ABA Affordably on Demand: Rethink Autism

If you're at all familiar with ABA Therapy (Applied Behavioral Analysis), you know that you can use its anchor techniques of carefully planned positive feedback and reward/reinforcer systems to influence almost anyone's behavior. And that's what I wrote about at BlogHer this week (I hope people decide to use their newfound behavioral powers for non-nefarious purposes):

BlogHer: Using Behavioral Approaches in Autism (And on Anyone)

I also wrote about ABA therapy in general, why it can be so useful for helping children with autism learn, and -- most importantly -- a new way for autism families who want but normally wouldn't have access to an ABA program to bring it to their child: an comprehensive online program called Rethink Autism. As I said on BlogHer:

Rethink Autism creates a customized ABA curriculum for your child, provides hundreds of concise but thorough video-based lessons supplemented by printed lesson plans to teach you how to teach your child, allows automated scheduling so that you can coordinate with with your ABA team as to who's teaching your child what and when, and produces really straightforward data tracking and analysis. They even provide email curriculum support. This is a valuable and very well done resource, and I recommend it.

But here is something that I didn't mention on BlogHer, and which I think new, overwhelmed autism families need to understand: You can use Rethink Autism's many, many videos to learn how to interact with your child. If the integrated data tracking and scheduling is too overwhelming, then put it off until you're ready.

Instead, browse the topics -- which include motor skills and social skills as well as academics -- watch the videos and print the lesson plans, and start practicing those techniques with your child. Learning to communicate and motivate children with autism aren't skills that come naturally to many parents, and how-to manuals can only describe, not model. Video demonstrations, however -- those show exactly what to do. And if you need clarification, Rethink Autism provides email support. Once you're comfortable using the techniques, start incorporating the data tracking elements.

I've included some screenshots of the Rethink Autism interface below, so that you can see for yourself how well organized and planned the program is. I found it easy to use and the interface beautifully and gracefully designed. Click on the screenshots to enlarge them:

Individual lesson plan interface

Tracking data and team comments within a lesson plan

Video lesson interface: choosing steps

Video Lesson demonstration, including physical prompt

Regarding cost, as I wrote on BlogHer:

Rethink autism is also affordable. In fact the monthly Personal (as opposed to Organziational) subscription rate is less than one hour's time with a veteran behavioral therapist. While this is an incredible value, if it's still outside your family's budget, there are organizations like ACT Today! that help autism families fund their children's needs.

Rethink Autism provides excellent resources beyond its paid ABA therapy programming. It also provides free-of-charge resources for new autism families in its What Is Autism section, including a thoughtful Coping/Living With Autism area that reminds parents to appreciate and accept their child, themselves, and to act instead of reacting. There is also a Community section, in which Rethink Autism participants can ask questions of the staff and each other about issues and concerns.

Rethink Autism is a resource that the ABA therapy-using section of the autism community has needed for a long time: comprehensive, easy to use, and accessible by any individual with a computer, internet connection, and browser. I am grateful to the good folks at Rethink Autism for creating these tools, and I encourage those of you who reach out to or mentor families with new autism diagnoses to spread the word.

Disclosure: Rethink Autism granted me a few days of trial access, but I was otherwise not compensated in any way. What I have written above is my honest opinion, as it always has been and will continue to be in any reviews that I post in this space.

Leelo Team Meeting Report August 2009

Here are the latest whats and hows of Leo, from his most recent team meeting. Leo himself left for week-long sleepaway this afternoon. I am trying not to freak too much, or worry about the sniffly nose his camp nurse said was fine as long as he avoids a fever. I am also convinced he'll lose his first front tooth while he's away -- it was flapping in his mouth like a broken gate. I hate to miss that. The camp crew said they'd try to save it, if possible.

Leo’s Team Meeting Notes 7/30/09: Squid, Therapist V, Supervisor E, Supervisor M

Headsprout
Does about 15 min per session, needs prompting to keep on task and not click mouse randomly, working on consonant-vowel (CV) and CVC words and simple sentences.

ACTION: continue with adult facilitation (not independent work)

Pants
Pants up: working on buckling at school, next step-transfer skill to belt on waist; Leo now using briefs (not boxers)

ACTION: get mirror in bedroom to increase Leo’s ability to self-monitor and manage his own pants; be sure to slow Leo down when he is dressing so underpants are pulled up neatly first, then pants. Keep pants short (e.g. cuffs)

Eating Speed
Nice, steady improvement at home and school, except when very hungry- frantic, grabs food.

Update from Therapist V
Nice progress re: folding laundry, following directions w/traveling; getting attention using name, giving a play idea; walking- fading out holding hand.

Action/CAUTION: - Leo may bolt into street without clear warning/provocation, be sure to reinforce his walking beside you and be ready to grab him if he runs into traffic.

