Catching up

You’d think I’d be all caught up since R. went back to school on Monday, but it is not happening yet.   I’ve been on a mad reorganizing binge because R. has found her way into drawers and cabinets that she did not bother before.

I was quite surprised to find out we had a box of caps stowed away in a drawer.  I saw her with a box, and saw small bits of what looked like paper all over the floor.  As I walked over to investigate, I stepped on the paper and heard pop pop pop.  What a mess!

She also discovered the china my Grandmother gave me that belonged to my Great, Great Aunt.  In R.’s defense, she wanted to set the table with them.

She is finally sitting on the toilet with her pants and pull-up down.  That just started this week, and it is going a bit better than expected.  She only has to sit for four seconds at a time.  They want to phase out the counting, but give her a cue, so they say for a count of four, and then just say one and four.

We just got our new ipad today.  I haven’t had much time with it yet.  I know it will be yet another distraction…

Showing her how rewarding life can be

One of the reasons that people seem to get down on ABA, is the use of reinforcers.  I’ve heard it equated to animal training.   There is some truth to that analogy, and I’ve learned that is not such a horrible thing.

When we started ABA during early intervention, the program director spent a lot of time asking me and working with R. to determine what she really liked.  At the time, it honestly wasn’t much.  Other than balls or bubbles, she had a few stuffed animals she liked.  She liked watching Sesame Street, but Elmo and friends weren’t BFFs yet.   Naturally they wanted to use food items, and I bristled at this, but I compromised, and asked that they not use her meal time food as a reinforcer, only snacks and treat.  As worried as I was, the food reinforcers actually did not work that well.  She would quickly tire of whatever it was, and she was not always hungry.  She had sessions for 5-6 hours a day at that time.  If every therapist offered her snacks, there was no way she could eat it all.

The Program Director asked about using videos on the therapist’s Iphones as a reinforcer.  I said my only concern was that R. might be more interested in watching videos and cry when they were not available.   The PD said that if they were that motivating, they would do the trick.

The videos actually worked great.  R. was really motivated to watch them, and she quickly learned that she was expected to do something before she could watch one.  That sounds really simple, but there are really several things that the consistent use of a reinforcer taught her, even at that early stage.

  • There are things she wants that an adult has to provide
  • Her actions are directly responsible for getting her desires met
  • If she pays attention to an adult’s requests, and complies with them, she will learn the actions required to get what she wants.
  • She can wait for things she wants, even for a short time.

I know that there are some parents who think that children are praised, rewarded and bribed too much, granted these are generally NT parents.   So what is the difference between a bribe and a reinforcer?   The way I see it, a reinforcer rewards desired behavior after it is done.  A bribe rewards a behavior whether it is desirable or not before it is finished.

A good example is crying.  If R is crying and I know some gummies will make her happy, if I give her the gummies while she is still crying I am bribing her to stop crying.  I am also teaching her that the way to get gummies is to cry.   If I show her the gummies, and  get her to stop crying and say gummies and then give then to her, I am reinforcing her use of words.  I’m teaching her that yes I know what she wants to make her happy, but she has to use words to get it.  Crying doesn’t work.

Now R. is really in touch with the fact that she is expected to do something to get her requests met.  She is primed, waiting for a prompt to tell her what to do.  We have to be careful to wait to see if she will say the word spontaneously.  Sometimes I’ll tap the item, which is a mistake because she will copy my tapping, thinking that is the response I’m looking for.  Slowly but surely we are hearing more spontaneous words.

I think that we all respond to reinforcers and even bribes all the time without thinking about it.  It is really necessary to analyze all of the ways that we are reinforcing her behavior even if it is unintentional.   I gave R. a piece of colored chalk and a chalkboard and she scribbled for a while until the chalk broke.  She brought me the pieces, I assume she wanted me to put them back together.  I gave her another piece of chalk.  She broke the next one, brought me the pieces and I gave her a new piece.  I was watching her and the first two times it seemed like it was an accident that she broke the chalk, it broke while she was scribbling.  But the third time, she scribbled for a bit, and then intentionally broke the chalk in half and came to me for another piece.  Even though I had her say chalk each time, she had quickly come to the conclusion that breaking the chalk was the key to getting another piece.

