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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 hope that you all are enjoying your summer as much as we are enjoying ours. We have each taken time off to spend non-work time with our families. Time off means that our blog suffers. Despite our absence, we truly appreciate the fact that readers are continuing to visit and have not given up hope on “fresh posts”.

This week we are going to do something a  little different. Historically, we have used our “What Works Wednesdays” to focus on our clinical success stories. Since we are running a clinic for intensive feeding therapy this week, we are going to take one of our clients, and highlight his/her progress each day.

Please check back each day for a brief summary of the child’s progress from the previous day. We think the results will surprise you.

 

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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 Ask Missy Mondays where I respond to a question from readers regarding a behavioral problem. Recently, Rebecca and I were contacted by a parent who is struggling with their child’s picky eating habits. She desperately wanted her child to receive feeding therapy and she had heard how great the outcomes in our clinic have been. For case examples from our clinic, read here, here, or here. The problem, she explained, is that she works and summer is the only time she is available to participate with her child.

Need Summer Feeding Therapy

Unfortunately, this mother is not alone. We have been contacted by 6 or 7 other parents who are desperately seeking services and they need the services this summer. Addressing feeding behaviors during the summer offers many benefits.

  1. Children are often out of school
  2. Parents may have a modified work schedule during the summer
  3. Many outdoor activities are available to get children out of the house and distract them between meals

Summer Clinic

As a result of these requests, Rebecca and I have decided to offer a summer feeding clinic. We have teamed up with Dr. Zwicker at The Easter Seals in Stamford. Their office will supply the space for therapy and Rebecca and I will provide the therapy.

Clinic Versus Home Therapy

In the clinical model, we run two concurrent feeding sessions each hour. Rebecca is 1:1 with a child in one room and I am 1:1 with the child in another room. We generalize therapy from us to one and/or both parents as well as any other individuals in your child’s life (e.g., speech therapist, behavior therapist, grandparents, or nannies). We also generalize therapy to community settings such as a restaurant or to your home if you live near Stamford.

Additional Information

The clinic is set to run from August 13 through August 17. During that time, your child will receive up to 15 sessions including generalization sessions to restaurants or home. Sessions also include parent training. The cost for the feeding clinic  includes the intake and record review, an exit report, and any follow-up consultations that are needed after therapy has finished. We require parent participation at every session. We also make accommodations for other individuals to participate as often as they are interested and available (e.g., spouses, grandparents, teachers, ABA therapists, etc).

Please contact us if you have questions or need additional information. We look forward to sharing the success of the clinic in our What Works Wednesdays postings.

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Hi and welcome to Ask Missy Mondays where I respond to a question from readers regarding a behavioral problem. Recently, I was asked, “Where have you and Rebecca been? We have missed the regular blog postings.”

Busy IEP Season

In all honesty, neither Rebecca or I followed our own advice regarding Individualized Education Program (IEP) season. We both had a number of annual reports to submit in preparation for meetings.Those reports need to show how much progress our clients have made over the past year and we need to document our clients’ present level of performance (PLOPs) for the schools’ IEPs.

Independent FBAs

However, in addition to those items, we have both been asked to complete Independent Educational Evaluations (IEEs) of behavior. It is not uncommon for a school to complete a Functional Behavioral Assessment (FBA) as required under the Individuals with Disabilities Education Improvement Act (IDEIA). But the IDEIA also affords the family a right to an independent FBA should they disagree with the findings from the school FBA. Independent FBAs also take substantial time.

Conferences

Both of us have been conferencing. First we had the Association of Behavior Analysts Annual Convention in Seattle. This conference is a must for behavior analysts or anyone interested in the field of behavior analysis. Days are filled with research, practical application, and behavior analysis across contexts while nights are filled with socialization and mingling with other behavior analysts (about 5,000 of your closest friends). While there, we conducted a day-long workshop on Special Education Law and Ethical responsibilities for behavior analysts. We also presented ethical responsibilities for completing FBAs, Behavior Intervention Plans (BIP), and the proposed law on restraint and seclusion.

Region 17 invited me to speak at their Autism Conference in Lubbock, Texas. If you live in the area, this is a conference that should not be missed. Anna Phillips runs an amazing conference with great speakers and a wide variety of topics. The exhibitors are also great and participants can purchase books, teaching materials, and even fun jewelry. I presented on behavioral feeding techniques, data collection, and using the iPad to teach communication, language, and academic skills.

