Different Roads to Learning

In the years immediately after a parent learns of a diagnosis of autism, it can be especially challenging to think of your child’s autism diagnosis long-term. But as parents advocate for their child, and as practitioners work with the family to create goals for that child, the long term must be considered. Here are a few suggestions to help with considering the long term, while focusing on short-term goals:

• Create a vision statement. One of my favorite books is From Emotions to Advocacy: The Special Education Survival Guide by Pam Wright and Pete Wright. This book covers everything parents need to know about advocating for a child with special needs. One of the first things they suggest is creating a vision statement. They describe this as “a visual picture that describes your child in the future.” While this exercise may be challenging, it can help hone in on what is important to you, your family, and your child with special needs in the long term.

• Look at your child’s behaviors, then try to imagine what it might look like if your child is still engaging in that behavior in five or ten years. Often, behaviors that are not problematic at three are highly problematic at 8 or 13 years old. Such behaviors might include hugging people unexpectedly or (for boys) dropping their pants all the way to the ground when urinating (which could result in bullying at older ages). While it is easy to prioritize other behaviors ahead of these, it’s important to remember that the longer a child has engaged in a behavior, the more difficult it may be to change.

• Talk to practitioners who work with older students. Many practitioners only work with a certain age group of children. While they may be an expert for the age group they work with, it may be helpful to speak with a practitioner who works with older kids and ask what skill deficits they often see, what recommendations they may make, and what skills are essential for independence at older ages.

• Talk with other parents. Speaking with other parents of children with special needs can be hugely beneficial. Over the years, I’ve worked with hundreds of parents who are spending countless hours focusing on providing the best possible outcomes for their children. And while it’s impossible to prepare for everything that will come in your child’s life, it may be helpful to find out what has blindsided other parents as their children with special needs have grown up.

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.

Token economies are used in many different environments. They’re typically simple to implement and achieve desired results for behavior change, especially in autism classrooms. Furthermore, there are tons of research on how to best use them. If you want to get the best results while simultaneously promoting independence in your learners, it is not as simple as just putting some stars on a chart.

• Use a preference assessment. This will help you identify reinforcers your learner may want to earn. As I’ve mentioned in previous posts, I often use the Reinforcer Assessment for Individuals with Severe Disability (Fisher, Piazza, Bowman, & Amari, 1996). 

• Define the target behavior. What behaviors do you want to increase? And how can you define them so they are clearly observable and measurable. For instance, your learner could earn tokens for raising his or her hand in class or responding to a question within 3 to 5 seconds. It is important the behavior is clear and everyone using the token economy agrees on what each behavior looks like.

• Choose your tokens. When I was a classroom teacher, I had a class-wide token economy in which my students earned paperclips. The paperclips had no value initially, but once the students understood the system, I could put paperclips in the bags of the students who were sitting quietly while still continuing to teach my lesson. It allowed them to reinforce the appropriate behaviors and make the most of instructional time. For other students, I’ve used things such as Blue’s Clues stickers, smiley faces I drew on a piece of paper, and even tally marks on an index card.

• Choose when and how tokens will be exchanged. With the paperclip system in my classroom, exchanges occurred at the end of the day. After everyone had their bags packed and were sitting at their desk, we did the “paperclip count” and students could decide whether to spend or save. There was a menu of options ranging in price from 10–100 paperclips. It was also a great way to reinforce some basic math skills (such as counting by fives and tens and completing basic operations). For other students, they might be able to exchange tokens after earning a set amount. Depending on their level of ability, that set amount may be very small (such as 2 to 3) or much larger (such as 25). Sometimes, students have a choice of items or activities, while at other times they earn a pre-selected item or activity.

• Keep it individualized. Conducting a preference assessment helps to make sure it’s individualized to your learner’s preferred items. With my students, the menu of items/activities they could earn was generated through a conversation with them.

• Decide if you will implement a response cost. For my students, I have never used a system in which they could lose tokens they had already earned. But you may find that utilizing it may help. It all depends on your particular learner, which makes the next point all the more important.

• Take data. You need to take data so you will know if your token economy is helping you achieve your goal with the target behaviors you have set.

• Thin the reinforcement over time or change the target behaviors. I do not want any of my learners to be using a token economy for one behavior for all eternity! Let’s say I start with a young learner who is not sitting down for instruction. I may start the token economy by having my student earn a token for every instance in which they are seated correctly for a specified period of time. As my student masters that, I will increase the amount of time required before a token will be earned. Once they’ve achieved the goal I set, I can either fade out the token economy, or keep the token economy but use it for a new behavior.

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.

Everyone does it! In a global pandemic, we do it more since our mouths are covered by masks.

What is it? Some people call them signs, talking with your hands, body language, and if we want to get real fancy, gesticulations…

But let’s keep it simple… gestures.