I suppose that someone who is anti-ABA could argue that the faulty methodology behind ABA’s teaching has led my daughter to make incorrect generalizations.  But I really think that this is a reflection of how R. tends to generalize things.  She does not make the same connections that I would.  Her vision of cause and effect is limited, but with repetition and experience her skill in this area gets better and more functional.

Now she has the ability to understand first this and then that, as long as we are talking about something she understands.   This is really useful.  There are many opportunities to tell her if you do this, then you get that.   I am working on getting her to wait for me when she requests something.  She always wants me to drop everything and comply with HER request.  I’ll tell her first I’m going to have a sip of my coffee, then I’ll get you a cookie.

I also find that when she needs to do something new or different that she is aversive to,  if I explain it simply and give specific perimeters like counting- do this for a count of five, she is much more compliant.

Some people ask if ABA is constantly rewarding for desired behaviors, does the child spend the rest of her life looking for a reward for every task completed?   ABA does actually have a system of fading reinforcers and using a hierarchy of more and less motivating items depending upon the difficulty of task.    I’ve also found that while the therapists still use toys and food reinforcers, they also sing songs and do all kinds of silly games with R. that she likes.   She asks for these activities, so it is like her reinforcer is doubly rewarding – she is rewarded for completing her task, and she is motivated to do something social.

I don’t see R. becoming like a trained dog, looking to perform tricks for treats.  It’s more like she’s a social being in training.  She’s making her own study and practice (with our help) of how rewarding just the act of socializing is, and how crucial engaging with others is is to getting her needs met.   She’s also learning that while the world is filled with many unknowns,  there are also plenty of great things.

And another meeting

We had our monthly ABA team meeting yesterday.  R.’s teacher wanted to come with us, so we picked them up at school.   R. seemed to want to show me around the room, she kept bringing me over to different things.

She brought me over to the toy area, pulled out a play phone and held it up to my ear.  I think this is quite amazing because I’ve been trying to figure out how to teach her about the telephone.  Every time I call someone and get them to talk to her she looks at the phone as if it should have a screen, and usually hands it back.

The temporary classroom is smaller than their other room, there is no sink or bathroom.   The teacher said that they started taking the kids to the cafeteria for lunch and it is going really well.

The supervisor and one of the therapists were out sick, and the behaviorist had not seen the new IEP (yet to be signed, because I just got the final copy today.).  So there were a lot of things that did not get covered, but it was good to have the teacher’s input.

We talked even more about the manding progam, and moving beyond the word want and noun, to play, drink eat and more specific verbs.  It seemed to me like we were worrying the same bone as last month.  But the teacher and behaviorist were able to talk about the reasoning in detail, and I think that helped everyone.   The behaviorist wanted to make sure that enough time had been spent on one word mands, in case R. was thinking two word mands are just one long word.  She had the teacher and I list words we hear spontaneously, and thought there were enough to proceed.

The behaviorist said she observed during recess recently.  R. was playing a drum with some other girls (in the gen-ed glass)  She saw the behaviorist and approached her,  obviously recognizing her and showed her the drum.

The teacher said that she is teaching R. to tap her on the shoulder and say her name instead of tugging on her hand when they are seated together.  I saw this in action several times,  R. tapped the teacher on the shoulder and said her name!

Made it through the IEP meeting

I survived R.’s second annual IEP meeting.   I don’t have a copy of the final IEP yet, they are still working on it.  The meeting lasted two and a half hours, the time flew by until the last 30 minutes or so.

The most exciting thing to me is that R. is now going to be getting OT.   In addition to the class fine/gross motor group, she will get individual therapy – 30 minutes a week.  Our school district works on what they call a 3:1 delivery model for direct therapies like OT and ST.  This means that the students get therapy three weeks a month and the therapists work on consultations and preparation.   I was expecting to maybe get just the 30 minutes of consultation.  I still have to decipher the OT assessment, I’m sure I’ll write more on this.

