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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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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 case is about a little girl named Bailey. Bailey was 7 at the time we served her. She was a petite and very quiet. She was also diagnosed with autism. Bailey enjoyed visual stimulation. She had her favorite pompom present at every meal. She also enjoyed watching movies like Toy Story and Finding Nemo.

Scheduling therapy sessions for Bailey was a bit complicated because of our schedule and her mom’s work schedule but we managed to make it happen. We started therapy on a Friday and her mom kept her home from school. Her teacher and BCBA from the school attended the breakfast session so they would be able to support Bailey when she returned to school the following week. Her ABA therapist also attended several sessions in order to fully support Bailey when intensive therapy was completed.

Picky Eating

Prior to therapy, Bailey ate few foods. Like most children with autism, she preferred the white and crunchy diet. She also liked to have ice cream. Bailey was also a grazer. She preferred to eat small snacks throughout the day without actually ever sitting for a meal. As if this wasn’t bad enough, her family had never enjoyed a family meal in a restaurant due to her challenging behaviors and restricted eating.

Day 1: Lots of Behaviors

For breakfast on the first day, we had pancakes, grapes, carrots. Bacon was a highly preferred food so we made it available as a reinforcer for her. Right from the beginning, Bailey was willing to chew and swallow new food! This is unusual as most of our children are so frightened of new food that initially, they will only agree to lick it or touch it to their tongues. So Bailey at the tiny bite of pancake and chased it with bacon. Next we offered a tiny bite of grape. Again, she ate it and received a bit of bacon. This was followed by carrot. Again, we had success! On the very first session of therapy, Bailey ate 26 bites of food! Don’t get us wrong. It wasn’t a party. Sweet little quiet Bailey, screamed, cried, aggressed towards us, and engaged in self-injurious behavior (hitting herself). She also tried to elope from the table but we just asked her to come back and she did. We did not allow her to use any of those behaviors to get out of trying the new foods.

After we left, Bailey’s mom reported that she asked for her preferred foods. She told Bailey to wait until lunch. We came back a couple of hours later offered chicken, hot dog, more carrots, and bananas. We used bacon as the reinforcer again. Bailey chewed and swallowed 38 bites of food. Bailey’s challenging behaviors were much better during this session. She only engaged in a few instances of crying and elopement.

For dinner, Bailey ate sweet potato, mushrooms, pork, and potato. We used a KBar as a reinforcer. This session was a little harder because Bailey was not as hungry. She only swallowed a couple of bites of new foods. She also engaged in a new behavior: gagging! She had approximately 50 gags and she also expelled food many times. Her screaming increased as did her elopement.

Day 2: Improvement

We returned the following day and started all over again. For breakfast we offered watermelon, banana, waffle, and sausage. We continued to use bacon as a reinforcer following really non-preferred foods. Bailey swallowed 23 bites of food. She continued to engage in a lot of screaming, particularly around the sausage. however, her aggression, gagging, and expelling were much better.

Lunch was another improvement. We offered orange, pizza (yes, some children dislike pizza!), mashed potatoes, avocado, and a muffin. Bailey ate 37 bites of food! While she was a little “fussy” the screaming was gone and she only expelled 2 bites.

We continued to see more success at dinner. We started the therapy session and then mom moved in to the driver’s seat after the first few bites. We usually see an increase in behaviors when the parents take over and this was true for Bailey as well. Her mom Bailey tried to run away and she screamed. She also started packing (holding) the food in her mouth. Silly girl! She didn’t realize that mom was in on it too! Mom held her ground and eventually Bailey ate for her as well. She ate pound cake, strawberries, cucumbers, and chicken parmesan. Bailey ate 27 bites!

Day 3: Discharge!

The next day mom supervised breakfast of egg, english muffin, ham, and cantaloupe. Bailey ate 25 bites of food but her behaviors were testy. She cried, fussed, and even threw a bite of food. Mom stood firm and eventually, the behaviors ceased.

Lunch was great as well. Bailey ate macaroni and cheese, grilled cheese, peas, and raspberries. For those of you who have not experienced picky eating, it may surprise you to know that children with autism and picky eating may avoid even the most preferred foods! Bailey ate 52 bites! She engaged in some fussy behavior but the screaming and aggression were gone.

For dinner, we all went out to a restaurant to celebrate. Bailey’s mom, dad, brother, and I all sat down together. Bailey ordered nachos with chili, broccoli, baked ziti, and french fries. It was a sight to see. Bailey ate 45 bites of food and she engaged in zero problem behaviors.

The next day, Bailey’s mom wrote to let me know that she ate some banana, a slice of bread with cream cheese, and her favorite bacon. There were no behaviors and she was off to school. School staff continued to support her good eating habits and Bailey has flourished. Bailey still needs encouragement to eat new foods. However, her mom has now learned how to successfully support her in trying and learning to like new foods. Intensive intervention is the boot camp that gets kids over the hump. The parents and teachers must continue to support the therapy after we are gone.

Follow Up

Seven months after therapy, Bailey’s mom wrote to us to let us know that Bailey had gained 7 pounds. Amazing! Congratulations to Bailey and her family. Your hard work has paid off.

