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Archive for March, 2012

In the social media world, you can make many friends. Our list of Tweeps, Facebook friends, and LinkedIn folks is growing every day. Recently, we met a blogger who is a great resource for families in the special education world. Her website is The Special Education Advisor and her name is Dennise Goldberg. You can follow her on Twitter @SpecialEdAdvice. (If all of the social media is confusing to you, we wrote about how Twitter can help you.You can read it here.)

Dennise asked us to write something for her website and, well, since it is IEP season, we thought a great piece on IEP minutes would be helpful for readers.

So, instead of reading our post on our site, hop on over to hers to read it there. Look around her website and check out the resources she has available.

Thanks for having us Dennise!

Also, we linked our blog from Monday up with Bruna over at Bees with Honey. Hop on over there and see what all of her friends have to say. It is another way to meet other bloggers and blog readers.

Bees With Honey

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We read an interesting post on one of our list serves reminding us that even when we use words that “we” believe are commonly understood, we may be assuming too much.The post we saw today referred to rewards as bad things because they lead to, among other things, “satiation.”

The post was published on Edutopia on March 6, 2012 (http://www.edutopia.org/blog/reward-fraud-richard-curwin). Dr. Curwin noted that

Satiation means that more of something is required to get the same effect. Examples are pain medication or hot water in a bath. I love a hot bath, but eventually it starts to feel cooler, and I add more hot water. Rewards are like that. Children never say, “That’s way too much. Please give me less.” They often say, “Is that all? I want more.” Eventually, rewards like stickers, food, parties, toys or candy become expected, and their effect is greatly reduced.”

Now, we know that Dr. Curwin’s interpretation of satiation does not align with the text-book definitions of satiation. In fact, the definition of satiation is almost the exact opposite of what Dr. Curwin described. Satiation, according to the Oxford English Dictionary, is “point at which satisfaction of a need or familiarity with a stimulus reduces or ends an organism’s responsiveness or motivation.” Dictionary.com, offers a much more user-friendly definition, “the point at which one is satisfied or more than satisfied“.

In our behavioral framework, we say that a person becomes satiated when overexposed to an item that previously was needed or wanted. Take thirst, for example. In a 4-term contingency that includes motivating operations (MO, also understood as internal motivations), “thirst” serves as an MO. That is, in the presence of water (Sd), given “thirst” as a precondition (MO), a person will drink the water (response) because the value of slaking his thirst is pretty high (Sr+). On the other hand, if I’m feeling pretty hydrated, I likely won’t drink water (‘response’) even when it is present (‘Sd’) because the value to me (Sr+) is diminished at that time.

Dr. Curwin is right when he says that satiation is not a good thing when working with kids, but he is not correct from a behaviorally analytical framework. When folks get too much of something (even if it’s awesome at first), they will want less of it in the future!

We think that sometimes folks just get confused with all these terms and their relationship to one another. So, next time you think you’ve explained everything clearly, check to see that you all share the same understanding. What you find may just surprise you!

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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 story is about a young man we call Boost (you will see why a bit later in this post).

Boost came to us with a long history of feeding difficulties and he was only 7. He was diagnosed with autism and he was also non-verbal. Boost had previously eaten food but only in wet ground form. By the time he got to us, he consumed only Boost and apple juice. Both liquids were consumed from a bottle with the top of the nipple cut off so the liquid would literally pour into his mouth.

Prior to any behavioral feeding therapy, we require a thorough record review and assessment to assess for any possible underlying issues. (Honestly, all intervention programs should be preceded by a thorough assessment to help with program planning. We have written about that previously here.) For Boost, we completed a record review to determine if any assessments were needed prior to therapy. Boost had a long history of gastrointestinal (GI) issues so we referred his family to a gastroenterologist for a thorough work up.

The gastroenterologist completed an endoscopy during which the gastroenterologist inserted a pill camera to complete an assessment of the entire small bowel. He discovered that Boost had serious inflammation in his GI tract. Specifically, Boost’s pylorus was so inflamed that even the pill camera would not pass. You heard us correctly. A tiny pill camera would not pass through his pylorus. And we all wondered why he had limited his calorie consumption to a pure liquid diet.