Currently R. gets ST twice a week, once individual and once in group.  She is not taken out of class, and at this point I do not want her to be removed.  The ST works with her individually in the classroom.  The ST said that to work on R.’s turn taking and peer related goals she would bring another student into the individual session.  It sounded to me like she wanted to change the IEP to be twice a week of group therapy.  I told her that I did not have a problem with her doing what she described, but I did not want to change the wording in the IEP.  I said that next year I might want R. to be removed from class for ST, and this would leave things in place for that.   She gave me the strangest smile and agreed.

Last year at our first IEP I really fought for that individual session.  At this point I think it probably is better for R. to have peers involved in ST.   I don’t want that written into the IEP, because I don’t know that it will be the best way in the future.  At least I have that option to push for the individual session to be one on one if it seems necessary.

R.’s ABA was continued at the same level of hours until her next annual IEP.   Last year they gave her six months of ABA with a required addendum IEP meeting to renew.  I did not think they would reduce hours or discontinue service, but you never know.  It is a relief to not have to worry about that for a year.

This is the first IEP meeting where everyone who attended really knew R.  Even the general ed teacher knew R.   She did not stay for the entire time (I gave permission for her to leave, technically I could have refused, but there was no reason to.).  She did give some input about activities that could be done on the playground to help with turn taking and peer related goals.

Everyone was positive and had a lot to say about progress.  When she started preschool last March she was non-verbal and reliant upon PECS.  She was not compliant, was aversive to a visual schedule (despite using one at home).  While she is not talking as much at school as at home, she is definitely able to repeat words and has some spontaneous speech.  She complies with simple instructions, she will stop doing something or take her hands off.   She uses the visual schedule, can pick her name out and transition from activity to activity.

The teacher, gen ed teacher, OT and ST all said that R. really enjoys being with the other kids in her class and in the other classes.  The OT said she thinks R. prefers to do activities with her classmates than one on one with her.

I actually learned some things R. can do at school that I have not seen at home – she hangs up her backpack and jacket after removing them.  (I’ve only seen the removing.)  She can wipe a table with a cloth.  That gives me so many possibilities, starting with window washing this afternoon!

She can pick her name out of a field of ten, and the OT thinks she can write the letters in her name with assistance.   They added goals related to handwriting, letter, number and symbol recognition, and one to one correspondence.  Basically all the academic goals I thought should be added.   I asked about a counting goal and they said they thought she could count and they did not see a need for a goal regarding she could already do.

They did make the change to make the goal I wrote about into two goals.  One goal for initiating with peers and another for adults.  I also asked them to add the qualification in a familiar situation, so that if this gets mastered we can track if she can do this in a unique situation.   I also asked about a waiting goal and the teacher said that from her perspective she was happy with R.’s ability to wait.  She described how R. would line up against the wall with the other students and look at books while waiting.

She made progress on all of her goals except drinking from a straw and using utensils.   The OT really wants to work on using a fork.   I suggested that they we try using the fork as a play utensil, picking up putty or something she knows she does not have to eat.

I also saw the new temporary classroom.  The teacher said that R. transitioned to the new room without a problem.   It is smaller, they had to put the class trampoline in the hallway, much to the delight of students in all the other classes.

January ABA team meeting

We had our monthly meeting today with the ABA team.  One of my concerns is that R. is over generalizing the mand, want book.  She is saying want book for nearly everything she wants.   The supervisor thought that this was typical for R, and she’s right. R. does have a tendency to over generalize specific mands when they are first learned.  She also said that they are working on an object identification program that will help R. increase her vocabulary, and this should help.

R. will come to me and say want book, while she hand leads me to what she wants, which is rarely a book.  If she wants a cookie, I’ll say want cookie and she will only repeat the word cookie.  I know it is common for children with autism to repeat just the last word.  I do find I can get R. to repeat two word requests when they don’t contain the word want.

