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Archive for April, 2012

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 “Dennis”.

Dennis came to us just slightly before his third birthday. He carried a diagnosis of autism. Like many of our children, he also had a history of reflux. His reflux was so bad that his parents reported having to place a plastic covering on the floor under his crib to protect the flooring.

Dennis was non-verbal but he had no problem making his needs known. One way that he communicated his wants and needs was by vomiting. Initially, when a non-preferred food was presented to him, he vomited until it was removed. Over time, he began to control what his Mommy ate too. If he saw her eating something he didn’t like, he vomited. By the time he got to us, he had whittled his diet down to only 3 foods: a certain brand of potato chips, peanut butter, and a beverage. His poor Mom couldn’t eat in front of him and was limited to consuming Coca Cola only in his presence. Can you even try to imagine the family stress in that house?

Readers should know that Dennis was the most adorable picky eater. His chubby cheeks were just ripe for the squeezing. His toddler hands and feet were precious. He was the kind of child that you just want to pick up and hug and kiss over and over again. With a child that cute, you know behavioral feeding therapy is going to be a challenge! It is really hard to be firm with a cutie-pie.

Because of the seriousness of the behavior and the extreme food selectivity, we asked that the parents have a complete medical work up prior to starting feeding therapy. Dennis came back clean as a whistle–he had no major issues other than the reflux.

On the first day of feeding therapy, we realized that we needed help. We rushed out to the nearest store to purchase protective gear–plastic aprons. Dennis could vomit without any effort at all and our clothes were doomed without protection. (Dennis is the worst case of vomiting we have seen in our practice to date.) In the first three sessions alone, he vomited 13 times when a total of 30 bites had been presented! When Dennis vomited, we simply cleaned up the area and re-presented a clean but identical bite of food. Dennis tried to use gagging to replace vomiting. When he gagged, we simply closed his mouth by gently pressing his chin up.

Dennis did not give up his preferences willingly. He fought us for the first two days. In addition to vomiting and gagging, he used head turns, crying, spoon batting, and other disruptive behaviors to avoid new foods. We ultimately used physical prompting to encourage him to open his mouth and take a bite. Once he accepted the bite, he discovered that it didn’t taste quite so bad. Keep in mind that Dennis was also hungry for each session. His parents did not feed him before or after therapy so if he didn’t eat with us, he didn’t eat again until the next therapy session a few hours later.

Over time, he began to fight less and less and he began accepting bites willingly. By the third day of treatment (9 sessions) Dennis had stopped vomiting.  Across the last three sessions of treatment, Dennis gagged only 2 times out of 142 bites of food and he had no vomits.

On the fourth day of treatment, we transitioned Dennis’ parents in to replace the feeding therapists. On this day, Dennis had begun to feed himself and his parents were there to make sure that his bites were not too big. His parents also reminded him to take a bite if he slowed down or looked as if he might be trying to avoid a food. It was also on this day that we taught Dennis how to eat cake for his upcoming birthday party. We all cried tears of joy to see him willingly scoop up gluten-free (GF) and dairy/casein-free birthday (CF) cake (and yes, GFCF cake tastes delicious)!

Dennis was discharged after only 12 sessions of treatment (4 days)! A few days later, his parents sent us pictures from his 3rd birthday party where he was happily eating his real birthday cake.

This success story did not come without extremely hard work by the parents. It was emotionally draining for them to see their child put up such a fight to avoid foods. It is not easy watching your baby vomit repeatedly at the sight of new/non-preferred foods. It is not easy hearing him cry repeatedly for an entire session. But they stuck with it. They stood their ground and they supported our treatment by not feeding him between meals and by requiring him to participate in therapy 3 times each day despite his tears. Congratulations on your success! The hard work paid off!

We would love to hear from readers. Have any of you worked with children who vomit? Parents, are any of your children vomiting to avoid foods? Parents, teachers, and behavior analysts, would you be able to stick with it like the parents and the therapists did?

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The Judge Rotenberg Center has come under fire in recent weeks. Apparently, The Center is literally at the center of a legal battle regarding alleged abuse and neglect to one of its clients. For more detailed information about the ongoing hearings, you may read here, here, here, and here. You may also watch these videos here, here, and here. You should know, this is not the first time The Center has come under fire (read here, here, and here).

