Getting Creative With Reinforcement

One of the most important things in a successful ABA program (and in many other areas of life, really) is compelling motivation.  Working with kids with autism, or being a parent of a child with autism, it gets necessary to get creative with motivation and reinforcement.  Kids with autism may not have the same interests as other kids, and they certainly are not going to follow the rules of what they "should" like.

One of the easiest ways to find creative reinforcers is just to watch the child in an environment with many options of what they can interact with.  Are they playing with a certain toy?  Are they approaching the adults in the room?  Are they approaching the children?  Is there a pet they are looking for?  Are they sliding pictures between the wall and the desk?  Are they ripping papers apart?

There are many creative things that can be used as reinforcers that we may overlook because they don't seem like they "should" be reinforcing, or we haven't thought of a way to be in control of them.  We need to think outside the box, because "the box" just doesn't exist for them.  Other reinforcers are just so in our face that we completely look past them.

I may make some updated posts with other creative reinforcers as I come up with more, but for right now here is a list of some off the top of my head.  Some are more creative than others, my current case load is chock full of easy to reinforce kiddos

• A box with a slit in the top (for the kid sliding the pictures between the wall and desk!)  As they correctly label the picture, they then get to place it in the slit in the box.
• Paper (for the kid ripping paper.)  Gives them the chance to rip without destroying something that may be important.
• Kittens (of course, calm ones with kids who are gentle with them!) Even better if the kitten reaches out to give you "high fives."
• Soft balls- to throw at each other.  Watch out for kids with a really good arm.
• Brushing your hair.  My hair is curly, and brushing it turns it into a HUGE puffball. Never underestimate the motivation of making the therapist "look like a lion!"
• Shout "YeeeeeHaw!"
• Do a handstand (if you can)
• Draw- animals, vehicles, whatever they are interested in! (If it is animals, check out howtodrawanimals.com I use it often because I can't draw well AT ALL.)
• Time with a prefered family member.
• Being left alone.  Not home alone, just being given space to not have someone on top of them.

As a general rule of thumb, things I use as reinforcers are virtually anything that the child 1) shows interest in, 2) is available, and 3) won't harm them or others.  Particularly for kids who are still working on requesting skills, if they ask for it and it falls under 2 and 3, they can have it.

Do you have any particularly creative reinforcers in your bag of tricks?

~KVL

Food Selectivity- Not Just a Health Problem

Working with kids with autism I frequently come across children with food selectivity.  This of course is not at all surprising, considering the varied sensory sensitivities these kids may have and that food plays into both the sense of taste as well as the sense of touch.  Though there are many other programs that I work on with multiple clients that I either currently have or had in the past, the eating programs really stand out to me for personal reasons.

I have to admit, I also have some food selectivity.  And when I say that, I don't mean I am your run of the mill picky eater.  I mean, I eat the diet of your average 8 year old.  Chicken nuggets, french fries, and pizza make up the majority of my diet.  I don't eat vegetables.  And when I say that, I don't mean "I don't like to eat vegetables" I really mean that I do not eat vegetables, unless you count grains (corn) or starch (potatoes) as vegetables.  I also do not eat sauces, except pizza sauce on pizza and even that I did not used to eat.  I have myself on my own program to work on this, and have a strong reserved reinforcer (Rolos!) I can only eat if I take a bite of a new or non preferred food.  When people say "if you had nothing else to eat, you would eat it" they never believe me that I would starve first.  Unless I had my Rolos.

Because of my own food selectivity I have vivid memories of not being able to leave the table until I ate my peas.  Let me tell you, I still do NOT eat peas.  I may, on rare occasion, swallow a couple of peas whole.  Usually when I am visiting my parents.  But you will never see me chewing up and swallowing peas like food is typically eaten.  For health purposes, I have used my reserved reinforcers to eat small amounts of other vegetables, however, the health effects are not my biggest concern with my food selectivity.