We discussed this for quite a while.   They suggested that when she says want book, we should give her a book, even if we know that is not what she wants.  Then when she refuses the book we should prompt her to say the correct mand.  We decided that we should limit our use of want, okay I pushed for this, but it wasn’t hard to get them to agree.    So instead of want cookie, I’ll say eat cookie, instead of want water I’ll say drink water, instead of want open, I’ll say open door.    They modified their mand program so they will work on eat cookie, play ball and want doll.

R. has started saying Hi spontaneously, mostly to inanimate objects.    She was cold so I put a sweater on her, she looked at it and said Hi, with the most joyous, glad to see you tone.  She said Hi to the water in her shower, to the box of cookies, to the new straw I put in her cup, always with that pleased as can be tone in her voice.   The behaviorist and supervisor thought this was a little weird, but cute.  The therapists said they thought it was typical behavior for  an early talker.

They are increasing R.’s sitting on the toilet to twenty seconds, up from ten seconds this week and last.  Her pants are still on while she is sitting.  We discussed the fact that she needs to sit for the entire twenty seconds with out any prompting.  They are giving her a reinforcer after sitting, and they wondered if they should give her the reinforcer while sitting.  I said that I would like to keep reinforcing her after sitting, until we get to her sitting with her pants down.   Then when we switch to pulling her pants down, she’ll also have the addition of a reinforcer while she is sitting.  They agreed.

R. has been doing jigsaw puzzles with the image on the background, so it is really matching.  They are going to start doing the same puzzles without the background.  I’ve been doing a jigsaw puzzle with her lately with no background, and she is starting to get it.   I think she has memorized the picture, but that is okay, at least she finds it interesting.   She’s bored with her insert puzzles, so I’m looking for other activities like that.  It’s like it needs to be a little challenging, but not too easy or difficult.

They are working on a new tracing program.  R. is supposed to trace a dotted horizontal line.  She needs a little bit of a prompt but she seems to like doing this.   I know she likes to have me hold her hand and we do dot to dots or write the alphabet.  The behaviorist wants me to stop doing that until she gets further along in this program.   It bugs me a little, but I do get where she is coming from.  We’ll do more coloring.

I finally asked about being provided a list, even a short one of activities that we could do with R. on days off and sick days.  She seems to be bored and looking for more to do on those days.   They said they could give me a list of the programs that were on maintenance, and seemed to think it was a good suggestion.

One of our therapists is leaving, Friday is his last day.   It happens all the time, but it always makes me a little sad, and he says he is too.  R. really loves him, I hear them both laughing throughout their sessions.

Gearing up for the annual IEP meeting

I confirmed the date for R’s annual IEP meeting.  We had an addendum IEP in October,  but this will be the first IEP with all of the current team present.  At next year’s  annual IEP meeting the decision will be made regarding kindergarten placement.  I feel kind of pressured to make sure that as many skills that she could possibly attain in regards to that transition are included now as opposed to then.

R.’s teacher and the general education preschool teacher have made changes to add mainstreaming and reverse mainstreaming opportunities during specific parts of the school day.  They are already integrated for all of their recess time.   Currently on her IEP, in the notes section, detailing the placement, it says there are opportunities for mainstreaming and reverse mainstreaming per teacher discretion.  I’m thinking of adding a specific goal related to mainstreaming, but I haven’t converted my thoughts into IEP-speak yet.

One of the things I’m learning from the classes I am taking is how to look at goals and see if they are attainable and measurable.  There’s a goal on R.’s IEP, under Developmental Skills R. will initiate with familiar adults or peers using appropriate eye gaze, body position, gestures or words as implemented by the Special education teacher, SPED staff, parents. It seems to me now, that initiating with adults and initiating with peers should be two separate goals.  The way the goal reads now, they may tell me that she has made 50% progress on this goal, meaning that 5 out of 10 times she initiated with an adult or a peer.  I know she initiates with adults at school and home, but with peers she rarely does so. If they are two separate goals the team will have to address and track her initiating with adults and peers separately.   She will have twice the programming and I’ll get twice the data.

