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Hi and welcome to Ask Missy Mondays where I respond to a question from readers. Today’s question comes from a frightened pregnant reader who has heard a popular news item”flu during pregnancy leads to autism“. Janet writes,

“Hi Missy, I’ve been a huge fan of your blog. As a teacher, I started reading for resources. My husband and I recently found out that we are expecting a baby. And now I’ve heard this news that if I get the flu while pregnant, it increases the likelihood that my baby will get autism. I thought that the flu vaccine itself was linked to autism. What should I do? Should I get the vaccine? I’m torn!”

Hi Janet. I’m so thrilled that you are a regular reader of the blog. Thanks! And congratulations on your pregnancy news! I can certainly understand your concern after hearing all of this on the news. It is an awful lot to make sense of.

Unfortunately, as a behavior analyst and special educator, I am not in a position to give you medical advice. I suggest that you speak with an appropriately trained health care practitioner to discuss your concerns. Also, please check back on Thursday when the Denmark study on pregnancy and the flu will be reviewed in detail.

P.S. frequent hand washing is recommended by all healthcare practitioners.

If you have a behavioral question for me email me directly at askmissy at applied behavioral strategies dot com. Thanks!

 
 

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We recently received the call for proposals for the upcoming conference in Dubai. If you will recall, we went last year and had a wonderful experience. The upcoming conference is going to focus on behavior analysis. We are super excited to submit something and we hope that our colleagues will as well. Here is the call for abstracts. Please share it with your colleagues! Due date extended to November 15th.

Abstract For Autism

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Here at Applied Behavioral Strategies, our mission is to improve the quality of life through effective intervention. One way we hope to do that is by reviewing research articles for our readers. Today’s article is titled “Brief Report: Increasing Verbal Greeting Initiations for a Student with Autism Via a Social StoryTM Intervention”. Brian Reichow and Edward Sabornie authored the article and The Journal of Autism and Developmental Disorders published the article.

Study Purpose

It is a known fact that children with autism spectrum disorders have social deficits. One intervention that has been used is Social Stories. While social stories are widely used, the research on the effectiveness has been limited. Thus, the authors set out to determine if a Social Story could be used to increase appropriate verbal greeting initiations.

Study Methods

The authors enrolled an 11-year-old male with autism in the study. “George” as he was called, had an average IQ and he had above average grades on his report card. While he attended a social skills group at school, his social skills did not seem to be improving.

The authors developed a story according the guidelines recommended by Carol Gray. We discussed some of the differences between Social Stories TM and social stories or social narratives earlier this week.

The authors used a withdrawal design to demonstrate experimental control. Basically, in this design, an intervention is implemented. If the intervention is effected, it is removed to determine if the behavior would return to pre-treatment levels.

The authors merely counted the number (or frequency) of verbal greeting initiations. Waves and gestures did not count, only verbal greetings (e.g., hi, hello, good morning).

In baseline, George reported to his home room, picked up his schedule, and went about his day.

During intervention, George picked up his schedule (which included “read your Social Story”) and then read his social story before heading out to classes. The authors faded the social story and moved to a simple “cue card”.

Results

During baseline, George had zero verbal initiations. During intervention, George had an immediate increase in verbal greeting initiations. Specifically, he initiated greetings between 2 and 6 times a day; including greetings to peers! However, when the intervention was “withdrawn”, George stopped initiating greetings. When the intervention was reinstated, his initiations increased again to 2 to 4 initiations per day; including initiations to peers. When the social story was faded and the cue card was taught, the verbal initiations continued.

Conclusions

As we have discussed, this intervention is effective. Also as we have discussed, all interventions should be developed on an individualized basis. This is not a one size fits all approach. This individualization means that teachers, behavior analysts, and other practitioners will need to spend time developing the materials that will be used to teach the skill(s).

