5.05.2008

Leo's Progress: The Good Stuff

Leelo's Progress: The Good Stuff

Although things have been rough for the past month, before then Leelo was having his best learning and behavior (and happiness) period to date. When Supervisor M called me to consult on details for the progress report below, she giggled and said she'd never had so much fun writing one of these reports. Enjoy the good long snapshot of happy Leelo before we were revisited by sad, pissed off Leelo from days of yore (who had two milestones today: pooping on the bus and hitting a classmate in the face; whom we're hoping to banish with Tylenol meltaways, comfortable undergarments, a working trampoline, and pool-friendly weather; and whom I both hope and hate to hope will be diagnosed with an ear or sinus infection tomorrow so we'll have some idea about why he's so miserable in his own skin).

PROGRESS REPORT

Student: Leelo Rosenberg
Date of Report: 4/9/08
Supervisor M, MA EdS

In the past year, Leelo has experienced many changes in his instructional program, including a change of placement to a classroom at the Saint Matthews County School at Cielo Azul, an increase in the use of visual supports at home and at school, and a greater emphasis on directly teaching appropriate alternative behaviors to replace aggressive behavior. He is also spending a full day at school.

Leelo has made exceptional progress this year. As his aggressive behavior decreased and his behavior replacement skills developed, he has been able to tolerate more challenging instruction and demands. He currently enjoys a complex and comprehensive instructional program.

VISUAL SCHEDULE AND INDEPENDENT WORK
Leelo transitioned easily to Room 4 at Cielo Azul. Everyone who knows him will agree: Leelo loves school. The physical layout allows for the outdoor gross motor activity which Leelo so enjoys. The classroom is convenient for working on his functional and academic goals. In September 2008, Leelo quickly learned to follow his individual visual schedule. He currently scans the entire day (at least 15 activities) upon arrival. He consistently checks the schedule when given a name card, and when he doesn’t have a name card- he approaches staff and says “check schedule”. He is currently learning to read a text schedule by fading the pictures and enlarging the text. Leelo also uses a picture schedule at home during ABA therapy.

This year Leelo made progress in independent work. He now consistently does 5 consecutive activities, with 3 to 6 prompts, for up to 25 minutes at home and about 10 minutes at school. The activity trays or shelves are numbered, and he matches a number on his desk with the number on the activity tray or shelf. He can do a variety of activities independently, including puzzles, folder tasks, lacing, and some open-ended tasks like listening to headphones, and playing with trains or a toy piano. At home, he is able to do independent work in a variety of locations, by moving the trays to each location. His parents use the independent work trays when they are busy, and need Leelo to play by himself.

NEW SKILL ACQUISITION AT HOME AND SCHOOL
Leelo has also begun to tolerate small group experiences, and one-to-one instruction of new skills in a classroom environment. Previously, Leelo generally mastered new skills mostly in a one-to-one environment using discrete trial methodology at home. This year, Leelo is tolerating one-to-one instruction with a teacher in a noisy, busy class, and he is also participating in group circle time with up to 6 other children. For new skills, he continues to require one-to-one instruction, and to do best with 3 to 5 repetitions of a single skill at once. Contingent, tangible reinforcement is essential.

New skill instruction includes the Edmark sight-word reading program. Leelo has progressed steadily through the pre-reading section, and has now begun the sight-word discrimination or actual reading section of the program. In class, he is also working on identifying emotions, developing one-to-one correspondence, sorting and categorizing, and learning the functions of objects and senses. This year he also learned to set a table place using a placemat jig, and he currently sets the table for his entire class at snack time, with 3 to 6 prompts. Recently simple cooking activities and dish-washing were introduced.

At home and at school, Leelo has been working on his computer skills. With an adapted mouse, he can click and drag to complete simple actions on the screen. He currently uses the TeachTown program at home, to reinforce computer skills and some basic vocabulary skills. He also plays simple leisure games which emphasize mouse skills. Computer has become a preferred activity for Leelo.

As his school program capacity has grown, Leo’s home program has been modified to emphasize more functional, life, and social skills. Leelo has learned to put away his clothes in the correct drawers, and is currently learning to fold them. He continues working on learning to play games and do craft activities, sing songs with actions, and to further develop his language and social social skills. His home independent work includes many open-ended activities, which he can play with for up to 25 minutes.

TOILET TRAINING
This year, Leo’s parents worked hard with Leelo on bowel training, and he is now mostly independent at toileting and washing up afterwards. He currently wears underpants during the daytime, and pullsup to bed. He typically has infrequent accidents at school (less that once per week). At home, Leelo has bowel accidents about once a week. He generally had been staying dry for about three months, but recently has had one to two urine accidents during the day.

