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Archive for August, 2012

 

We recognize that many of our readers have already started school. However, up here in the East Coast, school starts today for some children, later this week for others, and next week for the remaining students. This has resulted in a great deal of anxiety among parents, students, and teachers. While no specific question came in on this topic, our emails have been flooded with back to school woes from:

  • my child is starting a new school after 7 years with the same teacher
  • my child is starting a new private school
  • my child is leaving special education and moving to general education
  • my child was separated from her two best friends
  • my child is with a teacher who is not trained in special education

The list goes on and on!

We have a few tips for you to get through this week.

  1. Take one step at a time.

    Just like everything else we do for our students, we must approach the first day of school in baby steps. We cannot do it all on the first day so prioritize and worry about the most important things first.

  2. Planning is effective.

    In order to know what is most important, make a plan. For one of our clients, we planned to meet with and train school staff so they would know what to expect from him and from us. For another, we planned to make visits to the new school to ensure a smooth transition. For yet another, we scheduled play dates over the summer with new students in the class to assist with friendship development. Planning will help everyone feel more prepared and less stressed.

  3. Visual supports help everyone.

    We have written about visual supports before: here, here, and here.

  4. Reinforce often.

    Yes, we know that we suggest the use of reinforcement but everyone benefits. Reinforce your child for engaging in appropriate behaviors. Reinforce the teachers for their hard work. And don’t forget to reinforce yourself! Can you say wine, pedicures, manicures, massages? Oh and let’s not forget the Dads! football games, baseball games, golf, beer!

  5. Don’t beat yourself up.

    Finally, we all make mistakes. None of us are perfect. The new school, the new teacher, the new behavior therapist….none of them will be perfect. So don’t beat yourself up if something goes wrong or if something does not go as planned. Usually in these situations, you will have another opportunity to get it right.
    Readers, weigh in! Do you have advice for the “back to school blues”?

 

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How did Friday get here so quickly? School starts back for us next week so we are going to try to squeeze every last minute of fun time with our families. In wrapping up our description of a week-long feeding therapy “boot camp”, we thought this cartoon would be perfect! Thanks to Rick Detorie for the wonderful One Big Happy humor.

Readers, what strategies have you tried to distract your children while eating?

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Technically, Jackson met our requirements for graduation at breakfast on the 4th day. He successfully ate breakfast with his mom and his brother and he engaged in almost no challenging behavior. However, before we discharge, we like to make sure that our clients can generalize their behaviors to school or to a community restaurant (or both!). So, we used Friday to work on generalization.

Pretzel’s at the Mall

Kendall told us that one of the most difficult times had been when they went to the mall and Jackson tried to get pretzels. Since starting the gluten-free diet, he would not be able to eat those pretzels and she worried that he would have a tantrum if she told him no. So, we agreed to meet her at the mall to work on an intervention.

Jackson walked right past the pretzels to meet us in the middle of the mall. However, when we arrived, he took off walking. He was a man on a mission! He went straight for the pretzels. We told him “no pretzels today, we are going to eat lunch”. He grabbed his communication device and typed out “PRETZEL”. We affirmed his request and simply restated that we would not be having a pretzel but instead we would go to lunch and he could eat pizza (we had already selected a gluten-free pizza place). We showed him the picture of a pizza.

Jackson took off walking through the mall. He had one things on his mind: Pretzels! After circling the mall and arriving at the pretzels again, he walked over to the display and pointed. We reminded him again that we would not be having pretzel and that we were going to lunch. With that, he decided it was time to leave and he proceeded to his car.

Well that seemed a little too easy.

Planet Pizza

 

When we arrived at Planet Pizza, the manager was restocking the chips. Yes, you remembered correctly. Jackson has a thing for Lay’s potato chips. He was super excited! He went over, picked up a bag of chips and appeared happy as a clam. We reminded him that he was here for pizza and not for chips. We asked him to put the chips back. At first he was reluctant but we remained firm. Please put the chips away, we are going to eat pizza. Jackson put the chips away and we asked him to pick out a drink.

Prior to starting feeding therapy, Jackson only drank water. He drank water out of a faucet and out of the Long Island Sound. Wherever he could find water, Jackson drank it! We told him, “No water today, pick something else.” He told us no but we held up two types of juice and he picked one.

