Try It, You’ll Like It!

Hi and welcome to What Works Wednesdays where the focus is usually the description of a successful case story. Today’s story actually comes from a popular video. In this video, the photographers captured the faces of several young children as they tried new food for the first time. Matt Gilmour, the creative director and Hugh Miller, the cinematographer, capture the children’s reactions in 500 frames per second.

As a BCBA who has helped many, many children learn to eat new foods, I cannot help but recognize that the children in this video are not scared. The children in the video are willingly trying new food. Sadly, for children who have autism, trying new foods does not look like this. Trying new foods can result in aggressive behaviors, self-injurious behaviors, even vomiting!

However, after effective behavioral feeding therapy, children with autism can learn to try [and like] new foods. If you have a child who engages in picky eating, reach out for assistance from a behavioral feeding program; mealtime does not have to be stressful.

Related Articles

• Laura’s Story (Kennedy Krieger Pediatric Feeding Disorders Program)
• The A Word, Part 39: Feeding (Center for Autism and Related Disorders Blog)
• Eczema and Milk (Applied Behavioral Strategies Blog)
• Day 1 of Feeding Therapy (Applied Behavioral Strategies Blog)

 

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Parent-Professional Collaboration Maximizes Child Outcomes

Parents and professionals working together

Hi and Welcome to What Works Wednesday! where the focus is usually the description of a successful case story. The general public is slowly beginning to learn and appreciate the fact ABA works. However, in an ongoing comprehensive ABA program for individuals, more than just good ABA is required. Parent and professional collaboration is an essential ingredient. In ABA teams at Applied Behavioral Strategies, the BCBAs work to ensure that every case has 4 hours of parent-professional contact at a minimum each month. Collaboration occurs in a variety of contexts.

Team Meetings

In a comprehensive program, it is important for the team to meet frequently to guarantee that the team is implementing programs correctly and that programs are modified so that the child will continue to make progress. In most cases, the team meets twice per month for 2 hours. The first order of business at every meeting: parent concerns. The team includes all therapists, the supervisor (BCBA), the parents, and other outside professionals.

Clinic/Team Meeting Notes

During the team meetings, detailed notes are taken so that team members may review them before therapy. Everyone receives a copy of the notes, including the parents. The notes are also placed in the child’s program book so they are handy for team members.

Communication Logs

In cases where the child receives therapy in a setting where the parent is not present, therapists and supervisors keep a detailed communication log that is sent home with the child each day. These logs keep the parents informed about the child’s day and serves as another way to build cohesive team communication.

Phone Consultation

Supervisors at Applied Behavioral Strategies make themselves available by phone. Supervisors are extremely busy but a great time to return calls is between appointments when driving from place to place (don’t forget to use your headset!). Parents, if you need to speak to your supervisor, let him/her know so that time can be made for the call.

Emails

Finally, email is another way to remain in close contact with parents. Emails can be returned at any time of day; especially when talking by phone is not possible. Emails also provide a written record of your requests and decision making.

In summary, professionals be diligent to ensure parent-professional collaboration. Parents, do not be timid. Partner with your BCBA and team to help propel your child’s progress to its maximum potential.

Related articles

• Show Me The Data! – or not (appliedbehavioralstrategies.wordpress.com)
• The Very Busy BCBA(appliedbehavioralstrategies.wordpress.com)

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Abercrombie and Fitch: I’m Done!

Hi! and welcome to What Works Wednesdays where a success story from clinical files is shared. Sadly, today is going to be an example of what does not work.

On Cyber Monday, I took advantage of the sale and bought my bonus daughter a few items from Abercrombie Kids. They arrived, she tried them on and two items needed to be exchanged. To complete the exchange, I went to the Abercrombie website. The bonus daughter was super excited to learn how to exchange items so she watched eagerly over my shoulder. And then we both see this:

The bonus daughter says, “Why are her hands in his pants?”

And that folks, is how advertising does not work. Sex will not sell clothes to me or my family.

We will not buy any more clothes from this store.

And if this picture is not enough, here is another picture from the home page. Because if having her hands down his pants is not enough, let’s introduce our children to ménage à trois.

Apparently, this little advertising trick is working. The company’s stock is soaring. People are buying.

Please join me in sending Abercrombie a message that this type of advertising is not appropriate for our children. My family will not be buying clothes from this company until they change their practices.

