Behavior is back in town

I kind of knew that when they said she had no behavior issues at our IEP meeting last month that it was just a matter of time.  Now we have some new behavior issues.

Just last week she started to hit E. and I when we tell her to stop doing something.  Sometimes she will say R. no in a snotty voice and then she will try to hit us in the face.

She is really insistent about it too.  When I stop her from hitting me, she will get really mad and cry and follow me around until she can get in a smack.  She wants to hit our faces, she is tall enough that she can just about reach mine, but she has to pull E. down to reach his face.

She did it for the first time in school, she smacked an aide in the face.  Of course it had to happen during the time she was mainstreamed.  The teacher said that it has been going perfectly up until today.

She has also been running away at school.  Once she ran off when they were walking from the bus, and she ran from the cafeteria towards the SDC Kindergarten class.  The teacher said she got a look in there (it is right across from her classroom) and has been obsessed with gaining access since.

We discussed it with the behaviorist.   Regarding the hitting, we are going to make sure that we stop her before she hits us.  We will try not to use words like no or don’t, and phrase our requests in a positive way.   We are also going to say nothing when she is trying to hit us, so it does not become a power struggle.

They are going to work on teaching her to respond to the word stop, which I know she can do, just not consistently.   I asked if she could have a chance to explore the kindergarden class, to just get it out of her system.  She is very curious about new things.   They are also going to work on having her ask to leave the group.

R. was really prickly last week, and still is but not as much this week.  I was wondering if she was getting sick or if there was some cause for the changes.  This all started last week.

I also wondered if it is a developmental thing.  Maybe she is just becoming really aware that we are telling her what to do, even nagging from her perspective.   There was a time when she did not listen at all because she did not have the receptive language.  When she had the receptive language she began to follow instructions.  Maybe now that she has been doing that a while she is thinking about it more.

I know that hitting is not appropriate behavior, but I can’t help but be amused at her reaction after the fact.

I think that the running away at school is similar.  I’ve noticed when we go to the zoo recently that R. really seems to know her way around and she is asking to explore areas we have not seen.   (Usually because there is no stroller access, and she is walking holding my hand).

Maybe she never really noticed there was a classroom across the hall, or had the ability to think about how to get there when she was in another part of the building.

I certainly hope this is just a phase.

The many gifts of the ipad

There are so many things that R. has learned that can at least be partially attributed to the ipad.

She started to point purposefully after she learned to use it.  I’m sure the ipad is not the sole reason, but it seems to have helped.

Her receptive language has increased and it seems like she is picking up words (especially labels) faster and with less trouble generalizing.   I know that school and the techniques the ABA therapists are using deserve the most credit.  But I also know that the ipad is helping to reinforce these words -pun intended.

I think it also has helped with her auditory processing, she is pronouncing some words better.  I suspect it is because of apps like Bob Books, where she can hear the phonetic letter sound as many times as she wants.  She is touching the letter, seeing it and hearing a sound.

I have posted about how her youtube video selections seem to mirror what is happening in her life.   She will finish with her ABA session where they were working on the prepositions on top and under and go to youtube on the ipad and find Sesame Street videos that are teaching the same concepts.

She has stopped playing with her spit on the window (big hooray for that one!).  I really think it is because she can get that same sensation from the ipad.

She is writing letters, numbers and shapes.  She asks me to show her how to draw things -shapes and letters.   Of course they do this in school, and I give her teacher plenty of credit for helping to teach her these skills.  But I think that the ipad helped her focus in a way she could not before, and those positive experiences give her confidence and motivation.

She doesn’t have to to it all the time, but she will share the ipad with a friend, and even negotiate turn taking.   I never thought about the ipad as something that she could do with a peer, silly me.  They seem to do it themselves quite naturally.

 

Words, they are coming

R. is having her first real language explosion.  This is the first time in her whole life I feel like I can’t quite keep track of all the new things she is saying.   Her language is still a far cry from a typical four year old, but for us it is amazing and wonderful.

Mostly she is speaking in 1-2 words requesting (manding) things.  She will spontaneously say what she wants, and if we don’t respond right away she will repeat herself over and over again, and then point at the item and give me a determined look.  She is doing a lot less hand leading, it is like she realized she can get us to do what she wants with her other methods.

It is so interesting to me, I’ve been working for years now on increasing the exchanges (circles of communication) between R. and I.   For so long it was mostly gestures and facial expressions that we were exchanging, I guess I thought that when talking was the main method of communicating, it would decrease the number of circles of communication- because talking is so much more efficient, and R. is not able to really converse yet.   But I’m finding that while it is certainly more efficient to have R. talk to me, we are actually closing way more circles of communication during our exchanges.  She looks at me to see if I am paying attention when she speaks, she keeps looking back at me to see if I respond.

