Leelo Rosenberg’s Program Update 2/05/08

Leelo Rosenberg’s Program Update 2/05/08

By Supervisor M
Data inclusive from 9/15/07-12/31/07.

This quarter Leelo achieved many important learning milestones. Most significantly, Leelo learned to check a visual schedule to transition between activities. He also learned to play independently for over 10 minutes, switching to news toy when he was finished with the previous ones. Leelo became familiar with using headphones to listen to music. Leelo now enjoys hearing up to 10 minutes of his favorite music on CD using headsets (I-pod, here we come…). Leelo also learned to tap people when he wants to get their attention. All of these new skills are either aggression replacement behaviors or coping skills, and are critical to reducing Leelo’s aggressive behavior.

With this reduction in aggressive behavior, Leelo was able to master other new skills at home, and continue to make progress on other skills. Leelo mastered about 20 discrete skills in ABA therapy, including social questions, sorting, and introductory phonics. He has also made wonderful progress on more complex involved skills. He began the Edmark Reading Program, a sight reading program, to complement phonics instruction, and he has successfully completed the first, pre-reading section at home and at school. He also learned to set the table, and to sort his laundry and put it into drawers. Once he can fold it- he will be ready to teach his sisters. Despite an increase in accidents during the holidays, Leelo also continues to make progress on toileting, and is now in underwear all day long and using the toilet at home, school, and other environments for urine and bowel movements.

Importantly, so far Leelo has not had a marked increase in aggressive behavior this winter, as he has had for the past 3 winters. Leelo’s team suspects the Claritin, as well as his newly learned replacement behaviors, are responsible.

Bittersweet news: Therapist L, who has been Leelo’s home therapist since he was just shy of 3 years old, will be moving on from Leelo’s team at the end of February. Therapist L has been the bedrock of Leelo’s home ABA program, responsible for everything from teaching Leelo, to data collection and graphing, to material preparation, to running ABA sessions from a swimming pool in Kauai, and even massaging his feet with lotion. I think I can speak for us all when I say she has brought such expertise and good spirit to Leelo’s team. We are so grateful for all that she has shared with us over these years, and I’m sure she will shine at whatever she choses to do next.

The team has agreed that this is a good opportunity for Leelo’s school to take on more ABA-based instruction of new skills, and for Leelo to attend school for a full day. The past 2 months have been spent developing and implementing a transition plan to prepare everyone.

Program Data Summary: Based on research in skill mastery, for all programs, mastery criteria is 90% correct on 2 consecutive sessions, unless otherwise indicated. Previously, a criteria of 80% for 3/5 sessions was used. It is felt that the current criteria is more stringent, and will result in better learning.

GREETINGS: No change. Leelo continues to be fluent at independently saying goodbye, in response to other’s saying bye in a variety of ways, e.g. “I have to go now”, “see you later”, “bye”. For “Hi/hello”, Leelo consistently says “hi” in response to greetings/waves with a 2 – 4 second time delay. If the greeter waits, Leelo will greet back. Instructional strategies: It is essential that everyone in Leelo’s life wait for 2 to 4 seconds after greeting him, before prompting him. Please DO NOT prompt Leelo by saying “what do you say” or “say Hi to X”, as he is relying on these cues. The greeter can prompt Leelo by getting close to him, securing eye contact, and waving along with the greeting, and if necessary- limiting distractions and straw access.

MULTIPLE STEP IMITATIONS: SONGS AND HAND-CLAP GAMES: This quarter Leelo began learning to imitate sequences of actions from preschool songs, and hand clap games which are popular with his age mates; while he has historically had difficulty with finger plays since preschool, he is highly motivated by the music. He has mastered (5)Ram Sam Sam, Twinkle Twinkle, Itsy Bitsy Spider, Head Shoulders, and Down Town Baby (hand clap game); he is currently working on the Hokey Pokey. Next Steps: continue with age-appropriate songs and simple actions. Generalization: practice at school and with family and friends at home.

2-STEP IMITATIONS WITH OBJECTS/PLAY SEQUENCES: Current prompt level: verbal instruction paired with 2-step imitation during preferred play activities (e.g. trains, teletubbies); Generalization: practice with wider range of materials, at school, with siblings.

LAUNDRY: This task evolved from sorting and putting clothes into correct drawers, which are mastered. (2)Leelo is now learning to fold shorts, and put them into a drawer. Next step: fold pants, shirt, match and roll socks; multiple step- fold and put away.

SETTING TABLE: Mastered setting cup, plate, napkin, fork, spoon, and knife using placemat jig at small work table (1). Currently doing as independent work station task, and in school with modified table setting for up to 6 place settings (cup, plate, napkin). Next steps and generalization: practice at home at dining table. Practice prior to dinner, for functionality. Set 4 places. Fade out placemat jig.