 

 

 

 

 

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Hi! and welcome to What Works Wednesdays where we share a success story from our clinical files. We usually focus on the use of ABA and its effectiveness for our clients. Today, we are going to share a resource that works. The resource is the Office of the Health Care Advocate (OHA). We have one in Connecticut. Here is the website: http://www.ct.gov/oha/site/default.asp

Here is the contact information:

Mail To:
Office of the Healthcare Advocate
P.O.BOX 1543
Hartford CT,06144

Phone: Toll Free at: 1-866-HMO-4446

FAX:  (860) 297-3992

E-mail: Healthcare.advocate@ct.gov

On October 17th, the OHA held a public hearing on barriers to access to mental health and substance use services. I (Missy) went to testify. Here is my testimony:

Introduction

Hi and thank you for taking the time to listen to consumers, providers, and advocates. I am here today as a behavioral health provider. I am a Board Certified Behavior Analyst and my company, Applied Behavioral Strategies, LLC provides Applied Behavior Analysis (ABA) therapy services to children with autism under Public Act No. 09-115.

Autism Insurance Bill

Under Public Act No. 09-115, children under the age of 15 are eligible to receive ABA therapy if their parents have certain types of health insurance.

Success!

While I have only been in business 2 years, you will be pleased to know that all of the children on my caseload who receive services through mandated insurance coverage have made growth as a result of ABA therapy. For example:

  • “Matthew”
    • Learning to go on community outings without screaming when dogs pass
    • Learning to take a shower independently
    • Learning to shave
  • Casper
    • Used to request to avoid many school classes (specials), now participates in all instruction and specials
    • Before our therapy, he had no friends.  Now he has friends and makes play dates
    • Historically engaged in aggression with his parents and siblings, we haven’t seen aggression in many months
  • “Joanna”
    • After living off pureed food for 8 years, she learned to eat table food!
    • She is learning to wear different shoes, hats, gloves
  • “Sammy”
    • Learned to sit and relax by playing games on his iPad or watching music videos
    • Decreased self-injurious behaviors
    • Improving his spontaneous communication
  • “Charlie”
    • Decreased head banging
    • Learning to tolerate work at home
    • Learning to ride in the car without thrashing his head when his parents go a different route
  • “Clark”
    • After being restrained repeatedly in his public school, Clark attends a private school with support and only a few outbursts
    • In the past, cried because he didn’t want to do school work, now gets upset if he cannot finish his work

The “Unlucky” Ones

Those case studies illustrate how state policies improve the quality of lives for individuals with behavioral health challenges. But unfortunately, a group of clients exist who are not eligible for these services because they don’t have the right type of insurance, or their insurance originates from a different state, or even worse, they are too financially disadvantaged to have insurance and are covered by Husky.

It is for these clients, I am begging for your ear. These clients and their families will never share joys described to you previously because they will not receive the ABA therapy. They cannot afford to pay for it out of pocket so they do without.  Even as I write this, it feels like I’m writing about a different century or a third world country. How can this be? These clients and their families have just as many needs, if not more, than the clients who are receiving therapy. But as a result of not receiving therapy, their behavioral health needs worsen which only serves to exacerbate the mental health needs of their parents. And all of this costs more in the long run.

Provider Issues

But even worse than not having the appropriate insurance, are the clients who have the right insurance but cannot find a provider because there are not enough providers who accept insurance. Let me tell you why providers do not accept insurance:

  • The reimbursement rates are drastically reduced from fair market value
    • My highest rate of reimbursement is still 50% less than my billable rate
    • The insurance companies do not reimburse for services in a timely manner
      • Cigna currently owes me $18,000 on ONE client
      • The stress I experience at each payroll period is overwhelming because I am not sure if my cash flow is sufficient to pay my employees
      • The amount of administrative time that is needed to follow-up with insurance in order to get paid is almost a full-time position
  • The reimbursement for services does not cover my income and that of an administrative assistant (see rates above).

Amazing Resource

The Office of the Healthcare Advocate has been extremely helpful for me and my clients as staff (Vicki and Jody) have assisted my clients (and many others that are not my clients) in obtaining the coverage to which they are entitled. I am extremely grateful for their assistance over the past two years.

