The Lovaas Legacy in Autism Treatment

The autism community continues to mourn the loss of pioneer Dr. Ivar Lovaas. Realizing that Skinner’s systematic approach using reinforcement could be instrumental in teaching functional skills to children with autism , Lovaas was one of the pioneers in the implementation of  Applied Behavior Analysis (ABA) principles and procedures in the treatment of autism, and in doing so helped thousands of children across the globe. The Lovaas Method of ABA starts with "discrete trials therapy” often referred to as DTT. A discrete trial consists of a therapist asking a child to perform a particular behavior. For example, “Timmy, name the animals in this picture.” If the child complies, he is given a "reinforcer" which is usually a desired prize or reward that is meaningful to the child in order to increase motivation, often times an area of deficit in children in the spectrum. The reinforcer could be a food treat, a high five, stickers in a chart towards earning play time, or anything else that has meaning for the child. If the child does not comply, he does not receive the reward, and the trial is repeated. Prompts are added as necessary to ensure the trial ends in success.  Since ABA is a data-based decision making process, data collection and analysis is warranted in order to continue a specific program or make changes.  

It's important to note that ABA interventions are single-subject designs: the specific content of the discrete trials therapy is based on an assessment of the individual child, his needs, and his abilities. So for example a child who is already capable of sorting shapes would not be asked to sort shapes indefinitely for rewards. Instead his therapy would focus on different, more complex functional skills.

As children master specific programs, therapists will start to take them out of the therapy or home setting and into more natural environments, where they can practice their learned skills in the real world. This is the meaning of “Applied” in Applied Behavior Analysis, which differentiates ABA from other therapies that are implemented only in a contrive setting where the therapist has full control over the variables in place. In simple words, we consider that a skill is mastered when the child is fluent in the real world. This often presents a challenge because the therapist does not have control over the environment when at the groceries store, a restaurant or a play-date at the park. However, research shows that this is the only way to achieve generalization of gains across settings and maintenance across time.   

Additionally, ABA therapists are required to keep detailed records on their outcomes. This means that ABA has been extensively researched and replicated. As such, ABA has a reputation for being the most scientifically researched form of successful therapy available for autistic children.                     

As I said in a previous blog (see “Common misconceptions about Applied Behavior Analysis”) I fell in love with ABA when I learned all that. The more I learn, the more passionate I am. ABA gives me the answers I need to do my job effectively.  Everyone who jumps on the ABA bandwagon gets hooked. Have you ever thought about why?

 

 

Daniel Adatto, BCBA

 

Summer Time and Autism

The summer is already here. Having a child with special needs at home all summer is extremely stressful for parents. As we’ve discussed in previous blogs, this kind of stressful environment often leads to behavioral issues.  

Summer should be a time of joy, sharing and spending time with family and friends. However, for those with family members who have special needs, the holidays can present unique challenges because it can often be overwhelming to children. The comfort and predictability of the school time with its routines and schedules is gone and now there is a lot of free time.

As discussed in previous blogs, being sensitive to your child’s needs and keeping familiar routines in place are the best ways to avoid summer havoc. Let’s review some recommendations to help keep parents sane during the summer. 

Prepare your child for the unexpected event: Explain to your child what is going to happen when there are changes in routines ahead of time. Be specific about every detail that might occur in any given situation, such as meal times, preferred and non-preferred activities, time to come back home, etc. New or unexpected situations can be very frightening for a child with autism and being prepared can help him cope.

Prepare the social event for your child: Avoid long trips whenever possible. Airports, planes and long car rides could be very stressful.

Stick to your normal routine as much as possible. Keep sleep and meal/snack times as close to their usual time as possible.

Keep your child busy: Don’t expect that your child will entertain himself independently. Your role here is crucial. I know that finding activities for kids with special needs can be challenging. However, there are some options available. Consult with your Regional Center or your social services agency. Schools and community centers sometimes offer activities for children with special needs. Try to build a schedule of activities similar to the schedule your child follows during the school year. 

 

Know the triggers and read the precursors of challenging behaviors, such as facial expressions, changes in breathing, body movements, etc. Look for the signs that your child may be unraveling and retreat to your safe place. Preventing a meltdown is always easier than managing a tantrum once it begins.

