Different Roads to Learning

By: Stephanie Tafone, M.A., P.D., Behavior Intervention Specialist at Eden II Programs 

Working on the front lines of Autism care in a residential facility is both rewarding and, at times, challenging. Although our residents depend on us in many ways to teach them how to complete day-to-day tasks, it is important for all staff to recognize and respect that our residents each have their own preferences and interests. Therefore, we always strive to let our residents make as many choices as possible (provided they are healthy choices that do not cause harm to anyone). Just because we as staff might complete a particular task a certain way does not mean it is the “right” or only way to do so. Recognizing and respecting residents’ choices can help avoid negative behaviors or frustration for our residents. Our goal is always to teach and foster independence and self-direction. 

It is always important to build good rapport with our residents so we are in tune with their wants and needs, while also enabling them to better trust us, work with us, and learn from us. Unfortunately, with current staffing crises and funding cuts in residential care settings, one challenge we face is securing long-term, seasoned staff. This type of setting often suffers from a high turnover rate, which this is a matter that needs more global attention, as hardworking, dedicated, and experienced/trained staff are crucial for our population. 

One of the biggest considerations we have on a daily basis, particularly during the global COVID-19 pandemic, is finding creative and entertaining recreational and leisure activities to keep our residents happy and actively engaged. Anyone can become restless and bored with nothing to do, and those with Autism are no different, which is why active engagement is one of our top priorities in a group home setting. When selecting activities, we strive to ensure that each resident’s preferences are considered and incorporated. This includes a combination of both community outings and in-house events/activities. Going into the community on outings can be challenging at times when unpredictable factors (e.g. noise, crowds, etc.) may trigger negative behaviors. However, we do our best to avoid triggering situations by researching and/or visiting the activity or location before our residents experience it in order to help determine if there are any barriers that will prevent it from being an enjoyable and successful outing for all. We also do our best to go prepared on each community outing with preferred items that can be used as a source of redirection and comfort if needed. For example, headphones to drown out noise if it gets too noisy, as well as preferred snacks or drinks if our residents get hungry or thirsty. In the residence, we also strive to think of creative leisure activities, such as dance or karaoke parties, Bingo nights, movie nights, baking, and arts and crafts. Having an enthusiastic and supportive approach, as well as using preferred reinforcers, helps to engage our residents in these activities and increase their interest level. 

In addition to recreational and leisure activities for entertainment and socialization, day-to-day life in the residence is also a learning experience for our residents, as they work on a variety of individualized goals with their assigned staff. Examples of goals may include activities such as participating in a consistent exercise regimen, learning how to independently cook rice or make tea, learning how to independently count money and make purchases, and learning how to independently vacuum or clean one’s room. The selection of a participant’s goals is a collaborative process that involves input from parents/caregivers, input from the participant(s) if possible, and input from the management team at the residence. We strive to ensure that selected goals not only address a skill deficit, but are also aligned with the participant’s interests and will help the participant become more independent in daily living skills. Similarly, participants learn increased independence by participating in various chores around the house, such as setting the table for lunch and dinner, loading and emptying the dishwasher, and doing one’s laundry. Teaching many of these goals and chores can be accomplished through the use of a visual task analysis that breaks the task down into smaller components (i.e. individual steps), which are each depicted in visual images. Visuals are a very helpful teaching technique for those with Autism, who often struggle significantly with understanding verbal language and oral directions. It is also helpful for learning, especially in the initial stages, to use a preferred reinforcer to reward correct completion of steps. In the beginning of learning a new goal or chore, one step may need to be taught for a number of consecutive days until it is mastered and the next step can be taught. 

Overall, working in a residential setting has been a great learning experience and we know that our work has had, and continues to have, a significant influence on our residents’ lives, which is very rewarding for all staff. 

About the Author: 

Stephanie Tafone, M.A., P.D. earned her B.A. in Psychology from St. John's University before going on to earn her M.A. and Professional Diploma in School Psychology from Kean University. She is currently in the process of completing the requirements to obtain an Advanced Certificate in Applied Behavior Analysis as she pursues national certification. For the past ten years, she has been working with both children and adults with disabilities. She currently works as a behavior intervention specialist at a residential facility serving adults who have been diagnosed with Autism Spectrum Disorder. She also works as a school psychologist serving children with various diagnoses and disabilities, as well as an adjunct professor for courses pertaining to Applied Behavior Analysis, Autism, and Intellectual Disability. 

"This is hard" is a statement I often hear from families both in the midst of intervention, and pre-intervention during the assessment phase.

Families without support and services find it hard helping their Autistic child navigate the world, and families in the midst of therapies and interventions find generalizing them to be hard.

It's hard to consistently generalize an intervention plan outside in the home, on the weekends, on Sunday at the grocery store, on vacation at Grandma's house, or at 6am on a Saturday when your child only slept 2 hours.

