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Archive for September, 2011

Many children experience anxiety but this is especially true for children who are diagnosed with autism spectrum disorders. For higher functioning children on the spectrum (e.g., high functioning autism or Asperger’s syndrome), the anxiety combined with the awareness of personal social deficits may become exacerbated.

It is widely known that behavior therapy, particularly applied behavior analysis, has been proven effective at treating behavioral symptoms of autism spectrum disorders. however, the use of cognitive behavioral therapy for children with autism spectrum disorders has been studied less.

Thus, the study that we will review today, examined the effectiveness of cognitive behavior therapy (CBT) for children with autism spectrum disorders and anxiety. The study authors, White, Ollendick, Scahill, Oswald, & Albano, published the paper in 2009 in the Journal of Autism and Developmental Disorders. The authors stated that the study purpose was to “evaluate the preliminary efficacy of a cognitive-behavioral intervention program for anxious adolescents with autism spectrum disorders.” The authors based their treatment on previous research and designed a program to reduce anxiety and improve social functioning.

The authors treated 4 children between the ages of 12 and 17. The treatment consisted of common behavioral techniques such as modeling, feedback, and social reinforcement. However, the treatment was combined with approaches commonly used to treat anxiety such as exposure to stressful situations and education about stressful situations. The authors provided treatment by having individual treatment sessions, group sessions, and parent training sessions. In the group sessions, the participants practiced their strategies. In the parent training sessions, the parents were taught how to implement strategies.

The authors measured participant progress with several standardized tools. Three of the four participants experienced significant changes on measures of anxiety. The fourth child experienced an improvement in anxiety, it was just not clinically significant. Two of the four children maintained their progress 6 months following treatment.

In summary, while CBT may be a useful approach to treat anxiety, it may not be appropriate for all students. Additionally, some students may need longer periods of treatment as outcomes were not maintained 6 months after treatment.

Our hope with the research review posts is that we can share outcomes of recent research with our readers. If you have heard about a study that you would like us to review, please let us know.

 

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Hi and welcome to “What Works Wednesdays” where we share a success story from one of our clinical cases. All names have been changed to preserve the privacy of the child and family. Our intent is to show readers how successful ABA can be.

Today we would like to introduce you to a cute little fellow named Mikey. Mikey was 33 months old when we started intervention. Mikey was a typically developing toddler in every way except for his eating. Mikey preferred to drink his milk and he drank lots of it. His mother reported going through a gallon of milk in just one weekend. Mikey had some sensory processing issues which led to oral motor therapy from a speech and language pathologist (SLP). During oral motor therapy, he learned to tolerate having a toothbrush in his mouth and he learned to eat a few new foods.

Before we started intervention, Mikey occasionally ate cream cheese and jelly sandwiches on white bread. He also occasionally ate cheese sandwiches on white bread. His mother reported to us that she was very interested in Mikey becoming toilet trained.

We sent Mikey’s mom some written instructions on how to toilet train her child. We suggested that she start toilet training the weekend before we started feeding therapy. We have found, in our clinical practice, that children respond well when multiple areas of growth are targeted simultaneously. For Mikey, we could say that he was becoming a “big boy”. Big boys learn to pee on the potty and they learn to eat big boy food!

Mikey’s mom was a champion. She followed the toileting protocol that we provided and by the time we arrived for feeding therapy, Mikey was already urinating regularly on the toilet. He was also accurately reporting if he had to urinate when asked! His daytime diapers were gone and he was wearing big boy underpants.

The other curve ball we threw Mikey was that he was no longer allowed to drink from a sippy cup. He was starting preschool and big boys drink out of regular cups. We told Mikey that he could only have his sippy cup if he needed to drink while riding in the car to keep from spilling.

Prior to therapy, we encouraged Mikey’s mom to work with a nutritionist to determine if Mikey had any food sensitivities. Unbeknownst to her, Mikey was reactive to a number of common foods such as avocado. Additionally, Mikey suffered from a zinc deficiency. So, prior to therapy, Mikey’s mom started him on a few nutritional supplements. We believe that well-rounded nutrition is one of the best mechanisms to ensure success in our therapy sessions.