Many of the goals in the Developmental Skills section are really pre-learning skills.  I’m sure she hasn’t mastered all of them, but I know from conversations with R.’s teacher that she is in agreement that we will be adding actual educational goals.   I would like to add a goal to this section about waiting.  I do realize that goals need to be individual, but I found this goal on the internet to at least get the idea started.   Will be able to follow an adult’s request to wait for her turn given materials to manipulate during the waiting period for two minutes. I’d also like to add a goal about playing with toys appropriately, and possibly a second one relating to playground equipment.

I’m searching for a book on this topic, suggestions are welcome.  But for now I found a simple article that outlines preschool IEP goals that is helpful.  I’m sure that I will be writing more about this.

She sits

Last Tuesday the supervisor adjusted the potty training program again.  Instead of sitting on my lap, she had R. sit on the toilet ten times for one second.   R. fought the first few tries but by the end, she seemed resigned to do as asked.  A new, never seen Elmo potty training sticker book helped.   I should also mention that she is sitting while wearing her pants and diaper.

She did well all week, and by Friday she was laughing when the therapist sat her on the toilet, like she found the whole thing hilarious.    This week the supervisor extended the time to five seconds.  The therapist places her on the toilet, and she has to sit independently.  We count to five.   That doesn’t seem like a long time, but it is just long enough that she has to willingly decide to sit there on her own.

I’m sure we will have to start over again once her pants and diaper are actually pulled down.  But for the first time I’m actually letting myself imagine what a diaper free life might be like.

Reading material- Art as an EI Tool for Children with Autism

Thanks to the library, I recently read the book  Art as an Early Intervention Tool for Children with Autism by Nicole Martin.   Ms. Martin has a younger brother with autism.  She was trained by a behaviorist as a young adult to work with her brother.  As an adult she is an art therapist working with people on the spectrum.

The first chapter describes autism.   If you are like me and have read tons of autism books, this chapter seems unnecessary.  She does offer good descriptions of scripting (echolalia), perseverating and stimming.   I think my favorite part from this chapter is:  Children with autism hear “no” a lot from adults; helping them find ways to express and develop their talents lets them say “yes” to themselves.

She discusses how humans seem to have a natural tendency towards making art, and reasons that there is no reason to think that people with autism would be any more or less interested in art making then their typical peers.   She also mentions that symptoms of autism such as hyper focus or tactile defensiveness, can make it appear that the individual on the spectrum is not interested.

Ms. Martin outlines what she calls basic assumptions that  she writes need to be understood before using art as an intervention tool.

The adult is not “fixing” a child’s artwork, but using art to “fix” parts of the child that can be best engaged using art

The art itself (the product) is not as important as gaining the self-discovery, experimentation, tactile tolerance and so on (the process) that is required to make it.

Skills such as imagination and creativity are worth rehabilitating in children with autism.

You must believe that creativity can be learned.

The author describes “good scribbling” (focused, contemplative, experimental, sometimes even chaotic) and “bad scribbling” (symptomatic). She provides some really useful illustrations and easy to understand descriptions of children’s art development using the theories of Victor Lowenfeld and Rhoda Kellogg.

The author gives a number of good tips to help a child with autism move beyond scribbling.  She suggests reinforcing any scribbling or attempts at art work, but to give extra praise and reinforcement to attempt that are the best, or exhibit experimentation and variety.

Visual supports are also another tip- drawing a circle or line on the page can help jumpstart a drawing.  When a child puts art tools in their mouth she suggests offering an appropriate chew item. (I can attest that this works).

She also suggests that the parent (or therapist) make art along with the child.  She offers the idea of copying what the child is doing.  I found it really useful that she says the parent should attempt to draw at the child’s level, and to model appropriate scribbling and early drawing.  She mentions that a higher skill level can fascinate and frustrate a child with autism.  This reminds me of what John Holt wrote in How Children Learn, about how children lost interest in activities in which he clearly knew more then they did.

Ms. Martin lists nine autism symptoms and the corresponding artwork characteristics.  It is an interesting way to look at it.  One of the symptoms is sensory issues and the characteristics are – use of materials for self stimulation, tactile defensiveness and art material’s impact on regulation.