The biggest effect that my food selectivity has had has been in my social life.  It is embarrassing.  I cannot be invited over for dinner by people who aren't already accepting of my food choices without either turning them down, or bringing my Rolos but still feeling mortified that I only eat a few bites of what they are offering me, which is, by most standards, great food.  I can't go to a new restaurant without scoping out the menu first to make sure there is something I will eat.  Nice restaurants are the worst, because the more unique or complex or fancy the food, the less likely I am to eat it.  This puts a huge crimp in the works when I am with a group of people and a restaurant is chosen where there is nothing I eat, then I have the choice of leaving myself out, or being embarrassed by how little I eat.  When I was younger and naturally thin I constantly worried that people would think I was anorexic, because of how little I ate at times out in public.  Strangers had no way of knowing why I left my plate mostly full at a new restaurant, or at a pot luck gathering, or a party where there's little I eat.  The latter being what finally got me to write this blog, after attending a birthday party for my brother in law where all I would eat was chips and cake.  

In high school, I was fortunate enough that my first boyfriends mother catered to my food selectivity and kept hot dogs and frozen pizzas for when I was there for dinner.  She certainly didn't have to do that.  She could very well have chosen to not allow me to stay for dinner.  When I started dating my now husband, he mentioned that his mother wanted to have a big family dinner when we went to visit.  That sort of statement always raises the alarm bells in my head, what kind of impression am I going to make on his ENTIRE family if I don't eat anything his mother has cooked?  Thankfully he'd already mentioned to his mother about my eating habits and she planned to cook food I eat.  

All of these things cross my mind when I begin with a new client who has food selectivity issues.  My first thought, of course, is about their nutritional well being, but after that my mind always moves to the social repercussions of food selectivity.  Particularly for the kids who are more socially motivated, I can't help but think "I want you to be able to stay at your friends houses for dinner in high school.  I want you to be able to eat food in the dining hall at college regardless of the menu.  I want you to be able to go out on a date to a restaurant and not order off the kids menu."  While of course there may be other social skills to work on and plenty of time before these situations arise, I don't want any of the kids I work with to be held back after making so much progress simply because of what they do not eat.

With applied behavior analysis, one of the dimensions of behavior we consider is the "applied" aspect.  The social importance.  When working with food selectivity, I consider what foods the client is likely to come across not only with what the family typically eats but also what will be most likely available to them outside the home at friends houses, at school, and at restaurants.  I also try to build in some way for the client to have choice, so they aren't always being required to eat foods that they really do not and will never like.  Most people have foods that they simply don't eat, my goal is to get the client eating a greater variety so they are likely to find foods they will eat anywhere and will have a more balanced diet.  My goal isn't to get them to accept any and all foods.

It is my hope that other behavior analysts and other professionals who work with individuals with autism consider the social effects of food selectivity when working with clients who may have nutritionally acceptable diets that are extremely limited.  Particularly for individuals who are more socially motivated, and are likely to run into situations where their food selectivity limits their social opportunities.

~KVL

Important Thoughts Regarding the Recent BCBA/BCaBA Exam Pass Rates

It's been about a week since the most recent cohort to take the BCBA and BCaBA certification exams have found out whether or not they passed.  I either personally know or know of a number of people who both passed and failed the exam this go around, and I've been putting together some thoughts on it.

I have seen a lot of people who are upset because they have not passed.  They have put a lot of time and effort into becoming certified.  Taken the required courses, done their supervision hours, spent countless hours studying the material.  I can understand being frustrated by failing, especially frustrated by the pass rate.  I see some saying, but that's not fair!  I have worked years towards this.  Some people question if it is unfair, or if it is too hard.  I'm not sure those are the right questions to be asking.

What we need to be asking is, do we think this version of the test is focusing on the right things, in the right ways?  Is the test too hard, or do the programs leading up to the test failing in some way in preparing the students for the exam, and more importantly to be behavior analysts?  Are the people who are passing the exam the kinds of clinicians who we want to be in positions to make important decisions about people who truly need our help?

These are very, very important questions.  I took the exam before the changes, so I have not taken the new test to be able to see what it focuses on, or how the questions are phrased.  What I do know, is that I see amazing therapists who both do well 1:1 with kids, but also put forth their greatest effort to apply the material they are learning to their own clients, both for the benefit of their clients and for their own understanding of the material.   I have seen this type of therapist FAIL the exam.  Multiple times.  I have seen other therapists who in all honesty aren't great with kids, aren't open to feedback, and who may be able to give definitions but would be hard-pressed to apply the concepts in a real life situation who have PASSED the exam.  I will be honest, it rather scares me to see some of the people who have passed the exam (even with the lower pass rate) and are going to be flung forth into the field, thinking of themselves and being treated as experts, when they have only the vaguest idea of what they are doing.