Webinars

We offer continuing education for Board Certified Behavior Analysts and we try to offer a topic each month. We have recently completed webinars on Special Education Law and Using the iPad to Teach. While the webinars are designed for behavior analysts, anyone is welcome to attend. If you are interested in our upcoming webinars, check out our website for additional information or for registration instructions.

We Are Hiring!

Finally, Applied Behavioral Strategies continues to get referrals for ABA therapy, behavioral feeding therapy, and assessments. Because of all of these referrals, we are in need of a Board Certified Behavior Analyst (or two) as well as good front line therapists. So, if you like what we do, please consider applying for a position. If you live in Connecticut, contact me directly. If you live in or near Austin, contact Rebecca.

So, we apologize for our absence in recent weeks but we appreciate your on-going support.

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The ARI Conference was held this weekend in Newark, NJ. If you have never made it to an ARI Conference, you should put it on your list of things to do if you are a parent or caregiver of someone with autism.

The Conference Overview

The conference offers practitioner seminars on Thursday and Friday. A nutrition session is available on Saturday. Then, there is a General Session available on Friday, Saturday, and Sunday. This year, an adult track was offered on Sunday. If that is not enough, the conference also offers free workshops on Thursday and Friday evening plus Demo Room sessions are available throughout the day on Friday, Saturday, and Sunday. Plus (yes, there is more) there are many wonderful exhibitors including TACA, Autism Speaks, and Nourish Life, the makers of the Speak supplement (just to name a few).

Learning in Action

As a practicing behavior analyst with many years of education and experience “under my belt”, I (Missy) continue to learn something new at each conference. This year:

  • I picked up a complimentary copy of Dr. Herbert’s new book, The Autism Revolution.
  • I also learned about the importance of seeds. Who knew that ground flax seed was such an excellent source of prebiotic in addition to fiber and Omega 3s?
  • I learned that acid reflux may not always be caused by overproduction of acid. In fact, it could be caused by under production of acid!
  • I also learned that nutritional deficiencies (e.g., zinc) can alter the way food tastes and smells. This may lead to picky eating which may exacerbate nutritional deficiencies.
  • I ran in to several families who have successfully graduated from one of our feeding clinics. I love hearing about client progress and maintenance!
  • Finally, I learned that rice may have arsenic in it!

Picky Eating Free Workshop

I co-presented on Thursday evening with Vicki Kobliner of Holcare Nutrition. We covered the topic of dealing with picky eaters, a problem we see in as many as 50% of the children with autism. Vicki talked about the importance of evaluating any underlying medical issues before starting feeding therapy. This includes things like reflux or constipation. Vicki also talked about the importance of assessing for nutritional deficiencies and food allergies prior to starting therapy. I presented on the behavioral procedures for getting children to eat. This included changing antecedents to make sure the child is hungry, teaching new behaviors such as sitting at the table to eat, and changing consequences such as reinforcing children for trying new foods.

Who is in charge?Challenging Behavior Free Workshop

I presented on how to address challenging behavior on Friday evening. In this workshop I helped participants understand that behavior is supposed to be addressed through the IEP process. I helped them learn what to look for in an FBA. I taught them how the FBA is used to develop an IEP. The participants learned how to develop a BIP together with school staff and behavior analysts. This included learning to modify the antecedents to prevent the behavior from happening, teaching a replacement behavior such as communication, and changing the consequences so that we stop reinforcing challenging behavior.

Pill Swallowing in the Demo Room

I taught several parents how to teach their children to swallow pills. I taught them to use a stimulus fading approach so that their child learns to swallow small things without chewing. Over time, the objects get bigger until they are swallowing placebo capsules. I enjoyed my time in the demo room where other practitioners taught parents how to shop safely for gluten free and dairy free products, how to inject B12 shots, and how to prepare for your doctor’s appointment.

Education Plans

On Sunday, I taught parents how to make the most of their educational programs. Children under the age of 3 have different rights and policies than children over the age of 3. It is important for parents to know their rights so that they may advocate effectively for their children. Parents learned about a few resources to help them in this process. Some of the resources included COPAA, PACER, NICHCY, and Wright’s Law.

If any of my readers attended and want to chime in, please comment about what you learned or what your favorite part was. Mark your calendars for the fall conference to be held in Orange County October 11-14, 2012.


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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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