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Archive for December, 2011

Everyone has been asking us about our trip to Dubai so we thought we would provide a summary of our trip.

First, we are both jet lagged and still recovering. It is a super long trip. We started the trip by taking a train in to New York City. We visited several fun places like Macy’s and Rockefeller Center. Then we caught a cab to the airport for our almost midnight flight.

Upon arriving at the airport, we discovered that the flight was oversold. Luckily, some other passengers gave up their seats for us to make our trip. The flight over lasted 12 hours. When we landed, it was 8:30pm in Dubai. We made it through customs and retrieved our baggage quite uneventfully. Our hotel van driver greeted us and transported us to our hotel.

All the speakers stayed together in the Flora Creek Hotel Apartments. We had a bedroom, two bathrooms, a living area, dining area, and a kitchen. Later, we would learn that the kitchen would never be used because we ate every meal with the group. Our room  included a breakfast buffet every morning.

After a night of sleep, we arose to a beautiful Dubai skyline. Our apartment overlooked the Dubai Creek with views of the city. Wow. We were off and running. We enjoyed our breakfast but we also had to meet the other speakers promptly at 7:30am for the shuttle ride. This is when we learned the meaning of promptly in Dubai. Often, people will say ” Insh’allah” or God Willing. Nothing starts on time.

We repeated this pattern of sleeping, waking, eating breakfast, and busing over to the hotel for 3 days. During the course of the conference we met many wonderful people. Individuals in other cities and countries are doing their best to combat autism. We enjoyed seeing such a unified approach.

In the evenings, we participated in events for speakers. The first night we had a Speaker’s Dinner at The Address Hotel. The second night we took a dinner cruise down the Dubai Creek. The third night we went on a desert safari dinner.

Most of the speakers returned home or rested after the conference. Not us. We toured the Child Early Intervention Medical Center, all 3 locations. We observed two behavioral feeding intervention sessions, and we met many children and staff. If you live in Dubai and are interested in working in autism, you should definitely check out the center. If you live elsewhere and have always wanted to live and work in Dubai, the CEIMC may be an option.

Whew, we are tired just remembering our trip. Of course, we haven’t even touched on the conference content. We will do that another day.

We would like to thank the Conference planners for including us in this event and for planning an amazing trip for the speakers.

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Hi and welcome to “What Works Wednesdays” where we share a success story from one of our clinical cases. Our intent is to show readers how successful ABA can be.

Today’s post will be slightly different from our previous What Works Wednesdays. We received inspiration from a guest blogger over at Yeah.Good Times. If you don’t know Jillsmo, you should. She is a mom of two, blogger, and cartoonist. She is also funny. Before you go visit her site, however, be prepared to see foul language.

You Might Be an Autism Parent If

Anyway, Jillsmo asked Sunday, another mom and autism blogger here, to write a guest post. We should give you some background. If you tweet, you may have picked up on the #youmightbeanautismparentif. If you don’t tweet, you should know that many parents have been posting comments where they fill in the rest of the phrase (e.g., you might be an autism parent if your child is 8 and he still doesn’t sleep through the night.)

Picky Eaters

So, Sunday described her feelings about how someone responded to her comment about her picky eater. You will find her guest post here, and it’s called Your Child is Picky: My Child is Stalin. It is an awesome post. After reading her post (and the 57 comments about her post), I became very frustrated. Sunday’s child eats only 4 foods. Many of the commenters shared how their children also suffered from picky eaters. Then we completed some of our own research and clearly, we have a pervasive problem on our hands. Parents of children with autism are posting on websites such as CafeMom, Parenting, and MDJunction, in search of help for their picky eater.

Behavioral Feeding Intervention Works

How can children with autism get to a point where they are only eating 10 foods, 5 foods, or even 3 foods and yet no one refers them to a behavioral feeding clinic? Behavioral feeding intervention is effective. We just summarized a research review last week showing how effective therapy is. If you missed it, you may find it here.

However, intervention can only be effective if implemented. Thus, parents need to be referred to agencies with extensive training and experience in pediatric feeding disorders combined with a specialty in autism spectrum disorders. Many such programs exist. Obviously, we provide behavioral feeding services. The Center for Autism and Related Disorders (CARD) also provides behavioral feeding services, as does Clinic 4 Kidz. Each of these agencies have staff available to travel to your home to help you and your child overcome picky eating. Other centers are available but families will have to travel to them. These include Kennedy Krieger, The Marcus Autism Center, and the Cleveland Clinic to name a few.