I believe that what we, as currently certified behavior analysts, need to ensure, is that we are putting our support behind those who will do the best job being behavior analysts.  People we would be proud to call our peers.  People who do not come out of the exam with a failing grade with a sense of entitlement lost, but with a positive attitude that they are going to focus on how they can better themselves and do better next time.  People who take personal responsibility for their results.  People who truly do everything they can, before taking the exam and after failing or after passing, to continue to better themselves.  People who take an active role, because our field is growing and evolving and just passing the exam and standing still is not enough.

The BACB made their standards stricter because they are trying to weed out the people who aren't genuinely good behavior analysts.  Our field cannot afford a high percentage of poor behavior analysts- it makes us all look bad.  I applaud the BACB in their continued tightening of standards in an attempt to ensure the incoming behavior analysts are of higher quality.  We need to continue to examine whether or not the steps taken by the BACB are serving the desired purpose.

I believe we need to have an ongoing dialog about where the standards are set to currently, whether or not incoming behavior analysts are meeting our own professional standards, and what, if anything, we can or should do to continue to fine-tune the certification process.  I would love to hear others opinions on what is going right, or what is going wrong.

~KVL

Clearly We Are Not Doing Enough!

My heart is breaking today for the family of a young girl with autism who wandered off from her home around dinner time last night.  Tragically, her body was found in a nearby lake.  (You can read more about this story here: http://www.wavy.com/dpp/news/local_news/hampton/5-year-old-missing-in-hampton)

In addition to the clear tragedy of the loss of this child, it also saddens me greatly how little is known about autism by so many people still.  Some of the comments on the story make this clear, and this tells me we are not doing enough.  We need to continue to spread the information about what autism is, how it effects kids, and what cannot be assumed to be true for these kids.

In this case it is clear that people do not understand the wandering behavior that is seen in many kids with autism.  So many people assuming she was murdered, or that her parents left her alone outside to wander off.  While I do not have a child with autism, I have worked with enough families of children who wander to know that their child escaping the house unnoticed is one of many parents greatest fears.  Children can slip out of doors, or simple wander out of a yard when a parents eyes aren't on them for a split second.  In the case of this girl, she lived in a neighborhood with a lake 2 blocks away.  As children with autism do not follow our rules, my first assumption is this girl felt like swimming and went to do so, but perhaps can only swim in shallow water and the lake was too deep.  With the lake so close to the house, this horrible tragedy probably unfolded quite quickly for this poor girl.

How sad for the parents that in addition to losing their child, they have people questioning "where were the parents??"  My answer to them is mom was probably making dinner!  Certainly every parent has to cook for their children and use the bathroom.  It is quite simply impossible to have an eye on your child every moment of the day.  We do not know this family or this child, other than she had autism and did not speak and the family was new to the area.  Either this girl didn't have a history of wandering off (maybe her old neighborhood didn't have a lake she wanted to swim in!) or her parents simply hadn't had a chance to get alarms put on the doors or to get Project Lifesaver in place.

I believe that in addition to educating the general public about the wandering (and bolting) behaviors of these children, we also need to do a better job of educating parents of children with all disabilities who wander that there are options such as Project Lifesaver to help them track their child should he or she wander off.  Parents need to know that they can have some piece of mind, and the general public needs to be made aware of what to look for and what to do should they happen to encounter a child with autism where they should not be.

For more information on Project Lifesaver, you can find their website here: http://www.projectlifesaver.org/

~KVL

Far from the Truth- part 2

Continuing on from my previous entry:

"Funding"

http://www.youtube.com/watch?v=FwQiyHGb8dQ

ABA receives funding to be used in schools because it has been PROVEN over many years and countless studies to be effective.  Funding is rarely available for experimental treatments, which is what any treatment is that lacks empirical evidence.  This one, I have to say, is not our fault. ABA in no way prevents people from conducting studies to show evidence of the effectiveness of other therapies.  When other therapies prove effective, they will get more funding.  Seems pretty logical to me.

And while on the subject of money they forget to mention the HUGE number of schools that do NOT offer ABA and the huge number of families who DO seek ABA services- out of pocket- for upwards of $30,000 per year.  BUT there are also a number of organizations that are non-profit and offer services for reduced rates or offer pro bono services.

