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Archive for November, 2011

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 a little guy that we call Nihar. Nihar was not even three when we first met him. His mother contacted us because she needed help. Nihar was having difficulty with eating, getting dressed, and brushing his teeth. For a toddler, well, that was most of his life’s daily activities. Nihar had extreme difficulty coming to the table for all meals. He also had food selectivity, a condition that is common among children on the spectrum. Nihar often rolled around on the floor when it was time to get dressed. His mother often had to chase him and she could not get him to be still in order to put clothes on him. Tooth brushing was a nightmare. He screamed and ran and fought at even the mention of brushing his teeth.

The first step when we are introduced to a situation like this is to complete a functional behavioral assessment (FBA) to determine why the behavior is happening. We discovered that:

  1. Nihar was trying to avoid meal times at the table.
  2. Nihar was trying to avoid non-preferred foods.
  3. Nihar was trying to gain access to TV during meal time.
  4. Nihar was trying to gain access to preferred foods.
  5. Nihar was trying to gain his  mother’s attention during meal times.
  6. Nihar was trying to avoid tooth brushing.
  7. Nihar did not have any tooth brushing skills.
  8. Nihar was trying to gain his mother’s attention during tooth brushing.
  9. Nihar was trying to avoid getting dressed.
  10. Nihar was trying to gain his mother’s attention during dressing routines.

We offered Nihar’s mother a variety of interventions from which to choose. We have found that when parents are decision makers in their child’s behavior plan, they are more likely to implement the plan. When plans are implemented, they are more likely to be successful. Nihar’s mom selected an intervention called Premack’s Principle. In early childhood we call it If:Then or First: Then. Still others may call it Prespecified Reinforcement or Grandma’s Rule (“First eat your vegetables and then you can have dessert”). Regardless of what you call it, the Premack Principle is an easy intervention to implement. It is effective and it has substantial research to support its use. See for example this study, or this one, or even this one.

We first introduced the intervention during meal times. We used some other helpful strategies here as well (e.g., appropriate size table and chair, mom sitting with Nihar during meals). We simply told Nihar (and showed him with a visual support), “First eat your chicken and then you can have some mango.” Nihar quickly responded. When things were going well during meal times, we added the picture card to the dressing routine. Here we told Nihar that “First put on pants, and then have car”. His dressing behaviors improved immediately. Finally, we added it to tooth brushing. “First brush your bottom teeth, then you can have a hug from mommy”.

Congratulations Nihar on your great behaviors and congrats to your mom for all of her hard work. Also, Dr. Mandy Rispoli needs a shout out as she worked closely with Nihar’s family during this intervention.

Do you use Grandma’s Rule/Premack Principle/If Then with your child? Does it work? Please share with us!

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Morning Schedule

We are often called out to consult in classrooms to help with “problem children”. Most of those visits confirm that the child, is in fact, having difficulties in the classroom. Sadly, many staff in those settings view the child as the problem rather than recognizing that the child is merely responding to his environment. As teachers, we often forget that children with disabilities, including autism, need ongoing support to be successful. We often try a strategy for a few days and then over time the strategy slowly slips off our instructional radar. This is especially true for a support strategy such as visual schedules.

Similarly, we are frequently called by families who need our help with tantrums and other difficulties in the home. Many times, families do not have any strategies to use in the home. Often, we meet families who have never seen a visual schedule, let alone know what to do with one.

A visual schedule (also known  as visual supports and picture schedules) is a task list with pictures. For example, this picture shows the “task list” for a child’s morning. First, he must put away his backpack. Then he participates in circle time. Then he has math followed by snack and toileting. Finally, it is time for reading.

Just as task lists help us remember all that we need to do in a day, visual schedules help children remember what they need to do each day. Visual schedules also help children predict their day. When children anticipate activities, they are less likely to engage in challenging behaviors around those activities.