Action: next step for getting attention and giving a play idea- Leo needs to further expand these requests (currently fluent with tickles, hugs, physical play and affection); consider as next steps- requesting books and activities, using visual choice board prompt or the actual materials. (Therapist V, Therapist E, Therapist M, Squid and Seymour)

Behavioral Definitions/Approaches
Aggressive behaviors include: hitting, pushing, pinching, scratching, kicking, elbow grinding, head-butting others, throwing materials

Self-injurious behaviors include: slapping self on face and stomach, hitting head against surfaces, hitting hands against surfaces,

Precursor behavior: stomping

Responding to target behavior: (Therapist E and Therapist M modeled)

Aggressive: MOST IMPORTANT: EVADE (step back/away, do not approach or touch)

• “Stop” + visual
• “Sit Down” + gesture
• “Check schedule” +name card
• Leo transition to next activity +schedule icon

Reinforce Leo at end of this sequence if compliant.

Self-Injurious- prompt more appropriate replacement; redirect; ignore; remove straw if he is chewing/holding.

If blocking, do NOT make eye contact. In general, minimal eye contact when problem behavior is occurring.

Social interaction and play, and problem behaviors with siblings

Squid expressed concerned about safety, and is currently emphasizing preventing problematic contact, and keeping Leo engaged to reduce aggression;

Therapist M- Leo needs to develop a repertoire of positive ways to interact with Mali, Then, he needs to practice positive interactions with Mali at least 5 times as frequently as he is aggressive with her. So- if he hits her 3 times in a day, there should be at least 15 opportunities to practice some more appropriate way of interacting with Mali.

Leo also needs to be able to control himself (vs us managing his aggression by keeping him engaged, limiting his world to those environments that do not occasion aggression).

Supervisor M continues to recommend that Therapist V work with Leo to greet/hi-5 etc. Mali at least 5 times during their session, and that they do at least 1 table activity/game together, with Leo and Mali across from each other (e.g. try Eric Carle picture-imitation game), or an obstacle course (they have done this together in the past). If necessary, 2 adults can facilitate to ensure safety.

This activity should be a regular part of Leo’s visual schedule with Therapist V, so it becomes routine for Leo.

ACTION: Squid and Seymour to communicate with Therapist V, Therapist E and me around this, so that we can develop a comfortable plan for working to reduce Leo’s aggressive behavior at home.

Toilet Training
Next steps- Action: Squid elected to continue working on standing while peeing at the toilet at home and in other locations. Therapist M will facilitate at school.

ACTION: re-visit toileting initiations and night-time continence in 2 months.

Independent Work/Leisure at Home
Continue to manage materials- variety, novelty, high-interest, systematic rotation; and to do in various locations

ACTION: keep adult prompting to a minimum; if prompting is necessary (e.g. if Leo gets off task, needs help) , it should be a physical prompt or a gesture, and NO EYE CONTACT. (Therapist V, Therapist E, Squid, Seymour)

ACTION: store weekly supply in big bin- let Leo chose from these to set up own materials. Then rotate out each week. (Therapist M set up this week)

Visual Supports at Home
Family reports consistently using mini-schedule for 3-5 activities, or “first-then” situations, especially helpful when out of house, changes in routine, etc. Using mini-binder for storage (alphabetical).

ACTION: more name cards needed, and icons for going on trip (Therapist V, Therapist E)

ACTION: fade out picture on “snack” card to increase sight word vocabulary (Therapist E);
Put meals, snacks, and straws on schedule to reduce behavior problems (Squid, Seymour, Therapist V)

School Update
Therapist M met with new Teacher C and former teacher M to facilitate transition. It is likely one para from current class will move to Teacher C's class with Leo.

Leelo Status Report: Early June 2009

Yesterday began with a disappointment: The weather report predicted rain, which meant I needed to cancel the planned SEPTAR/families of kids with special needs picnic.

I had really been looking forward to bringing all our kids to a local park and taking it over, would not have entirely minded if the mommies and toddlers that usually dominate decided to leave rather than conceptualize my son and his friends, and had wanted to have a good, worry-minimized outing with all my kids, their friends, and my friends.

Instead, Signora Blog and her family came over for pizza and a rollicking good time, and we all watched the sky not rain. D'oh!

Leo's therapist, V, was here for part of the evening, but left at 7:30. All the kids were still tumbling like puppies in a cardboard box, and Leo jumped right in when SB's son Alfredo encouraged him to come jump on the trampoline. Leo. Playing. With other kids. For a long, long time. Watching them bounce and run made me grateful for just how beautifully Leo is doing right now.

We have documentation, strategies, and next steps for trying to keep that beautifully going.

Seymour and I met with Leo's two program supervisors on Tuesday (Supervisor M runs his program but concentrates on the school angle; she subcontracts Supervisor E to do QA and run the home program; the school district pays for both).

I don't know if it was the caffeine-fueled environment (I love you, Coffee Bar) or just how well Leo is doing at the moment, but we charged through a very full agenda with focus and results. Here are Supervisor M's notes, slightly modified.

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READING
Home/home program: Headsprout reading: computer phonics-based, to supplement reading instruction at school.

• Action: Squid and Seymour will do 30 day trial, consider purchasing 1st half of the program

Reading at school. Leo is only doing about 10 minutes of EdMark sight reading program each day, because Leo's teacher is the only one of the classroom staff trained in its use.