Then we escorted him to find a table while the pizza cooked.

  1. Note: Kendall brought her own dairy free cheese and the staff cooked the gluten-free crust with the special cheese.
  2. Note: Bring things to do in restaurants while you wait!

While we are great at helping kids in the community, we have so much knowledge and training that we have a hard time remembering to teach the parents all that we know. We forgot to prep Kendall for the things that Jackson would need to keep himself busy. Luckily, we had iPhones so he tried to watch YouTube while waiting.

Jackson made a few noises during his wait. Unfortunately, restaurant patrons stared at us. The staring makes all parents uncomfortable. We let Kendall know that bringing Jackson out actually helps to educate others. Plus, Jackson has every right to be there too!

Success

The pizza arrived after only a 15-minute wait but then we had to wait for it to cool. Finally, Jackson could try pizza for the first time in many, many years. He loved it! He didn’t mind the spinach or the broccoli. He even picked up his fork and stabbed a few pieces on his own. He ate the entire piece that Kendall had prepared for him. He did this without aggression and without any expels!

Jackson still has some skills to work on:

  • cutting his own food
  • stabbing his own food using the fork
  • scooping his own food with a spoon
  • learning to wait quietly at restaurants
  • wiping his mouth with a napkin without reminders

However, he has come a tremendous distance in only 5 short days. Congratulations Kendall on all of your hard work. Jackson is a champion eater and you are a champion mom!

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Needless to say, Rebecca and I were running on fumes at this point in our week. We started the day hoping that 3 of 5 clients would graduate if all goes well. Because of his great success, Jackson was scheduled for only 2 meals: Breakfast with his brother and dinner with his father watching.

Breakfast with Brother

For breakfast, Kendall brought bananas, yogurt (coconut milk), gluten-free hot cereal, and raspberries. Jackson engaged in quite a few behaviors today which is common each time we change the conditions. He engaged in 20 verbal/vocal refusals, 6 physical refusals, and he cried two times. His brother, on the other hand, gagged a few times and had to leave the room several times. Hmmmm, maybe we should enroll another client in feeding therapy!

Dinner with Dad

Jackson was ready to show off his mad skills to his dad. Kendall brought sauerkraut and wieners, quinoa, beets, pears, and dried cranberries. What a champion! Jackson ate everything and he had only 2 gags! (beets would make us gag as well!) Throughout the meal, Jackson engaged in only 5 instances of verbal/vocal refusal. Dad was floored! He could not believe how much progress his son had made in just 4 days.

We also taught Jackson how to eat potato chips without making a mess. In the past, he ate them like a wood chipper with chip crumbs flying around. We taught him how to place the entire chip in his mouth without making crumbs.

Be sure to tune in tomorrow to see how Jackson handles going to the mall when he cannot eat his favorite Auntie Annie pretzels!

 

 

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Feeding therapy has been going great. So well, in fact, that one of our clients has transitioned to eating at home with his mom! Two other clients are eating with their moms at the clinic. Jackson is one of those two!

Kendal came in bragging about the standoff she had with Jackson the night before. When asked who won, she replied, “me, of course!”

Breakfast Day 2

Jackson started the day by generalizing his eating skills to a new therapist. Jackson ate gluten-free waffles, bacon, blueberries, and hash browns. He also started working on cutting his food. He consumed a total of 36 bites.

He engaged in only 21 verbal or vocal behaviors and only 1 attempt to elope.

Lunch Day 3

At lunch, we transitioned Kendall in to the driver’s seat. She supervised Jackson as he ate tuna sandwich on gluten-free bread, apple slices, and salad with dressing. His sitter, Chardonnay, made humus and he ate that with cucumbers and corn chips.

During lunch, Jackson realized that his mom was “in on it”. He cried for the first time. In fact, he cried 26 times. He laid on the floor and he refused to eat for 3 minutes. He also engaged in verbal/vocal refusal a total of 26 times. But, he continued to eat. He ate a total of 53 bites of food with only 1 gag and 4 expels.

At one point, Jackson reached out to grab his mom and she showed him her open palm indicating that he could push his chin on her hand for deep pressure. He pushed his chin into her hand over and over. He leaned back up in his chair and was ready to eat again. Kendall looked around at her fan club (therapists, interns, and sitters) with tears in her eyes. Then she said beneath her tears of joy, “In the past he would have attacked me.”