Summary

In closing, I feel fortunate that ABA services are available to children in this state. Thirty years ago, these services were not available to my brother. I cannot help but wonder where he would be today, had he received the services that my clients receive today.

Thank you for taking the time to listen to us today and please do not hesitate to contact me if you have questions regarding this testimony.

If you want to watch the entire hearing, you can do so here:

If you live in CT, be sure to use your OHA. If you do not live in CT, check your state’s resources to see if you have an OHA in your state.

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Today is election day in the United States.As you head out to the polls to vote, think about the issues that are important to you:

  • autism
  • disability issues
  • behavior analysis
  • children
  • vulnerable adults
  • special education
  • public education
  • (any others that matter to you and your family)

If we lived in Australia, we would be fined for not voting. In the U.S., people have died fighting for our right to vote. Exercise your right today (if you haven’t already). Just do it. Vote.

 

 

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Hi and welcome to Ask Missy Mondays where I respond to a question from readers. Today’s post is in response to multiple requests and questions about social stories and visual supports. Common questions include:

  1. I thought the story had to be written in first person? (e.g., “I like” versus “Charlie likes”)
  2. I thought the story had to be just like Dr. Gray says (A specifically defined style and format: sharing accurate social information and affirming something positive about the child)
  3. Is there any research to support social stories or visual supports?
  4. We do ABA.  Social stories aren’t behavioral.
  5. My child cannot read so why should we have a story?

Overview

Social stories and visual supports serve a specific purpose of providing visual information to individuals so that they can be successful in difficult situations. Some examples of difficult situations include:

  • Non-preferred but required activities (e.g., shopping, haircuts, blood draws)
  • Changes to routine (schedule is disrupted, substitute teacher, different bus route, school cancellations)
  • Novel situations (first time to hospital, first time on an airplane, first time to a play or show, storms)
  • Special but routine situations (dr. appointments, dentist appointments, hair cuts)

 

Individualized

Social stories and visual supports should be individualized to the user. While it may  not be convenient for a teacher to create 12-15 stories/visual supports, what works for one person may not be appropriate for another. When developing stories and visual supports keep the following considerations in mind:

  • age of the individual (resources must be age appropriate for the user)
  • reading ability (adjust the text of the visual depending on the reading level)
  • visual acuity (content should be selected based on the individual’s vision and ability, 3D versus 2D, color versus black and white)
  • attention span (the length and detail of the story or visual support)

Content

While Dr. Gray has created a trademark, there are many options beyond what she describes. Because social stories and visual supports should be individualized, the content should be determined based on the individual’s needs. For example, a mom here in CT created a social story for her child regarding Hurricane Sandy. The story included information about the storm, how it would affect trees and power, and how power could be restored. The story was developed for her son because the issue of losing power is important for him. He becomes upset if he cannot turn on lights or play on computers. However, another child may be scared of the wind or scared of the heavy rain. That child would need a story that focuses on the wind and the rain and how to make the noise go away. And then another child may not fully understand why she cannot go to school. Because she cannot read, her story may show a picture of wind and rain and a picture saying “no school”. The story would end with a picture of the little girl at home working with her ABA therapist.

Research

We have written about visual supports before: here, here, and here. We recommend only evidence-based strategies for our readers. So obviously there is ample research to support social stories and visual supports. A research group has developed a list of evidence-based practices for individuals with autism. Social narratives and visual supports are both on the list. For additional information on those practices and to read the research visit here.

ABA and Social Stories and Visual Supports

ABA, applied behavioral analysis, is simply the application of behavioral principles, to everyday situations, that will, over time, increase or decrease targeted behaviors. For additional information on ABA, visit our website. Thus, the use of visual supports and social stories does not preclude someone from doing ABA. Similarly, implementing ABA does not preclude someone from using visual supports and social stories.

I hope this helps to answer the many questions about social stories and visual supports. If you have a behavioral question for me email me directly at askmissy at applied behavioral strategies dot com. Thanks!

 

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We are so excited to announce that we will be speaking at SXSW in Austin, TX in March, 2013. We will be part of the interactive conference under the Diversity and Emerging Markets topics.