You see, Boost was non-verbal. He could not tell us that he had GI pain. He could not tell us that it hurt to eat. Had we started therapy without the GI Assessment, we could have caused Boost a great deal of pain. This case is an excellent example for demonstrating the importance of assessment prior to treatment.

The GI Doctor placed Boost on an elemental formula and anti-inflammatory medication so that Boost could obtain appropriate nutrition while allowing his GI tract to heal, a process that took 6 months.

Parents, if you have a picky eater, please make sure that you obtain assessment in all areas to rule out underlying issues. Behavior analysts, do due diligence in the assessment process to ensure that you do no harm in your behavioral feeding therapy.

We would love to hear from readers. Please share what types of information you have gained from the assessment process prior to behavioral feeding therapy.

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For those of you who haven’t noticed, or who are walking around with your eyes closed so you won’t notice, spring has sprung! This, of course, means only one thing for educators, parents of children with disabilities, and behavior analysts: IEP Season is nearing!

You can recognize the signs anywhere:

  • school personnel are scrambling around trying to get consent to re-assess
  • parents are panicked that their child is going to have the same IEP again
  • behavior analysts are writing progress reports to submit at meetings
  • we are all checking our calendars like we are Hollywood elite

Stop. Take a deep breath. Relax.

IEP Season does not have to be chaotic. We have a few tips for you to remain in control of your life during this busy time.

Calendars

Stay on top of your work load by keeping your calendar with you at all times. We realize that some of you may be stuck in the dinosaur ages with your paper calendars. Utilize a digital calendar such as Outlook to manage your meeting schedule. Sync it up with your iPhone, Blackberry, or other PDA. Be sure to sync it often so that you do not inadvertently double book yourself.

Many digital calendars have reminders. Set the reminders and heed their warnings. You can remind yourself days, weeks, and even minutes before the scheduled activity.

Calendars are a great way to keep track of your appointments, mileage, and due dates.

Task Lists

Task lists are another tool that you can use to simplify your life. Software such as Outlook allow for a task list that comes with due dates, alarms, and space to indicate progress. Some people prefer to start the day by developing a task list for the day. Then items may be crossed off as they are completed. Whichever strategy you prefer, choose one and use it.

Just Say No: to Procrastination

The weather is turning beautiful in many places. Do not forgo a deadline in order to bask in the beautiful sunlight–unless you can kill two birds with one stone. This time of year, it is hard to make yourself remain indoors to finish that report or send that last email. However, if you don’t work through that Task List, you will find yourself in a panic as the deadlines near.

Just say No: to Requests You Cannot Fulfill

Only you know what your task list and calendar look like. Thus, only you can determine if your schedule permits you to take on another task. If you do not have the time to complete the task correctly, consider declining the responsibility. If you are the only person who can complete the task, then you may be spread too thin and work adjustments should be made.

Use Assistance and Assistants Wisely

Many of us have an assistant available who can perform some tasks for us (e.g., returning phone calls, printing documents, etc). If you have access to an assistant, use the assistant wisely to make the most of your busy days.

Even if you do not have an assistant, be aware of the resources that surround you. Seek out assistance from others when possible. Is it feasible to ask someone else to complete a task? Is the task within their skill level and training competency? Are there individuals who are looking for more opportunities? Enlist their assistance as part of on-going training and experience.

Clean Your Desk Daily

Take a few minutes each day to clean your desk and organize your piles. Starting each day fresh with a clean desk will help you organize your daily task list. Additionally, if you clean your desk each day, your files will remain better organized and you will spend less time searching for that elusive note or document. Finally, if your desk is clean, you will be certain to avoid any HIPAA violations.

We hope you approach this upcoming busy season with great success. We would love to hear what strategies you use to remain sane during this busy time. Please share!