 

Related articles

• Abercrombie & Fitch making a comeback as stock surges 30% (buzz.money.cnn.com)
• Abercrombie & Fitch – Strong Quarter Gives Investors An Opportunity To Take Profits (seekingalpha.com)
• Abercrombie & Fitch CEO’s Insane Rules for His Private Flight Crew Include What Kind of Underwear They Should Wear (fashionista.com)

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Beating Classroom Behavior Blues

Ginger rated her behavior during carpet time

Hi! and welcome to What Works Wednesdays where a success story from clinical files is shared. Today’s story is about a little girl named Ginger who happens to be a typically developing 3rd grade. Ginger’s teacher contacted Applied Behavioral Strategies to assist her with Ginger’s behavior because Ginger had difficulty paying attention during morning meeting, sitting quietly during group instruction, and staying on task during independent seat work.

Record Review

A review of Ginger’s academic records indicated that she was performing at grade level in all areas. While she had some struggles learning to read, with focused intervention, she has remained on a 3rd grade reading level. Ginger is also very active and has difficulty keeping her hands, arms, and legs still. Finally, Ginger is highly distractable. Her focus is disrupted by butterflies, peers walking by, and particles on the floor.

Ginger’s teacher felt overwhelmed because she had tried verbal reminders, notes home to parents, and seating arrangements. She felt that none of these strategies worked effectively.

Student Interview

The behavior analyst asked Ginger why she had difficulty sitting quietly, completing her seat work, and listening to teacher instruction. She responded that, “I try to sit still and listen but my friend talks to me” and “I try to do my work but I have to sharpen my pencil” and “I sit away from my friend but she comes to sit next to me”.

ABC Observation and Analysis

Direct observation revealed that a variety of consequences followed these target behaviors. Sometimes Ginger received a verbal warning, sometimes the class received a reminder, and some times, no consequence occurred at all.

Self-Management

The behavior analyst needed more time to complete the assessment

so she developed a brief self-monitoring plan for Ginger to use until the assessment and behavior intervention plan could be completed. The self-monitoring plan consisted of Ginger evaluating her own behavior following each instructional activity. Her teacher reviewed the evaluation and confirmed if the evaluation matched reality. Ginger received praise and positive feedback for desired behaviors and her parents provided additional positive attention each day when Ginger shared her rating at home.

Additional Tips

The form was printed and put onto Ginger’s favorite color of construction paper. Then it was laminated so that one side showed the seat work and the other side showed the carpet time. Using a dry erase marker, Ginger could self-rate each day and then the chart could be wiped clean for the next day.

Ginger rated her behavior during seat work

Success

After 2 weeks, the assessment had to be put on hold because Ginger’s behavior improved. As with any student, Ginger continues to have difficulty when substitute teachers are present. However, this simple intervention worked to focus on Ginger’s strengths by reinforcing desirable behaviors.

Readers, have any of you tried self-management? What worked? Parents, have any of your children been placed on self-management plans? Did you like it? Did your child?

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Reading Research

Hi! and welcome to What Works Wednesdays where historically a success story from clinical files is shared. With all the buzz about the latest “research” on getting the flu while pregnant and the supposed link to autism, it seems logical to help readers better understand research so they can interpret findings themselves. If readers know how to read research, then they are better able to know if an intervention works (or if the conclusions from a study are flawed or misinterpreted).

What is Research?

• “work undertaken systematically to increase the stock of knowledge” (Wikipedia.org)
• “diligent and systematic inquiry or investigation into a subject in order to discover or revise facts, theories, applications, etc.” (dictionary.com)

Most scientists conduct research by utilizing the scientific method. The scientific method requires the development of a hypothesis (which is usually formed from observation or reading other research), conducting the experiment, gathering results, and determining if the results support the original hypothesis.

Different Types of Research

Using the scientific method, scientists design different types of studies. These study types include:

1. Experiments. In experimental studies, researchers recruit participants and assign them to treatment groups. Researchers can study one or more treatments and participants may receive some treatments or they may receive a placebo or no treatment at all. Usually, researchers measure one or more important variables before the study and they measure the variable(s) again after the study.
2. Single Subject Experimental Studies. In these studies (most often conducted by behavior analysts), researchers recruit participants who are observed and measured carefully for a period of time before receiving treatment. Researchers then implement treatment while continuing to observe and measure carefully.
3. Correlational studies. In these studies, researchers use existing data sets (e.g., collected for some other purpose) or they recruit participants. Researchers gather a wide range of information on each participant (e.g., age, SES, education, health history). Participants do not generally receive treatments or interventions of any kind.
4. Qualitative studies. In qualitative studies, researchers occasional recruit participants but at times they enroll participants with whom they are already familiar. In qualitative studies, researchers study one or more individuals or one or more groups (e.g., one class). Researchers carefully study the participant and take copious notes. Researchers may interview the participants and they may use focus groups to better understand some of the issues. If a treatment is provided, the researcher continues to carefully study the participants to document the participants’ responses to the treatment.