Dinner Day 3

Kendal and Jackson came back for dinner with baked ham and pineapple, baked sweet potato, raisins, and green beans. In this meal, he didn’t cry, not even once. Instead, we saw the opposite. Jackson was happy and laughing and felling wonderful. He ate a total of 58 bites. He engaged in 10 verbal and vocal behaviors and he pressed on his eyes a few times. He did not try to elope and he did not gag at all. He tried to expel just one bite. He started engaging in some eye pressing but we coached Kendall how to interrupt the behavior without calling attention to it.

As if all this learning was not enough, Jackson learned how to drink from a straw! A few years ago, he knew how to drink from a straw but he lost the skill. Using coconut milk, a newly acquired beverage, Jackson quickly re-mastered it!

Day 3 was a continued success. Check back tomorrow to see how Jackson handles eating with his brother, going to the mall, eating at a restaurant, and having Dad observe.

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The feeding clinic was busier than we had expected (or perhaps we were too ambitious to think we could post every day). So, we will post Jackson’s daily progress each day this week.

For starters, we could not believe all of the progress that our clients made in the first 2 days. By the end of day 2, three children were eating well! One child was having severe withdrawals from his gluten and dairy. If you have not heard of this (his physicians had not either), you can read more about what another little girl went through as she came off her addicting Sonic Grilled Cheese here. The other little boy who is still struggling to eat has a combination of physiological (he has oral motor delays) and non-physiological feeding difficulties (behavioral issues around food preferences for flavor and texture).

Changing Reinforcers

Meanwhile, we tried to move Jackson from fluff to a different, more natural reinforcer. Jackson loves Lay’s potato chips so we tried to see if he would eat new foods in exchange for a few chips. Again, Kendall had to keep Jackson from having chips during other times of the day and this is not an easy task but she was a champ and she made it happen.

Breakfast Day 2

Jackson had gluten-free pancakes, sausage, strawberries, and grilled tomatoes for breakfast. He consumed a total of 30 bites. After the 8th bite, we began requiring Jackson to eat 2 bites before he could get his reinforcer. As his food acceptance and consumption increased, his behaviors decreased. He expelled only 4 bites, he tried to elope only twice, and he had only 12 instances of aggression towards Missy. Jackson engaged in 9 instances of verbal and vocal refusal and he engaged in 8 instances of physical refusal. How many adolescents do you know who will eat grilled tomato for breakfast? What a champ!

Lunch Day 2

Lunch on the second day of therapy included coconut milk yogurt with gluten-free granola, ham sandwich with gluten-free bread, oranges, and gluten-free cookies for dessert. Jackson consumed another 30 bites during lunch. He expelled food on 9 times but he did not elope at all. He stood up once as if to elope but he sat down when Missy asked. Jackson had 2 gags during lunch and both were with oranges. Fruit has proven to be hard for him. This is probably due to its wet texture. Jackson has dyspraxia so he obviously has some oral motor issues as well. He is learning to chew and keep his lips closed but this will take continued practice.

Jackson engaged in 20 instances of verbal and vocal refusal and 12 instances of physical refusal (e.g., turning his head or pushing the spoon). Jackson started a new behavior of bouncing up and down in his seat. It was unclear to us if this was a new avoidant behavior or if he was happy about learning to eat these new foods. He engaged in this behavior 22 times.

Dinner Day 2

For dinner on the second day of therapy, Jackson ate cooked carrots, white rice, chicken, and grapes. He ate 3/4 of an entire chicken breast, a portion of rice, and several carrots. After dinner, Jackson ate a gluten-free cupcake with dairy free icing. In the past, he only wanted to lick the icing so Kendall wanted him to learn to eat the cupcake and icing together. He ate about 1/2 of the dessert.

Jackson’s behaviors improved dramatically for this least meal of the day. He engaged in only 1 vocal refusal. He stood up 3 times (but he sat down when asked). He tried to take Missy’s gloves off once (as if to finish the meal). Jackson gagged only once during this meal (over the carrot). After the first 8 bites, we moved Jackson to a fixed ratio schedule meaning that he had to eat 3 bites of new food before he could have a chip.