Start Early

We also know that intervention works best when implemented as soon as possible. While we have treated children of a variety of ages, younger children respond more quickly because their behaviors are less engrained than older children. Physicians, teachers, and related service therapy personnel should refer families to help as soon as they notice a child limiting her foods.

Paying for It

Behavioral feeding therapy can be expensive depending on the type of program, how many therapy sessions are provided, and where services are provided. However, funding options do exist. First, try using health insurance to cover the costs. If that is denied, check with your state developmental services office to see if special funds are available for your child. Finally, if your child has an IEP or an IFSP, you may be able to write a feeding goal for your child and that goal will be used to design services to address your child’s feeding needs.

We know that having a child with autism is stressful. Having a child with autism who is also a picky eater is even worse. However, behavioral feeding intervention works.

Do you have a picky eater? Have you experienced behavioral feeding therapy? Tell us about your experiences.

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Hi and welcome to Ask Missy Mondays where I respond to email questions from readers who have questions about behavior. Today’s question comes from a team of professionals who provide feeding therapy to children who are struggling with eating. The team writes,

“Hi Missy, we run a feeding clinic and have recently been receiving calls from a number of parents with very young children. How young is too young to start feeding therapy?”

I thought this was a great question but I wasn’t sure that I had enough information. So, I emailed back and asked them to elaborate. Specifically, what ages are the children? The team responded,

“Well, one child is 11 months old and the other child just turned 2.”

I was stunned. It broke my heart to learn that a mom was struggling with such a very young baby. My first response was that 11 month old clients are still, technically, infants. Thus, my recommendation was for the mother to seek support from her pediatrician or even mid-wife. Of course, the team should recommend a good nutritional, gastrointestinal (GI), and allergy work up. If, after all of those referrals and support, the mother still struggled with feeding, perhaps the child and parent could attend behavioral feeding sessions. However, I would want to exhaust all support services for infants before starting services that are primarily targeted for preschoolers.

We have treated several two year olds in our clinic. However, each client approached or celebrated their third birthday during clinic. Additionally, we modify our intervention strategies slightly due to their young age. There is a big developmental difference between a 34 month old and a 24 month old. So, I urged the team to use caution.

Assess

First, teams should carefully assess all participants prior to commencement of feeding therapy. This is especially true for very young children. The assessment should include a thorough record review of the medical history including assessing for any history of reflux or other GI issue. Swallowing function should be assessed by an appropriate professional. Chewing function should be assessed to ensure that the child knows how to manipulate food appropriately in his/her mouth without choking.

Rapport

Given the child’s young age, the team should first establish rapport with the child so that he/she feels comfortable with each therapist. Second, the child needs to feel safe in the therapy environment. Of course, his/her parents should be present at all times. Finally, be sure to include play time before and after therapy so the child maintains positive associations with the environment. We recommend providing services in the home if possible. However, if not possible, the clinic area should be modified to meet the needs of very young toddlers.

Instruction

The team should take some time to teach the child some basic compliance skills like gross motor imitation, singing songs, or playing together on the iPad. Once the child has demonstrated an ability to follow basic instructions and he/she has learned that fun things happen following compliance, then it is safe to begin therapy.

Feeding Therapy

Staff should take care to utilize child-friendly approaches during feeding therapy. Staff should never trick the child to eat or sneak food in when he/she is not looking. Staff should, instead, focus on teaching the child to tolerate new foods and to pair new foods with reinforcers such as hugs, cheers, high 5s, and even songs or games on the iPad.

Good luck helping those very young children. We know that the sooner you start, the better the long-term outcome. Please keep us posted on their progress. We know they are in good hands!

If you have a behavior question that you need assistance on, please email: askmissy at appliedbehavioralstrategies dot com.

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Happy Friday to you! We are busy presenting in Dubai so we thought we would keep it simple today. Don’t you just love this? There sits Pavlov thinking he is making some great scientific breakthroughs. Meanwhile, his dog is playing him!

Has your child with autism or other disability played you? Please share!