But its also hard to supervise/monitor your child 24-7, to break up sibling fights all day long because your child can't share, to find quality childcare options when your child is highly aggressive, or to figure out if your child is ill or sick when they can't tell you.

Both are hard.

It is rarely a discussion of hard vs easy, and much more common is a decision regarding which "hard" is acceptable. Yes, toilet training is hard work. On the flip side, changing an 8 year-olds diaper isn't exactly easy. Nor is it easy to afford to buy diapers for that many years.

Yes, teaching your child to use utensils instead of eating with their hands is hard. On the flip side, restricted diet and issues around mealtimes can be made worse if the child will only eat finger foods (typically, starches and carbs). That is also hard.

Yes, it is hard to consistently follow a Behavior Plan when in public with your child. On the flip side, being asked to leave locations, having friends ask that you not visit, or being scared someone will call the police on your child during a public outburst, is a hard reality to live out.

You have to decide which "hard" to accept.

I intentionally use the phrase "intervention plan" and not "ABA therapy", because maybe your child isn't receiving ABA services. Maybe you don't want that, or can't access it.

But are they receiving Speech services? OT? PT? In special education at school? Attending an Autism preschool program?

If so, these are all interventions designed to minimize developmental delays and target current deficits.

Whatever kind of intervention your child participates in, there are a few components that tend to be the same across different therapies:

1. Consistency. In order to be effective, the intervention must be applied consistently. Frequent staff turnover, frequently canceling appointments, or other issues like this can negatively impact results.

2. Training must carry over to the home setting/caregivers. There is no way to generalize the intervention if you have no idea what it is.

3. Caregiver Participation. In order for #2 to happen, the caregivers must be willing and available to participate in the intervention/treatment plan.

4. Focus on progress vs miracles. Progress can be slow, it can be up and down, and at times it can mean treading water. Sometimes an absence of regression IS progress. If you have sky high expectations of the intervention process, this can cause "provider hopping" where families move from one agency, provider, or intervention to the next looking for magic. That just is not how quality, ethical treatment works.

5. Individualized Intervention. It doesn't matter if your child receives 30 minutes of Speech each week, or 15 hours of ABA. Are the treatment goals and the teaching methodology suitable and appropriate for your child? "Cookie-cutter" intervention is when treatment is applied in a lazy, vague, and generic way across multiple clients. In order for intervention to be effective, it must meet your child where they are and incorporate their unique interests and motivation(s).

About The Author: Tameika Meadows, BCBA

“I’ve been providing ABA therapy services to young children with Autism since early 2003. My career in ABA began when I stumbled upon a flyer on my college campus for what I assumed was a babysitting job. The job turned out to be an entry level ABA therapy position working with an adorable little boy with Autism. This would prove to be the unplanned beginning of a passionate career for me.

From those early days in the field, I am now an author, blogger, Consultant/Supervisor, and I regularly lead intensive training sessions for ABA staff and parents. If you are interested in my consultation services, or just have questions about the blog: contact me here.”

This piece originally appeared at www.iloveaba.com. 

When a child first gets diagnosed with Autism, parents are often overwhelmed. A good doctor will give a prescription for ABA therapy as well as other necessary therapies such as Speech, OT,  PT, Feeding, etc. However, of those therapies, the one that is usually not familiar is ABA. A simple Google search or, even worse, joining a Facebook group is going to lead a parent down a path full of controversy, fear mongering, and misinformation. This will often leave parents very leery of any ABA facility they meet with, or completely turned off from the best medically-proved therapy for young Autistic children.

So I created a list of questions for parents to ask potential ABA facilities to find the best match for their family. After all, they’re entrusting you with their child for hours upon hours. The child is often non-verbal and unable to tell you how their day was. So a parent must trust the facility completely. In writing this list, I also kept in mind the warnings/worries of abuse touted by certain internet groups, in hopes to appease them should they come across this list. Parents can use this list in their ABA search and clinics can have this list on hand for parents, and their potential answers ready.

1) Do you force eye contact or stop unharmful stims? This is one of the top citations of “abuse” from certain internet groups. Some parents don’t want to force eye contact and view their child’s non-harmful, non-disruptive stims as a beautiful part of their personality.

2) How do you avoid meltdowns? Knowing that you are going to avoid meltdowns will help parents feel far more comfortable about sending their child.

3) Do you ever withhold food? Even neurotypical kids are picky. Us “Autism Parents” are usually self-conscious about the fact that our kids survive on pretzels and Pediasure. Telling a child “No chicken nuggets until you’ve finished your green beans” will probably mean a hungry child, and an unhappy parent.

4) How do you handle naps? With the diagnostic age of Autism getting increasingly lower, children are starting ABA before they are ready to phase out of naps. Having a plan in place for nap time will make a parent know their child is getting their needs met.

5) What are your parent training session requirements? ABA is a fantastic therapy, but without the parents upholding it at home, it’s pretty hard to fully instill the methodology and give the child all the help they deserve Parent training lets parents feel more involved in their child’s therapy which is essential!