Thanks go out to the Autism Society of Greater Austin (Fran Kennedy and Ann Hart) for thinking about and supporting the proposal.

We will be speaking about Apps for Autism. If any of you are app developers and would like for us to consider including your app in our presentation, please contact us for information that we will need in order to be able to do that.

We will be covering:

  • apps that support communication
  • apps that support language development
  • apps that support academic development such as reading, writing, spelling, and math
  • apps that teach and/or support social skills development
  • apps that teach and/or support fine motor development

Hope to see you there!

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Today marks one year for our blog. On September 19th, 2011, we started blogging regularly. The first blog appeared in August of 2011 but we didn’t become regular until September. Of course, we paused for life here and there along the way.

We want to take today to thank all of our readers and followers. We appreciate your support, your criticisms, and your suggestions.

Our all time busiest day so far was April 3, 2012 when we posted about free apps for Autism Awareness

And here are our top 10 posts based on total number of views.

10. Help! My Child Has ADHD

9. Peanut Butter Bread: Battle It Out?

8. My Child Won’t Poop in the Toilet: HELP!

7. Inclusion is an Individualized Decision

6. What Inclusion Teaches Us

5. Updated iPad Application List

4. Homework Habits That Work

3. Autism Awareness Free Apps

2. Using ABA to Teach Math

And the number one post of all time? Do You Use Visual Schedules?

Readers, we love hearing from you. Please let us know if you have any questions to answer about behavior or if you have a topic that you want us to write about. And most importantly, thanks for hanging around.

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Here at Applied Behavioral Strategies, our mission is to improve the quality of life through effective intervention. One way we hope to do that is by reviewing research articles for our readers. Today’s article is titled, Intervention for Food Selectivity in a Specialized School Setting: Teacher Implemented Prompting, Reinforcement, and Demand Fading for an Adolescent Student with Autism (wonder if they could make that a little longer?). A journal called Education and Treatment of Children published the article and Maria Knox, Hanna C. Rue, Leah Wildenger, Kara Lamb, and James K. Luiselli authored it. (If you want to read the entire article, you will find it on www.freelibrary.com)

Background

Many children with autism engage in picky eating or what researchers call “food selectivity“. For example some children live on a white foods diet (chicken nuggets, french fries, and bread) while others remain stuck in pureed foods.

Applied Behavior Analysis (ABA) is one intervention that has been demonstrated repeatedly to be effective at addressing picky eating behavior. However, the intervention often results in challenging behaviors that make it difficult for parents and caregivers to implement on their own. In fact, most of the research to date has been implemented by highly trained therapists.

Purpose of the Study

Thus, authors set out to determine if an intervention could be implemented by school staff in the school setting.

Study Method: Participants

The authors enrolled one child in the study. “Anna” was 16 and had autism. She was verbal and she could follow simple instructions. Anna could feed herself. However, she limited her diet to  a few brand-specific crackers, dry cereal, and apple juice . During the study, Anna’s mother provided new foods including one main food (chicken nuggets, macaroni and cheese, or turkey and cheese sandwich) and two side foods (cheese cubes, vegetable chips, carrots, mandarin oranges, or apples).

The authors implemented all study procedures at the school in Anna’s lunchroom or her classroom. The teacher and the teaching assistants collected all the data for the study.

Study Method: Design

The authors used a changing criteria design which is one type of single subject design. In this design, the expectations are gradually increased across phases. Thus, the teacher required Anna to eat more and more food across the study.

In baseline, the food were presented. If Anna did not eat within 2.5 minutes, the food was removed. After 10 minutes, Anna was allowed to eat her preferred foods.

Study Method: Intervention Technique

The researchers taught the teacher how to implement the intervention prior to the beginning of intervention.

Prespecified Reinforcement (First-Then)

During intervention, the teacher presented the new food on a separate plate and told Anna when she ate the new food (small amount at first), she could have her preferred food.

Reinforcement

Additionally, Anna earned verbal praise and stickers for eating new food. Anna cashed her stickers in for small trinkets.