Finally, relax and enjoy. You are your child’s barometer and if you are stressed out, he will be too.

 

Daniel Adatto, BCBA

Pivotal Behaviors

Individuals with developmental disabilities present a myriad of challenging behaviors. Addressing each one of them separately can be a daunting task for parents, staff and the clients themselves. Successfully addressing multiple behaviors with one intervention is often necessary. PRT (Pivotal Response Training- Koegel, O’Dell and Koegel, 1987) focuses on critical behaviors that are central to many areas of functioning, such as communication and social skills. PRT is built on the premise that improvement in these key pivotal behaviors opens the door to improvement in other areas as well. In other words, teaching pivotal behaviors produces widespread positive effects on other behaviors.  

This is a positive, naturalistic behavior intervention based on Applied Behavior Analysis principles that focus on teaching specific behaviors in the natural settings and is used successfully to help children with ASD and other developmental disabilities. Key pivotal behaviors addressed include motivation and responsivity to multiple cues. 

Motivation: Children with developmental disabilities are frequently viewed as lacking motivation to initiate and respond appropriately to stimuli, to learn new tasks or engage in their social environments. They demonstrate this lack of motivation by engaging in non-compliance, tantrums or other challenging behaviors to escape tasks and social interactions. They may not initiate conversations or ask and answer questions. These children are so difficult to motivate perhaps because since they often fail, they have learned not to try.

Thus, motivation is a key component of a behavior modification program. Lack of motivation constitutes a barrier to teaching appropriate behaviors. A motivated child is interested in learning. Research indicates that increase motivation has a dramatic positive effect on children’s learning (Koegel, O’Dell, & Dunlap).

I like the phrase “We can not teach if we cannot motivate” because it summarizes the importance of focusing on motivation.

Responsivity: Children with developmental disabilities are characterized by “stimulus overselectivity”, and attention deficit in which they select or focus on only one part of the environment or an object. A child may focus only on round part of an object such as the wheels on a car. Increasing children’s responsivity to multiple cues is an important pivotal behavior that may help them to learn more from typical educational strategies and naturally occurring situations, which ultimately leads to engage more in desirable and functional social behaviors.

Parents and professional should focus and take advantage of naturalistic child and family-centered situations. Here are some tips:

1. Implement teaching sessions around objects, activities or topics that the child prefers in order to increase motivation. For example, if your child is “crazy” about cars, engage in playing with him the way he plays with cars (start imitating what he does), and slowly include and model social interactions, such as “the red car asks the blue car to play”, or “all the cars are having a playdate” and they take turns while playing games, share toys, collaborate in building with Legos, etc.

2. Take advantage of natural situations to teach. For example, having dinner, taking a bath or doing groceries are great opportunities to model behaviors and increase motivation.  

3. Parent, teacher, make sure that the child is attending to you by getting down to his level, calling his name or asking “Are you ready?”, and then presents the child with a question or instruction that is directly related to the setting, task and material available. In our example, playing with cars.

4. Very Important: All attempts to respond appropriately (even if the response is not perfect) are rewarded. Ample time is allowed so the child can try to respond without stress. Prompt (model, guide) appropriate responses to end always on a positive note, the reward. This allows the child to experience success, which increases motivation.

5. Use rewards directly related to the task and the natural environment. If you are playing cars, the child receives another car, or gets access to his favorite car, for example.  

In sum, teaching pivotal behaviors is a child-centered intervention that can be implemented across settings (school, home and the community) and across caregivers. Once parents learn how to do it, they become the therapists and thus, the intervention is in place 24/7.  

This intervention has been most successful in improving social and communicational behaviors of children with developmental disabilities in the areas of language, play and social interaction.

Another example of an effective way we can help to improve the quality of live of individuals with developmental disabilities and their families.

 

 

Daniel Adatto, BCBA

 

The Power of Structure and Routines

Try to imagine your life “unstructured”: you don’t know when you are going to have food again, or where it’s coming from; you don’t know at what time you’re going to be home, or if you are going home at all today; you don’t know when you are going to be done with a non-preferred activity, how long it’s going to last; and you don’t know when you are going to be able to rest, have fun with you preferred activity or see your loved ones again. In sum, your life is unpredictable, uncertain, chaotic.

 

I don’t know about you, but I’m “freaking out” just by thinking about that possibility.