6) What are the requirements of your staff? Parents researching ABA are shocked to hear you only need a high school diploma to be an RBT. If you have a higher standard for your staff of any sort, parents will feel more comfortable sending their children to your facility.

7) What will my child’s daily schedule look like? Knowing what a child does throughout the day helps a parent make the decision for what works best for their child.

8) How do you incorporate academics? Many parents are choosing between ABA and Preschool. Being able to tell parents your ABA facilitates some sort of Academics (We focus on writing, the alphabet, etc) will make the decision far easier!

9) How do you prevent harmful stims? Parents recoil at the thought of their child being restrained. What are your rules around touching kids? How do you keep our child from harming themselves, or anyone else?

10) How do you communicate with me? My child can’t tell me about his day. So I need his therapists to do so. What are you doing to tell me about his day? What he ate? Did he name? Diaper changes? Injuries? The more communication, the better!

This list isn’t comprehensive. It won’t work for every facility. However, these are the questions I have found most parents want the answers to in order to find the best facility for their kids. And to feel they aren’t sending their children to an “abusive” environment.

About the Author:

Cassie Hauschildt is the mother of her Autistic son, Percival, who was diagnosed at 20 months old. Since his diagnosis, she has become an advocate for autistic children. She dedicates her time to mentoring parents of autistic kids through the tough first few months post-diagnosis. She also is trying to get rid of the negativity surrounding ABA therapy. She does this through humor, while using real talk, on her TikTok @AnotherAutismMom. She also runs “The Dino and Nuggets Corner” Facebook Group.

Its common, its common, its common.

That is the first thing that needs to be said to any caregiver who ended up here while researching "picky eater" + Autism. You are not the only one experiencing this.

Autistic individuals (because this is not just an issue for children) exhibit higher rates of food refusal, and a more limited food repertoire, when compared to typically developing individuals (Bandini et al, 2010).

Examples? Sure.

Across my clients, I regularly see issues with:

Rigidity around meals (where to sit at the table, what plate to eat off, which spoon to use, must have the tablet in order to eat)

Food refusal challenging behavior (throwing plates, flinging cups to the floor, spitting food out, tantrums, pouring liquids out onto the floor)

Highly selective food intake (daily diet consists of less than 10 foods, likes chicken nuggets but only from a specific fast food place, will only take specific liquid from a specific sippy cup or bottle)

To define the term, a picky eater can be described as regularly refusing foods, or consistently only eating the same foods with little to no variation permitted.

Many parents of toddlers deal with a picky eating phase at some point or another, and often the child outgrows it.

So, what is the critical determining factor when it comes to Autism that tips the scale from someone who is just "picky" to a serious health problem and concern? Usually, it is a combination of variables that must be examined and weighed:

How old is the individual? If out of the toddler phase, how frequently is this issue happening (weekly? daily? or only at holiday meals?)

Does food refusal occur with challenging or aggressive behavior?

Is this impacting school/daycare, or the ability to go into community locations?

Will the individual skip several consecutive meals (refuse to eat across more than one day)?

Is this impacting the individual's weight, organs, toileting/digestion, skin, hair, or nutrition? Is your doctor concerned?

The key factor for seeking out intervention for this issue is when the food selectivity is causing harm to the individual. When any specific behavior impacts the health/body of the person exhibiting it, that is clinically referred to as a "self-injurious" behavior. Self-injurious behaviors should not be ignored, and often require intervention and treatment.

So what to do? 

 It may be helpful to reframe the way we view picky eaters. Sometimes families can view this behavior as their child willfully choosing to make meals a dreadful adventure. Choosing to be difficult and fling plates across the room in order to cause chaos. However, challenging behaviors often occur for complex or multifaceted reasons. Some Autistics use the term "sensory eater" and not "picky eater" to describe this issue, and explain it like this:  

"Picky eaters don’t like a variety of foods, much like the sensory eater. However, when picky eaters try new foods, it doesn’t cause a sensory overload....There is a sensitivity to textures, where children can only handle one texture, such as smooth, pureed foods. In this case, they might be able to eat yogurt, however, hand them a bag of chips or a slice of turkey and they immediately begin to gag" (www.researchautism.org).

If a specific food texture, smell, sight, or tactile experience is causing significant distress, if there are tooth or gum issues making eating painful or uncomfortable, if the individual has trouble swallowing, or if unknown allergies are present, making digestion painful or uncomfortable, doesn't it make sense for the individual to refuse a food (or eventually, any food that looks like THAT food) or exhibit excessive selectivity? Now, imagine the individual has no means to communicate how food makes them feel. Doesn't it make sense that they may cry, spit, hit or punch, or fling a plate onto the floor? 

When seeking out Feeding Intervention (which is a clinical specialty), it is important to first obtain medical rule out. This means first speaking with your doctor to discuss the issue, and see if the individual's health has been impacted. The doctor may also be able to make a referral to a qualified specialist.