She is also doing a lot more labeling, she hardly did that at all before.  It seems like anytime she sees something she recognizes she labels it and seems so pleased with herself.   We were at the playground and some adults were riding bikes just outside the fence.  She said bicycle, bicycle clear as could be and ran to follow them.

R. does not seem to have the same problems with over generalizing that she did a few months ago.  I think the behaviorist was correct to say that increasing R.’s receptive language would help her generalizing abilities.   Sometimes she comes up with the wrong word for something, but it is different, I can usually get her to say the right word with repetition.  But I do have to figure out what she means first.  She was asking for peacock, so I showed her pictures.   Later, I gave her some peas to eat (she likes to eat them frozen out of the bag) and she got all excited saying peacock peacock.   I only had to model the word pea a few times until she started asking for pea instead of peacock.  I also don’t think she exactly understand what it means when someone says ow.  She bopped me on the head with a toy, and then rubbed my head and said ow R.

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.

Writing the Family Rule Book – Rule #1

I keep getting annoyed at E. because he won’t follow what I consider to be a simple rule for disciplining and communicating with R.  He told me to write a rule book, so here goes.

When giving R. an instruction, (An instruction is any time you are telling R. to do something, whether it is regarding misbehavior or not.  Sit down, come here, put down, are examples) only repeat the request twice.  After the first request, if she is not complying, move towards her, and repeat the request a second time when you are a hands reach away, if she does not comply after the second request, physically force her to comply.

So it looks like this:

R. is jumping on the couch.
I say Sit down, wait a second or two and move towards her.
She continues jumping.
I’m standing in front of her and I repeat Sit down and physically sit her down.

I’ve been using this method since R. was 18 months old, before we knew about the autism.  A Mom in my typical Moms group suggested it because she was tired of yelling all day.  In the beginning I was careful to use commands that told R. what she should do – sit down as opposed to what not to do – stop jumping.  It doesn’t matter as much any more, she seems to understand.  But what is the best part, is when I use this method I almost never have to say the request twice.  As soon as she sees me moving towards her, she will usually comply.  She does test me a lot, she’ll wait until my back is turned and start jumping again.  But that kind of testing seems like a good thing to see in a child with autism, so I try to be patient.

This can be an annoying method, because it means I have to stop what I’m doing to follow through.  I have to be consistent, especially regarding discipline.  But it is really worth it, she listens to me and to her teachers.  She also listens to E., but she would listen even better if he would be consistent about forcing her to comply.

I don’t mean to imply that E. is not cooperative in general about working with R.  I think that it has become one of my pet peeves to hear someone repeat things endlessly to her.

Encouraging Communication – What’s working Part 2

Play skills are directly related to communication abilities.

One of the first things that our first ST told me was that developing play skills is crucial for early communication.   I would like to understand the hows and whys better, but I have seen that as R.’s play skills increase so does her ability to communicate.
In the beginning I felt like I should always be working on something with her.  I’d talk to her constantly, follow her around reading books, doing all kinds of things that did not hold her interest.   One afternoon I just started with what she would like to do – I chased her, and she loved it, she engaged with me and was smiling and laughing.  I realized that although it did not seem to have anything to do with encouraging her to talk, our play was a step in the right direction.

R. like many children on the spectrum only engaged in exploratory play.  She would shake, hit, throw, mouth and examine toys.  Sometimes she would line them up.  I hosted a playgroup for a typical Mom’s group before R. turned two.  I did not know about the autism yet, but I knew R. did not play like other kids.  A baby who wasn’t even walking yet crawled over to the toy box, found a car and proceeded to drive it across the carpet.   His older sister put a doll in a play stroller, flung a play purse over her arm and said she was going out.  R. spent most of the time rolling around under the dining room table.

It is hard to figure out how to play with someone who doesn’t seem to want to play with you. When that person is your child, it can be even harder.  I had to realize that any kind of interaction was the goal, and any activity that she found enjoyable was worth pursuing.  I did not need to worry about if the activity was educational or appropriate or anything else.

Activities that require me or another adult’s participation were (and are) the easiest to engage R.   We still play “baby games” like peek-a-boo, chasing, tickles and raspberries.  In the beginning one of the few sure fire ways to engage her  was to let her knock over a tower of blocks that I stacked, she would do this over and over.   Bubbles, wind up toys, even a whoopie cushion all got her attention and made her want more of the activity.  The ABA therapists are really good at coming up with their own silly games.