Visual schedules may be used to show a morning routine such as the one just described. Visual schedules may also be used to show

Hand washing Steps

steps of a routine such as hand washing, toileting, or getting dressed. Visual schedules are a great support for individuals who are learning a new job such as putting together a packing list.

iPrompts Countdown Timer

Many resources exist to help you make visual schedules. One of our favorites is an application for the iPad called iPrompts. The photo library in iPrompts is not nearly as inclusive or as high quality as the one in Proloquo2go. However, you may add as many pictures from your personal library in to the iPrompts library.

Another excellent resource is Meyer-Johnson. We have used their product, Boardmaker, for many years. While it is somewhat cost prohibitive, you will find the software to be extremely useful. Using Boardmaker, we have made countless picture schedules, communication icons, choice boards. We work with a parent who uses the software to make many instructional materials for her child. You will need some training and practice to become proficient with this software. However, once you learn to use it, your options are unlimited.

Finally, Do2Learn is another excellent source of support for making visual schedules. You will find their website helpful with pictures, schedules and other tools.

Meyer-Johnson Afternoon Schedule

We recommend the use of visual schedules for children with and without disabilities. Children need to understand and predict the activities within their day. Visual supports will help them. Visual supports are another excellent way to support the beginning stages of reading as well.

Do you use visual schedules? Do you find them helpful for your child? What resources have you found helpful?

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Hi and welcome to Ask Missy Mondays where I respond to email questions from parents who are having difficulty with their child’s behavior. Today’s question comes from Sasha.

“My 8 year old is STILL not pooping in the toilet. He does a great job keeping his pants dry all day long with regular prompted bathroom breaks, but he seems to prefer NOT to poop in the toilet for some reason. What he will do most evenings (he usually poops in the evenings) is go to his room and get a diaper (which he still wears overnight because he still wets overnight) and sometimes he’ll even put it on himself to go poop.

Do you have any suggestions for how I can get him used to pooping in the toilet instead of in his pants? It seems like he’s starting to understand when he needs to go, it’s just that sometimes he doesn’t care to keep himself clean.”

Great question Sasha!  I would start with a social story which I am including at the bottom of this post. This word and picture story helps children better understand that poop goes in the toilet and not in the pants. The use of social stories also has research to back it up here, here, and here.

As gross as it may seem, perhaps your child should watch you go poop on the potty as well. Sometimes children need concrete examples to help solidify their learning. If that is too difficult for you to do, then try to find some movies or clips on iTunes that show people pooping. Even babies can poop on the potty!

I also really like the Poop in the Potty song. I have a dear friend with an excellent Nanny who taught me about that song. It is the BOMB! You can hear it here.

Next, you are going to have to be on your toes and catch him as he is trying to “sneak one in”. Quickly rush him to the toilet and stay with him. Read the social story to him. Encourage him. Tell him it is scary.

Finally, find the biggest, coolest, best ever reward and make it available ONLY when poop goes on the potty. Explain to him (using pictures if possible) that when he poops in the potty, he can have _______.

Good luck! and please let us know how it goes!

If you have a behavior or situation that you need assistance on, please email me at askmissy at applied behavioral strategies dot-com.

Social Story

Poop goes in the potty . 

Sometimes your tummy hurts .

Sitting on the potty will help the poop come out .

Poop does not go in your pants.

Poop goes in the potty .

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We recently discovered the Twitter World. Sure, we know it’s been out there for a while but we have only recently learned how to use it. We hope to learn more about it over the coming weeks and months. Today, we want to share with you how Twitter can help you.

In preparing for today’s post, we learned a few things. First, twitter is a microblogging service. Who knew? We thought it was just for social networking. Apparently, the tweets that folks send out are actually microblogs of 140 characters are less. If you are long winded, Twitter is not for you!

We also learned that Twitter was created in 2006. That means we are only 5 years behind. Our favorite learning in preparing for today’s post was that twitter took off at the 2007 SXSW. For those of you who do not live in Texas, SXSW is one of the coolest festivals ever and it is located in Austin. We both regularly attend KGSR shows at the Four Seasons during SXSW—but we digress. We’re talking about Twitter, right, not singers and songwriters. Sorry.

Anyway, after the 2007 debut at SXSW, Twitter took off. By 2009, when Michael Jackson died, servers crashed when people were updating their status to include his name in tweets at 100,000 per hour. So what does all of this have to do with you?