Not every professional will be trained in feeding interventions, so this isn't as simple as just asking the current therapist to also target feeding. I see families do that a lot, without also asking about the therapist's qualifications to address this issue. 

It probably doesn't need to be said, but feeding challenges can have serious health complications and you don't want to gamble on unproven treatments, untrained professionals, or questionable practices. Not only could they harm your child, they could worsen/ingrain the problem even further.

SLPs, BCBAs, OTs, Healthcare professionals, and Multi-Disciplinary clinics or facilities, can all incorporate feeding intervention into therapy goals. The Children's Healthcare of Atlanta recommends the following step-by-step process for initiating feeding intervention/feeding therapy:

• Medical Screening
• Behavioral Evaluation
• Nutrition Assessment
• Oral-Motor Skills Assessment

Remember, before seeking out therapy or treatment talk to your doctor first. Also, any feeding intervention that occurs on-site will need a caregiver training portion where the parents are taught how to implement the procedure at home/in the community.

About The Author: Tameika Meadows, BCBA

“I’ve been providing ABA therapy services to young children with Autism since early 2003. My career in ABA began when I stumbled upon a flyer on my college campus for what I assumed was a babysitting job. The job turned out to be an entry level ABA therapy position working with an adorable little boy with Autism. This would prove to be the unplanned beginning of a passionate career for me.

From those early days in the field, I am now an author, blogger, Consultant/Supervisor, and I regularly lead intensive training sessions for ABA staff and parents. If you are interested in my consultation services, or just have questions about the blog: contact me here.”

This month’s ASAT feature comes to us from Robert LaRue, PhD, BCBA-D. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

I am the parent of a student with autism who has developed some challenging behavior at school and the team has suggested a more formal assessment. What is meant by “functional analysis?” When should this be done and who should do it?

Answered by Robert LaRue, PhD, BCBA-D
Douglass Developmental Disabilities Center and Rutgers Center for Adult Autism Services

Prior to a discussion about functional analysis, it is important to make the distinction between functional analysis and functional assessment. Functional assessment represents a variety of techniques and strategies used to gather information about the cause (or “function”) of challenging behavior. This information is used to maximize the effectiveness and efficiency of behavioral support. There are three broad categories of functional assessment. One category involves talking to caregivers (e.g., parents, teachers) about why problem behavior occurs (i.e., interviews and rating scales). The second type is referred to as descriptive assessment, which involves observing behavior and collecting data regarding the events that precede problem behavior (antecedents) and the events that follow problem behavior (consequences). The third type of functional assessment is functional analysis, which is a more thorough assessment procedure described in more detail below.

What is a Functional Analysis?

A functional analysis (FA) is a specific type of functional assessment that involves the direct manipulation of antecedents and/or consequences to identify why problem behavior occurs (Iwata et al., 1982/1994). In other words, a practitioner conducting an FA directly tests the hypothesis in an experimental manner, rather than waiting for the behavior to occur naturally. For example, if a practitioner wanted to see if problem behavior was maintained by attention from others, they might withhold attention for a brief period of time (e.g., acting distracted) and then provide it if and when problem behavior occurs. As with other forms of functional assessment, the purpose of an FA is to identify why problem behavior occurs. What distinguishes FA from other forms of functional assessment is that FAs involve making deliberate, short-term, and systematic changes to the environment to evaluate the effects of different conditions on the target behavior(s).

In an FA, a practitioner arranges “conditions” that are common in the natural environment (e.g., a teacher presenting non-preferred work tasks, a distracted teacher or parent not attending to a child). While there are many ways to individualize FA conditions, there are four or five conditions that are typically run as part of the assessment.

• Social Attention: The attention condition is a test to determine if problem behavior occurs to access social attention from others. In this condition, attention is typically withheld (e.g., a therapist acts distracted) and is provided following target behavior for a brief period of time (e.g., 20-30 seconds). This might take the form of a reprimand (e.g., “Stop doing that!”) or soothing comments (e.g., “It’s going to be ok.”). If the individual engages in high rates of inappropriate behavior in this condition as compared to the control condition, it indicates that social attention functions as reinforcement for maladaptive behavior.
• Tangible: The tangible condition is another test to determine if problem behavior is maintained by access to preferred items or activities. In this condition, access to preferred items is typically withheld (e.g., a toy is removed) and is provided following target behavior. If the individual engages in high rates of inappropriate behavior in this condition, it indicates that problem behavior occurs to access preferred items.
• Escape: The escape condition is a test to determine if problem behavior occurs to escape demands. In this condition, a nonpreferred activity is typically presented (e.g., school work) and a break (escape) is provided following target behavior for a brief period of time (e.g., 20-30 seconds). If the individual engages in high rates of inappropriate behavior in this condition, it indicates that escape is a reinforcer for maladaptive behavior.
• Alone or Ignore: The alone or ignore condition is a test for to determine if problem behavior occurs for nonsocial reasons. In other words, the behavior (e.g., hand flapping, repeating words or phrases) is likely to occur when they are by themselves. In this condition, the individual is usually left alone for some period of time to see if the behavior persists when no one else is present. If the behavior persists while no one else is present, it suggests that they are not engaging in the behavior for social reasons. This is sometimes referred to as “automatic reinforcement”. In cases where the behavior is potentially dangerous, or if the individual cannot be left alone, an ignore condition can be implemented where the therapist remains in the room, but does not interact.
• Control: The control (or toy play) condition serves as the comparison for all of the other conditions. In this condition, the individual has free access to social attention, preferred items/activities, and no demands are present. As such, there is usually very little motivation to engage in problem behavior.