For Mikey, we provided all services in his home and his mother was present for every session. Mikey’s father attended one session to ensure that he knew how to support Mikey when therapy was finished. In addition to having well-rounded nutrition, we have found (along with other researchers) that hunger inducement is one of the best strategies for feeding intervention. When children are hungry, they are more likely to want to eat. For Mikey, this meant that multiple cups of milk were eliminated each day. Unfortunately, Mikey’s mom had to deal with Mikey’s unhappiness about this change in the early morning hours before the first session. As we said previously, she is a champ and she handled this challenge like a true fighter. Mikey was definitely hungry at mealtime and he soon learned to get along without all that milk.

Mikey received services over the course of 4 days. On the first and second day he received services at breakfast, lunch, and dinner. Mikey’s mom took over the meals starting at dinner on the second day. On the third day, Mikey received services for lunch and dinner. On the final day, he received services for breakfast. So in just 9 one-hour sessions, Mikey learned to eat new foods when asked.

We had several pleasant surprises when working with this client. First, Mikey had never eaten protein in solid form. We were all pleased that protein was becoming a fast favorite for Mikey. Additionally, Mikey loved fruits. We couldn’t find a fruit that he disliked. Despite the great progress that Mikey made in such a short period of time, Mikey will still need to work on chewing his new foods. As his mouth becomes accustomed to all the textures and flavors, he will become desensitized and more willing to use all of his mouth when eating. Additionally, as he learns to use his mouth to chew all of these foods, his overall motor function should improve.

Mikey, congrats on your progress. And to Mikey’s mom—he could not have done it without you. Now go get yourself that manicure, pedicure, or date night that you deserve. Tell your husband “it’s the doctor’s orders!”

Happy Eating!

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Addressing challenging behaviors is one of the most talked about topics among educators and parents alike. Here at Applied Behavioral Strategies, we are often asked for advice about how to deal with hitting, biting, self-injury (e.g., self-hitting, self-biting), and tantrums. While we would love to give a quick-fix, one-size approach answer to everyone, we have learned over the years that behavior simply does not work that way.

“What?!?!” you ask. “There are no quick-fixes for behavior problems?!?!”. Sadly, we must tell you that there are no quick-fixes. Short of locking your child in the closet (which we would never advise you to do), there is no fast way to make bad behaviors disappear.

What we can tell you is that with persistent and predictable parenting, the behavior will subside. However, you need to know a few things before you decide to nip the behavior in the bud. First, all behavior is a form of communication. If your child is misbehaving, she is trying to tell you something.

Second, all behavior has a purpose. Children act out because, quite frankly, it works. What does your son get when he has a tantrum in Target? What does your daughter avoid when she takes all morning to get ready for school? How much of your attention is all the negative behavior demanding?

Finally, positive behaviors will replace negative behaviors if the positive behaviors are reinforced. If your child is trying to get candy at the check out lane at Target, go ahead and give him candy at the check out lane. However, promise him the candy if he can get through target without any tantrums. Do not give the candy if your child has a tantrum.

If your daughter moves at a snail’s pace each morning, perhaps she is trying to purposefully miss the bus. Instead, offer to take her to school but only if she is ready by a certain time.You may have to consider getting her up earlier or even helping her get dressed in order to make the bus. And, if your child must go to school in her pajamas, I can assure you she won’t be the first child to come to school in pj’s.

If your child is misbehaving in order to demand all of your attention, beef up the attention you provide but make sure you are attending to the positive behaviors. We call it “catch them being good”. When children see that good behavior gets attention, they will enjoy engaging in good behavior over bad behavior any day.

While we cannot solve your child’s problem in a blog post, we would like to direct you to some additional resources to help you in your time of need. First check out this great site called Technical Assistance Center on Social Emotional Intervention for Young Children.This site is full of resources, many of them free. Here you will find access to power point lectures and handouts, access to a newsletter, and information related to managing challenging behavior.

If you need assistance with older children, check out this great site called the Positive Behavior Intervention and Supports. This site has information for families, teachers, and community members. Information is available regarding research, training, and program evaluation. Find out who is available to help in your state!

I came across a nice parent- and teacher-friendly post regarding challenging behavior. The authors, Elizabeth Erwin and Leslie Soodak, provide some helpful information regarding why behaviors occur and how to address them.

Finally, you can always submit your question to receive help during our Ask Missy Monday blogs. Simply email: askmissy at applied behavioral strategies dot-com.

The bottom line is that the sooner you address the behavior problem, the better.

Happy Parenting and Happy Teaching!