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We try to review a research article each week. Today, since one of us is conducting a 4-hour workshop on feeding in Dubai, it seems appropriate to review a study related to feeding. William Sharp and his colleagues at Marcus Autism Center (David Jaquess, Jane Morton,  and Caitlin Herzinger) authored the study titled, “Pediatric Feeding Disorders: A Quantitative Synthesis of Treatment Outcomes”. The Journal Clinical Child and Family Psychology Review published the study in 2010.

Literature Review

This paper is a literature review or literature synthesis. In research papers like this, the authors search for all the studies on a particular topic and then they analyze the results collectively and use those results to make treatment recommendations. These authors did just that. They identified the topic of interest and consulted a search on all studies of treatment for severe food refusal or selectivity. We have written about this topic on several occasions because many of the children we see have food selectivity (where they will eat only a few things) in addition to their autism. You can read more about our case studies here, here, or here.

Food Refusal and Food Selectivity

The Journal publishing this paper, is a peer-reviewed research journal. This means that a review panel of experts read the paper and deemed it scientific and valid. Thus, the authors only included studies in the review that utilized strong experimental control or what you, as readers may call, a good experiment. With these criteria in place, the authors identified 46 published studies wherein a total of 96 children received treatment for food refusal or food selectivity.

Outcomes

The authors noted that the majority of studies in the review had been published after 2000. Many of the children in these studies were male and most had a developmental issue of some sort including global developmental delay or autism. Over half of the children in these studies also had an underlying medical condition including Failure to Thrive (FTT), Gastroesophageal Reflux Disease (GERD), and gastrointestinal problems. Treatment occurred in hospitals, homes, schools, and outpatient centers and was provided by highly trained therapists. The majority of studies reported extremely favorable outcomes (large effect size) for participating children. Authors reported other positive changes such as a decreased need for tube feeding, complete removal of tube feeding, weight gain, discontinuance of bottle feeding, and improved consumption.

Behavioral Therapy

The authors reported that for all reviewed studies, researchers used a behavioral approach to feeding therapy. The authors noted that they could not locate any well-controlled studies utilizing other treatment methods.Within behavioral treatments, the authors noted that escape extinction (not getting out of the non-preferred bite) was the most widely used treatment with over 83% of the studies utilizing it in some form. Non-removal of the spoon and physical guidance were also used to prevent escape or avoidance of non-preferred foods. Also within behavioral treatments, authors used differential reinforcement of alternative (DRA) behaviors. Specifically, when the child engaged in eating, he was provided with a reinforcing toy, game, or possibly even food.

Recommendations

The authors of the review noted the continued support for behavioral treatment to address food refusal and selectivity. While a great number of studies utilized escape extinction procedures, it should be noted that the authors reviewed the literature on severe feeding disorders. As such, milder cases may not require the use of escape extinction. In our practice, many of our children arrive eating 5 foods or fewer. In our opinion, that is a severe situation and prompt treatment is warranted.

The review authors also point out that escape extinction was never used in isolation but was rather, a part of a complex package of intervention treatments. This is also important because we know from other research that extinction alone can result in an increase in problem behaviors and that when extinction is paired with reinforcement, the severity of the behaviors is reduced.

We want to hear from you. Did your child participate in feeding therapy? Were behavioral procedures used? Was feeding therapy effective?

If you are interested in behavioral feeding therapy, we offer this service in the convenience of your home. We also collaborate with your child’s school and ABA team to ensure successful maintenance of behaviors following intervention. Please contact us for additional information: info at appliedbehavioralstrategies dot com.

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Rebecca and I are headed to Dubai today, well actually it will already be tomorrow there when we leave here today. Whew! I am confused and we haven’t even left yet!

We are both excited about this trip, not only because we have never been to Dubai but because we will be presenting alongside many other distinguished speakers.

The conference, Autism Around the World, should be an exciting one as multiple disciplines will be brought together to address the many facets of autism. The Child Early Intervention Medical Center, has worked carefully to put the conference together.

Glancing at the schedule, we will both be busy! Rebecca is presenting on social skills on Thursday and then she will conduct a 4-hour workshop on social skills on Saturday.

Missy will be conducting a workshop on feeding intervention on Thursday. On Friday she will be speaking on addressing challenging behavior and using the iPad for communication development and academic instruction. Finally, she will be conducting two workshops on communication intervention. One will address general strategies and the other will address strategies for classroom use.

How will we have to time to shop? And see the sights?

