. The words "Just 5 more minutes", or "We'll do that later", may mean nothing. Autistic clients can also have a rigidity of interests and a need to follow a schedule, which makes the child want their needs/wants met now...now...NOW.

I was inspired to do this post after seeing a child meltdown this morning inside a shoe store. As I was deciding between two pairs of shoes,  I saw this adorable little boy who had clearly reached his internal time limit for shoe shopping. First he began to whine, whining escalated to crying, and then crying escalated to throwing shoes across the store. I kid you not....pumps began to fly across the store.  I'm sure for many people witnessing this, it just looked like a bratty child having a tantrum. What I saw was a child who didn't know how to wait.

Many aggressive and challenging behaviors can stem from a child's inability to wait.  You might be wondering why is it so important to teach waiting skills. The reason why this is such an important skill is because its a pivotal skill, meaning it impacts the success of learning more advanced skills. Children have to wait, because adults have to wait. 

As a child matures and starts interacting with society they will have to wait in the classroom, at the park, at the grocery store, inside the home, at the airport, etc.  Here's a few examples of what difficulty with waiting can look like:

• Whenever the teacher tells the class to line up to go outside, Doug gets very excited. Doug loves playing outside. Doug gets so excited and impatient while waiting in line that he regularly pushes other kids down, and steps on their feet.
• Iyanna is at the mall with her dad. Iyanna makes the sign "eat" to her dad to signify she is hungry. Her dad tells her they are leaving the mall in 15 minutes, and and she can eat then. Iyanna begins to cry, and a few minutes later bolts away from her dad and runs to the food court where she starts eating leftover food off of tables.
• Tyrone's daycare teacher just bought a new trampoline for all the children to play with. Tyrone has fun all morning jumping on the trampoline by himself. After lunch, another child tries to climb onto the trampoline with Tyrone. The daycare teacher says only 1 child can jump at a time and tells Tyrone to get down. Tyrone watches the other child jump for a few seconds, and then he screams and pushes the other child off the trampoline. 

A child who doesn't know how to wait may become aggressive, defiant, and may eventually have a meltdown. Most people just see the behavior as the problem and try things such as blocking the aggression, telling the child to stop pushing, or putting the child in Time Out for throwing chairs. The problem with that approach is that in all of these situations the behavior was the by-product of a skill deficit. These children did not know how to wait. 

When put in situations where they didn't get a desired item or activity "right now" they engaged in problem behaviors. In order to effectively terminate these problem behaviors you have to target the skill deficit, not just the outcome behavior. Don't be the type of professional or parent who sticks band-aids on problems. Eventually that band-aid will stop working and the wound will be worse than before.

When teaching waiting you can work on this skill incidentally or you can write up a program and teach it in a structured way. I tend to do both. I write up a Waiting program and I also show the adults in the child's life how to work on this skill outside of therapy. The more the child gets to practice waiting, the better.

So lets look at both approaches:

Teaching a Child to Wait: Program-

For a step by step explanation of how to write ABA programs see my Writing ABA Programs post. For a Waiting program you will need  activities or objects the child enjoys. You may also need a timer (but it's not required). Before writing the program you need to determine the child s current ability to wait appropriately. Appropriate just means the child doesn't try to reach for or grab at the item they are waiting for, and if the child is vocal they don't whine or plead for the item. If its an activity, the child doesn't try to run past you to access the item. If you determine the child can wait about 20 seconds before they grab at the item, set your first target at 10 seconds. You always want to start a little below what the child can currently do to ensure they contact reinforcement. Slowly build up the amount of time using small increments. Select a simple SD, such as "Wait/Hold On/Just A Minute". Allow the child to access the preferred item for a few seconds. For example, give them a highly preferred doll to play with for a few seconds. Then take the doll away, say "Wait". Place the doll where the child can clearly see it but not reach/touch it. Once the designated time of waiting has ended, give the child the item. It's important to also practice waiting for activities, not just tangible items. So waiting to go outside, waiting to access mom's attention, or waiting to watch a favorite TV show.  Practice daily.

Teaching a Child to Wait: Incidental-

Create opportunities during the day for the child to wait for something. At breakfast, start to hand the child the orange juice and then stop and say hold on, wait a minute, or some other natural wording. When getting the child out of the car, reach to unbuckle their car seat and then stop and pretend to be busy with something so the child has to wait. Use varied opportunities and various items. Have the child wait for toys, to leave a location, to enter a location, and to start an activity. Be sure to always provide quick praise and reinforcement for good waiting. Everyone who interacts with the child should give the child opportunities to practice this skill. If you are in public and don't want to use a timer you can do a finger countdown. Hold up 2-10 fingers and do a countdown to zero. Not all children will need timers or finger countdowns, but they can make waiting much easier for those who do.

**Quick Tip: Visuals can be a great way to  help teach waiting. For children who don't understand the passage of time using a visual makes time much more tangible and real. What kind of visual you use will depend on the age and cognitive ability of the child. For a young child maybe a stoplight visual colored green-yellow-red. The red card could mean "wait",   yellow could mean "almost", and the green card could mean "go", or access the item. For an older child maybe number cards. This is great if you are having a conversation with another adult or on the phone and need the child to wait before speaking to you. Flip through the cards starting at number 10 working down to 0. Once you get to 0 give the child your full attention and praise them for good waiting. This gives the child a much more concrete understanding of time rather than you saying "Hold on!" over and over. When using visuals always pair language with the visual  so you can eventually just use language and fade out the visual.

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Tameika Meadows, BCBA, Blog Author

“An ounce of prevention is worth a pound of cure.”

~ Benjamin Franklin, 1706-1790

I like to think of this quote as directly referencing early intervention; The foundation that you build today will impact your future results.

 

 

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Tameika Meadows, BCBA, Blog Author