Her detailed notes should give you an idea of where Leelo is, what he is doing, what we are working on, and what his main challenges are. Hopefully there will be some helpful information for families facing similar scenarios.
Note: I observed Leelo in the classroom yesterday, and was impressed by how nicely he was thriving and learning in his well-run environment. Particularly amazing was his tolerance of multiple children screaming in his vicinity, as long as he was engaged and on-task.
He was still stimming and taking off shoes whenever possible, plus acting out whenever he didn't like what was going on. Though because of his extremely well-structured and 1:1 supervised environment, he did not act out very often. As mentioned below, we need to replicate as much of the class structure and visual supports as we can, in our home.
An important goal for Leelo for the past 2 years has been to increase his ability to access instruction in a classroom environment, and to reduce his need for highly individualized, home-based instruction. Since April 2008, Leelo has been attending Playa Azul School for a full day every day, and his home program has been reduced to 2 afternoons per week (total 4-6 hours). He adapted quickly to the longer school day, and the increased learning opportunities occurring at school. At school, Leelo responds to effective teaching strategies and increased learning opportunities in his daily schedule. Leelo is now mastering newly introduced skills at school, while continuing to generalize skills previously mastered in the home program. With Leelo better able to access academic instruction in the classroom environment, his home program has been modified to increase emphasis on leisure skills, independent living skills and chores. His home staff and family are working to integrate visual supports in the home. Leelo’s aggressive behaviors are managed with behavioral interventions based on his Functional Analysis Assessment, and with allergy/decongestant medication. Despite this, aggressive behavior continues to threaten Leelo’s safety and the safety of those around him. Compulsive, repetitive behaviors also interfere with learning.
BEHAVIORAL CONSULTATION FOR HOME ABA PROGRAM
- The main focus of the in-home component of Leelo’s program has been generalization of skills mastered in the school setting, maintenance of previously mastered skills and increasing Leelo’s repertoire of self-help and independent living skills.
- Independent Work: Leelo is able to work on 5 tasks independently for up to 30 minutes. Leelo requires (on average) 0-4 indirect non-verbal cues per activity to remain on task. In the past month, Leelo has begun to choose the activities and put together his work station with one verbal cue per activity. Leelo has also been observed to initiate cleaning up the materials with 100% independence. Next steps: have multiple areas around the home in which Leelo can access his independent work.
- Community Outings: Leelo and the staff working with him in the home go on walks around the immediate neighborhood each session. Leelo is able to put his shoes on with one visual cue. Staff working with Leelo use a visual cue (a picture card that reads “walk together”) to keep Leelo on task and safe. Leelo requires physical re-direction on average 2-4 times per outing. In an effort to increase Leelo’s independence out in the community and to decrease the need for physical re-direction, learning “stop” has been added to Leelo’s program. Instructional protocols for teaching Leelo “stop” include walking in front of Leelo, presenting both visual prompts (a picture card) and verbal cues to “stop” and reinforcing correct responses with social praise. When Leelo does require re-redirection during outings, staff use both physical prompts and the visual prompt to “stop”.
- Visual Supports: The importance of the use of visual supports for all individuals who come into contact with Leelo cannot be overstated. Use of visual supports increase Leelo’s independence and allow him to spend more time engaged in meaningful activities. Also, staff reports strongly suggest that use of visual supports decrease anxiety and the rate of target behavior.
- Functional Life Skills: Leelo has begun to work on setting a place for mealtime with decreasing visual prompts. Staff working with Leelo have identified that he would benefit from learning to make a snack. Increased skill acquisition in the areas of community living and independent work increase Leelo’s ability to function as independently as possible.
- Increasing Tolerance to Foods: A system for increasing Leelo’s tolerance to a variety of foods has been identified (see attached). Currently, Leelo is working on increasing his tolerance to hard boiled egg whites and oranges.
- Behaviors that have been given priority for intervention and behavior support in the home are hitting others, hitting self and repetitive behaviors. While antecedents can be difficult to identify and functions multiple, it is becoming increasingly clear that not being engaged in meaningful activities increases the likelihood that Leelo could engage in target behavior. In other words, when Leelo is actively engaged, he is less likely to engage in target behavior. High risk times for hitting self and others in the home are:
While on the computer (hitting self)
While attention is diverted to another person
When left alone or with no clear activity or task
In the presence of his siblings
- Repetitive behaviors are unpredictable and appear to spike in clusters. For example, Leelo was persistent in placing numbers on a Velcro strip. Staff blocked the behavior and then Leelo would not put numbers on the strip unless staff weren’t available to block multiple responses. The numbers were removed for a period of time and represented several days later without incident.
- Due to the complexity of antecedents and functions, it is important that staff working with Leelo understand those interventions that decrease the likelihood that target behaviors will occur (e.g., use of visual supports and increased engagement).
Emphasis has been on increasing staff use of effective instructional strategies to reduce Leelo’s aggressive behavior and increase appropriate behavior and learning. Previously, Leelo was unable to access instruction in noisy, busy classroom environments. As Leelo’s staff further develops their expertise in teaching Leelo and managing his behavior, the SDC classroom has become the main setting for academic instruction.
Using contingent reinforcement and multiple repetitions: new skills
- Leelo’s teacher currently uses contingent tangible reinforcement paired with praise when teaching new skills. That is, Leelo is praised, and earns short periods with a preferred toy or straw for correct responses. In addition, Leelo is presented with 3 to 5 repeated, consecutive learning opportunities when learning new skills. These 2 strategies are effective and essential for teaching Leelo new skills. Leelo works on new skills during 7-8 minute work-with-teacher times. Examples of skills taught during work-with-teacher include sight-word recognition, one-to-one correspondence, and receptive and expressive labels for emotions. In addition, Leelo’s teacher consistently tracks Leelo’s practice and progress on skills. Mastered independent skills are moved to work-station, so that additional new skills can be introduced. Next steps: Para-educators should be trained to introduce new skills to Leelo during work-with-teacher time; increase work-with-teacher time from 7/8 minutes to 12 minutes per session, at least 2 sessions/day; add social and conversational skills to work-with-teacher time.