Well, not only is Twitter wildly popular, it can also be a source of information for you. You see, Facebook (if you use it), is really for connecting people who actually know each other. Perhaps it is different now as people connect through similar interests such as running, driving Mini Coopers, reading, or connecting over autism awareness. Twitter, on the other hand, is full of people who have never met each other. When people follow you on Twitter, they are not really following you and checking out your daily moves. They are really “listening” to your words. And even then, they may not be listening. As tweets are posted, the tweets come across a feed. So, your followers may not even hear you if they are not actually on Twitter when you hit send. However, once tweeted, your tweets remain visible for anyone to see when they visit your profile.

So, how is that going to help you? Well, it’s not. unless you have something really important to say–like Vote For Me on American Idol!

On the other hand, Twitter can help you if you listen. You see, there is an entire world of people out there sharing information in 140 characters or less. Some of it may be of interest to you. If you like to read, you will find a group of authors, aspiring authors, and literarians. If disability awareness is your thing, you will find a group of people who are interested in all disabilities. If you are interested in celebrities, you can get the daily dish on just about anyone. Tweets with links to blogs and other sources of information are shortened to remain under the 140 character limit. You may then visit the blog or simply bookmark it to visit later.

The best way to get started is to get an account. Then search for your topic of interest. Let’s say that you are interested in autism. If you search  for autism, you will find a stream of tweets where people have mentioned the word autism. Simply follow the people who wrote the posts in which you are interested. Twitter will recommend similar profiles so that you may find additional followers. If you come across someone who is following thousands of people, read through their list of people and follow the ones who seem interesting. You may find it most helpful to follow people who actually post tweets regularly. You will see how many tweets each person has when you check out his or her profile.

Before you know it, you will have a stream of tweets coming across on topics that are of interest to you. Often, people tweet about blogs or current research or current trends (e.g., the NY autism insurance bill passed!). This allows you to follow subtopics of interest while also hearing about breaking news items related to your interests.

Just yesterday, we saw this great post by @BobbiSheahan: http://www.bobbisheahan.com/guestarticles.htm In it, the Special Education Advisor wrote a guest post highlighting their top 50 Special Education Twitter people. Of course, we added quite a few people to our list of people to follow thanks to that great post. If you are in the autism world, there are great “Tweeps” out there including @PaulCBrady, @Calormom, @autismspeaks, @ageofautism, @ARIconference, and @TannersDad to name a few.

As we said, we are just getting started. We hope to learn more and we will share it with you as we learn. In the meantime, only one of us is tweeting regularly. You can follow Missy @melissaolive.

Happy Tweeting!

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Each week, we try to review a research article. This week, instead of reviewing an article, we are going to review a type of research. We are doing this because lately, news outlets have highlighted various studies about autism (e.g., autism and prematurity, autism and diabetes, and autism and IVF to name a few). While these findings are certainly interesting, we should point out that all of these studies are correlational rather than causal. Specifically, prematurity does not cause autism but rather it is associated with or correlated to autism.

A correlational study is designed to measure behaviors, outcomes, or characteristics within a sample and then determine through the use of statistics if any relationships exist between or among the variables. This is usually done by surveying a large group of people and comparing the results from within the group. For example, IVF, or in-vitro fertilization has been shown to be associated with autism.We are sure you are not surprised that IVF is also associated with older mothers. Other factors that should be considered when studying IVF include the rate of prematurity, complications with pregnancy, low birth weight. You see, if a family is using IVF, by nature, the parents had difficulty getting pregnant naturally. Thus, other factors may be at play. These factors may impact the later development, labor, and delivery of the fetus. As the author of the study, Dr. Zachor, pointed out, “mothers in her study who had IVF tended to be older — with a median age of 32.6 years. Also significantly, nearly 4% of the children with autism were born prematurely, and about 5% of those had a low birth weight. In the general population, only about 1% of all newborns are delivered with a low birth weight.” Thus, we should use caution when interpreting the results of this study. Other, more salient factors, may be linked to autism. I would want to know how many of those babies had other complications (e.g., reflux, ear infections, fevers) and how many of those babies also had autism.