At Issue

As best as we can tell, the case appears to be about medical malpractice with regards to treatment for a client. The client, Andre McCollins, was a resident at The Center for a period of time. According to various sources, he engaged in challenging behavior such as aggression, non-compliance, and disruption. According to the video and various sources, the client was restrained for several hours during which he was shocked 31 times. Apparently, the entire incident began because the client wouldn’t take off his coat.

Under Fire

In addition to the lawsuit against The Center, a number of individuals have come under fire. In particular are The Center medical doctor (Dr. James Riley), The Center Clinical Director, (Robert Von Heyn), and The Center Founder (Matthew Israel).

Client Rights

We will not pretend to be experts in the ethical requirements for physicians, despite a previous post on The Hippocratic Oath. We will, however, address client rights as it relates to ethical principles for Psychologists and Behavior Analysts. Dr. Von Heyn and Dr. Israel appear to be psychologists and/or Behavior Analysts.

As a psychologist, one of the general principles is Beneficence and Non-maleficence. Generally speaking, psychologists are to Do No Harm to their clients. It seems as if this general principle was overlooked when the client received 31 instances of electric shock.

As a behavior analyst, the behavior analyst should “recommend reinforcement rather than punishment whenever possible“.

Do Unto Others

Our philosophy in designing programs for individuals with behavioral challenges is to improve quality of life through effective intervention. We do that in a number of ways.

  1. First we modify antecedents to prevent challenging behavior from occurring in the first place.
  2. Then we identify replacement behaviors for the challenging behavior. This is often communication skills but it also includes teaching compliance.
  3. Finally, we reinforce new, appropriate behaviors and we stop reinforcing the problem behavior.

But most important of all, we recommend strategies that are humane. We ask that adults interact with and provide discipline in a respectful manner. We often use the old saying “Do unto others as you would have them do to you”. If you are in the middle of a tantrum, would you want your husband, wife, or teacher to put you in a restraint and yell at you? Probably not.

Please share your thoughts on the case at The JRC. How would you want your loved one to be disciplined?

We are linking up again this week with Erica over at Yeah Write. Please hop on over there to see all the other wonderful posts this week.

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

“Do you know of any behavior screening checklists that could be used to determine if further behavior services are warranted?”

Hi Carmen, and thanks for writing! This is an excellent question.

Is the Child Eligible or being considered for Special Education Services?

If the child is in public school, then we have to follow the Individual with Disabilities Education Improvement Act (IDEIA)  requirements and ask the question:

“is the child’s behavior impeding his learning or that of others?”

If the answer to this question is yes, then a comprehensive behavioral evaluation complete with recommendations is warranted.

Is the Child in a Private Placement?

If the child is in a private program and you are just trying to decide if behavioral services are needed, I like to use standardized measures to compare the child’s behavior to that of his/her same age peers. These assessments can also be done as part of a comprehensive behavioral evaluation. These assessments can include the Child Behavior Checklist (CBCL), the Social Skills Improvement Rating Scales (SSIS). This measure assesses social skills as well as behavior problems. Finally, The Behavior Assessment System for Children (BASC) is another good tool to consider. The assessment allows for input from teachers, parents, and the individual student.

You might also find this website helpful. http://www.txautism.net/docs/Guide/Evaluation/EmotionalBehavioral.pdf

Thanks for writing in! If you have a question about behavior, please email me at askmissy at applied behavioral strategies dot com.

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As Behavior Analysts, we can never overstate the importance of attending to antecedents. This is particularly true when we are assessing challenging behavior. Many times, teachers, parents, and behavior analysts can “miss” antecedents if constant observation of the child is not possible. In the cartoon below, a number of plausible antecedents could have occurred to which the child responded by throwing his food. Check it out, mull it over, and then use the comments section to voice your opinion. Of course, none of us will ever know the real antecedent except Jim Unger, the cartoonist responsible for such great creativity.

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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 “Jack”. Today’s post is slightly different from previous posts because it was written (and illustrated) by Jack’s 8-year-old sister. Please note that Jack and his mother participated in feeding therapy for a total of 5 days.

Before!

Oh no! Mom is trying to feed Jack mush, but Jack is crying, hitting, and pushing the spoon away!

Now!

Yay! Mom is turning on Wonder Pet Shows on the iPad and putting cookies and parsnips on his plate and Jack is feeding himself!

