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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Inclusion is an Individualized Decision

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 post is about a 4-year-old little girl named Nahir who carries a dual diagnosis of Down syndrome and autism. Nahir began receiving early intervention services early in life. She began receiving ABA services shortly after she was diagnosed with autism. She began receiving ABA services from us last year.

Nahir’s parents wanted Nahir to be a community member in her neighborhood and they wanted her to learn alongside other children her age without disabilities. We designed an ABA program that consisted of about 10 hours per week of supported inclusion and 10-15 hours per week of 1:1 ABA instruction. Nahir responded to the intervention and began showing an interest in her peers at school and she began learning many skills at home. She even began using the toilet!

After several months, Nahir’s parents wanted to increase the amount of time in inclusive settings to 20 hours per week combined with 10-15 hours of 1:1 ABA. Nahir began engaging in non-compliant behavior and her rapid learning tapered off. We discussed our concerns about this change in learning with the parents and we encouraged them to consider making a change.

As a result, the family agreed to decrease inclusion time and increase 1:1 ABA time. Watch out! Nahir’s learning took off. She began imitating, her non-compliance decreased, and she started to communicate using her new iPad and Proloquo2go.

You see, inclusion is not all or nothing. Decisions about inclusion should be made individually for each child based on his or her unique situation.

We would love to hear from readers! Share your successful ABA and inclusion stories!

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My Child Won’t Poop in the Toilet: HELP!

Hi and welcome to Ask Missy Mondays where I respond to email questions from parents who are having difficulty with their child’s behavior. Today’s question comes from Sasha.

“My 8 year old is STILL not pooping in the toilet. He does a great job keeping his pants dry all day long with regular prompted bathroom breaks, but he seems to prefer NOT to poop in the toilet for some reason. What he will do most evenings (he usually poops in the evenings) is go to his room and get a diaper (which he still wears overnight because he still wets overnight) and sometimes he’ll even put it on himself to go poop.

Do you have any suggestions for how I can get him used to pooping in the toilet instead of in his pants? It seems like he’s starting to understand when he needs to go, it’s just that sometimes he doesn’t care to keep himself clean.”

Great question Sasha!  I would start with a social story which I am including at the bottom of this post. This word and picture story helps children better understand that poop goes in the toilet and not in the pants. The use of social stories also has research to back it up here, here, and here.

As gross as it may seem, perhaps your child should watch you go poop on the potty as well. Sometimes children need concrete examples to help solidify their learning. If that is too difficult for you to do, then try to find some movies or clips on iTunes that show people pooping. Even babies can poop on the potty!

I also really like the Poop in the Potty song. I have a dear friend with an excellent Nanny who taught me about that song. It is the BOMB! You can hear it here.

Next, you are going to have to be on your toes and catch him as he is trying to “sneak one in”. Quickly rush him to the toilet and stay with him. Read the social story to him. Encourage him. Tell him it is scary.

Finally, find the biggest, coolest, best ever reward and make it available ONLY when poop goes on the potty. Explain to him (using pictures if possible) that when he poops in the potty, he can have _______.

Good luck! and please let us know how it goes!

If you have a behavior or situation that you need assistance on, please email me at askmissy at applied behavioral strategies dot-com.

Social Story

Poop goes in the potty . 

Sometimes your tummy hurts .

Sitting on the potty will help the poop come out .

Poop does not go in your pants.

Poop goes in the potty .

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Toilet Training: How Long Will It Take?

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 client and family. Our intent is to show readers how successful ABA can be.

Recently, we have been sharing success stories from our feeding clinic. Today, we are going to discuss a success story about using ABA to teach toilet training. We want you to meet Christopher. Christopher is an adorable little 2.5 year old. He has curly hair, talks up a storm, and he is ALL boy! He loves to run around the yard, drive his trucks, and wrestle. He does not have a disability of any sort.

His mother approached us in August because it was time to move up in the preschool. Christopher wouldn’t be turning 3 until November but the toddlers were moving up to the three-year old class. Christopher could not move up until he was toilet trained. His mother did not want to hold him back with the toddlers. How was she going to get him toilet trained in less than a month?

“That is easy!” We told her. “You can train him in a weekend.” She did not believe us. So, we sent her the toilet training protocol with instructions on how to teach toileting skills.

For toilet training, we approach it in several steps. First, diapers and pull ups must go. Throw a party and throw them away. Well, do not throw them all away because you will still need them for overnight. Diapers and pull ups keep children dry. Children need to feel wet if they have an accident. The discomfort of being wet is often all that is needed to stop future accidents.

Second, go out and buy fun underwear or panties. Take care to have your child help you pick them out. Christopher loved Transformers so they bought him some great underpants. Celebrate growing up and moving on to “big boy” or “big girl” underpants.

Third, plan the weekend where it will happen. While this can be done in one day, for some children it may take 2-3 days to fully get the routine down. We recommend that families select a holiday weekend to ensure success before going back to work and school.

Fourth, identify a fun reinforcer or reward that will be used ONLY when success is achieved on the toilet. This can be a book, food, movie, or other preferred object. You may also find it helpful to use a sticker chart to show successes.