Another study recently demonstrated that prematurity increased the risk of autism. Before reading the study, think about all of the factors regarding “preemies”. We would expect preemies to have longer hospitalizations when compared to full-term babies. When babies live in hospitals, they are more likely to be exposed to germs and other illnesses that they would not experience in the safety of their home. Preemies are more likely to have disturbed sleep patterns. Hospital lights, noises, and other disruptions make it difficult to sleep comfortably. Preemies are also more likely to have brain bleeds. Finally, preemies are also more likely to weigh less. None of these factors alone (hospitalization, disturbed sleep, low birth weight) cause autism just as being premature doesn’t cause autism. However, the fact that a child is born prematurely increases the likelihood of other complications. More interesting to us is what other issues did those babies have (e.g., reflux, ear infections, fevers) and were those babies also more likely to develop autism?

So your take away today is this: When you read studies, pay careful attention to the nature of the study. Is it a correlational study where researchers have merely conducted a series of statistical analyses and reported a finding? If so, dig deeper to find other variables that may be the real culprit and continue to push scientists to design experimental prospective studies so that we may learn the real causes of autism.

With that, we are off to sip on a glass of wine and ponder the latest research on alcohol consumption and breast cancer.

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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 case highlights the struggles of a little peanut who reminded us of a cherub–hence the name Little Cherub. She was angelic, beautiful, and gentle (except when you asked her to eat). She was fair-skinned, fair-haired, and fair-tempered (unless you asked her to take a bite).

Little Cherub was a twin who developed normally until she was 18 months old. She once spoke 30 words–until she regressed in to autism. Then one day, the words started disappearing one by one. What a horrible nightmare for families to live. Our sympathy goes out to each and every one of you who have lived (or who are living that nightmare).

Not only did Little Cherub lose her words and her desire to live in our world, she lost all of her eating skills. She no longer loved salmon. She no longer enjoyed cantaloupe. In fact, by the time we got our hands on her, she had whittled herself down to just two foods. Yes, you heard us correctly–just two foods. Can you imagine the stress for her family? (yes, some of you may be living that stress right now.) She loved pretzels and she loved peanut butter. She drank her almond milk from a bottle and she refused to drink it from a cup (although she could drink water from a cup).

As if her case wasn’t hard enough, Little Cherub had been diagnosed recently with celiac. Celiac is a condition when a person cannot digest the protein found in gluten. If you are uninformed on this topic, you should know that gluten is found in almost every yummy food: bread, pasta, crackers, cookies, batter-fried food, and anything else with flour. Living a gluten-free (or GF) lifestyle is not that hard but it can certainly complicate matters–particularly when you only eat 2 foods.

Little Cherub’s parents agreed to have us come in to their home for a week of therapy. During that time, Little Cherub stayed home from school and focused on eating and toileting. Yes, we sought to address both eating and toileting because we have found in our practice, that children respond well when they are challenged. So, with that, we started both treatments on the same day.

The first day started with Little Cherub putting on her big girl panties. She had the cutest little panties–Hello Kitty and Cinderella. She was not particularly interested in her new panties though. We put her on the toilet and she didn’t produce. We made the mistake of putting her clothes on and turning our backs. Bam! She wet herself. We quickly rushed her to the potty and told her that pee goes in the potty. She did not produce since she had already peed it all out. So she got dressed and washed her hands. Oh yes, toilet training is a great time to work on those self-help skills because you get to practice them over and over and over.

Then she proceeded straight to breakfast. Little Cherub was somewhat confused as to why she wasn’t having peanut butter. She was angry when she found out that eggs were on the menu instead. During breakfast we tried to shape up a self-feeding response. We wanted her to pick up the spoon, touch it to her lips and put it back down. In return, she could watch her favorite movie, The Backyardigans.

We also threw away the bottles. If she wanted her almond milk, she would have to drink it out of a cup. She fought this for at least two days straight. It was almost as if the cup had cooties—except she drank water out of an identical cup. It made no sense to us either. We are certain that when she starts talking one day, she will tell us. None the less, the first meal was not easy but she soon figured it out. Breakfast lasted over an hour.