Conclusions Based on Study Type

Researchers must use caution when drawing conclusions about their studies. Researchers who use well-designed experimental designs can draw cause-effect conclusions. For example, a researcher can enroll a bunch of smokers in a study. Some of the smokers receive a behavioral treatment, some of the smokers receive nicotine patches, and other participants receive both. At the end of the study (if the researchers have conducted the study carefully), the researchers will be able to say that one or more methods is successful at helping smokers quit.

Similarly, in a single subject experimental study, researchers can demonstrate if a treatment changes behavior. Again, the study must be carefully designed and conducted but it is possible to draw cause-effect conclusions. For example, a researcher could study 3 smokers. The researcher would observe the smokers and collect data. One smoker could receive treatment. While she is being studied, the other smokers would still be studied. After the first smoker quits successfully, the next smoker would receive treatment. He would continue to be studied as would the non-treated smoker. Finally, when the last smoker receives treatment, researchers continue to observe him. If the researchers successfully help all 3 participants quit smoking (and the study is carefully designed and carried out), they will be able to say that the treatment caused the behavior change.

Correlational versus Causal

Correlational studies are designed to determine if any relationships exist between variables. Researchers could gather data on 1,000 people from an existing data base. They could sort the data into smokers and non-smokers. They could run a simple data analysis to see if smokers have other tendencies (e.g., like to go to race car events, like to drink socially, and so forth). Researchers may not conclude causal relationships from their studies. They are only able to conclude that a relationship exists. Of more importance is the strength of the relationship. For example, if researchers ran an analysis on the relationship between giving birth to a child and gender, they would find a very strong (almost perfect) relationship between giving birth and being a female. If a weak relationship exists between variables it is more likely due to chance.

Go Forth and Read

In these days of social media, spin rooms, and media crazed talk shows, very poorly designed studies are being presented to the public without appropriate interpretation of the study or its results. If you are interested in reading a few examples of this, check previous posts here and here.

In summary, don’t believe everything you read about the “latest scientific study” unless you read the study itself. When you read the actual study, what you find may actually surprise you.

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Office of the HealthCare Advocate

Hi! and welcome to What Works Wednesdays where we share a success story from our clinical files. We usually focus on the use of ABA and its effectiveness for our clients. Today, we are going to share a resource that works. The resource is the Office of the Health Care Advocate (OHA). We have one in Connecticut. Here is the website: http://www.ct.gov/oha/site/default.asp

Here is the contact information:

Mail To:
Office of the Healthcare Advocate
P.O.BOX 1543
Hartford CT,06144

Phone: Toll Free at: 1-866-HMO-4446

FAX:  (860) 297-3992

E-mail: Healthcare.advocate@ct.gov

On October 17th, the OHA held a public hearing on barriers to access to mental health and substance use services. I (Missy) went to testify. Here is my testimony:

Introduction

Hi and thank you for taking the time to listen to consumers, providers, and advocates. I am here today as a behavioral health provider. I am a Board Certified Behavior Analyst and my company, Applied Behavioral Strategies, LLC provides Applied Behavior Analysis (ABA) therapy services to children with autism under Public Act No. 09-115.

Autism Insurance Bill

Under Public Act No. 09-115, children under the age of 15 are eligible to receive ABA therapy if their parents have certain types of health insurance.

Success!

While I have only been in business 2 years, you will be pleased to know that all of the children on my caseload who receive services through mandated insurance coverage have made growth as a result of ABA therapy. For example:

• “Matthew”
  • Learning to go on community outings without screaming when dogs pass
  • Learning to take a shower independently
  • Learning to shave
• Casper
  • Used to request to avoid many school classes (specials), now participates in all instruction and specials
  • Before our therapy, he had no friends.  Now he has friends and makes play dates
  • Historically engaged in aggression with his parents and siblings, we haven’t seen aggression in many months
• “Joanna”
  • After living off pureed food for 8 years, she learned to eat table food!
  • She is learning to wear different shoes, hats, gloves
• “Sammy”
  • Learned to sit and relax by playing games on his iPad or watching music videos
  • Decreased self-injurious behaviors
  • Improving his spontaneous communication
• “Charlie”
  • Decreased head banging
  • Learning to tolerate work at home
  • Learning to ride in the car without thrashing his head when his parents go a different route
• “Clark”
  • After being restrained repeatedly in his public school, Clark attends a private school with support and only a few outbursts
  • In the past, cried because he didn’t want to do school work, now gets upset if he cannot finish his work

The “Unlucky” Ones

Those case studies illustrate how state policies improve the quality of lives for individuals with behavioral health challenges. But unfortunately, a group of clients exist who are not eligible for these services because they don’t have the right type of insurance, or their insurance originates from a different state, or even worse, they are too financially disadvantaged to have insurance and are covered by Husky.