On the day that toilet training starts, get your child out of bed as soon as she awakens. Take her straight to the bathroom. Do not pass go, do not collect $200….I digress. Have her sit for a few minutes reading fun stories or listening to music. If she urinates on the toilet, cheer wildly. Give her the reinforcer/reward. Put on the big girl panties and do not look back!

If she does not urinate, allow her to get up. Put on her big girl panties and remind her that she must urinate on the toilet or she will get wet. You will need to take her back to the toilet every 15 minutes until she urinates on the toilet.

If your child has an accident, do not get upset. If you can catch it early enough, carry her  to the toilet to finish on the toilet. Have her assist with the clean up. Again, do not make a big deal out of the accident. Simply say, “oops, pee pee goes in the toilet”.

Once your child urinates successfully, be sure to take her back to the toilet about every hour. Over time, your child will learn to tell you that she has to go. However, initially, you will need to remind her. Always watch for the potty dance. We have provided you with an example picture. Just know that it looks slightly different for each child. When you see the potty dance, take your child to the toilet. Do not ask, “do you have to go potty?” as children often say no because they are doing something fun.

A few weeks later, Christopher’s mother emailed to let us know that Christopher was toilet trained and moving up to the Three Year Old class! Congratulations Christopher. You rocked the toilet! And your mom is awesome too!

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Mikey and his Milk

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 we would like to introduce you to a cute little fellow named Mikey. Mikey was 33 months old when we started intervention. Mikey was a typically developing toddler in every way except for his eating. Mikey preferred to drink his milk and he drank lots of it. His mother reported going through a gallon of milk in just one weekend. Mikey had some sensory processing issues which led to oral motor therapy from a speech and language pathologist (SLP). During oral motor therapy, he learned to tolerate having a toothbrush in his mouth and he learned to eat a few new foods.

Before we started intervention, Mikey occasionally ate cream cheese and jelly sandwiches on white bread. He also occasionally ate cheese sandwiches on white bread. His mother reported to us that she was very interested in Mikey becoming toilet trained.

We sent Mikey’s mom some written instructions on how to toilet train her child. We suggested that she start toilet training the weekend before we started feeding therapy. We have found, in our clinical practice, that children respond well when multiple areas of growth are targeted simultaneously. For Mikey, we could say that he was becoming a “big boy”. Big boys learn to pee on the potty and they learn to eat big boy food!

Mikey’s mom was a champion. She followed the toileting protocol that we provided and by the time we arrived for feeding therapy, Mikey was already urinating regularly on the toilet. He was also accurately reporting if he had to urinate when asked! His daytime diapers were gone and he was wearing big boy underpants.

The other curve ball we threw Mikey was that he was no longer allowed to drink from a sippy cup. He was starting preschool and big boys drink out of regular cups. We told Mikey that he could only have his sippy cup if he needed to drink while riding in the car to keep from spilling.

Prior to therapy, we encouraged Mikey’s mom to work with a nutritionist to determine if Mikey had any food sensitivities. Unbeknownst to her, Mikey was reactive to a number of common foods such as avocado. Additionally, Mikey suffered from a zinc deficiency. So, prior to therapy, Mikey’s mom started him on a few nutritional supplements. We believe that well-rounded nutrition is one of the best mechanisms to ensure success in our therapy sessions.

For Mikey, we provided all services in his home and his mother was present for every session. Mikey’s father attended one session to ensure that he knew how to support Mikey when therapy was finished. In addition to having well-rounded nutrition, we have found (along with other researchers) that hunger inducement is one of the best strategies for feeding intervention. When children are hungry, they are more likely to want to eat. For Mikey, this meant that multiple cups of milk were eliminated each day. Unfortunately, Mikey’s mom had to deal with Mikey’s unhappiness about this change in the early morning hours before the first session. As we said previously, she is a champ and she handled this challenge like a true fighter. Mikey was definitely hungry at mealtime and he soon learned to get along without all that milk.

Mikey received services over the course of 4 days. On the first and second day he received services at breakfast, lunch, and dinner. Mikey’s mom took over the meals starting at dinner on the second day. On the third day, Mikey received services for lunch and dinner. On the final day, he received services for breakfast. So in just 9 one-hour sessions, Mikey learned to eat new foods when asked.

We had several pleasant surprises when working with this client. First, Mikey had never eaten protein in solid form. We were all pleased that protein was becoming a fast favorite for Mikey. Additionally, Mikey loved fruits. We couldn’t find a fruit that he disliked. Despite the great progress that Mikey made in such a short period of time, Mikey will still need to work on chewing his new foods. As his mouth becomes accustomed to all the textures and flavors, he will become desensitized and more willing to use all of his mouth when eating. Additionally, as he learns to use his mouth to chew all of these foods, his overall motor function should improve.

Mikey, congrats on your progress. And to Mikey’s mom—he could not have done it without you. Now go get yourself that manicure, pedicure, or date night that you deserve. Tell your husband “it’s the doctor’s orders!”

Happy Eating!

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