If funding in schools is upsetting them, they must be having a hay day with the fact that new insurance legislation in many states specifically requires insurance policies to cover ABA.

"Friends"

http://www.youtube.com/watch?v=2VGbdl-LHSM

The assertion that ABA only focuses on academic and self help skills is completely false.  As is the idea that ABA always requires children to sit still.  ABA can be done on the floor, it can be done while bouncing on a ball, while taking a walk, or while sitting in a chair.  Besides the fact that the skills taught with ABA are ones that are important to be able to be independent and as successful as possible in life, the idea that ABA doesn't promote making friends is just plain crazy.  Frequently siblings and peers are included in ABA programming in order for the child with autism to learn play skills and other interactions.  There are ABA based social skills groups.  Skills used to develop social relationships are just as much of a priority in a good ABA program as communication, self-help, and academic skills.

"Training"

http://www.youtube.com/watch?v=nDB3-_Gw5yI

I would love to know where they got this information.  When I began doing ABA I was trained for weeks, full-time, before being able to work with the children.  When I did begin working with the children, I was directly observed and trained further.  I was trained on the specific children I worked with, in depth, and training was ongoing.  This video also ignores the fact that ALL ABA therapists should be directly overseen by a qualified BCBA or BCaBA, both of which require a degree (graduate for the BCBA), additional specialized coursework, and intensive on-site training for at least 1000 hours(BCaBA) or 1500 hours (BCBA), in addition to passing a board certification exam.  Non certified ABA therapists are overseen regularly and it is the BCBA or BCaBA that designs the programming based on the child's needs and the parents priorities.  Anyone who performs ABA therapy needs to not only be trained in ABA procedures but also be trained on the child they are working with.  So no, by no means is our training short.  Nor do we pump out "lots and lots of peeps."

"History"

http://www.youtube.com/watch?v=k4mDUp2m2pg&NR=1

Ok they are right, ABA was started by a behavioral scientist.  I don't know about you, but I would rather follow treatments designed by a professional.  As great as mom's home-made chicken soup may be, nothing soothes strep throat like some anti-biotics.  Additionally they are misleading when they say "some" people who use ABA have dropped using aversives.  The truth is MOST have dropped aversives.

"Social vs Academic"

http://www.youtube.com/watch?v=6QW6bIbUzK0

Autism is a development, social and COMMUNICATION disorder.  Kids with autism do not learn in the ways that typical children do.  It is not that we do not address social deficits- as I stated in response to an earlier video WE DO.  We simply address ALL areas of need the child has.  It is a PERVASIVE developmental disorder that affects nearly every area of development- including academic.  ABA does NOT focus solely on academics.  If anything, ABA is tending recently to focus on communication

"Published Research"

http://www.youtube.com/watch?v=6D2NwgiX72Q

I admit, there are many people who dispute the idea that ABA is the only therapy scientifically proven to benefit kids with autism.  The truth of the matter is, from what I have seen, other therapies that have research supporting them are ABA based programs that just don't call themselves ABA.  There is a HUGE amount of published, peer reviewed, research supporting the use of ABA techniques- and not only for autism.  There are entire journals dedicated to the ongoing research.  The claim that the results of the original study haven't been reproduced is just silly.  Perhaps the gains seen in further studies haven't matched the original study, but this does not mean the recent research doesn't show ABA is effective.  There have been LARGE studies being run to examine the effectiveness in recent years, government funded, which have shown SIGNIFICANT gains from ABA therapy.

"Attitude"

http://www.youtube.com/watch?v=XnHybdgAMX8

This video is trying to make it sound as though ABA is cold, unwelcoming, unenthusiastic, and doesn't promote hope.  As with the other videos, not true.  Excitement, positivity, and certainly hope are rampant in ABA programs.

As a final note I would like to point out that of course, not every ABA therapist is a GOOD one and not every ABA program is a good program.  Certainly, there are therapists and programs out there that are not using the current best practices, or that focus too strongly on academics, etc.  These programs are NOT the typical ABA program.  ABA programs help families and children see and make real change and great progress.  ABA helps children lead productive, happy, social lives.