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Here at Applied Behavioral Strategies, our mission is to improve the quality of life through effective intervention. One way we hope to do that is by reviewing research articles for our readers. Today’s article is titled,”Six Developmental Trajectories Characterize Children With Autism”. Christine Fountain served as the lead author along with Alix S. Winter and Peter S. Bearman. The journal called Pediatrics published the study. The original paper is available online now, and will come out in paper in May, 2012.

This paper has received quite a bit of press lately so we thought that we could shed some light on the study for our readers. We want to point out that the National Institutes of Health (NIH) funded the study as part of their early career awards for new scientists.

Study Purpose

The authors noted that the purpose of the study was to “describe the typical longitudinal developmental trajectories of social and communication functioning in children with autism and to determine the correlates of these trajectories”. In reader terms that means that this is not an experimental study but rather a correlational study. The authors did not apply any treatments, they merely looked for patterns and relationships in existing data.

Study Methodology

The authors examined data from a group of children in California. They analyzed data from the age of diagnosis until the children turned 14. The California Department of Developmental Services (DDS) provided the data set to the authors. This is important because the data are most likely skewed as every parent does not necessarily register their child with the state. For example, parents who are living in the state illegally are not likely to register their children. Additionally, it is highly unlikely that wealthy families took the time to register their children (think Hollywood, movie stars, secrets). Finally, parents who are not connected to community resources, may not find out that such a service exists. Thus, we must look at this study as extremely limited in validity because the sample is biased from the start.

Study Sample

The authors analyzed data from 6, 975 children. The authors also noted if any of the children had a diagnosed intellectual disability. The diagnoses were all completed by California DDS psychologists.

The authors examined the birth records of the children paying attention to several factors:

  • maternal age at birth
  • maternal education
  • maternal race and ethnicity
  • place of birth
  • child’s gender and birth weight
  • and whether Medi-Cal (California’s Medicaid program) paid for the birth (a loose indicator of Socio-economic Status

 Measures

A somewhat standardized measure was used to identify the functioning level of the child. The measure was also completed the DDS staff an it was completed annually. The measure included several questions about social skills, several questions about communication skills, and several questions about adaptive behavior. These items were used to examine improvement or change over time.

It is important to note that the authors did not contact the children or their parents at any point in this study. Additionally, the authors did not attempt to document what types of intervention the children received to address the autism. This is incredibly important

because some interventions have been proven to have long-term effectiveness for children with autism. If children were receiving this intervention, the data in the study would be impacted. If you are interested in reading about the effective intervention, you can read this, or this, or even this.

Results

Children with autism do NOT bloom like flowers!The authors then ran some statistical analyses on the data set (scores from the measure that was completed approximately annually). The authors summarized their findings.

  1. Many of the children showed substantial improvement over time.
  2. Some children changed quickly and greatly while others remained “flat lined” or experienced little growth over time.
  3. Children who appeared to be “high functioning” at the beginning tended to improve more rapidly.
  4. The most rapid development occurred before age 6 (note: this is consistent with the original studies on ABA).
  5. The authors then identified a group of “bloomers” that started out fairly low at first but then improved at a rapid pace appearing similar to the higher functioning individuals
  6. The authors reported that the repetitive behaviors remained fairly stable over time across groups.
  7. Sadly, the lower functioning group tended to be non-white, Medi-Cal recipients, with mothers who were younger and foreign-born.
  8. And not surprisingly, the higher functioning group tended to be born to older, more educated, white mothers, and they were less likely to be a Medi-Cal recipient.

Important Points

This peer-reviewed published paper is an absolute joke. It is horrifying (and embarrassing) to think that a person with advanced training in research would publish a disgrace of a paper. The authors failed to consider the fact that these children were most likely receiving intervention paid for by DDS. The Center for Autism and Related Disorders has 12 offices in California and they regularly provide ABA services to children using funds from DDS. Why was this important point not mentioned?

Even more disgraceful is the fact that this study was funded by the NIH! Clearly, our tax-payer dollars are not being used to fund important research. Why did the authors ask important research questions like:

  • How much intervention were the bloomers receiving compared to the other groups?
  • What type of intervention if any were the children of non-white, low-income, and uneducated mothers receiving?
  • Does more intervention lead to better outcomes?

Sadly, the results of this lame “study” found themselves all over the media: here, here, and here just to name a few.

