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cursiveHi and welcome to Ask Missy Mondays where I respond to a question from readers. Today’s question comes from Angela who is the mother of a 3rd grader with a diagnosis of autism. Angela asks,

“Hi Missy, I have been reading your blog for a while. Thanks for all the help and advice you provide to us as parents. I’m writing now because I have come to a crossroad for my child. Chris has responded brilliantly to ABA and is doing very well in many areas. He is reading on grade level, he is doing math on grade level, and he is above grade level in science. He continues to struggle with fine motor skills which is common among children in this population. As you probably know, in third grade, children learn to write in cursive. Chris tried this for the first two days but it is going to take him a long time to master the entire alphabet. Who knows how long it will take him to put letters together to form words? What do you think about this? Should we keep working on this even if it means he may fall behind in reading and math? Thanks in advance for your help on this.”

Hi Angela, and thanks for writing. It is ironic that you emailed with this question. One of my current clients went through this exact issue just a few weeks ago. As a supervisor, I always take the family preferences in to consideration.

Parent Input

Right away, the first thing I would do is ask the parent (in this case, it is you), “How important is it for you for your child to learn to write in cursive?”

Socially Stigmatizing

The next question I ask is, “If your child does not learn to do this skill, will it be socially stigmatizing for him?” In this same area, I have to also ask, “Is it going to be socially stigmatizing for him to learn how to do this skill? Will his friends laugh at him if he doesn’t learn it as fast as they do?”

Essential Life Skill

The next question I ask is, “Is this skill essential for your child to do in order to be independent?”. Some skills are absolutely necessary. Handwriting is not one of those essential skills. I cannot tell you the last time I wrote in cursive. Even my signature is a scribble more than a signature. So, your child will need to learn to sign his name but he is allowed some creativity in doing this. I honestly don’t think the majority of people use proper D’Nealian when signing important documents.

I hope this helped to answer your question, Angela. I also want to point you to some other blogs on this same topic (listed below) as you may find them helpful too.

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

 

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Here at Applied Behavioral Strategies, the 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 has actually been the topic of a lot of social media. See these headlines here and here and a reader actually wrote in about it on Monday.

Do pregnant women who get the flu or a fever actually increase the likelihood that their child will get autism? Let’s find out by actually reading the research.

The journal called Pediatrics published this study and Hjördis Ósk Atladóttir, Tine Brink Henriksen, Diana E. Schendel and Erik T. Parner authored the study. A quick search on Medline reveals that Dr. Atladóttir is chasing this topic of autism trying to find something to explain how it develops. He published a similar paper in 2010 in the Journal of Autism and Developmental Disorders. In that paper, he discussed pregnant women who had been hospitalized and later had a child with autism. He has published on cytokine levels and autism, patterns of contact with hospitals and autism, and family history of autoimmune disease and autism.

Purpose of the Study

The authors set out to “assess the association between self-reported common infections and autism in the child“. The authors clearly state that they estimated an association. Yet, when this study hit the news, reporters and scientists discussing the study omitted these little details.

Methods

The sample. The authors used an existing data base to gather their data (Danish National Birth Cohort). The authors selected 31% of the cohort for their data analysis.

The data collection. All the interview questions asked to the mothers occurred during the initial cohort recruitment completed by different researchers. These authors did not have contact with the mothers. Interestingly, the authors actually reported that “there was no specific question regarding respiratory disease and influenza”. It should make you wonder how they “estimated” the results of their highly disseminated “study”. In fact, the researchers actually asked the mothers, “did you take an antibiotic?” The authors clarified further, “The questionnaire did not include a question concerning the direct disease indication for the antibiotic use”. Wow! Yet all the media around this paper specifically said “flu”.

Data facts. Only 1% of the sample actually reported having the flu. Compare that to the percent of women with other issues: fever (24%), antibiotic use (19%), yeast infection (19%), cystitis (12%) and urinary tract infection (12%). Another interesting fact is that the researchers compared maternal responses during interviews with data from hospital records (e.g., diagnosis at discharge). The authors state, “The overall agreement between maternal reports of infection episodes and a corresponding hospital contact record was fairly good for most infections” (e.g., cystitis, pyelonephritis, and vaginal yeast infection). However, the authors also noted that “there was a very low agreement between maternal-reported infection and hospital-registered infection when the self-reported information was retrieved from open-ended questions” (e.g., flu). Thus, it seems that the likelihood the mothers really had the flu when they reported that they did, is actually quite low.

Data analysis. The authors used statistical analysis to determine if any relationships between the variables existed. What the media did not cover in reporting this study, is the important fact that the authors examined relationships between illnesses and any form of autism spectrum disorder as well as any relationship between diseases and infantile autism.