When conducting a traditional FA, each of these conditions are usually conducted at least three to five times, with each session lasting 5 to 15 minutes. Sessions are typically alternated until a clear pattern emerges.

FAs represent the most sophisticated and empirically-supported functional assessment procedures. There are hundreds of studies validating the use of FAs for identifying the function of problem behavior (for a review, see Beavers et al., 2013). In addition, interventions that are based on the results of FAs have consistently been shown to be more effective than those that are not (e.g., Carr & Durand, 1985). In recent years, FA procedures have evolved to become more manageable in educational settings, with modifications that provide results in less time and fewer instances of challenging behavior (e.g., Bloom et al., 2011, Hanley et al., 2014; LaRue et al, 2010; Northup et al., 1991; Smith & Churchill, 2002; Thomasson-Sassi, et al., 2011).

When Should an FA be Conducted?

From a clinical standpoint, functional assessments should be conducted when the student‘s behavior interferes with their own learning or the learning of others, presents a danger to self or others, or the behavior results in suspension or interim placement in an alternative setting approaching 10 total days. FA is a specific procedure for conducting these functional assessments. There are no specific guidelines for when practitioners should use functional analyses rather than other types of assessment. Typically, the use of FA procedures is determined by the skill level of the practitioner, the resources available to the practitioner, and the setting itself.

Who Should Conduct an FA?

Conducting FAs does require a high level of expertise to be done effectively. FAs should be conducted by individuals with experience using the procedures (or while supervised by someone with experience). Many (though not all) people who have board certification in behavior analysis (BCBA) have experience conducting FAs. Consumers should ask practitioners about their level of experience and comfort prior to starting these analyses.

Summary

Functional assessments are an essential tool for identifying why problem behavior occurs. Functional analysis is a specific type of functional assessment that is incredibly effective for this purpose. In fact, hundreds of studies have shown FAs to be effective for identifying why problem behavior occurs. In recent decades, user-friendly ways to conduct FAs have emerged, which has made their use more common in educational settings. Most BCBAs should have training to implement FAs safely and efficiently. The use of these procedures can lead to effective, function-based treatments that improve outcomes for children and adults who have behavioral difficulties.

Citations:

Beavers, G. A., Iwata, B. A., & Lerman, D. C. (2013). Thirty years of research on the functional analysis of problem behavior. Journal of Applied Behavior Analysis, 46(1), 1-21.

Bloom, S. E, Iwata, B. A, Fritz, J. N, Roscoe, E. M., & Carreau, A. B. (2011). Classroom application of a trial-based functional analysis. Journal of Applied Behavior Analysis, 44, 19-31.

Carr, E. G., & Durand V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis, 18, 111-126.

Hanley, G. P., Jin, C. S., Vanselow, N. R., & Hanratty, L. A. (2014). Producing meaningful improvements in problem behavior of children with autism via synthesized analyses and treatments. Journal of Applied Behavior Analysis, 47, 16-36.

Iwata, B. A., Dorsey M. F., Slifer K. J., Bauman K. E., & Richman, G. S. (1982/1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27(2), 197-209.

LaRue, R. H., Lenard, K., Weiss, M. J., Bamond, M., Palmieri, M., & Kelley, M. E. (2010). Comparison of traditional and trial-based methodologies for conducting functional analyses. Research in Developmental Disabilities, 31, 480-487.

Northup, J., Wacker, D., Sasso, G., Steege, M., Cigrand, K., Cook, J., & DeRaad, A. (1991). A brief functional analysis of aggressive and alternative behavior in an outclinic setting. Journal of Applied Behavior Analysis, 24(3), 509-22.

Smith, R. G., & Churchill, R. M. (2002). Identification of environmental determinants of behavior disorders through functional analysis of precursor behaviors. Journal of Applied Behavior Analysis, 35(2), 125-136.

Thomason-Sassi, J. L., Iwata, B. A., Neidert, P. L., & Roscoe, E. M. (2011). Response latency as an index of response strength during functional analyses of problem behavior. Journal of Applied Behavior Analysis, 44(1), 51-67.

Citation for this article:

LaRue, R. (2021). Clinical Corner: When should a functional analysis be done and who should do it? Science in Autism Treatment, 18(12).