If you are able to join us in Dubai, please take a moment to say hello. We would love to meet our readers face to face. If you cannot make it to Dubai, we will post an update when we return. If you have ever been to Dubai, please recommend things for us to do? Where to eat? Where to shop? Sights to see? Something tells me we will not get much sleep for the next few days!

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Hi and welcome to Ask Missy Mondays where I respond to email questions from readers who have questions about behavior. Today’s question comes from Erin who asks

Last week, my four-year old son was just diagnosed with autism by a neurologist. However, at the IEP (Individualized Education Program) meeting back in March, the school told us our child was “fine” and that he no longer needed services. We moved to a new school district a few months ago. So when we received the autism diagnosis, we went to the new school to ask what to do. They told us that since we had our IEP meeting back in March at the other district, that whatever happened in that meeting determined what services would be available to us now.

Our child needs help! He has been kicked out of several day cares because of his behaviors. He is hyper, biting, loud, and wiggly. I cannot take him in public. Where can I get medication to make this all better? Can’t someone help us?

Wow Erin, I’m speechless. First, I am sorry that your child’s behaviors feel so out of control for you. It sounds like he definitely needs some help  in that area. But also, let’s not forget that he was also given an autism diagnosis and thus, he is going to need help in the three main areas related to autism: speech and language, social interactions, and other behaviors such as stereotypical behaviors and/or adaptive behaviors.

Request an IEP Meeting

I am going to back you up and have you start over with your new school district. Go to the district and bring copies of the new diagnosis and that person’s recommendations. Bring a letter that you have hand-written and dated (and saved a copy of at home) requesting an IEP meeting as soon as possible–preferably before the holiday break. While the IEP meeting in March resulted in your child being dismissed from services, new information is available suggesting that your child does, in fact, need services. The school must arrange an IEP meeting to be held within a reasonable amount of time.

At this new IEP meeting, the new team will determine if your child is eligible for services. According to federal guidelines, two things are required for him to be eligible for services. The first is that he must have 1 of the 14 disability categories identified in the Individuals with Disabilities Education Improvement Act (IDEIA). Autism is one of those 14 categories , so you are in luck there. The second requirement is that he needs special education in order to benefit from education. Your child cannot possibly benefit from education because he has been kicked out of an educational setting due to his behavior. Thus, he needs special education services to address his behavior so that he will benefit from the education available to him.

Develop a Behavior Intervention Plan

This brings me to another point. Under federal guidelines, if a child’s behavior interferes with his learning, then the team must consider positive behavior supports. By definition, in order for a child to receive positive behavior supports, he must first have a Functional Behavioral Assessment to determine why his behaviors are occurring. The assessment is then used to develop the Behavior Intervention Plan (BIP). All people involved in your child’s program must be trained on the plan and they must implement the plan. This includes you, your husband, the bus driver, the teacher, the speech teacher, and so forth.

Design a Program

Throughout the meeting, the team, including you and your husband, should develop a program that will address each and every one of your child’s needs. This is in addition to the BIP that should be developed. During the program development, it will be important to identify a number of goals and objectives that your child needs to master throughout the course of the year.

Particular attention should be paid to the three main areas of autism: communication, social skills, and behaviors. Additionally, the school is required to use evidence based methodology to teach your child. Currently, instruction based on principles of Applied Behavior Analysis (ABA), is widely recognized as one successful method for teaching children with autism. Any ABA program should be overseen by a Board Certified Behavior Analyst (BCBA) or someone with training and experience equivalent to a BCBA.

To Medicate or Not

I can certainly relate to your desires to medicate your child to control his behaviors. However, before you go down that route, might I suggest that you try other proven strategies first. For example, we know that certain foods may cause an increase in behaviors. You may read a bit more about that here and here.

Additionally, the BIP and comprehensive IEP, should be designed to teach your child to better control his behaviors. Multiple strategies, including the use of self-management, should be a part of his program.

If, after 6-12 months of following all of these techniques, your child’s impulsivity and hyperactivity has not improved, then perhaps you should visit an appropriately trained health care practitioner to discuss medication options.

You have a long road ahead of you. However, research has shown that an autism diagnosis is not the end of the road. Children can recover from autism and go on to function independently and indistinguishable from their peers. Get to work! And please send me updates!

If you have a behavior question that you need assistance on, please email: askmissy at appliedbehavioralstrategies dot com.

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