• Action: Squid and Seymour will request teachers to dedicate more time to teaching Leo to read, less time in unstructured recreational activities with no clear goals (indoor play, walks).

PANTS (and how to keep them up)
All agreed Leo’s body shape not able to combat the forces of gravity; solutions to be tried this summer:

• Dedicating time to teach Leo to better pull up underpants, then pants, using mirror for feedback
• Trying alternative types of pants (e.g. zipper and snap, briefs instead of boxer-briefs)
• Trying a belt
• Keeping pants cuffed so they don’t get pulled down from being too long

EATING
Further slowing Leo down when he eats; Supervisor E noticed great improvement, after not seeing Leo for five months; at school, trying to further slow him by having him chew for 5 seconds prior to drinking water; caution being taking to prevent Leo from becoming insistent/dependent on adult counting.

S: I would note that we have encouraged Leo to take a drink of water between bites, and to "take a small bite." He has made this part of his routine, and now asks us to repeat the quoted phrase before beginning to eat. He does continue to take the smaller and alternating bites for the remainder of the meal. Not sure if this is a negative; at the moment he's not capable of making his own meals and we don't leave him unsupervised around food, so an adult will always be there to give him that first prompt.

TOILETING
Night-time training; preliminary data suggests Leo withholding BMs in daytime and going in pullup on his bed; also suspicion that Leo is often dry when he wakes, and then wets pullup once awake if not taken immediately to bathroom; also drinking a lot in pool/tub- primes him for accidents.

• Action: Supervisor M will send out questionnaire this month for Squid & Seymour to complete, to gather more info, identify objectives, make a plan.
• Action: Squid & Seymour will resume the use of food reinforcers for spontaenous & successful BMs during the day.
  

AGGRESSIVE & SELF-INJURIOUS BEHAVIOR
Behavioral definitions of aggressive behavior and self-injurious behavior: review, revise to make sure we are all describing what we see the same way:

• Aggressive behaviors- have potential to injure others: hitting, pushing, pinching, scratching, kicking, elbow grinding, head-butting others, throwing materials
• Self-injurious behaviors- have potential to injure Leo: slapping self on face and stomach, hitting head against surfaces; hitting hands against surfaces;
• Precursor behavior: stomping

• Action: Supervisor E to review with Therapist V, Supervisor M to work with Squid to incorporate on google spreadsheet (see below), Supervisor M to incorporate clarifications at school.

HOME PROGRAM
Changing emphasis on home programming; shift towards quality of life arrangements, and away from precision programming more typical of intensive early intervention; in general, all programming should: increase access to reinforcement, reduce exposure to situations associated with problem behaviors.

Strategies generally include: using visual supports, maintaining consistency and routines while introducing variety and novelty in controlled, manageable ways, making most of periods of reduced behavior problems.

Squid & Seymour gave examples of how Leo is participating more in family and other activities that increase his access to “life reinforcements,” such as trip to the Maker Faire, hiking with family, kicking soccer ball back and forth with Iz and Seymour for about 10 minutes, playing with siblings on trampoline, took off with Squid to go hiking, stay in motel and swim.

Now is a great time to make the most of Leo's current low rates of behavior in terms of teaching replacement behaviors, social interaction skills.

Leo better tolerating Mali when she is crying, screaming; important first step for replacing hitting others with an actual skill/behavior; consider having dedicated weekly time for Leo to do specific activities with each sister.

Seymour: idea of having Mali participate by sharing materials with Leo, especially things he likes (e.g. getting him his straw, swimsuit to go swim, etc).

Critical to all of the above: repetition. Leo learns best with frequent, brief, repeated opportunities to practice. So:

• Action: plan regularly for soccer, or hiking, or other family fun.

INDEPENDENT WORK RESISTANCE
Squid & Seymour indicated Leo resistant to doing independent work, possibly due to boredom.

• Action: Supervisor M and Squid will create 6 bins of activities for Leo to do during independent time, possibly including “my busy kits” activities. Bins can be rotated weekly to prevent boredom. About every 2 months, consider adding new materials and toys to keep it interesting, varied, and fun for Leo.

VISUAL SCHEDULE
Important strategy for increasing independence, further increasing Leo’s tolerance for new things and changes in routines; Important to expand schedule, and increase Leo’s independent use of schedule, rather than fade it out. Keep in mind- we all use schedules, datebooks, blackberry/iphones to maintain our schedules too.

• Action 1: continue morning routine, switch “new straw” location, so Leo maintains flexibility around this
• Action 2: begin using schedule for evening routine or “witching hour”
• Action 3: next steps to increase independence- Leo should independently travel to schedule, and/or keep modified version of schedule on his person
• Action 4: Leo should set up parts of schedule in which there is some choice

GOOGLE SPREADSHEET
Revising the online google spreadsheet: make more quantitave for more effective analysis, also quicker to complete.

• Action: Supervisor M gave Squid sample of more ideal formatting, Squid will implement.