About the Author

Robert H. LaRue, Ph.D., BCBA-D is a Clinical Professor at the Graduate School of Applied and Professional Psychology (GSAPP) at Rutgers University. He earned a dual doctorate in biological and school psychology from Louisiana State University in 2002. He completed his predoctoral internship with the Kennedy Krieger Institute at Johns Hopkins University and a postdoctoral fellowship with the Marcus Institute (now the Marcus Autism Center) at Emory University. He currently serves as the Director of Behavioral Services at the Douglass Developmental Disabilities Center (DDDC) and the Rutgers Center for Adult Autism Services (RCAAS), where provides consultative support for students and staff providing intensive behavioral services to students and adults within the Centers. His research interests include the assessment and treatment of maladaptive behavior, improving transitional outcomes for adolescents and adults with ASD, the use of behavioral economics in intervention, and the evaluation of psychotropic medications used with at-risk populations. He has authored articles in peer-reviewed journals, written several book chapters, and presented at national and international conferences.

There are many things that I would love to change about the treatment of individuals with Autism Spectrum Disorder. One of them is the notion that all kids with ASD are motivated by the same things. Certainly, some kids with autism love light up toys, squeezes, or music, but that’s true of the population at large. After all, I am mesmerized by Christmas lights, love a good head massage, and have songs I listen to on repeat.

The issue with the assumption that all kids with ASD are motivated by these small number of things is that it can lead to some very specific problems, such as practitioners trying out a smaller number of toys or activities with the child, practitioners depending solely on “sensory toys” for reinforcers instead of working to expand the number of reinforcers a child responds to, or the larger community making assumptions about the preferences of the child. Furthermore, there is evidence that the broader the range of reinforcers is for a child, the better the learning outcomes (Klintwall & Eikeseth, 2012.) Failing to think beyond the stereotypes about the interests of kids with ASD impedes their ability to learn and develop new skills.

The children I’ve worked with over the years have varied interests, ranging from dinosaurs and maps to bean bag toss and board games. And while some of the kids I work with love light up toys or trains, it’s important that we don’t take a whole swath of the population and decide that they all have similar interests. It doesn’t serve their skill development or our potential to develop real relationships with people with ASD.

As a practitioner, here are some important questions to ask yourself in relation to reinforcers and developing interests:

• Have you conducted a preference assessment? This should be one of the first things you do whenever you start a new case, and something you should continue to do informally.

• Have you talked to the client and/or the parents about what interests they would like to develop? If the client is able to discuss goals and interests with you, you should definitely be having that conversation with them. You should also talk to the parents about their goals. Perhaps they have seen some interest in one area that they would like to further develop. It’s also possible that there are specific family activities or traditions they would like their child to enjoy with the family.

• Have you read about this topic? A great place to start is Chapter 3 of the book A Work in Progress. It clearly explains how to use reinforcers and expand the reinforcer repertoire. There is also a ton of research out there about reinforcement. Take the time to search journals such as Journal of Applied Behavior Analysis and Journal of Developmental Disabilities.

Klintwall, L., & Eikeseth, S. (2012). Number and controllability of reinforcers as predictors of individual outcome for children with autism receiving early and intensive behavioral intervention: A preliminary study. Research in Autism Spectrum Disorders, 6(1), 493-499.

McEachin, J. & Leaf, R. B. (1999). A work in progress: Behavior management strategies and a curriculum for intensive behavioral treatment of autism. New York: DRL Books.

Sam Blanco, PhD, LBA, BCBA is an ABA provider for students ages 3-15 in NYC. Working in education for sixteen years with students with Autism Spectrum Disorders and other developmental delays, Sam utilizes strategies for achieving a multitude of academic, behavior, and social goals. She is also an assistant professor in the ABA program at The Sage Colleges, and she is the Senior Clinical Strategist at Chorus Software Solutions.

My own introduction to prompting and fading

I was first introduced to the idea of prompting and fading when I co-ordinated a home based early learning program for my eldest son, Christopher, who is on the spectrum of autism. I soon came to appreciate how important these strategies were and are in supporting his learning. We are now into his teenage years and whilst the skills he is learning are far more complex compared with those early years, the use and importance of prompting and fading remains unchanged.

About prompting.

A prompt is a cue (or hint) given to a student to encourage them to learn a new skill. There is extensive evidence to support my own experience that prompting is a highly effective way of teaching. An example of this evidence is noted at the end of this article.

Flashcards and prompting

A lot of the work we did around prompting with Christopher in the early years of his life related to the use of flashcards. We used them to expand his vocabulary, articulate words clearly and put together sentences. We also used them to build his academic skills in literacy and numeracy and his capacity for problem solving.

The different types of prompts

There are five different types of prompts and we used all of them in our flashcard based activities. These prompts are ranked accordingly to the level of support they offer, with 1 being the most supportive and five the least.