Let's BEE Friends

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The Connecticut Association for Behavior Analysis (CT ABA) is tomorrow. Are you registered? Missy will be speaking on Special Education Laws and the Ethical Issues for Behavior Analysts. Rebecca will be speaking about how to use Applied Behavior Analysis (ABA) to teach social skills to children with autism.

The conference committee has lined up other great speakers too. These include Dr. Bill Heward, Dr. Richard Graff, Dr. Kathleen Dyer, Dr. Judith Ursitti, and Dr. Amy Odum. Participants will earn Continuing Education Credits plus lunch is included.

Applied Behavioral Strategies will have a booth so please stop by to see us between sessions.

Enjoy the conference!

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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.

Readers really gravitated to our story on Monday about adults with disabilities so we thought we would share a success story about one of the adults we have served. Alwan’s adult service provider reached out to us because they needed help with his Self Injurious Behavior (SIB). Alwan hit his head about 2,000 times per month. The SIB was so severe that Alwan was required to wear a helmet all day. Alwan was blind in one eye from the SIB and he was developing cataracts in the other eye. Alwan was 28 years old and carried several diagnoses including profound mental retardation and autism.

Record Review

Because we “inherited” Alwan, we first completed an extensive record review. From the record review we learned that Alwan was heavily medicated in an attempt to decrease the SIB. Alwan had no formal communication system. Alwan had serious feeding issues and was on a strict puree diet. Additionally, he had a protocol for drinking liquids to prevent aspiration. Finally, Alwan had 1:1 staffing all day and 2:1 staffing when out in the community. Additionally, he was “pre-sedated” before all appointments and the staffing ratio on appointments was 4:1.

The record review also referenced a set amount of top spinning time. From the review we learned that Alwan enjoyed spinning tops, lids, etc. We did not, however, understand why this time was limited to only 30 minutes per day.

Functional Behavioral Assessment

The next step was to complete a functional behavioral assessment. We have defined, described, and given examples of these before. To get started, we created an ABC chart for the staff to complete when they observed these behaviors.

We also completed direct observations of Alwan. The observations revealed that Alwan was physically tugged, pulled, and directed all day long. Staff literally dragged him from place to place. Moreover, he had no choice about what to eat, what to drink, or even how to spend his time. Because he lacked communication, staff determined everything for him. The only thing Alwan could control was dropping to the floor and hitting himself in the head.

The observations also provided clarity about the issue around top spinning. When Alwan spent time spinning tops, he became very “worked up” and excitable. All of those behaviors led to an immediate increase of SIB. Essentially, he rocked, flicked the tops, watched them spin, laughed, and then proceeded to hit himself. However, if top spinning did not occur, head hitting was kept to a minimum.

We conducted interviews with staff to find out additional information about Alwan and his behavior. Staff revealed that Alwan really enjoyed walking to the park and riding in the van. Alwan also enjoyed taking a bath.

Many times, SIB is associated with pain, so we asked a few questions to help determine if underlying pain existed. We learned that Alwan had gastrointestinal (GI) issues that needed medical attention so we referred Alwan for a GI workup. Honestly, one bowel movement every 5 days is enough to make us hit our heads a few times.

Finally, we noticed that whenever Alwan was denied something that he wanted, he engaged in head hitting as if to say he was mad about being told no.

Intervention Priority: Communication

Our first concern for Alwan related to his need for a method of communication. We encouraged the provider to hire a speech and language pathologist to help design an appropriate communication system for him. Seriously, who graduates from a program at age 21 without a form of communication? We feel strongly that his IEP team neglected their duty to teach him important skills such as effective communication.

Intervention Priority: Leisure Skills and Reinforcement

We recognized early on that top spinning was a problem. First, it is not an appropriate leisure skill. Second, top spinning was directly correlated with head hitting. Thus, we wanted Alwan to learn new leisure skills. We also wanted Alwan to have more time doing the things he enjoys such as taking baths, going for van rides, and taking walks in the park. It is important for Alwan to have a meaningful day filled with things that he enjoys (and is capable) of doing.

