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Archive for the ‘What Works Wednesdays’ Category

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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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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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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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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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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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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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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