1. Full physical
   Example: I placed my hand over Christopher’s hand and guided him to place the flashcard he was holding over the associated one on the table - so the image of the sock was placed on top of the shoe, rather than on the image of the bed or the bowl
2. Partial physical
   Example: I gently touched Christopher’s shoulder - to indicate it was time for him to respond to my request of naming the flashcard I was showing him.
3. Modelling
   Example: I sorted the flashcards on the table into groups - animal, transport and instrument. I then shuffled the cards and asked Christopher to sort them in the same way
4. Gestural
   Example: I nodded as he started to place the letter A next to the image of the apple. It provided him with the encouragement and confidence to continue with B and C.
5. Positional
   Example: I placed two associated cards on the table next to one another so that Christopher could connect the two – so the picture of the fork was next to the picture of the person eating and the picture of the bed was next to the picture of the person sleeping

The goal is to select the type of prompt that is the least intrusive and results in the student providing the correct response. So, if a modelling prompt is not working then a partial or full physical prompt should be tried.

Why prompts need to be faded

Whilst prompts are a great teaching strategy, it is equally important that they be faded over time. You might ask why. The answer is so that the student doesn’t become dependent on the prompt. We were mindful of this in Christopher’s early learning program. There were instances where we started with a full hand over hand prompt. We then faded to a gestural prompt (by pointing at the flashcard) before omitting the prompt all together.

I like to think of prompting and fading as stepping stones on the way to independence with a new skill. Christopher and I have trod on those stones for a number of years now and going forward I know there will be more. I hope there will be more, As I’m so appreciative of the opportunities for learning they ultimately afford my son.

1 Hayes, D., (2013) The Use of Prompting as an Evidence Based Strategy to Support children with ASD in School Settings in New Zealand. ERIC 1-5

About The Author 

Kate is the owner of Picture My Picture, an international business which specializes in educational flashcards. She is the mother of three boys, Christopher, Louis and Tom. Christopher is on the spectrum of Autism. The flashcard based teaching program she oversaw in the early years of his life was the inspiration for the business she owns today. 

After watching for about ten minutes, I asked if we could change the seating arrangement. We moved her student to the end of the table, then had the therapist sit next to her, but on the perpendicular side. This way, eye contact was much easier as they were able to face each other. The student’s eye contact improved instantly with a small environmental change. (Of course, once we made the environmental change, we worked together to address other changes that could be made to encourage eye contact.)

Environmental changes can be a quick and simple solution to some problem behaviors. Here are some questions to consider in order to alter the environment effectively:

Is it possible that a change in furnishings could change the behavior?

For example, moving a child’s locker closer to the classroom door may decrease tardiness, putting a child’s desk in the furthest corner from the door may decrease opportunities for elopement, or giving your child a shorter chair that allows them to put their feet on the ground may decrease the amount of times they kick their sibling from across the table. You may also want to consider partitions that allow for personal space, clearly-marked spaces for organizing materials, proximity to students and distractions (such as windows or the hallway).

Can you add something to the environment to change the behavior?

For example, your student may be able to focus better on independent work if you provide noise-canceling headphones, line up correctly if a square for him/her to stand is taped to the floor, or your child may be more efficient with completing chores if they’re allowed to listen to their favorite music while doing so. I’ve also seen some cases in which the teacher wears a microphone that wirelessly links to a student’s headphones, increasing that student’s ability to attend to the teacher’s instruction.

Will decreasing access to materials impact the behavior? 

For example, removing visuals such as posters and student work may increase your student’s ability to attend or locking materials in a closet when not in use may decrease your student’s ability to destroy or damage materials.

Will increasing access to materials impact the behavior? 

For example, making a box of pre-sharpened pencils may decrease the behavior of getting up frequently to sharpen pencils. (I recently visited a classroom in which the teacher put pre-sharpened pencils in a straw dispenser on her desk, and each week one student was assigned the job of sharpening pencils at the end of the day).

Whenever you do make changes to the environment, you may want to consider if the changes require fading. 

For example, if I make a square on the floor out of tape to teach my student where to stand in the line, I will want to fade that out over time to increase their independence.

A final consideration is that whatever impact you expect the environmental change to have should be clearly defined and measured. Take data to ensure that the intervention is working so you can make adjustments as necessary.

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About The Author

Sam Blanco, PhD, LBA, BCBA is an ABA provider for students ages 3-15 in NYC. Working in education for sixteen years with students with Autism Spectrum Disorders and other developmental delays, Sam utilizes strategies for achieving a multitude of academic, behavior, and social goals. She is also an assistant professor in the ABA program at The Sage Colleges, and she is the Senior Clinical Strategist at Chorus Software Solutions.