Next it was time to potty again. We had learned from her teachers that Little Cherub could hold it all day so we did not need to stop breakfast to potty. She did not produce after breakfast either. This time we kept our eyes on her while we waited for lunch. During this time she asked for pretzels and peanut butter. We simply told her that breakfast was over and that lunch would be soon. Then the crying ensued. She was clearly unhappy about these new rules.

We finally got her to pee on the potty after what seemed like hours (oh yeah, it really was hours). We sprinkled warm water down there and she made the connection. We gave her GFCF pretzels as a treat. She was happy. She managed to pee on the potty once each day and then she would have a soaker over night. This is pretty common when children are rigid and have already learned to hold it. Eventually, she will figure out that the only way she is going to get pretzels is to pee on the potty. By the time we left after 6 days (thanks to a snow storm that kept us longer), she had peed on the potty at least once each day and sometimes twice depending on her liquid consumption.

The feeding was turning out to be much more difficult. In fact, Little Cherub proved to be the toughest case we have had to date (we reserve the right to change that–though we hope to never meet anyone more difficult). As we said, on the first day, she was willingly picking up the utensil and touching it to her mouth. On the second day, she would willingly eat a food if it was mixed with the peanut butter. We were also successful at putting some food on a chip–a once favored food. However, after two days, she was still not interested in eating food that was not accompanied with another preferred food. So, on day 3, we got tough. We no longer allowed mixing foods. She needed to eat it plain. She put up an awful fight. You would not believe us even if you saw it on video. For a tiny little peanut, Little Cherub was fierce. She fought us for the first meal on Day 3 and then it was as if nothing had happened. She came to lunch ready to eat.

Thus, lunch and dinner on Day 3 were great. She was eating all the foods (we ask parents to bring 4 NEW foods to each meal–protein, fruit, vegetable, and starch). She was feeding herself all the foods. So, at dinner, Mommy took over with us coaching. She tried to fight it but she soon realized that Mommy was no longer playing the old way–she meant business. On the 4th day, Daddy did breakfast. It is funny because Little Cherub thinks she can convert people back to her world. That is until she realizes that they have been trained. No more peanut butter, no more pretzels. Uh oh.

During breakfast we discovered that Little Cherub does not like eggs. She fought and fought and eventually self-fed the eggs. (Sadly, even after 6 days, she was still not thrilled with eggs. Her parents will continue presenting eggs for a few more weeks before deciding if they are simply non-preferred).

Next, we were off to school. It is important to generalize these skills to new people. Remember, Little Cherub put up a fight for Mommy and then Daddy. You know she is going to fight her teachers. We arrived at school during snack. Little Cherub tried to eat her friends’ snacks! What a pleasant surprise! However, due to her allergies, she cannot eat her friends’ food. We started off the lunch session and after a few bites, we transitioned in her assistant teacher. Wouldn’t you know, Little Cherub decided to try out the fight again. Quickly she realized that all the teaching staff were “in on it” so she settled down and ate her blueberries, coconut milk yogurt, and chicken soup with carrots and chunks of chicken.

When the snow cleared and we could travel, we said our good byes. We arrived home to the most brilliant email. Little Cherub ate (and I quote you from Dad’s email), “Steak sautéed in onions, home fry style potatoes and onions, peas, and strawberry for dinner. She loved the steak and potato and asked for several helpings!” We wanted to know if she ate them willingly or if she put up a fight. To this, Dad replied, “she grabbed that steak like a hungry NFL lineman. I started with a few small pieces and she probably ate about 2 oz in total. I had to push with the potato for the first bite but that was her second favorite food of the meal”

Let’s pause to cheer for our Little Lineman. Way to go Little Cherub! Hats off to your Mom, Dad, Grandpa, Mimi, and wonderful teachers. You have the best army possible fighting for you. Mom and Dad, it was a wonderful journey. Thanks for taking us along for the ride.

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It never occurred to us that we could take our existing knowledge about the iPad and applications and write an informative blog post for readers. So, thanks @PaulCBrady for asking us for a list!