My newest favorite gesture, in this era of Zoom meetings, is to silently give the double thumbs up to communicate my happiness when one of my team members has a good idea or is asking for a response. I learned this gesture from my 16-year-old daughter, who uses it during her face time interactions with friends and Zoom virtual schooling.  Since it is hard to talk in groups over Zoom, this subtle and fun gesture allows for effective communication and proof of engagement.

Are gestures a big deal to communication?

In short, YES! There are many different types of gestures, and many different names that go along with these gestures. To simplify the categories and language, I will be focusing today on gestures that serve two functions:  for requesting and sharing communication.

Requesting gestures are used to gain something from another person. A young child may point at a toy that is out of reach so his mother can grab it. You may hand your friend a jar that is tightly shut to ask for help with opening it. Without words, communication is clearly happening between people. 

On the other hand, requests for sharing communication are those gestures used to communicate an interest, or lack of interest in something. For example, pointing to the loud, annoying helicopter in the sky or showing that new trending social media video to your friend. These communicative gestures are integrated seamlessly and automatically into our daily interactions with others.

Do I need to teach gestures?

Yes! There are natural differences between people in how much they use their bodies when orally communicating with another person. But from a developmental perspective, gesturing is an important aspect to early communication skills. 

Gesturing actually helps facilitate language development. Child-initiated gestures engage attention and language, and increase word and concept development. Gestures reflect what the children know, and provide opportunity for developmental change. Gesturing in young children is predictive of later language skills such as expressive vocabulary, but also of perspective taking and abstract thinking. Lack of gestures in very young children may indicate developmental concerns.

Recently some professionals and parents of older preverbal children have expressed resistance to including gestures as a language target – stating that intense focus should be placed on oral language or assistive technology, and claiming that gestures will replace the child’s use of broader communication.  This fear is unfounded, and research supports the benefit of gestures throughout development to facilitate and assist, not to hinder.

A child’s language abilities should not dictate whether or not gestures are taught. Further, gestures should be taught along with other communication modalities, regardless of what method of communication your preverbal child is learning.  Whether they use sounds, word approximations or sound generating devices, gestures enhance communication skills across their lifetime.

This PCSES curriculum, though it provides activities to teach various early social behaviors with both adults and peers, also focuses on teaching early initiating and responding gestures. This includes teaching your child to gesture “up” to be carried, teaching your child to give high fives to friends, and even teaching your child to lead you to something cool to share. 

Where should I begin?

So how do you integrate these gestures? It’s simple. Pick one gesture to teach, then model that gesture across different activities. Your child, in return, should imitate your model in all opportunities. I am a big proponent of social reinforcement, so please don’t forget to praise your child for gesturing. For example, you want to teach the “high five” gesture. Easy. Plan to do some fun and easy gross motor activities with your child like jumping forward on the lines found on concrete sidewalks. After each jump (or attempt), raise your hand to receive the high five gesture from your child. Once they give you the high five, socially praise by saying, “Wow, awesome high five!” Your child may need some physical support at first, and that’s okay too. Reinforce all high fives. One more thing to keep in mind. Focus your attention on the gesture being taught, not how well your child completes the activity. That can be left for another day.

I’m pointing at you all right now with a tilt of my head, followed by a thumbs up, and a high five.

Capone, N. C., & McGregor, K. K. (2004).  Gesture development:  A review for clinical and research practices.  Journal of Speech, Language, and Hearing Research, 47, 173-186.

Crais, E., Douglas, D. D., & Campbell, C. C. (2004). The intersection of the development of gestures and intentionality. Journal of Speech, Language, and Hearing Research 47, 678–694.

Goldin-Meadow, S. (2009). How gesture promotes learning through childhood.  Child Development Perspectives, 3, 106-111.

Manwaring, S.S., Stevens, A.L., Mowdood, A., & Lackey, M., (2018). A scoping review of deictic gesture use in toddlers with or at-risk for autism spectrum disorder. Autism & Developmental Language Impairments, 3, 1-27.

Written by Stephanny Freeman PhD

Today, we are going to take a closer look at Differential Reinforcement of Incompatible behavior (DRI). DRI is defined as “a procedure for decreasing problem behavior in which reinforcement is delivered for a behavior that is topographically incompatible with the behavior targeted for reduction and withheld following instances of the problem behavior (e.g., sitting in seat is incompatible with walking around the room) (Cooper, Heron, & Heward, 2007).

Let’s look at a few examples of DRI in action:

• Mrs. Clark is teaching a classroom with six students with autism. One of her students has recently begun to pinch his arms. She takes data on the behavior and discovers that it functions for attention. (When he pinches his arms, she or a teacher’s aid comes over and tells him “no pinching.”) She decided to implement an intervention that utilizes DRI. She teaches him how to sit with his hands intertwined on his desk. This is an incompatible behavior with pinching because he is not able to pinch while his hands are intertwined. She and the teacher’s aid reinforce him for intertwining his hands (come over and tell him, “great job” or “I like how you’re sitting”) and do not provide attention when he engages in arm pinching.