It is for these clients, I am begging for your ear. These clients and their families will never share joys described to you previously because they will not receive the ABA therapy. They cannot afford to pay for it out of pocket so they do without.  Even as I write this, it feels like I’m writing about a different century or a third world country. How can this be? These clients and their families have just as many needs, if not more, than the clients who are receiving therapy. But as a result of not receiving therapy, their behavioral health needs worsen which only serves to exacerbate the mental health needs of their parents. And all of this costs more in the long run.

Provider Issues

But even worse than not having the appropriate insurance, are the clients who have the right insurance but cannot find a provider because there are not enough providers who accept insurance. Let me tell you why providers do not accept insurance:

• The reimbursement rates are drastically reduced from fair market value
  • My highest rate of reimbursement is still 50% less than my billable rate
  • The insurance companies do not reimburse for services in a timely manner
    • Cigna currently owes me $18,000 on ONE client
    • The stress I experience at each payroll period is overwhelming because I am not sure if my cash flow is sufficient to pay my employees
    • The amount of administrative time that is needed to follow-up with insurance in order to get paid is almost a full-time position

• The reimbursement for services does not cover my income and that of an administrative assistant (see rates above).

Amazing Resource

The Office of the Healthcare Advocate has been extremely helpful for me and my clients as staff (Vicki and Jody) have assisted my clients (and many others that are not my clients) in obtaining the coverage to which they are entitled. I am extremely grateful for their assistance over the past two years.

Summary

In closing, I feel fortunate that ABA services are available to children in this state. Thirty years ago, these services were not available to my brother. I cannot help but wonder where he would be today, had he received the services that my clients receive today.

Thank you for taking the time to listen to us today and please do not hesitate to contact me if you have questions regarding this testimony.

If you want to watch the entire hearing, you can do so here:

If you live in CT, be sure to use your OHA. If you do not live in CT, check your state’s resources to see if you have an OHA in your state.

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Early Morning School Routines

Hi! and welcome to What Works Wednesdays where we share a success story from our clinical files. Today’s success story is personal.

If you are a parent, step-parent, nanny, or in-home behavior support person, you know full-well, how difficult the early morning routine can be. I (Missy) have always been an early morning person. Back before I acquired my new status (Bonus Mom), I often arose before 5am to get in my workout before showering and heading to a local coffee shop to write. Oh those were the days……..Oh, sorry! I lost track of my purpose. I started dreaming of Austin and those stress-free mornings.

Now it’s all different. I often wake as early as 5am so that I can write, answer emails, bill for services, grade quizzes for class, and a host of other morning duties. That is all done before the kids get up. We let the kids sleep until they wake up naturally. There are advantages of this (less crabby) and disadvantages (crazy mornings). However, we follow a few simple steps to make sure that our mornings are successful regardless of the waking hour.

Start the Night Before

Yes, I know that after school is just as hectic as before school. However, if you take a few steps the night before, stress the next day is eliminated.

 Lay Out Clothes

Have the kids pick out the clothes for the next day before they go to sleep. This prevents tantrums over what to wear and dilly dallying about finding matching outfits. We require this step to be completed before the kids have night time television. If the clothes are new (or from last year), consider having the child try the clothes on to ensure a proper fit.

Identify breakfast foods

Yes, we plan ahead. We have learned that if we identify the food for breakfast, we have less junk behavior leading up to and during breakfast. And no, we don’t allow changes to the menu (unless we have a serious issue such as the molded cream cheese we had this morning).

Pack lunches

Ok, we totally get that we are over-achievers. But seriously, if the lunch is packed the night before, we have less to do in the morning.  We ask the kids to decide if they are eating school lunch (totally over-fat and over processed) or lunch from home. From there, we ask them to pick their protein, fruit, vegetable, and starch. Our kids get at least one snack in school so we have them pick those as well. If we have time, we have the kids make their own lunch. This is not always feasible given the afternoon and evening schedules.