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We must help educate the public that ABA intervention works. Children do not outgrow autism and they do not magically “bloom” like spring flowers. Their growth is the result of hard-working parents, teachers, and therapists. Please get the facts straight.

Of course, if you have a topic that you would like for us to review, please let us know by posting in the comments below or you may always reach us at info at applied behavioral strategies dot com

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It occurred to us one day not too long ago, that parents are turning to the internet when they need help with something. This can include searching for help on getting pregnant, cooking delicious low-fat meals, training pets to stop barking, and many other things.

Then it hit us! People may be searching for help when their child won’t eat! We have been posting success stories from our clinical practice regularly in our “What Works Wednesday” posts. Several  of those posts include success stories from our behavioral feeding therapy. For example:

  1. We had the little girl who only ate Sonic grilled cheese sandwiches (we recently had a little boy that only ate Sonic grilled cheese too! Maybe they should meet up!)
  2. We described a little boy who would only eat bacon and rice waffles.
  3. We introduced you to our hardest clinical case, a little girl who would only eat peanut butter, pretzels, and jalapeno chips.
  4. We helped an adolescent boy who had suffered from 9+ years of picky eating.
  5. We shared the success of our first intensive case.

Clearly, behavioral feeding therapy works!

For those of you who stumbled across our site because your child won’t eat and you need help, you’ve come to the right place! Help is available for you and your child. You just need to know how to find it. In order to find help, you need to know what you are looking for. For starters, why is your child having difficulty with feeding?

  • Was he born prematurely and everything has been hard?
  • Does your child have gastrointestinal issues (e.g., having trouble with bowel movements or having too many)?
  • Does your child have a feeding tube or did he have one in the past?
  • Does she have an identified disability that may be contributing to the problem (e.g., Down syndrome, Cerebral Palsy)?
  • Has your child ever been treated for reflux?
  • Does you child have a structural problem such as a cleft lip or swallowing difficulty?
  • Is your child allergic to certain foods?
  • Does your child have preferences for certain brands, colors (or lack thereof), or textures?
  • Is your child on the white diet (chicken, french fries, and chips)?

Assess First

If you are here looking for help, chances are, your child needs an assessment. Any good feeding program will complete an assessment prior to starting therapy. The assessment should be multi-pronged in that underlying medical issues should be diagnosed, potential mechanical problems (e.g., swallowing or chewing) should be pinpointed, and any nutritional deficiencies should be identified. In addition to those areas, a good behavioral assessment is also warranted. While your child could have developed a feeding problem because of an underlying medical or mechanical issue, he or she may have learned to control mealtimes.

Is Feeding Therapy Warranted?

If you learn from the assessments that your child is medically, mechanically, and nutritionally OK, you may not need a treatment program. We generally say that if a child is eating 30 or more foods, that the problem is minor and can most likely be addressed with due diligence. We will post some helpful steps that you can do to help if you believe that your child’s case is minor.

If your child has limited himself to fewer than 30 total foods, or she has limited herself to only one type of texture (e.g., puree only or liquid only or crunchy only), if your child engages in inappropriate mealtime behavior such as aggression, self-injury, or disruption, or if your child is really behind on the height and/or weight chart compared to other children in the same culture, a feeding program may be needed.

Treatment Planning

Once a comprehensive assessment has been completed, and it has been determined that feeding therapy is necessary, it will be important to develop a treatment plan. Depending on the results of the assessment, your child may need regular and on-going therapy to learn to chew. She may need medication to treat inflammation in the GI tract. He may need to go on a special diet due to a food allergy. The results of the assessment(s) will drive the treatment.

Parent, Family, and School Involvement

A good feeding program will work collaboratively with the parents, other family members, and school personnel as needed. Feeding does not occur in a bubble but in many environments. Thus, everyone who interacts with your child during mealtimes should be involved in the therapy program.

Data Driven Program with Results

Finally, any quality program will have data documenting the effectiveness of their treatment. This may be limited to the success of your own child but it may also include success rates of graduates of their program. Do not be too shy to ask for this information. Embarking on a journey of feeding therapy is stressful, time-consuming, and expensive in many cases.

Of course, we would love it if you come to us for help. We offer a variety of feeding services including direct therapy with you and your child in the comfort of your home. Please check out our website for additional information about our services. You may also email us for information. Info at applied behavioral strategies dot com.

We wish you luck in helping your child eat. We know first-hand how stressful it can be.

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