~KVL

Far from the Truth- part1

I am going to outline for you the misinformation presented by the video series "ABA vs Son Rise Program" in order as it appears.  There is just so much of it, and as you can see from the comments in the videos most people are starting to catch on that those who made the videos are either greatly misinformed or intentionally spreading untruths to make themselves look better.  I will give them the benefit of the doubt, and assume that they have not had much experience with ABA beyond the outdated methodology first outlines many years ago.

Let me start with the first video, found here on "Joining":
http://www.youtube.com/watch?v=N6CWf9H7F8k

Now, this one is just silly.  For starters, and this is just purely superficial, you will be far more likely to find ABA therapists in jeans than in suits.  Why?  Because we work with kids.  Ones with autism.  Through the course of the day we will likely be joining a child on the floor or engaging in an activity that is likely to require frequent washing of our clothes.  Kids are messy.

Next they tell us the first order of business with ABA is to extinguish repetitive behaviors.  This is just ridiculous!  Do we sometimes do this?  Yes- when the behaviors are harmful or greatly interfere with the child's ability to learn and interact.  However unless the behavior is physically harmful (head banging, picking nails off of fingers, etc) they aren't likely to be the "first order of business."

Now on to scripted behaviors vs relating to people.  Yes, ABA may teach certain things in a scripted manner for some children.  However, there are many ABA techniques that teach the same skills in an un-scripted manner.  I question, as well, their definition of "relating to people."  By joining in repetitive behaviors, are they relating to us, or are we relating to them?  And will they be able to relate to other people, out in the real world, who are not going to join in their repetitive behaviors?  Which will lead to relating better to more people- joining a child in their hand flapping, or teaching them to ask and answer "how are you?"  And is there a reason we can't do both?

The second video in the series is about "Choice":
http://www.youtube.com/watch?v=SRZqOro8dmo&NR=1

ABA therapists don't necessarily want everyone to choose ABA.  We want parents to choose therapies that are EFFECTIVE and have been proven to be so.  We do not want parents wasting their valuable time and resources of treatments that have no effect or are even harmful.  If there is only one therapy available that is proven effective, then it does not seem to me that there IS a choice, however.  Not having a choice of treatments doesn't imply there is anything wrong with the current treatment.  How often do people refuse speech therapy for a child who stutters?  Chemotherapy for a kid with cancer?

This cookie cutter idea.  This is one of the craziest things I have ever heard.  ABA is a highly individualized therapy.  Skills addressed are entirely determined by what the child's strengths and weaknesses are, and specific techniques within ABA which are used to teach those skills are tailored to what works best for each individual child.

The third video in the series talks about "Motivation":
http://www.youtube.com/watch?v=fy6T7FXmnJI&NR=1

Here is where the really out-dated information comes in.  Discrete Trials is ONE of the methodologies encompassed in the universe that is ABA.  This is NOT all that ABA is all about, though this is a popular misconception.  There are other, newer, methodologies such as Verbal Behavior which really use and focus on a child's natural motivation.  We do use things other than candy and food items.  If a child, for example, is enjoying playing with a shape sorter we use that to practice learning shapes and colors.  If a child really wants to talk about monkeys today, we can use that to practice differentiating facts and opinions.


I have decided that this deserves two parts, as this entry is getting long.  Stay tuned for my response to the remaining videos!

~KVL

Pet Peeve

Let me be frank here.  Little cheeses me off more than coming across misinformation being presented as the truth when it comes to ABA.  Very often, people who have NO real experience with ABA programs insist that ABA is... any number of things it is not.  Harsh, cold, robotic.  Not guided by the child's interests.  Doesn't address the core deficits of autism.  None of these things is true!  It is important to note that there are a number of different techniques which are all considered "ABA."  These techniques can look vastly different from one another, however, all are guided by the principles of reinforcement and operant conditioning.  Some are child led,others more structured and scripted.  What determines this?  In a good ABA program, what determines this is what is best for the child.

I particularly dislike the videos from the Son-Rise program, which has no empirical evidence backing it (despite misleading people into thinking that there is) that compare their program to ABA in a manner mimicking the Mac vs PC commercials.

In the following entry I will point out all of the misinformation contained in these videos.  For now, I will leave you with the following link, which is an open letter to the CEO of the Son-Rise program, Raun Kaufman: http://www.asatonline.org/media_watches/41

~KVL