Prompts

The teaching staff verbally prompted Anna to eat her lunch, if, 30 seconds after swallowing she had not taken her bite.

Demand Fading (Increasing the Volume Slowly)

Gradually, the teaching staff increased the amount of food that Anna needed to eat in order to get her preferred foods.

Results

By the 23rd lunch session, Anna consumed 100% of the new food and she repeated this on the 24th and 25th lunch sessions. The authors came back to assess her eating 2 weeks, 6 weeks, and 7 months later. Anna continued to eat 100% of her new food.

Congrats to Anna and the research team on such a successful intervention. ABA works!

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Technically, Jackson met our requirements for graduation at breakfast on the 4th day. He successfully ate breakfast with his mom and his brother and he engaged in almost no challenging behavior. However, before we discharge, we like to make sure that our clients can generalize their behaviors to school or to a community restaurant (or both!). So, we used Friday to work on generalization.

Pretzel’s at the Mall

Kendall told us that one of the most difficult times had been when they went to the mall and Jackson tried to get pretzels. Since starting the gluten-free diet, he would not be able to eat those pretzels and she worried that he would have a tantrum if she told him no. So, we agreed to meet her at the mall to work on an intervention.

Jackson walked right past the pretzels to meet us in the middle of the mall. However, when we arrived, he took off walking. He was a man on a mission! He went straight for the pretzels. We told him “no pretzels today, we are going to eat lunch”. He grabbed his communication device and typed out “PRETZEL”. We affirmed his request and simply restated that we would not be having a pretzel but instead we would go to lunch and he could eat pizza (we had already selected a gluten-free pizza place). We showed him the picture of a pizza.

Jackson took off walking through the mall. He had one things on his mind: Pretzels! After circling the mall and arriving at the pretzels again, he walked over to the display and pointed. We reminded him again that we would not be having pretzel and that we were going to lunch. With that, he decided it was time to leave and he proceeded to his car.

Well that seemed a little too easy.

Planet Pizza

 

When we arrived at Planet Pizza, the manager was restocking the chips. Yes, you remembered correctly. Jackson has a thing for Lay’s potato chips. He was super excited! He went over, picked up a bag of chips and appeared happy as a clam. We reminded him that he was here for pizza and not for chips. We asked him to put the chips back. At first he was reluctant but we remained firm. Please put the chips away, we are going to eat pizza. Jackson put the chips away and we asked him to pick out a drink.

Prior to starting feeding therapy, Jackson only drank water. He drank water out of a faucet and out of the Long Island Sound. Wherever he could find water, Jackson drank it! We told him, “No water today, pick something else.” He told us no but we held up two types of juice and he picked one.

Then we escorted him to find a table while the pizza cooked.

  1. Note: Kendall brought her own dairy free cheese and the staff cooked the gluten-free crust with the special cheese.
  2. Note: Bring things to do in restaurants while you wait!

While we are great at helping kids in the community, we have so much knowledge and training that we have a hard time remembering to teach the parents all that we know. We forgot to prep Kendall for the things that Jackson would need to keep himself busy. Luckily, we had iPhones so he tried to watch YouTube while waiting.

Jackson made a few noises during his wait. Unfortunately, restaurant patrons stared at us. The staring makes all parents uncomfortable. We let Kendall know that bringing Jackson out actually helps to educate others. Plus, Jackson has every right to be there too!

Success

The pizza arrived after only a 15-minute wait but then we had to wait for it to cool. Finally, Jackson could try pizza for the first time in many, many years. He loved it! He didn’t mind the spinach or the broccoli. He even picked up his fork and stabbed a few pieces on his own. He ate the entire piece that Kendall had prepared for him. He did this without aggression and without any expels!

Jackson still has some skills to work on:

  • cutting his own food
  • stabbing his own food using the fork
  • scooping his own food with a spoon
  • learning to wait quietly at restaurants
  • wiping his mouth with a napkin without reminders

However, he has come a tremendous distance in only 5 short days. Congratulations Kendall on all of your hard work. Jackson is a champion eater and you are a champion mom!

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