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Hi and welcome to Ask Missy Monday where I respond to email questions from parents who are having difficulty with their child’s behavior. Today, we have a question in from Kristen who writes:

We recently attended one of your feeding clinics. I’m proud to say that our child is doing GREAT!!! Here is my question: our child will eat anything you put in front of her as long as there is peanut butter bread on the plate.

We still require her to eat bites of new food before she can have the peanut butter bread. If we do not have the peanut butter bread on the plate, we still make her eat her food, but it takes three times as long and there is a lot of crying and screaming.

So is it okay to keep that one food on her plate at lunch and supper? Or do you advise to battle it out with her and not give it to her?

This is an excellent question Kristen!

Well, for those of you who know me, you know I am never one to allow the children to make the rules. So, my advice to you is to have something preferred at every meal–just not the same preferred food. In other words…..battle it out.

Over time, your child will get less and less of the preferred food while you are simultaneously requiring your child to eat more and more of the non-preferred food. For example, let’s say that your child likes coconut yogurt. For dinner she is having her protein, fruit, vegetable, and starch. Initially, you give her one bite of any of the non-preferred foods followed by one regular size bite of yogurt. After 2 or 3 bites, the yogurt bites becomes smaller and smaller so by the end of the meal, she is only getting a dollop of yogurt. Meanwhile, after a couple of bites of non-preferred followed by single bites of yogurt, you say, “Now I want you to eat 2 bites before you get yogurt”. After 4-6 bites, then say, “now I want you to eat 3 bites before yogurt”. You keep doing this until she is eating most of her meal before she gets the preferred food. That is what we do, right? We eat the food and then we get the good stuff (dessert)!

I have no concerns with her having some peanut butter and bread following some meals but you should not allow her to have it at every meal. In terms of food allergies, there may be some issues with eating that same food meal after meal so it will be important to wean her off of it quickly.

Now for the screaming and crying…..once you get her eating a few bites, then you say, “oh, you can only have the _______ if you eat your food without fussing”. When or if she fusses, put her bite of preferred food in the trash and tell her, “No _____ because you screamed. You need to eat without screaming.”

I hope this helps. Keep reminding her who the boss is!

If you have a question that you would like to see in a future post, please email me at: askmissy at applied behavioral strategies dot com.

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Happy Friday!

(Just kidding! I added that picture for emphasis.)

Today we are going to talk about the importance of just saying no. To those of you that know me or who have worked with me over the years, this piece of advice may come as a bit of a shock to you. For those of you who are just getting to know me, I’ll explain myself a bit more.

You see, I often advise parents, teachers, siblings, and peers to refrain from telling a child “no” in response to challenging behavior. As you can see from these images, my advice has been   well-heeded by many! NOT! Images have been made to tell children “no” in response to their behaviors despite my frequent recommendations.

I suggest that we refrain from saying no in response to challenging behaviors because saying no does not teach children what TO do. Additionally, if a child is biting for  attention or hitting for attention, telling the child “no” gives him the attention he is looking for. While many educators believe that a firm no gives the child feedback that what she is doing is wrong, I argue that the child already knows what she is doing is wrong. She does not care. She has learned that the challenging behavior gets her what she wants so she keeps using the behavior for her own benefit.

But this is not why we are here today. We are here today to talk about the importance of saying no to your children. I cannot stress the importance of teaching your child to learn to accept no. Children must learn they cannot have everything they want. Case in point: I was at Target (one of my favorite places to shop and watch parenting at its finest). I observed a mother and child in the check out line. The child asked for candy to which the parent replied, “oh honey, it is too close to dinner.” The child began crying and yelling about how much she loved the candy and how “mommy never lets me have what I want!” Because mommy did not want to hear her child cry, she caved and she bought the candy. The little girl learned that all she has to do is cry and yell and mommy will give her what she wants. The little girl also learned that when mommy says no, she does not really mean it. This little girl is the boss. See, here she is strutting her bad self.

I see this type of parenting over and over in various settings every day:

“Mommy, I’m full, I don’t want to eat my vegetables.”

“Daddy, I don’t want to put my dirty clothes in the hamper.”

“Mommy, I don’t want to do my homework. I want to go outside.”