Jackson’s sitter, Chardonnay learned to help with data collection during this session (thanks for the help–any chance you want a job?!?!). Meanwhile, Kendall will learn to implement the intervention tomorrow. Stay tuned to see how Jackson progresses!

 

 

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We have completed the first day of our intensive feeding clinic. Needless to say, teaching 5 children to eat over the course of the day adds up to 15 meals in the day. Between two people, it is exhausting. All we can say is “Thank Goodness for staff who are there to assist!”

Thanks!

Thanks to Dr. Tom Zwicker and The Eastern Seals for hosting the clinic.

Thanks to Yolanda, Applied Behavioral Strategies Office Manager,  for bringing us lunch.

Thanks to Maria, Applied Behavioral Strategies intern for taking data.

Thanks to Laura for videotaping, assisting with data collection, serving as a generalization therapist, and for all around good emotional support.

Thanks to the parents for having faith in us to help your children. And thank you Kendal for bringing the strawberry fluff!

Focus on Jackson

As much as we would love to share the stories of all of our clients, we are going to focus on one client for the entire week. We are going to introduce you to Jackson and his mother Kendal.

Jackson is an adolescent male with autism. Jackson is about 5’9″ and weighs about 120 lbs. He towers over Missy and he is eye-to-eye with Rebecca.

Jackson is mostly non-verbal and he has only a handful of words and word approximations in his vocabulary. Let’s get this clear, the boy can say “NO!” as plain as day! Jackson can also type and spell and he has a fairly large and accurate written vocabulary.

Jackson: Breakfast

Jackson greeted Missy with his upbeat “NO!” and he used that word for everything including following simple instructions such as “sit down” and “it’s time to eat.”

When they entered the therapy room, Jackson continued his cordial behaviors by grabbing Missy by the hair on her head (what little she has). He also attempted to shove her so that he could escape the room. You should see Missy hold her own against someone bigger than her!

It’s All About Reinforcement!

Then, Kendal whipped out the strawberry flavored fluff. Instantly, Jackson sat down and indicated his interest in this new activity. (note: parents know their children! Kendal knew that Jackson would work for Fluff–and he can almost say “fluff”).

Jackson was not happy about this new arrangement. He was not interested in eggs, Gluten Free toast, breakfast potatoes, or watermelon. He tried to pack up his mother’s things to GET OUT! He turned off the iPad. He turned off his communication device. He wanted no part of this—until the fluff. Missy told him, “Want fluff? Then eat. First egg, then fluff”. Jackson thought about it. He had not had fluff in quite a while thanks to Kendal’s determination to help her child. HE WANTED THE FLUFF! So, he accepted the egg. In it went, out it came. He accepted the egg again, and again. Finally, he chewed it and swallowed it. SUCCESS! Then Jackson savored his fluff.

Missy repeated this with each of the remaining foods. First take a bite, then fluff. In behavior analysis, we call this DRA or differential reinforcement of an alternative behavior. The alternative behavior is eating (instead of food refusal). This is also contingent reinforcement. When Jackson eats, he receives the preferred item instantly.

During breakfast, Jackson grabbed Missy’s hair multiple times (10-15 is the best guess without looking at the data sheet). He also attempted to elope multiple times. But the biggest success is that Jackson ate new and healthy foods for the first time in many years!

Jackson: Lunch

Jackson did not want to come back for lunch. He typed on a phone notepad: car, lays potato chips, fluff. Jackson knows what he wants! And given his size and challenging behaviors, he often gets it.

For lunch, Missy used the same intervention. Jackson at a turkey sandwich. His first sandwich EVER! This time, Missy started increasing the demands. She expected Jackson to eat two bites before receiving fluff. Within this same session, she was able to get Jackson to eat three bites of new foods before eating fluff.

During lunch, Jackson grabbed Missy’s hair less and he attempted to escape less.

Jackson: Dinner

Jackson ate a hamburger, broccoli, mashed potatoes, and cantaloupe for dinner and he drank coconut milk! Missy continued to increase the expectations and she decreased the size of the fluff bites.

During dinner, Jackson grabbed Missy’s hair only once and he did not attempt to elope until the end of the meal.

What an amazing first day of therapy for Jackson! Check back tomorrow to see how Jackson responds to Day 2 of intensive feeding therapy.

 

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