The picture to the left comes from a wonderful (and free) application for Halloween. Children may carve by hand, carve by facial feature, carve by various faces, or use stickers to decorate. When the decorating is complete, a picture may be saved to your photo files. So, given that it is so close to Halloween, we’ll start with Halloween applications.

Halloween Applications

  • Carve a Pumpkin (to make the cute Jack-O-Lantern)
  • Pumpkin Lite
  • PumpknXplod
  • Pumpkin Plus
  • Skeleton (interactive and imitative)
  • Halloween Coloring Book
  • Carve It
  • Halloween Heat

Interactive Food Games (Thank you Maverick Software)

  • More Grillin
  • More Cookies
  • More Buffet
  • Cupcakes
  • More Pizza
  • More Cowbell
  • More Salad
  • Little Match Ups Fruits

Interactive Echo Games

  • Talking Gugi
  • Talking Tom
  • Talking Babies
  • Talking Gina
  • Talking John
  • Talking Roby
  • Talking Larry

Reading and Reading Readiness

  • Smiley Sight Words
  • Teach Me Toddler
  • Teach Me Kindergarten
  • Teach Me 1st Grade
  • Super Why
  • ABC Match Ups
  • Intro to Letters (by Montessorium)
  • Bob Books
  • Elmo’s ABCs (amazing and worth every penny)

Interactive Books

  • Misty Island (Thomas the Train complete with puzzles, coloring, and dot to dot)
  • 5 Little Monkys
  • Green Eggs and Ham
  • Me and Mom Go to the City
  • Toy Story (with reading and painting)
  • On The Farm
  • Ronki

Books

  • Read me Stories (a library with one free book each day)
  • Mee Genius (a library)
  • Reading Bug
  • Food Fight
  • Christmas Tale
  • The Ugly Duckling
  • Three Pigs
  • Sesame Books
  • Elmo’s Birthday

Vocabulary Builders

  • Kindergarten dot com Flash Cards (there are many! actions, alphabet, zoo, fruits, toys, instruments)
  • Verbs with Milo
  • First Words Deluxe

Math

  • Bert’s Bag
  • Intro to Math (by Montessorium)
  • Free Multiplication Tables
  • Grasshopper
  • Ace Math Flash Cards

Interactive Games

  • Bowling
  • Mini Cooper Liquid Assests
  • Monkey Flight (by Donut Games)
  • Sunday Lawn (by Donut Games)
  • Skee Ball
  • Flashlight
  • Spin the Coke Bottle
  • Spinning Plates

Interactive Songs and Music

  • Wheels on the Bus (Duck Duck Moose developers)
  • Old MacDonald (Duck Duck Moose)
  • Wheels on the Bus (Duck Duck Moose)
  • Itsy Bitsy Spider (Duck Duck Moose)
  • Kid’s Songs
  • Virtuosa Piano

Art Tools

  • Drawing Pad
  • Draw Free
  • Kid Paint
  • Whiteboard

Puzzles

  • Children’s Wooden Puzzles
  • Wooden Puzzles (these are not all good but the good ones are great. Sadly, the developers did not advertise on their app so we can’t tell you the exact name or developer)

Data Collection (I don’t think any of these are worth the money)

  • DT Data
  • ABC Logbook
  • ABC Data Pro

Applications for Autism

  • Proloquo2go–we love it.
  • Dexteria (developed by an OT and teaches fine motor skills)
  • iPrompts (thanks for the reminder Kristen!). iPrompts may be used to make schedules, choice boards, and a countdown timer. We LOVE this one.

Websites with Application Reviews

Parents of children with special needs will find the application called IEP Checklist very helpful.

We should clarify that we are not application developers and we have not been paid by any app developer to list their product. Missy is friends with Glenda, owner of Maverick software. Missy and Rebecca have both been given complimentary copies of Proloquo2go so that children may test out the software before making the purchase.

Finally, while these applications have been helpful for us in our therapy sessions, your child may no necessarily enjoy them. Before purchasing, read the ratings and comments. Check out the sample pages to make sure you know what you are purchasing.

Have fun with your applications. We sure do!

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