COUNTING/ONE TO ONE CORRESPONDENCE: Instructional strategy currently modified as follows: point and label 5 stickers/ pictures on strip, coordinating pointing with label. Next steps: Once mastered, replace stickers with numerals; eventually return to count objects.

FUNCTION OF OBJECTS: answering the questions “what do you do with a X?” and “what’s a X for ?”. Mastered (6): toothbrush, cup, book, scissors, crayons, chair. Currently working on piano. Next steps: continue learning the functions of objects; later work on the senses in the same way (e.g. what is a nose for- smelling). Generalization: practice at school, with family;

RECIPROCATE INFORMATION/COMMENTING: ON HOLD, due to lack of live models; will consider introducing at school instead; Generalization: practice observing and commenting on what people are doing around the house, at school,

ASKING SOCIAL QUESTIONS: Mastered (5) answering “how old are you?” ( 7), and “when is your birthday”. Mastered answering AND asking back “what’s your name”, “how old are you?”, and “how are you” (although Leelo confuses these 2, so they are never asked sequentially). Next steps: continue learning to ask more questions following giving a response to a question. Instructional strategies: if necessary, use visual cue with 2 squares, to indicate when Leelo should answer question, and then ask question. Use video model to support skill once he is using it with about 50 % proficiency. Generalization: practice mastered skill with family, on play dates, at school with staff, peers.

FOLLOWING DIRECTIONS/TRAVEL AND TRANSFER INFORMATION: No change, due to lack of practice opportunities during therapy. Discontinue during therapy, and emphasize instruction at school and with family. When given a direction to do so, Leelo is working on traveling to a person who is out of sight, to tell them something/make a request. Generalization: Practice traveling and transfer of info directions with family, peers, at school.

WAIT: (1)In therapy, Leelo can now wait at least 45 seconds for something he wants, when shown a red “WAIT” card. Practice occurs in real life contexts. Leelo also responds with appropriate waiting behavior when shown card in non-therapy contexts. Next steps: continue to increase wait time in dtt setting, up to about 45 seconds. Begin to practice in response to a request- when Leelo really wants something. Generalization: wait cards should be available to all people who spend time with Leelo, and should be used to cue him to wait appropriately. Leelo should be reinforced with tangibles/ whatever he has requested for waiting appropriately in all settings.

PHONICS/BEGINNING READING: Currently working on Jj. Leelo has mastered the sounds for Aa Bb Cc Gg Hh Ii Ll Mm Pp Qq Ss Tt Ww Yy Next steps: continue introducing single letter sounds. Begin consonant-vowel-consonant (cvc) blending, introducing very DIFFERENT words (e.g. sat and mom). Similar rhyming words which are traditionally introduced together (e.g. cat, hat, rat) previously confusing for him

EDMARK READING: Begun at home and at school; initial pre-reading section completed and skills mastered; currently working on discrimination test; Generalization: practice sight words by labeling around home and school environments, and creating sight word matching and labeling activities (e.g. folder tasks).

FINE MOTOR SCISSOR SKILLS: Cutting thick square shapes (turning paper while cutting); Leelo attending to lines, and self-corrects when he veers far from the line; Instructional strategies: while wrist weight was discontinued, staff felt Leelo’s skills NOT as good; continue with wrist weight;

FINE MOTOR WRITING: Leelo currently working on Letter L; Instructional strategies; OT recommends tracing shaded lines, rather than dotted lines; emphasize diagonal lines;

COMPUTER LEARNING: Teach town (numeral identification) and PBS games; current goal to click, and to drag interspersed as separate skills; Generalization: Leelo also working on computer use at school, and with family

TOILETING: Currently dry when reminded to use toilet every 1.25 to 1.5 hours; generally compliant to go to bathroom at home and at school; bowel accidents reduced to about 1 per week prior to holidays, with increase in accidents during the holidays Next steps: Increase Leelo’s spontaneous initiations to use the toilet by reducing verbal prompt, using visual cues when necessary. Instructional Strategies: Use photo prompts for Leelo to state need to use toilet, and to initiate going to the bathroom, continue to reinforce with straw or other preferred, but no need for chocolate/most preferred; stay out of Leelo’s visual field while he is using the toilet.