One of our duties as parents, is to teach children to accept no. When children learn to accept no at an early age, they learn to handle bigger disappointments later in life (e.g., I want to be a cheerleader but the judges told me no.) Parents, on the other hand,  need to practice saying no and sticking to it–even when the going gets tough. Why? Because as children grow up, their tantrums grow up too. Soon, crying becomes ugly, hurtful words (“I hate you!” or “I want to go live with Daddy!”) Who wants that kind of interaction later in life?

You know the old saying, “practice makes perfect”….if you practice saying no to children when they are younger (and while their tantrums are short and cute), you will be an expert at saying no when the going gets really tough (“Mommy, I want to have a curfew at midnight”, “Dad, can I have $250 for a new pair of jeans?”). So, head off in to the weekend and practice saying no to your little angels. Come back on Monday and tell me how hard it was!

Happy Parenting!

P.S. Can I have a new Mini Countryman?

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One day each week, we would like to review a research article on a topic related to our clinical practice. If you would like for us to review an article that you have heard about, please contact us at info at applied behavioral strategies dot com. As long as it is related to ABA, intervention for children with behavioral challenges, feeding intervention, and parent/teacher training, we will be happy to consider your suggestion.

The article that we are reviewing today is called, “Assessment of Feeding Problems in Children with Autism Spectrum Disorders”. The article appeared in 2010 the Journal of Developmental and Physical Disabilities volume 22 (pages 401-413). Laura Seiverling, Keith Williams, & Peter Sturmey authored the article.

Feeding difficulties among children with autism is not a new phenomenon. Kanner reported it in 1943 and many others have subsequently validated his findings. While children with autism may experience a wide range of feeding difficulties, the most commonly reported issue is “food selectivity”. Most people would call it picky eating. However, for children with autism, the issue is much more extreme than merely picky eating. Children with autism may limit their food consumption to just a few foods. We’ve described this in our own clinical practice here and here.

Despite the severity of feeding difficulties among children with autism, professionals have only recently been able to accurately assess feeding difficulties. Thus, the purpose of the paper was to review various assessments of feeding difficulties including recently developed measures. The authors organized the review into categories of assessments. These included Questionnaires, Direct Observations of mealtimes, functional assessment or functional analysis of mealtime behavior, and use of the Diagnostic and Statistical Manual (DSM).

The authors reviewed a total of 9 different measures or approaches and they concluded with strengths and weaknesses of each. Finally, the authors made recommendations for future directions in assessment.

Have any of you utilized these measures in your practice? Parents, have practitioners used these methods when assessing your child?

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Hi and welcome to “What Works Wednesdays” where we share a success story from one of our clinical cases. All names have been changed to preserve the privacy of the child and family. Our intent is to show readers how successful ABA can be.

Today’s success story is about Mary Lea, a sweet little peanut who had just turned 3 prior to coming to feeding clinic. In addition to being diagnosed with autism, Mary Lea had experienced some medical issues in her young life. However, her Mother’s biggest concern was Mary Lea’s eating. Mary Lea only ate with her fingers and she refused to use utensils. Mary Lea also drank out of one cup and she showed no interest in drinking from any other container.

Mary Lea loved to drink apple juice and almond milk. She consumed Lays Stax chips, mini muffins, McDonald’s french fries, and chocolate pop tarts. Mary Lea also had an affinity for Sonic Grilled Cheese. Her mother bought a sandwich maker, special bread, and Sonic wrappers so she could make them at home. Mary Lea wanted nothing to do with her mother’s grilled cheese. She cried and refused to eat until her mother bought her a Sonic grilled cheese.

Mary Lea and her mother packed their bags and made the trek to Austin, Texas where we were offering a week of intensive feeding therapy. Mary Lea and her mother attended sessions 3 times each day (breakfast, lunch, and dinner). It is hard work for the parents because they have to take off from work to bring their child to the clinic. The parents have to prepare all the food and bring it to clinic for each meal. Finally, parents watch all sessions for the first day or two so they can learn the strategies that we use.

In the initial stages of intervention, we target an easy skill to ensure that the child will get access to preferred items or activities (also known as reinforcers). For Mary Lea, we quickly learned that she loved the new coconut milk yogurt we offered her. We were able to use the new yogurt to get her to try other new foods. Within the first day, Mary Lea was taking food from our hand and placing it in her mouth. Our next goal was to teach her to eat from a utensil.