• Carly has a 9-year-old daughter. When her daughter wants a break from doing homework, she reaches over and hits Carly’s arm. Carly typically says, “Do you need a break now?” Then, she allows her to take a five-minute break. Carly recognized that her daughter’s intensity with hitting seemed to be increasing, and she was worried she might get hurt. She decided to implement an intervention that utilized DRI. She put a timer on the table within her daughter’s reach, and taught her daughter to touch the timer when she wanted a break. This is an incompatible behavior because her daughter cannot simultaneously touch the timer and hit Carly. When Carly’s daughter touched the timer, she immediately received a break. When she hit Carly, she did not receive a break. This was an especially useful intervention because, over time, Carly taught her daughter to set the timer on her own and become more independent with managing break times.

• Mr. Holley teaches a preschool class. During circle time, many of his students become very excited and can be quite loud. Sometimes it seems as though all of his students are yelling at the same time. Once they become too loud, it is very challenging to regain their attention. He decides to implement an intervention utilizing DRI. He uses a decibel meter on his tablet (such as the app Too Noisy). He teaches the students that when the noise level is below a certain number or threshold they all earn stickers. This is differential reinforcement of an incompatible behavior because the children cannot possibly speak loudly and softly simultaneously.

DRI is not always the best option. For example, it may be very challenging to come up with an incompatible behavior. Or, in the case of self-injurious or aggressive behavior, it may be dangerous to use such an intervention.

If you do use DRI, you may consider explicitly telling your learner(s) that you are implementing this new plan, such as Mr. Holley did in the third example above. And remember, this is only one form of differential reinforcement. If DRI is not appropriate for your situation, there are definitely still options for reinforcing appropriate behavior in an effective and efficient manner.

REFERENCES

Cooper, J.O., Heron, T.E., & Heward, W.L. (2007). Applied Behavior Analysis – 2nd ed. Englewood Cliffs, NJ: Prentice-Hall.

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

David Celiberti, PhD, BCBA-D, Maithri Sivaraman, MSc, BCBA, and Yash Gupta
Association for Science in Autism Treatment

Resistance associated with dental visits is an all-too-common challenge for many individuals with (and without) autism spectrum disorder (ASD).  Such resistance can lead to the use of restraint or pharmacological management, and sadly in some instances can be associated with inadequate preventative dental care or delays to access treatment which can lead to more serious health complications. More specifically, individuals with autism requiring special needs such as anesthesia dentistry, can face long waits for service (Bai, 2020). Furthermore, interventions that rely heavily on exposure training require a clinical setting able to make that investment which is often hampered by billing constraints, limited insurance reimbursement, and other logistical barriers.

This list of annotated resources has been created to serve as a helpful reference for families, clinicians, and educators alike. We have incorporated resources for dental providers as well, since there is some research suggesting that the majority of dentists feel anxious or uncomfortable treating patients with special needs (e.g., Dao et al., 2005).  We showcase online resources that highlight strategies and information to address the myriad of obstacles surrounding dental care. We hope that this information shared below will support your efforts, promote cooperation, and help improve dental outcomes. This piece was initially published a few years ago and is now expanded and updated.

Resources for Families (Video/Audio):

Child Preparation- Bergen Pediatric Dentistry. On this very helpful page, Dr. Purnima Hernandez shares several video models and narratives for parents, providers, and children. The videos showcase specific tools and their corresponding sounds which may help prepare your child for a cleaning visit. These videos expose the child to some of the more potentially aversive sensory experiences in a brief and non-threatening manner.

Making Going to the Dentist Easier for Kids with Autism. This helpful video blog by Dr. Mary Barbera describes several strategies you can consider to make dental visits and oral care easier. Dr. Barbera discusses the importance of careful reflection on past visits, learning from those experiences, and setting reasonable goals. She models some of these strategies in this 11-minute video.

Autism: Making Tooth Brushing Possible/Fun. This 12-minute 2013 video by Autism Live includes an interview with Dr. Jonathan Tarbox and addresses the role of reinforcement and shaping/exposure procedures.  Specifically, Dr. Tarbox outlines strategies to reduce the motivation to escape, including criteria to guide gradual progression, and careful use of probes to guide toleration efforts. He also discusses the importance of limiting access to high-ticket rewards so that they can only be achieved by completing one certain task, for example tooth brushing.

Dental Toolkit. In recognition that good oral health habits can be challenging for many individuals with autism, Autism Speaks collaborated with Colgate and Philips-Sonicare to create this 10-minute video. It provides tips for families so they can help their loved ones with autism access a suitable dental care provider as well as how to choose the right brush/toothpaste and practice skills at home, including getting ready for the first visit. Two dentists shared their experiences serving patients with autism offering numerous suggestions, such as how to adapt the examination depending on the child’s reactions.