BEHAVIOR: REPLACEMENT and COPING SKILLS: Most importantly, in contrast with the past 3 years, Leelo is not having a marked increase in behavior problems this December or January; during the holidays, his family reported an increase in aggression in general, and especially towards his younger sister during the holidays, which has currently been reduced again; At school, Leelo is observed to hit himself or others between 0 and 8 times per hour, with an average of about 3 times per hour. Most observed aggression functions to escape from demands, with some aggression occurring to access straws. When he is sick with a cold, aggression increases across all functions. Leelo has a tendency toward compulsive repetition of behaviors, such as flushing the toilet, leaning his head back to look up and side to side while seated, and repeatedly dropping and picking up straws. This is currently being managed by blocking the behavior and generally redirecting him to prevent or delay him from repeating the behavior. The following are Leelo’s progress on replacement skills that help Leelo to better meet his own needs, or on coping skills that help him to tolerate the demands of everyday life.

INDEPENDENT WORK TIME (Leelo time) Leelo has increased his attention span while working alone, and is now able to attend to 4 activities for about 10 minutes. He is able to do open-ended activities (e.g. playing with an instrument, rolling in the body sock) and to transition independently to the next activity when he feels finished with the open-ended one. When Leelo is completely finished, he approaches his therapist to tell her that he is all done, or that he cleaned up. Next steps: continue to increase variety of tasks and length of time and number of tasks Generalization: Leelo is currently doing independent work at school using closed-ended tasks; Leelo should do independent work with family at home at least twice daily.

REQUESTING AND TAKING BREAKS: After introducing a pre-recorded break button, Leelo now independently presses the button to request a break, often echoing the request “Can I have a break?”. He is directed to sit on the carpet, and chose between two enjoyable activities. When he is done, he is beginning to independently put the toy away, and tell Therapist L that he cleaned up. He continues to have behavior problems when he feels finished but has not been directed to clean up. Next steps: increase frequency of practice; when pressing button independent in all situations, then fade button to increase verbal request or break card exchange. Generalization: Begin practice taking breaks at home and at school, using break button

TAPPING AND CALLING PEOPLE BY NAME: Tapping people is mastered at home and at school. Continue working on calling people by name. Generalization: continue practice with various people in all environments.

PICTURE AND TEXT SCHEDULE/PROMPT CARDS; Mastered in ABA therapy and at school. Leelo also requests “check schedule please” if he finishes an activity at school, and is not handed a name card. He is beginning to use his picture schedule occasionally when with a babysitter. Next step: Fade use of name cards, so that Leelo is completely independent of adults in knowing to check his schedule whenever he has finished something and is not sure what to do next. Begin using schedule with family. Generalization: Leelo should use visual cues in all environments.

WEARING HEADPHONES: This quarter, Leelo has progress from 5 seconds to up to 10 minutes of listening to preferred music CDs at home. Instructional strategies: continue to increase time and vary music and/or stories on CD; begin practice at school; NEXT STEPS: teach Leelo to operate CD player; offer as break choice, or independent work station choice;

MANAGING STRAWS: During ABA therapy, Leelo receives a straw as a reinforcer for good work for a brief (5 sec to 30 sec) interval as a keeping straw use brief (10 seconds to 1 minute); Generalization: At school, staff are working on using straws as reinforcers for good work, and on limiting straw access to brief intervals of less than 3 minutes. having Leelo earn straws as a reinforcer for good work;

CALMING/RELAXATION ACTIVITIES: Leelo’s need for calming activities has been reduced, as his aggressive behaviors are at lower frequency and intensity, and he is healthy. In general, the following calming activities are used as needed: massage with lotion, obstacle course, ambient background music, pressure on his forehead and cheeks (sinus area).

NLP, SPONTANEOUS LANGUAGE, REQUESTS: (S=spontaneous, P=prompted/modeled) Exciting new language includes use of newly learned words to describe emotions and feelings, eg: Leelo has recently been dancing around saying “I’m happy” with a huge grin on his face. Leelo continues to use vocabulary which he has learned from the natural environment (e.g. “I’m thirsty”). His negating of things he actually does want is recently not as pronounced. He continues to tag please on to most of his utterances. Next steps: increase spontaneous language opportunities in the classroom
S- I’m happy (thirsty, sleepy)
S- Want to go downstairs and see mommy please
S-Help me please
S- I cleaned up
S- I want to play body sock
S- No french fries (example of negating when he really DOES want something)
S- Its on your head, please.
S- Take off the bracelet, please.
S- Sunny (the cat) is coming
S- Here comes Annie (during play with trains)

MEDICATION and HEALTH: No change: Leelo has generally been in good health this autumn and winter. He has taken Claritin daily, as recommended by his pediatrician for sinus congestion, and his team suspects this may be contributing significantly to his maintaining appropriate behavior throughout the winter season. He continues to take a daily dose of cod liver oil. His food preferences remain restricted, generally including bananas, pancakes, croissants, pretzels, and peanut butter sandwiches.

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