Intervention Priority: Response Interruption and Redirection (RIRD)

Finally

Intervention Priority: Staff Training

We scheduled time for the staff to learn about why challenging behavior occurs. We also reviewed the current BIP and discussed our suggestions regarding changes to the BIP. We taught them how to increase the amount of time that Alwan spent doing things that we liked. We taught them how to interact with him in a way that decreased the amount of time their hands were tugging on his body and increased the amount of time they had positive physical interactions with him. We also taught staff how to implement RIRD.

Outcome

The team is continuing to follow up on Alwan’s GI care. They are making sure that he has regular bowel movements. They are increasing his opportunity for choice in what he eats and what he drinks. They are increasing access to preferred activities such as van rides and trips to the park.

The speech and language pathologist continues to work with staff on developing and implementing a formal mode of communication for Alwan. He is beginning to point to indicate what he wants and needs.

Staff are learning to attend to positive behaviors and to interrupt negative behaviors. They are also learning to interact with and enjoy Alwan.

Most importantly, Alwan has reduced his head hitting to only a few episodes each month! Isn’t it amazing how effective an assessment and function-based approach can be?

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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 list serve on which I participate. The list serve is reserved to parents and guardians of individuals on the autism spectrum. The question actually came about because a reader posted a link to a great story about an adult with disabilities and the lack of resources available for adults once they age out of the school system. You can read the article here.

When people read the article, they became alarmed as they thought about “what would happen to their child with disabilities if/when something happened to them”, the parents/guardians. The sad reality is that our systems are not currently set up to properly care for our loved ones. I know this first hand, as my brother has been in the adult system for 13 years now.

  • housing choices are limited
  • 24-hour staffing is expensive
  • community support staff are underpaid
  • community support staff lack training
  • funds do not exist within state budgets to care for all of those individuals who are going to enter the adult services system

So, what will happen to your loved one when you are gone? I will tell you what we have experienced first-hand: Abuse and Neglect. My brother experienced both of these and I am still around to advocate on his behalf. I never go more than 2 weeks without seeing him. Yet, he still suffered from abuse (broken bones) and neglect (malnutrition and dehydration) on more than one occasion. The details of those stories are for another day (and I book that I am working on). So what do I advise you to do? Start. Planning. NOW.

Guardianship

  1. Follow all the steps to make sure that you have appropriate guardianship/conservatorship as soon as your loved one turns 18.
  2. Make sure that you have a guardian lined up who will take over the duties when you are gone. It will be best to have someone who can start sharing some responsibility now so that the change will not be such a shock.
  3. Guardianship, at this time, does not transfer across states. We learned the hard way. If you are planning on relocating to another state, find out what steps are necessary and get it taken care of as soon as you have relocated.

Housing

  1. It is not normal for your loved one to live with you beyond age 18. Begin searching for appropriate housing options. It can take years to find the right place.
  2. A variety of housing options exist. Choose one that is right for you and your loved one.
  3. You will find it important for your loved one to live near you. Frequent and unplanned visitations are important

Adult Services

  1. Most states have long waiting lists for adults with disabilities. My brother waited for 9 years in Texas before receiving appropriate services. Get on the list today. If you do nothing else for your loved one, register them with the state today.
  2. Be honest about what your loved one needs. We all want to find the positives in our loved ones. However, your loved one will get more services based on his/her deficits. Do not sing his/her praises during the evaluation. Be honest about all the things and types of supports your loved one needs.

Adaptive and Self-Help Skills

  1. Begin teaching your child how to be as independent as possible.
  2. Make sure that the IEP focuses on functional skills. Remember, functional skills are those skills that if an individual cannot do the skill himself, someone else must do it for him.
  3. Refrain from doing things for your loved one. Instead, help them do things. Just last night my brother helped start the fire. He brought the wood in and he opened the glass doors for the fireplace. Every little step counts.

This is a scary and thought-provoking post. I assure you, it is better to think about it now while you are still healthy and able to plan and prepare. We would love to hear from readers who have already begun the planning process. Share your ideas with us!

If you have questions about behavior, email Missy at askmissy at appliedbehavioralstrategies dot com.

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