One of the most important goals of behavioral intervention is to increase independence.  Teachers, parents, and behavior analysts are almost always focused on teaching individuals how to do things or access what they need on their own, without support from others, and without prompt dependence.  Prompt dependence refers to the situation when a learner’s behavior is dependent on stimuli in addition to the teaching or natural environment events that would ideally control the occurrence and non-occurrence of behavior.  Of course, there are times when it is perfectly fine to rely on someone else for your wants and needs.  Most people are not trained in everything they might need to have done in their lives, so we rely on dentists for our dental care, mechanics for our car maintenance, and lawyers for legal advice.  We do, however, want to be able to brush and floss, drive our cars, know when we need appointments, make those appointments, and understand how to access expert solutions as needed - all independently.  Prompt dependence is a problem when it limits the person’s independence, if they find relying on others distressing, and/or if the needed supports are limited in availability. 

Here are some examples that might reflect problematic prompt dependence:

• Your student looks at you for confirmation or correction before saying or writing an answer in academic tasks
• If you don’t follow your child into the bathroom and narrate his actions, he may miss a step
• You tell your student how to unpack their bag and hang up their coat every morning without waiting for them to do it on their own
• Your client needs to be told to take a bite of her favorite food, or she will sit and wait or even cry because she is hungry - even if the food is easily reached

Prompt dependence can be avoided by starting from a good operational definition of the behavior to be taught or increased.  If the goal is independence, then that should be part of the way the behavior is defined.  In most cases, what we are looking to teach should be independent, not perfect.  Considering two of the examples above, students are not expected to get every answer correct in school, especially when doing work in school or at home on their own.  It would probably be preferable for the student to independently say or write a wrong answer, than to wait for prompting.  Similarly, although bathroom routines are important and should be done with accuracy most or all of the time, the person who relies on this level of prompting in the bathroom is likely to face greater dangers as they get older and family members are no longer able to provide this support.  Unless the behavior being taught presents a high level of risk if there is error, independence should probably be as, if not more, important than accuracy.

Independence can be included in the definition of target behavior by adding considerations such as latency to respond, level of assistance, and specific controlling stimuli to the usual description of topography (what the behavior should look and/or sound like).  To take the third example, “Jordan will hang up their coat and unpack their backpack” can be adjusted to “Jordan will hang up their coat and unpack their backpack within 5 minutes of entering the classroom, with no prompting, upon hearing the second bell.”  This enables the teacher or interventionist to shape to a clear goal that will give Jordan the autonomy to start their day independently, rather than simply with a hung-up coat and unpacked backpack that was mostly due to an adult’s prompting. 

Prompt dependence often occurs because of an overuse of verbal prompts, which leads to an association between behavior and the prompting person, rather than the natural or environmental cues that generally facilitate the behavior in the target environment.  In the example of the child who does not eat her favorite food without instruction, eating has come under the control of a person rather than hunger or the presence of food. It’s not reasonable or necessary to try to avoid verbal prompts entirely, but we can be cautious about overusing verbal prompts.  If verbal prompts seem like nagging, coaxing, or bribing, they are probably problematic. Strategies such as repeating or rephrasing instructions, asking leading questions, and talking through steps may also lead to prompt dependence if they are overused, so use them thoughtfully and not routinely.

The dependence on another person to deliver prompts can be transferred to other types of prompts that are less problematic.  Most very successful, functional, independent people rely on prompts such as calendars, reminder apps, alarms, planners, emails, texts, and to do lists.  These prompts are usually perfectly fine to be dependent on, because they are under the control of the person using them.  Unless they become dysfunctional in some way, these sorts of prompts can be used without limit.  We can teach our learners to use these prompts instead of relying on people to deliver prompts as an important step toward independence.  Other pivotal responses that can lead to greater independence include referencing lists, using a schedule, telling time, and observing and modeling from what others are doing.  Teaching someone to ask for help is also a great way to facilitate independence, because then prompts can be delivered only as needed - when they are asked for by the individual.

Finally, self-management is a crucial skill that can be taught to facilitate independence.  Self-management involves transferring control of behavior from external stimuli to the learner, by teaching the learner to engage in specific strategies.  These strategies include self-monitoring, or noticing and recording one’s own behavior, and self-reinforcement.  When someone learns to self-manage, they learn a skill set that can be applied to every area of life for increased autonomy and dignity.

About The Author

Dana Reinecke is a doctoral level Board-Certified Behavior Analyst (BCBA-D) and a New York State Licensed Behavior Analyst (LBA). Dana is a Core Faculty member and Associate Chair in the Applied Behavior Analysis department at Capella University. She is also co-owner of SupervisorABA, an online platform for BACB supervision curriculum and documentation. Dana provides training and consultation to school districts, private schools, agencies, and families for individuals with disabilities. She has presented original research and workshops on the treatment of autism and applications of ABA at regional, national, and international conferences. She has published her research in peer-reviewed journals, written chapters in published books, and co-edited books on ABA and autism. Current areas of research include use of technology to support students with and without disabilities and online teaching strategies for effective college and graduate education. Dana is actively involved in the New York State Association for Behavior Analysis (NYSABA), and is currently serving as Past President (2019-2020).