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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.

Nathan

Today’s success story is about a little guy named Nathan. At the time of intervention, Nathan was 6. Nathan had beautiful black hair, a heartwarming smile, and a contagious belly laugh. Nathan also had a pretty healthy belly–his nutritionist diagnosed him as obese. So, you ask, how could a picky eater be obese?

We cannot answer that question. However, we can tell you that Nathan was diagnosed with a genetic deletion syndrome as well as autism. Nathan demanded food at all hours of the day. If his parents did not feed him, he screamed, tantrummed, and hit himself in the head (also known as Self Injurious Behavior or SIB). When his parents offered him a non-preferred food, the tantrum and SIB worsened. As parents, they did not know what to do so they fed him preferred foods.

Nathan’s mother reported that Nathan would wake as early as 3 or 4 demanding food. He had never slept through the night. As you can imagine (or possibly even relate if you are a parent of a child with autism), this lifestyle caused a great deal of stress for Nathan and his family.

Given the presentation of demanding food at all hours of the day, combined with the fact that he was overweight and had low tone, we first suspected that “little” Nathan had Prader Willi Syndrome. However, his mother reported that he had been tested for this condition on more than one occasion and doctors had confirmed this was not the case.

Before Our Therapy Started

Nathan had been receiving feeding therapy for about 2.5 years from a speech therapist who specialized in feeding disorders. Nathan also had feeding objectives in his IEP. However, Nathan failed to make progress in eating a variety of foods. Thus, his mom contacted us. Prior to our services, we suggested that Nathan be seen by a nutritionist. As part of the services there, the nutritionist discovered that Nathan had a milk allergy. Nathan’s mom stopped all dairy products the weekend before we started therapy. Nathan was not happy about this change so you can imagine his distaste when he discovered that we had additional plans for him. Surprisingly though, Nathan immediately started sleeping through the night once dairy was removed! (Since Nathan started a dairy free diet, he has experienced a couple of dairy infractions. Each time this occurred, Nathan awakened during the night.)

Our Therapy

We originally scheduled 5 days of therapy with three one-hour sessions each day (one for each meal). However, Nathan was sick on the first day so we postponed therapy leaving 4 days of scheduled therapy. (More therapy is always provided when necessary.) We started therapy by finding a highly preferred item that Nathan wanted to work for (interactive book on the iPad). This is also called a preference assessment. We allowed Nathan to play with the item and then we removed it and told him that when he tried his new food, he could have the item back.

At first, we only asked Nathan to touch the new food to his lip. This is called shaping. Nathan screamed, cried, and attempted to hit himself in the head. We simply blocked the behavior from happening by inserting our hand between his fist and his head. He also attempted to bang his elbows on the table. We blocked this behavior as well. Soon, Nathan decided that he should put the food to his lip and we praised him and gave him access to his iPad book. After a few trials, Nathan decided that the new food was not so scary and he ate it. Soon, Nathan was willing to try (and eat) all of the foods we presented to him. He continued to show his distaste for the new foods by screaming and crying. He also gagged a few times. However, it did not take long for him to realize that these new foods actually tasted good.

Generalization (Transferring the Behavior to New Situations)

Nathan’s challenging behaviors subsided and it was time to transfer therapy to Nathan’s parents. Nathan’s mom started therapy on the 3rd day of services. As we often see when the parents take over, Nathan attempted to scream, cry, and hit his head. His mom knew how to block the behaviors and she held strong. By the end of lunch on the 3rd day, Nathan ate willingly with his mother so Nathan’s dad joined Nathan and his mom for dinner. For the first time, Nathan and his family shared a meal with all family members eating the same foods!

On the last day of therapy, Nathan and his parents celebrated by going out to eat. The family enjoyed a healthy meal free from challenging behaviors. The following week, we accompanied Nathan to school to show his teachers how to support him during lunch and snacks. Sadly, Nathan’s classmate brought in pizza for lunch. Poor Nathan! He could no longer eat his favorite food. He cried briefly but his teacher showed him the wonderful new foods in his lunch box and ate his meal. Over time, Nathan began enjoying healthy foods. In fact, we recently posted a picture of a meal Nathan ate when we dropped by for a visit 7 months after feeding therapy. Nathan ate grilled chicken, Texas Caviar, raspberries, blackberries, and grilled vegetables with no challenging behaviors. In fact, he is now learning to eat slowly without stuffing and he is learning table manners such as wiping his mouth and putting his silverware down between bites.

Way to go Nathan! You worked hard to learn to eat such healthy foods! Giving up milk was not easy for you. Give your mom and dad a huge hug for their support through this difficult phase! It was not easy for them either.

Side Note

We often see children in our clinic who have food sensitivities, allergies, and gastrointestinal issues. As such, we require the support and consultation of appropriately trained professionals prior to the commencement of feeding therapy. We see observable changes in behavior when milk or other allergens are removed from the diets of some (but not all) children. If you are interested in reading more about the Devil in the Milk, we found the book to be informative.

 

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