 

Your child might be living in that state of confusion and anxiety all the time. So, let’s structure. 

 

What does "Structure" mean?

 

A predictable and consistent daily schedule (time-space-people in charge). Lack of predictability increases anxiety, which leads to problematic behaviors. Yes, I’m talking about your kids. Are you with me?

 

Predictability is what your children need, and something you can implement at home. You don’t need complicated IEPs, or your insurance to approve services, balanced state/federal budgets or lawmakers to pass bills.    

 

Benefits of "Structure":

 

q  Builds Confidence

 

q  Decreases Anxiety and Fears

 

q  Develops Positive Expectations

 

q  Encourages Cooperation and Compliance

 

q  Increases Predictability

 

q  Increases Motivation (when desired activities follow undesired activities)

 

q  Increases sense of Control

 

q  Increases Independence

 

q  Anticipates future events

  

Sounds good? Well, it is.

I can hear your question, How to Structure Activities?

--Keep times, places and people in charge as consistent as possible. Start with the “must do”: meals, bed time, etc.

--Adjust the environment to focus on the activity. For example, turn off the TV when it is bed time.

--Present scheduled activities in a positive manner. Do not be overly rigid. Some flexibility is necessary.

--Include free and play time: children need it.

--It is very important to allow time for transitions between activities. For example, when your child comes from school he/she typically will need some free, unstructured time. Or when transitioning between activities. Prepare the child ahead of time. For example: "It is almost dinner time, so you will need to come in soon. Be ready to put your toys away".

--Have preferred activities follow non- preferred activities. In order to be able to do the desired activity, the child has to finish the undesired activity. For example, "homework first, then play"; or "bath first, then video".

Children may not have independent play skills. You may have to set aside time to play with your child.

Choices can be built into the schedule by allowing the child to choose between 2 activities, such as "bath or shower", or "going to the park or to the store", or "video or TV".

In sum, structure and routines do not mean “militaristic”. They mean “predictable”.

Very cost-effective: easy to implement, excellent benefits. Sometimes, the solution is simple.

 

Daniel Adatto, MA, BCBA

 

 

Parents with Special Needs

Are you a parent of a child with special needs? If so, you know how challenging it can be. You are a parent with special needs.

Children with special needs are, first and foremost, children, and thus, they share kids’ basic needs: love, acceptance, care, and support and guidance to overcome challenges. Parenting is arguably the most difficult job on earth. However, the emotional toll you pay due to your child’s deficits and excesses can drain you, making it more challenging than raising a non-special needs child. 

But you are not alone. The state health department, social services agencies, parents support groups, schools and health insurers are there to support you.

When parents learn for the first time that their child has special needs, strong emotions such as denial, anger, fear and/or guilt take over. This is common and understandable. Parents feel alone and worry that their child will have an unhappy life. However, you need to learn to manage your emotions. Some helpful recommendations are:

- Communicating with others about how you feel.

- Seeking help from family, friends and other parents who have kids with special needs. Do not hide. Do not feel ashamed. Your worst mistake could be isolating and pretending that nothing is going on.

 - Learning about children with special needs, effective treatments, and educational and legal rights.

- Taking care of yourself (see previous blogs about Stress Management). It is difficult to help your family and your child if you are stressed, depressed and out of energy. Remember to rest, exercise, eat healthy and relax.

- Seeking counseling if your emotions and responsibilities are overwhelming.

And don’t forget to spend quality time with your child. Be sure to have fun!

Yes, having a child with special needs is challenging. Would you believe me if I tell you it can be rewarding too?

Daniel Adatto, BCBA

Anger Management

In my everyday practice, I see a lot of parents who struggle with anger. I don’t blame them. Having a child with special needs is very challenging, stressful and frustrating. But reacting out of anger only leads to more anger. Thus, this made me think about anger management.

We know that anger is a common emotion. Everybody feels angry from time to time. Different situations or people can make us angry. Even when we may not be able to change that situation or person, we can control our behaviors so we respond to the situation instead of reacting out of anger. The goal is to control and express anger in a positive, safe, appropriate and constructive way. Avoiding anger may not be realistic. Managing anger is the solution. 

In order to manage our anger it is important to know what situations make us angry, where the anger comes from, as well as recognize when the emotion is taking over.