To bed! ON TIME

We have done this without fail since I moved in to this step-mothering role. In fact, Norm engaged in this practice long before me. But honestly, if I hadn’t read Ado’s blog, I probably would have left this one off the list because it is so engrained in our lives.

 

The Morning

Wake up naturally

Again, there are advantages and disadvantages to this. If we see that the kids are sleeping too long, we will begin to make natural noise (e.g., walking around, talking more loudly, etc).

Work Before Play

My other half likes to allow the kids to wake up slowly by vegging in front of the television. He keeps a strict rule of TV off at 7:30. This goes against the laws of behavior. You see, children will work faster to earn a reinforcer. So, my rule is TV does not go on until breakfast is eaten, teeth are brushed, beds are made, and children are fully clothed. Then I reward all of that hard work with TV time. The beauty here is that the faster the children get ready, the more TV time they earn.

Backpacks Ready

We like to make the children be responsible. How else will they learn to take care of themselves? So, they have to put their lunches and fluids in to their backpacks. Homework folders, permission forms, and the like must also go in the back pack. Again, we prefer to do this the night before but it is good to walk the kids through the process of remembering everything before they leave.

Bus or Drop Off

Our school requests that children ride the bus. First, this is more green. Second, it cuts down on traffic at the school. Finally, the bus comes about 20 minutes before drop-off time. I need all the time I can get. So, I institute another rule: if you miss the bus, no TV time after homework.

How do you get through the morning routine? Do you start the night before like we do? Do you have anything to add to our strategies?

 

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Day 4 of Feeding Therapy

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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Little Cherub Succeeds Again!

Hi! and welcome to What Works Wednesdays where we share a success story from our clinical files.Today’s success story is a follow up to a previous clinical case. Do you remember Little Cherub? She first came to us over a year ago. Little Cherub’s dad attended a presentation we did in Atlanta. He desperately wanted help because she had very restricted eating. After listening to dad talk about her symptoms, we suggested that Little Cherub be seen by a specialist to determine if she had celiac, an autoimmune condition that leaves the body unable to digest gluten, a type of protein found in bread, pasta, and cakes.

Sure enough, Little Cherub had celiac. After putting her on a gluten-free (GF) diet, she further restricted her eating. After 5 of the toughest days imaginable, we finally helped Little Cherub learn that new foods are not scary and that, in fact, new foods can actually taste good. Little Cherub’s parents were amazed to see her chasing them down to get more cantaloupe!

In addition to her eating behaviors, Little Cherub has a fear of many new things. Take toileting for example. Little Cherub wanted to continue using her pull up for toileting. Urinating on the toilet was not painful for her. But from the look on her face and the behaviors she exhibited, one would think she felt extreme pain on the toilet. In the same week we taught her to eat, we taught her to use the toilet for urinating and defecating. We made a simple visual schedule to show her that “pee” goes in the toilet.

Within 2 days, Little Cherub overcame her fears of using the toilet. We reserved her very favorite jalapeno corn chips as a treat and she learned to associate positive things with the toilet.

Less than 10 months after overcoming her fears of new foods and toilets, Little Cherub began showing fear-like behaviors in public places such as Target and grocery stores. Little Cherub’s dad reached out to us again for assistance.

Public places can be very scary for children on the spectrum. Public places are loud, they have strange lighting, and things are not always predictable. However, once you teach children the routine, and associate the public place with something positive, children learn that public places are not scary after all.

Little Cherub’s parents used the same intensive model we used with feeding. They began taking her to public places two times per day, every day, for a week. Little Cherub’s dad writes,

She went from cowering to smiling when we went twice a day for a week and explained to her what everything was she was seeing and hearing.

Congrats again to Little Cherub and her parents for working so hard on overcoming these fears. The work parents do is never easy but with success stories like this, it makes all the work worthwhile!

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What Works Wednesdays

Hi! and welcome to What Works Wednesdays where we share a success story from our clinical files. Today, we are going to take a pause from our personal stories and share a resource with our readers. The resource is called the What Works Clearinghouse from the Institute of Educational Sciences (IES). the website for the resource is http://ies.ed.gov/ncee/wwc/.

 

Educators (special education and general education alike) are required to use evidence-based strategies in their teaching as required under the No Child Left Behind Act and the Individuals with Disabilities Education Improvement Act. Educators often find it difficult to determine what strategies have evidence.

As a result, the Institute for Educational Sciences (which also happens to hand out research money to educational researchers) developed the clearing house as a resource. The criteria used to determine if a methodology may be listed in the Clearinghouse is very stringent. However,  if you are ever in doubt about teaching methodologies and “what works”, their website is a good place to start.

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