- Using effective strategies for maintaining mastered skills
Increasing food tolerance
- At school and at home, Leelo is working on tolerating an increased variety of foods. In both settings, Leelo can put oranges and scramble eggs to his mouth and lips, and is now working on putting them in his mouth. A protocol for introducing new foods has been developed (attached below). Leelo’s parent, classroom staff, and OT work together to coordinate instrution.
- At school, Leelo follows an individualized visual schedule. He has a morning schedule and an afternoon schedule, each with about 10 activities listed.
- The schedule, made with Boardmaker software, vertically displays text (3/4 of card) and a small icon (1/4 of card) beside the text. A name card cues Leelo to check his schedule.
- Upon arrival at school, Leelo typically receives the name card from the bus driver; this was begun to prevent dropping on the floor of the bus when disembarking.
- With the card in hand, Leelo knows to walk to class.
- He checks his schedule by scanning the entire morning’s schedule.
- Leelo consistently checks his schedule when handed a name card, and also independently requests his name card when finished with an activity.
- He consistently transitions to both preferred and less-preferred activities using the schedule.
- He occasionally requests a different activity in response to a less-preferred e.g. in response to circle time he may say “I want recess”, but is able to tolerate the less-preferred activity with a “first circle time, then recess” prompt.
- Next steps: fade out icons on most familiar activities, to increase sight-word recognition.
Leelo independently works on 6 consecutive tasks with 2 to 5 prompts on average. Each work-station session takes between 5 and 15 minutes, and occurs 2 to 3 times per day. Tasks include chore-type (e.g. sorting silverware), academic (matching sight words to pictures, writing name), and leisure (listening to music on headphones, reading story to self). Staff assist Leelo physically if necessary, with little or no verbal interaction. Staff also keep busy with other jobs, to reduce Leelo’s dependence on them during this independent work time. Next steps: rotate work-station location/have Leelo travel to get materials himself; increase emphasis on leisure skills and open-ended tasks (e.g. toy play); increase time spent on work station to 15-20 minutes; consider using choice board so Leelo can help decide which tasks to work on; train all staff to use non-verbal prompts
Aggressive behavior: hitting self, hitting others
At school, Leelo’s aggressive behaviors averaged 4 times per hour this quarter, with a range from 0 to 8. This is an increase from 2 times per hour from last quarter. In general, he hits himself more often than he hits others. At school, hitting self and others most often appears to function to escape demands/noise (other children screaming), and to gain access to preferred tangibles and activities (usually a straw, or outside time). Less frequently, Leelo appears to use aggression to get attention. Occasionally aggression appears to have a sensory function.
Further understanding aggressive behavior for Leelo:
Aggressive behavior increases when he is sick or has physical discomfort (e.g. cut or scrape).
The frequency of aggression may vary across time within a day, as in the graph on 5/1a and 5/1b; during the first hour of observation Leelo hit himself and others 8 times, and during the second hour there was no aggression.
Aggression does not correlate with time of day at school, as Leelo may have a calm morning and have increased aggression in the afternoon, or vice versa.
Aggression does correlate with activities: Leelo continues to have highest likelihood of aggression during circle time, recesses lasting more than 10 minutes, and motor/sensory room periods.
Aggression increases when staff use loud, and/or lengthy directions when working with Leelo, and when staff respond to aggression by giving Leelo a straw or another reinforcer.
Replacement behaviors: requesting a break;
When a break card is visible, Leelo can consistently, verbally request a break from work-with-teacher. He is beginning to request a break in circle time. Next steps: staff should consistently honor Leelo’s request for break during circle time; during work-with-teacher, staff should have Leelo do “1 more”, and then give him a break; breaks should be brief (1-2 minutes), and should entail Leelo leaving the work/circle area, sitting at a desk, and completing a small puzzle; Leelo should return to work after his break is over.
Repetitive behaviors: These may interfere with learning, and sometimes lead to aggressive behavior. Included are: repeatedly sliding finger on surfaces such as the computer screen, desk, visual schedule, and floor, repeatedly matching the numbers on the independent work station activities, and bending the visual schedule cards. These behaviors appear to lessen when Leelo is blocked from performing them, or when the antecedent for the behavior is removed from the environment (e.g. removing the matching component to the independent work).
Straws: Leelo continues to request, chew and manipulate straws as a preferred material. Prolonged time with straws tends to lead to aggressive behavior, and interferes with learning and speaking. On average, Leelo has a straw about 40% of the time when at school. Straw use varies between activities. During work-with-teacher, straws are used as reinforcers for correct responses, for brief 3-5 second intervals. During recess, straws appear “custodial”; something for Leelo to play with during often extended (20 minutes), unstructured time.
Increase rate of engagement throughout the day: Data suggest that Leelo is more productive and engages in lower rates of problem behavior when he is engaged.
Increase use of visual supports across all environments. It is critical that all individuals who come into contact with Leelo increase their use of visual supports. Those who are not fluent in the use of visual supports would benefit from ongoing training and feedback in the use of visual supports.
Track mastered skills for maintenance
Increase work-with-teacher time; have paras as well as teacher implement this
Emphasize training across all staff, to increase consistency in use of effective strategies
Reduce straw use and increase engagement during recess
Ongoing feedback from school staff regarding skills that are ready to be generalized in the home.