Anger can be expressed in a destructive and hurtful way. Relations can be damaged or destroyed.  Jobs can be lost. Lives can be ruined. This is why it is necessary to develop effective anger management skills in order to promote peaceful and healthy environments and teach our children how to manage their anger too.

Identifying “anger triggers” for us and our child allows us to be equipped to respond in a positive manner. Common triggers are:

For us 
- Children's behavior
- Unexpected events
- Traffic jam
- Relationship problems
- Stress at work
- Health problems
- Financial problems

For children
 - Conflict with other kids
 - Peers rejection
 - Not getting their way
- Delaying gratification
- Waiting
- Being scolded or punished
- Being ignored

By paying attention to our body’s signs, we can “cool down” before losing control. Some signs are:
- Rapid heartbeat
- Tense muscles
- Sweaty palms
- Feeling warm
- Destructive thoughts
- Snapping at people

Children need help to understand and recognize their feelings of anger. Some signs are:
- Yelling or crying
- Throwing things
- Pulling out own hair
- Tightening fists and muscles
- Hitting self or others

I would like to share with you some ideas for “cooling down” in healthy ways:

For us:
- Exercising
- Taking deep breaths
- Time-outs: Removing ourselves from the person or situation that makes us angry
- Writing about feelings
- Going for a walk
- Sleeping/resting
- Talking to a friend or a professional

For our kids:
- Talking to an adult about their feeling: Instead of asking them to stop with the behaviors, open the door to talking, so they can learn a way to vent feelings appropriately
- Playing outside
- Removing them from the person or the environment
- Writing about their feelings
- Time-outs as a way of calming down (not as a punishment)

Anger can be expressed with words. Not communicating anger does not make it go away. It might build up and lead to an “explosion” later.

As we teach our kids effective anger management skills, they become more responsible, develop independence, and learn how to solve problems. 

Remember that our children learn by watching us coping with anger. They learn what they see, not what we tell them to do.

Good parenting involves modeling good behaviors. We have to know how to behave, so our kids will too.

 

Daniel Adatto, BCBA

 

 

Autism Screening Quiz

There are many early warning signs and symptoms of autism that can present in babies, some say as early as 6 months to one year old, though most children get diagnosed with autism-like symptoms closer to the age of 18 months when the signs become more apparent. Some of the early warning signs include:

 

 

• Impaired social interaction


• Problems with verbal and non-verbal communication


• Failure to respond to name


• Avoidance of eye contact with other people


• Repetitive movements such as rocking or twirling


• Self-abusive behavior such as biting or head-banging

 

 

With autism numbers on the rise (a CDC study shows that as many as 1 in 100 children have autism), it is only natural that paranoia may set in when it comes to signs of this baffling disorder whose cause is so unknown. How many of us haven’t felt that twinge of fear when your baby doesn’t respond to his name, or doesn’t say any words by the age of 12 months? How many parents have woken up panicked in the middle of the night and gone to the computer to Google the signs of autism? If you’ve ever worried that your baby may have autism but did not want to ask your pediatrician for fear of sounding like an over-worried parent, now there is a quiz you can take that will help you know if you really should ask a professional to evaluate your child.  According to the National Institute of Child Health and Human Development, there are a number of things that parents, teachers, and others who care for children can look for to determine if a child needs to be evaluated for autism. This autism quiz asks about 'red flags' that could be a sign that a Pediatrician or other health professional should evaluate a child for autism or a related communication disorder.

 

 

But before you panic, keep in mind that other conditions can also cause these symptoms, that you have to consider what your child can do in an age appropriate manner (for example, a 6 month old likely won't respond to his name), and that normal children can have some of these symptoms and behaviors (like being independent, walking on her toes, or preferring to play alone).

Having one or more of these signs, symptoms, and behaviors should prompt a discussion with your Pediatrician to see if further evaluation needs to be done. If you have any doubt, you should never fear asking a professional for help. Countless scientific studies show that when caught at a young age, early intervention using the treatment methods of applied behavior analysis (ABA) are extremely effective at helping a child with autism lead a more typical life.

To start the quiz, click on the link:

http://pediatrics.about.com/od/autism/l/bl_autism.htm

 

Daniel Adatto, BCBA