A couple of silly games we are playing now- R. will lead me to a computer chair with wheels , I’ll prompt her to say come, and when she wants me to sit, I’ll verbally prompt her to say sit.  She will then climb in my lap, say ready, set go and then I have to give her a chair ride.   A variation of this is that she will lead me up the stairs, I’ll prompt her to say come and then up.  She then pulls me to sit down on the top step, and I’ll prompt sit.   She’ll climb in my lap and say down- again she wants a ride.  I’ll make her say down for every step.   With games like this that are consistent, she seems to be able to say a spontaneous word for the start of a desired activity  (ABA calls this manding) more consistently.  So she will say ready set go, or down with no prompt most of the time, but the lead in words -come, sit, still require verbal prompting the majority of the time.

I keep some toys out of reach, and some are in boxes or bags that she can’t always open, so she has to ask for them.  During EI, R. had a program that was just the therapists demonstrating different things to do with toys and taking data on her interest level and attention span.   I try to come up with interesting and different things to do with her toys, so she will ask me to repeat the activity.

Floortime talks about joining in a child’s play, and this is a good way to engage R. when she is perseverating or just on her own agenda.  When we started, one of her favorite activities was to carry all of something, like blocks or stuffed animals one or two at a time from one side of the house to another.  I would get in the way and hand her the animal or whatever, and just insert myself into her game.  I would also mess up her pile, which sometimes annoyed her, but hey I got her attention.

I think the reason that children on the spectrum are limited in their play is because they literally have difficulties imagining anything else to do.   It seems to me that the repetitive nature of her play was (and is) comforting to her.   Most people have an easier time in most situations if they have some idea about what is going to happen.  Perhaps for R. it is that she can not even conceive of a unique situation until she has seen it, and often she might need to see it several times.   If I pick up R. in the kitchen and run or spin her or do something fun, she will hand lead me back to the exact same spot to repeat the activity.  It doesn’t occur to her that I could do this anywhere, until I show her.

Thinking about pretend/symbolic play it makes sense that children on the spectrum would have difficulties in this area.  Why is symbolic play so significant?  I wondered this after our diagnosis, and I’m probably not the only one.   Symbolic play is essentially how she is perceiving and reenacting her experiences.   I think that when R. did not have any symbolic play skills, she also did not have much knowledge about or ability to manipulate her environment.   As R.’s symbolic play increases so does her expressive and receptive language abilities.  I think in the wait for spoken words, I kind of forget about receptive language.  It is so amazing to get responses to things I say, that tells me that not only is she understanding me, she can imagine and conceive of a familiar situation she is not experiencing at that moment.

As an example, We went to Home Depot recently, and as soon as we pulled into the parking lot R. started to cry.  It was clear she did not want to go.  A year ago she would not have even noticed where we were until we were in the store.  She could see the store and imagine (I’m guessing here) the last time we went.  She did not cry the last time, but we had been there the day before, so I’m sure she was tired of it.  I told her that Daddy would go to Home Depot and she and I would go get a cookie at the bakery.  I repeated this a few times and she stopped crying and she even said cookie a couple of times as she climbed into the stroller.

I think it has been the most difficult to encourage pretend play as opposed to other kinds of play.  Probably because I have a tendency to over think it.   R. really liked to set up toys on the dining room table, so it seems like a natural thing to encourage her to set the table with play dishes and food and have her dolls eat and drink.  She will set the table, feed and give drinks to her dolls (mostly Elmo and company).   She will try hats on Elmo or Ernie and she is starting to try out things that aren’t actually hats.  This is a great improvement over a year ago when this kind of play was non-existent.  But her symbolic play skills are still very much in the beginning stages.    She’ll brush Ernie’s hair for a few minutes and then go on to something else.  I’m not seeing many complex scenes acted out.  It is not always easy to interpret what she means by what she is doing.  When we are out she’ll have Elmo and Ernie try out things, she’ll dangle them over the side of the shopping cart and she will be babbling in a conversational tone the entire time.

I set up different play scenarios and I try to mix up the locations and how they are set up, so she doesn’t become too fixed on one way.   I also try to jump in and make her play sessions a little longer.  She will put a doll to sleep and I’ll pick her up and make her tell R. that she doesn’t want to go to sleep.  Or when she removes the doll’s clothes I’ll have the doll complain that she is cold.  R. is becoming very receptive to me playing like this.  She smiles and is very engaged and will give me items to use to play.

Encouraging Communication-What’s working Part 1

Find an alternative communication method.
We used PECS (Picture Exchange Communication System) with R.  We were fortunate that our ABA provider made all the icons and set up the binders.  We used a combination of the standard icons and actual photographs.  We started hand over hand and offered preferred items.    In the beginning the therapists would put her trampoline against the wall and she would have to hand over the icon for the trampoline to get them to put it down so she could play with it.   We keep two PECS books around the house,  one for food and the other for activities.  R. does not use them as much as she used to, I think she really understands it is easier to be prompted to say the word than retrieve the icon, but she will occasionally go back to them and bring us one of the cards.