Results

The authors reported a number of results, most of which had no statistical significance. The authors noted that a statistically significant difference was found among mothers who self-report the flu (be sure to see the note above regarding the accuracy of reporting) and went on to have a child with autism. Specifically, out of the entire sample, only about 800 mothers reported having the flu. Of those, only 9 went on to be diagnosed with an autism spectrum disorder. This is hardly reason for alarm especially since we are having autism diagnosed at a rate of 1 in 86!

The authors noted that another statistically significant association was found between mothers who had a fever longer than 7 days. The number of women with a fever episode was quite high 23, 027). The number of them who went on to have a child with infantile autism was 101. Again, this hardly seems reason for alarm given the staggering rate of autism. Finally, the number of women who had a fever lasting longer than 7 days was 1361. Of those, only 14 went on to have a child diagnosed with infantile autism.

The authors found similar associations with antibiotic use. Again, the numbers are not alarming given the overwhelming rate of autism.

Discussion

The key statement in the discussion section should be highlighted: “There was little evidence that self-reported common infections during pregnancy are risk
factors for ASD in the child”

Can someone explain how the media complete twisted this in to a “flu during pregnancy increases the risk of autism” headline?

The authors did go on to talk about their previous work on this topic, ” We reported in our previous study that viral infection during the first trimester gave rise to an almost threefold increased risk of ASD“.

Side note: We all know that the flu is a virus. But isn’t the vaccine for the flu a live virus? Let’s see what the CDC has to say about it. Well, I’ll be darned, it appears that the nasal spray is a live virus. “Live, attenuated influenza vaccine (LAIV) contains live but attenuated (weakened) influenza virus. It is sprayed into the nostrils“. The CDC goes on to say that pregnant women should not take the live virus spray.

Other Thoughts

This study is full of methodological errors. Yet, Pediatrics continue to publish it and the media continue to twist the findings. Please, before you believe the “latest medical study”, you might find it more helpful to actually read the study rather than believe what someone tells you about the study.

The Elephant in the Room

So, if the researchers had access to all this data, why didn’t they ask better research questions? Why didn’t they look for associations between women who got the flu vaccine and still got the flu? Or how about this one: “does getting the flu shot increase the likelihood of your child getting autism?” There is so much more that could be asked, yet these researchers did not seem interested. Maybe it wasn’t the “politically incorrect” thing to do.

 

 

 

 

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The field of behavior analysis is growing. This is due in part to:

  1. International Board Certification in Behavior Analysis (www.bacb.com)
  2. Increased insurance legislation mandating coverage of Applied Behavior Analysis (ABA) (http://www.autismspeaks.org/advocacy/states)
  3. Increased behavioral needs of all children

Demand

Because of these, and other reasons (e.g., CT has a law requiring BCBA {or similar} supervision of some school programs), BCBAs are hot commodities. Check out Craig’s List in your area and count how many companies are hiring behavior therapists and/or behavior analysts. Agencies will pay top dollar for a highly qualified and experienced BCBA. In fact, a recent email went out to certain BCBAs advertising up to $125,000 annually for a BCBA on the east coast.

Overworked?

Recently the Behavior Analysis Certification Board, produced two important documents. You can read more about them here and here. Essentially, the Board described expectations for supervisors regarding case loads and professional duties. Supervising the provision of ABA services requires on-going and regular contact with the client and therapists on the team. To do this well, BCBAs should maintain a small case load. If the BCBA has a BCaBA to assist with some duties then additional clients may be served. The bottom line is that clients need regular contact and supervision of the program.

In some instances, an agency may hire a BCBA and expect the BCBA to provide all the services for the clients or students within the agencies. For example, numerous school districts hire one BCBA to cover the entire caseload of special education students. The end result is poorly supervised ABA programs and a BCBA who is unable to fulfill his/her job duties effectively.

Important Personal Duties

In addition to all the professional duties required, BCBAs must also tend to multiple personal duties. These include:

  • maintaining certification
  • completing continuing education credits
  • registering for and attending conferences
  • reading and keeping up with the professional literature

During the course of the continuing education webinars provided by Applied Behavioral Strategies, LLC (an approved BACB provider), BCBAs seem to be so busy that they:

  • don’t have time to check their email
  • forget to include important documentation such as BACB certification number
  • forget to come to the webinar

Yes, BCBAs are so busy that they forget to come to a webinar that they have paid for and one that they need in order to maintain their certification.

So, slow down, organize yourself, make priorities, and do not overextend yourself. You owe it to your clients and you owe it to yourself.

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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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