Leelo does not yet consistently initiate toilet use, but is scheduled trained and will always use the bathroom when given a bathroom card or when taken. At school he can withhold urine for about 2 hours. He occasionally independently initiates toilet use at home.


BEHAVIOR
Critical to this progress has been Leelo’s improvement in behavior. Since his FAA (Functional Analysis Assessment, 3/26/07), Leo’s aggressive behavior (hitting himself and hitting others) at school has been reduced from an average of 8 episodes per hour (range 3 to 16) to 2 episodes per hour (range 0 to 5). Previous episodes at school often involved 5 or more hits to himself and/or others, plus an escalation in intensity. Current episodes are generally 1 to 3 hits, and his behavior does not escalate.

Appropriate Replacement Behaviors: Leelo has learned some key replacement and coping behaviors that address his needs to either escape from demands, get attention, or to get tangible materials (usually a straw). He has learned to request a break using a voice-recorder break button, and this month he has been verbally requesting a break without the button. He has mastered tapping adults to get their attention, and continues to work on calling them by name. With a “wait card” prompt, he can wait appropriately for at least 30 seconds in context. He independently transitions between activities with a name card, even when his behavior is escalated. He is learning to use headphones to enjoy music and also block out aversive crying, screaming, and other noises. He has learned to tolerate ending preferred activities, especially access to a straw, which he now consistently ends by counting to five and giving the straw back to the adult. And he has learned to play and work by himself, without adult attention, for up to 25 minutes.

Medication: Leelo’s behavior improvement is likely due in part to ongoing use of the medication Claritin since Spring 2007. His aggressive behavior had previously increased during the winter and spring, and he appeared to have headache pain (head hitting, rubbing, preference for forehead pressure); so there was some suspicion that he was suffering from allergies and sinus problems. This winter/spring of 2007-08, while on Claritin, Leelo has not experienced a long period of behavior escalation. [SNORT. Did I brag too much? Sigh.]

Problem Behavior Prevention and Response: In addition, implementation of other behavior plan interventions have been critical to his learning and maintaining appropriate replacement behaviors. Staff currently prevent behavior problems by using a range of strategies, including managing straw access, maintaining routine, using visual supports and reducing verbal instruction. Staff also teach Leelo replacement and coping behaviors, including waiting, requesting breaks, tapping or calling people for attention, and schedule use. Staff respond to problem behavior by prompting Leelo to use these more appropriate skills to meet his needs. The staff at Cielo Azul rotate within the class, so Leelo has had to learn to tolerate some variation in instruction. This is beneficial to Leelo, as long as all staff are skilled in his behavior plan implementation and instructional goals.

Visual schedule and prompts: Learning to follow a visual schedule has been central to Leelo’s reduction in aggressive behavior. Previously, Leelo was regularly aggressive during transitions, including transitions within a multiple-part activity. With the visual schedule, Leelo understands what is happening now, and what will happen next and later, and he appears much more relaxed and able to engage with this understanding of his day. In addition, visual prompts have been helpful in teaching Leelo to wait, and to walk together instead of running ahead.

Independent work: Engaging in independent activity has also been important in reducing problem behaviors. Leelo enjoys attention, and previously engaged in aggression and self-injury to get attention. In addition to asking for attention in more appropriate ways, it was also important for Leelo to learn to tolerate and enjoy his time alone, and to engage in activities without adult attention. His progress in this area has been wonderful to observe. Leelo is becoming self-directed, and independent. Most importantly, he appears to be enjoying himself in purposeful ways, and is now better able to participate in his family and school communities.

SUMMARY AND RECOMMENDATIONS
Leelo has made great progress in the past year. He has mastered skills which are pivotal to his ability to learn in a classroom and to function independently. The use of Applied Behavior Analysis (ABA) in understanding Leo’s problem behavior and learning challenges, in developing and modifying interventions, and in tracking his progress has been critical. Specifically, Leelo behaves more appropriately and makes progress when skills are taught in small steps, when reinforcement is consistently provided contingent on correct responding, and when data is collected immediately.

It is recommended that he continue to receive ongoing behavioral consultation at school and at home. His home program should emphasize functional living/self-care, social/ language, and leisure skills. Generalization to siblings, parents, and family friends should be the focus. Instruction to increase food tolerance is recommended. Classroom consultation should continue to emphasize implementation of Leo’s behavior plan; the use of effective instructional strategies to teach new skills and to increase Leo’s time actively engaged in learning across the school day. Opportunities for peer social interaction and group learning should also be increased.

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