She also lists six major goals for children on the spectrum that can be best addressed using art.   One of them is sensory regulation and integration.  She writes Some children on the spectrum get “stuck” in the kinesthetic feeling of using art materials and are slow to move into representational work.    Her suggestions are to become aware of a child’s reactions to different textures and to take control of art activities.  She also suggests activities that create artwork using the entire body like tracing and masks.  I would have liked to read more details about how to work with this.

The author details what she calls tools of the trade, describing paints and other art materials.  And she also gives tips for providing the optimal environment for creating art, what she calls a quality art experience.  She writes An individualized directive with least invasive prompt possible is my personal rule of thumb when working with a child with ASD.  She gives a very good and detailed description of prompt hierarchy, and shows her knowlege of ABA with suggestions for problem behaviors and reinforcements.

Reference: Art as An Early Intervention Tool for Children with Autism by Nicole Martin, (Jessica Kingsley Publishers, 2009) Pages 25, 30, 31, 41, 59, 73, 113

Echolalia is kind of cool for now

R.’s talking is about the same.  We’re hearing a few more spontaneous words.  She’s saying uh oh and oh with a variety of inflections in response to things, and we’re hearing yeah and no more often.

Mostly though she is repeating what we are saying.  In a few months I may be frustrated  with this, but now I think it is quite awesome.  It means that she will say hi and bye to people if they say it first, and she’s paying attention.   I’m discovering that there are so many kinds of games to play where I get her to repeat what I’m saying.  I’ll give her stuffed animals one by one, getting her to repeat duck or whatever.  We’re actually playing with flash cards.

E. is much sillier with her and they play these games echoing babble phrases.  He touches his forehead to hers and says “bonk” and she says bonk and they play a head bopping game.  I’ve been trying to put a stop to this game, imagining her head butting one of her class mates.   But I think I end up sounding like a control freak because they are having fun.

Right before Christmas vacation the behaviorist said she was not doing as well with two word mands, they are working on want book, want ball.   She suggested I work on it over vacation.  I did and did not have much luck with any mand that started with want, she would just repeat the last word.  She would however repeat two words for requests like lights on, socks off and that kind of thing.  I also noticed that over vacation her response seemed to be a little slower, I had to work a little harder at prompting.   I was wondering if I was seeing a regression.  Monday when she came home from school she was back to responding to a verbal prompt almost instantly and it has been that way all week.   I can’t help but wonder if this is a part of having vacations or if we could be doing something else.

She also has new sounds.  Her screaming has become more dramatic.  She has this new angry, tearless scream that is so loud and high pitched, it must get the attention of all the dogs in our neighborhood.   No one told me that her voice could get louder.   She also has a new happy sound, I guess it is really a vocal stim.  She sounds like Arnold Horshack’s little sister.   She makes this sound and runs around grinning and being mischievous.

What ever it takes

We are in the beginning stages of potty training, it is like we are in the training for potty training stage.    Starting in November, we spent several weeks just taking R. into the bathroom at the end of her daily ABA session.

The supervisor decided that the next step was to get R. to lift the lid of the toilet seat.  She wrote the program so that R. was supposed to open and close the toilet seat lid ten times in a row.   I stepped in immediately and said no way are you having her do that ten times in a row.  I mean talk about teaching a repetitive behavior.   It did not take too long for R. to master lifting the toilet seat lid once.

Sitting on the toilet is a problem for R., she does not want to do it at all.   If I want to get her out of the bathroom all I have to do is suggest she have a seat on the potty. (Maybe I should stop doing that).   The supervisor’s suggestion for the next step, is to have me sit on the toilet and put her on my lap for 30 seconds.    I did mention that this happens during R.’s ABA session.

So yesterday here I am in the bathroom sitting on the toilet with R in my lap, her male therapist watching and counting.   Counting out loud to 30 was the only way to get her to stop screaming and fighting.   To his credit, the therapist did not seem the least bit embarrassed or flustered.     I’m just going to have to get over it.