Sign language is another option.  R. did not have the imitation skills when we began, so this really was not a good fit for us.  I have met other children with ASD who are as adept with signing as R. is with PECS.  One advantage to signing is that you don’t have to bring your PECS book everywhere and keep track of all of those icons.

Our former program director would talk about PECS enabling R. to learn the power of communication. It really is not possible to physically prompt a child to speak, but both of these methods can be physically prompted.  The advantage of being able to physically prompt the correct response, in ABA speak is errorless learning.  The prompt level will be gradually decreased.  When R. started using PECS the prompt was to hand over hand help her remove the icon and hand it over.   After a while the only prompt she needed was for us to show her the PECS book.

Several family members asked me if R.’s using PECS was going to delay her ability to speak.  They were concerned that it appeared easy for her, and she would become reliant upon the method.  I think PECS is what enabled R. to get to the point she is now with speaking.   She was not at the developmental point to be able to access language, but she was able to be taught how to communicate.  NT infants and toddlers in the pre-verbal stage are becoming experts at non-verbal communication,  R. needed to develop these skills before she could speak.  PECS enabled her to have the benefit of being able to communicate at her developmental level.

The ipad and other devices will be opening up new worlds in alternative communication for children on the spectrum.

Don’t reward crying/tantrums

Crying and tantrums are a form of communication.   They were R.’s main method when we started on this journey.  ABA was very helpful in teaching me that I should not give her what she wants when she cries, I should prompt her to communicate her wants.  I wrote about this a few months ago. I’ve read discussions on different ASD boards that describe this method as not acknowledging or ignoring crying/tantrums, and I think this is an incorrect interpretation.   Crying should be acknowledged for what it is, a complaint.  The message I want to send R. is that, I hear you, you are upset, but if you want whatever it is you have to say a word or give me an icon.  Crying may get my attention, but only communication is going to get you what you want.
At this point I can usually prompt R. to say a word if she is crying for something she wants.  This actually happens rarely, because most of the time she will start with a gestural communication (hand leading) and then will either say or be prompted to say what she wants.  But sometimes she can’t have what she wants, or she has to wait and then she will cry.  This is probably more accurately described as a complaint, she usually has no tears and there is babble and sometimes words among the yells.  I also try to explain why she can’t have what she wants and offer an alternative.  So if she’s crying because she’s impatient for the popcorn to finish in the microwave, I can show her the bag that is popping, the countdown timer and say we have to wait.   It’s always harder if it is something she can’t have, but it is getting so much better.  So if she is crying because she wants to go outside, I can tell her it is too late to go out and offer something else to do.  I’m still in awe every time this works.

Consider that communication is more than just words.
Shortly after we started ABA, R. began hand leading.  I realize now this is quite common among children with ASD.  At the time it seemed quite amazing, and now it is so much a part of how she communicates.  Prior to any gestural communication it seemed her only method of communicating was by crying or with a look or expression .   The first programs that ABA started with were what they called anticipation games.  They would do something she liked – tickles, spins, bubbles… and then wait for her to look at them to repeat it.    It wasn’t long before she would gesture by grabbing their hand to continue the activity.     These play activities taught R. that people could do fun things if she communicated.

In the book The Special Needs Child by Dr. Stanley Greenspan, he writes about closing circles of communication.   If I tickle her and she looked at me to continue, that would be one circle of communication.  I really liked this concept because it gave me a sense of actually doing something using skills she already had.    It still feels like a game to see if I can get her to close just another circle or two.   Floortime lite Mama writes about Floortime as a lifestyle, and that is how we do things around here.

What a mess

It is weird, R. has been playing more appropriately,but she has also been  taking all her toys out and making what looks to me like a big mess.

Building Mount Stuffie

I don’t mind the stuffed animals tossed around, or piled up, but her throwing everything else into a big pile makes me crazy.   I don’t know why. I find myself either following her around compulsively cleaning up after her or totally ignoring it until the ABA therapists show up or the end of the day.

She's not distressed by the mess

Seeing the books thrown around bothers me the most, so I did the most incredible (and obvious) thing.  I told her to stop throwing the books.  And you know what?  She DID!  She tried again a couple of minutes later, and when I told her not to throw the books, she listened.   So I sat there and every couple of minutes I had to tell her not to throw the books, but I did not have to physically prompt her or force her to do anything.  I sat on my butt and talked, and she listened and followed a direction.   Of course as soon as I left the room she hurled the rest of the books and laughed.

I realize that the answer is to just keep a few books out and rotate them.  I’ll work on that when she is at school.

Reading Time