Mary Lea was not happy about this change in feeding expectations. Since she refused to eat from the utensil in one session, she did not get access to the yogurt. After one session with no access to yogurt, Mary Lea realized that the only way she could have the yogurt was to try new foods. Soon, she was self-feeding with the utensils. After this, we transitioned her mother in to sit next to her and her eating continued to improve.

Once Mary Lea mastered eating in the clinic, we moved therapy to a local restaurant. Mary Lea’s mom brought the yogurt in to the restaurant to use as a reinforcer. Mary Lea does not handle change well so she was initially unhappy about eating in a new place with new plates and new utensils. However, she quickly realized that the restaurant also had good food to eat. (As a side note, most restaurants are ok with families bringing in special food, you just need to clear it with them first. In our experience, restaurant staff are very understanding of the issues associated with autism including eating challenges. Restaurant staff have been most accommodating.)

Not only did Mary Lea learn to eat within the 5 days of intervention, she stopped using her pacifier and  she started walking everywhere instead of being carried! Finally, on the last day, we introduced the iPad2 equipped with Proloquo2go software. We offered dairy-free pudding as dessert at the end of the meal. Mary Lea was prompted to touch the “I want pudding” button after which she received one bite of pudding. On the third try, Mary Lea touched the “I want pudding” button on her own.

Congratulations Mary Lea on your success. You could not have done it without your mom. She rocks!

Happy eating!

.

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The topic of #pickyeaters has received a lot of attention lately. You can search for it on twitter (#pickyeater), there are blogs about it like this one,  and even Dr. Oz talked about it here.  Everyone has an opinion about how to help picky eaters.

After searching the internet to learn what others had to say, I found this great link on Whole Foods. I have to say, I really like the advice that was offered. I’ll summarize it here:

First, the author, Paige Brady, suggested talking to your children. Children are bombarded daily with advertisements for junk food, fast food, and candy. Paige is right! We have to get in as much good food talk as we can.

Next Paige suggests that we get real with our meals. I like that too! Serve food that looks like real food. Real food is more appetizing than processed foods. My mouth is watering as I’m typing.

Paige also suggests that we serve a rainbow. Look at your child’s plate. Is it all white? Strive to have varied colors for each meal. Real food has color. Let it shine.

Paige tells readers to hand over the reigns. In the intervention world, we call it choice making. Give children choices. You will eat a vegetable tonight. Is it going to be broccoli or brussels sprouts?

In our house, the kids help shop. They pick out the fruits for the week, they pick out the vegetables for the week, we allow them to pick the meats that will be cooked. By including them in the shopping and meal planning, they are much more likely to want to eat what is served. Moreover, when they are older, they will be empowered with the ability to make good choices on their own.

Happy eating!

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Hi and welcome to “Ask Missy Mondays”. On this day, I will answer questions submitted from readers. If you want to submit a question, email ask missy at Applied Behavioral Strategies dot-com.

Today’s question comes from Emily in Brooklyn. Emily writes: “My nephew, 8 years old with autism, won’t eat very many veggies.  The only veggie I’ve seen him eat willingly is tomato sauce.  He doesn’t seem to mind the taste of other veggies when they’re pureed and put into the sauce. However, if  he puts it in his mouth, he will not chew it. He swallows small pieces of it without chewing. How can I work on getting him to chew his food?  Does he just need more practice?  Are there other techniques I should be trying besides offering veggies and occasionally expecting them to be consumed?”

Emily, this is a great question! Rebecca and I see many children who do not want to chew their food. They do this to avoid the taste and/or to avoid the texture. When we enroll children in feeding therapy, we always start with one bite; one very small bite. Think about how you try new foods. You do not try a new food by ordering a huge plate and you certainly don’t fill the fork on that first bite. Children need the same approach.

Next we start with small expectations. First just have your nephew put the food to his lip. Once he can put the broccoli to his lip using a fork without fussing, then he is ready for the next step; touching it to his tongue. After he touches it to his tongue successfully, he is ready to put it in his mouth, followed by chewing and swallowing. During the meal, remove all the preferred food until he complies with touching the new food to his lip. When he does, give him more (but small amounts of) preferred food. After he consumes the preferred food and when he is ready for more preferred food, say, “oh, I need you to try my broccoli again”.

Within one meal, you should have him chewing and swallowing very small bites of broccoli. Keep in mind that an appropriate sized bite of new food is a dime or smaller.

Good luck with the veggies. Please let us know how it goes!

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