How To Help Your Autistic Child During A Dental Appointment | Autism Tips by Maria Borde.   

This quick, 3-minute video by Maria Borde showcases many strategies to help prepare for the dentist. Some tips mentioned for children with autism at the dentist are: preparing them in advance by showing them the tools and making them comfortable with the tools, bringing a tablet with your child's favorite shows as a distraction, and using sunglasses and sound cancelling headphones for children who find bright lights or loud sounds aversive.

Resources for Families (Print Materials):

Autism Dental Information Guide for Families and Caregivers. In an effort to create information guides for families of individuals with autism, service providers, and dental professionals, the Southwest Autism Research & Resource Center (SARRC) published this booklet in collaboration with dental experts and academics. This well-organized and consumer friendly booklet contains background information on the importance of good oral hygiene and care. It provides a comprehensive list of suggestions for scheduling the dental appointment, including a sample form for use when calling the dentist to set up the initial appointment. The sections related to preparing for the office visit and carrying out oral care in the home are particularly detailed and helpful. Finally, there is information about the use of fluoride and metal fillings (amalgam) to help parents become more informed about these products.

Taking Your Son/Daughter with an Autism Spectrum Disorder to the Dentist. This resource was prepared by the Indiana Resource Center for Autism. The article contains many helpful tips, such as bringing the child’s toothbrush and toothpaste to the dental visit for familiarity and having the dental chair already in a reclined position for those children who may not like to be moved backward mechanically. A Tell/Show/Do strategy is described for promoting cooperation and participation during dental routines. This strategy first involves verbally describing the forthcoming step, followed by displaying the tool or instrument and allowing the child to see it, and finally, carrying out the step. Appendices include a list of books, a sample social story, and a visual schedule for visiting the dentist.

Healthy Smiles for Autism: Oral Hygiene Tips for Children with Autism Spectrum Disorders. This publication is based on a collaboration of the National Museum of Dentistry, the Kennedy Krieger Institute’s Center for Autism and Related Disorders, and the University of Maryland Dental School. It showcases best practices related to oral health care for children with ASD. This booklet highlights the importance of parental modeling and recommends that parents invest time in choosing a toothbrush, toothpaste, and flossing materials that work best for the child. Guidelines for helping children brush and floss successfully are consistent with well-established behavior analytic principles and are consumer-friendly, as are the suggestions surrounding how to access dental care (e.g., finding a dental provider, getting ready for the initial visit). This booklet includes well-designed visual sequencing cards, social stories, and a picture dictionary.

Helping Your Child Overcome Fear of the Dentist and Develop Lifelong Oral Hygiene Habits. In this resource shared by Solving Autism, readers will find a brief overview of the common challenges observed in children with autism, tips for finding the right dentist including helpful questions to ask, and proactive strategies in preparation for the visit. There is also a user-friendly set of suggestions for developing sound oral hygiene habits.

Autism and Dental Care: A Guide for Their Oral Treatment. In this resource, Drs. Greg Grillo and David Hudnall offer many helpful strategies in preparing for upcoming dental visits, as well as tips and techniques to promote the development of proper oral health habits. They discuss sedation as well as the benefits of splitting examination components over multiple visits. This resource is available in Spanish (Autismo y el Cuidado Dental) and also refers to a blog in Spanish.

Dental Health Guidance for Parents and Caregivers of Children with Autism Spectrum Disorder. This fact sheet put together by the Washington State Department of Health and University of Washington’s DECOD (Dental Education in the Care of Persons with Disabilities) Program provides a very helpful list of questions to guide initial conversations with the dentist. It includes an array of tips and strategies to prepare for the visit, as well as some action items for the day of the visit.

Resources for Dental Professionals:

Autism Dental Information Guide for Professionals. This guide has been created by SARRC for dental professionals. Besides information on relevant dental issues associated with ASD, and what to expect with a patient with ASD, the guide offers valuable input on specific items to include in a welcome package. An important strategy for an individual with ASD to have a successful visit to a dental clinic is the preparedness of the professional and the patient for the experience. The guide offers suggestions such as sending pictures of the dental team and the office prior to the visit and providing pamphlets (when appropriate) and parent questionnaires to learn about existing behavioral challenges and sensory preferences towards preparedness.

Autism Speaks Dental Toolkit. The dental toolkit by Autism Speaks is aimed at both parents and professionals. Specifically, the 10-minute video has advice from dental experts with experience treating patients with ASD and highlights the importance of rapport-building for a successful experience. The toolkit also offers a visual schedule that dental professionals can adapt to help their patients anticipate and tolerate the different steps and activities that will occur during their visit to the clinic. Autism Speaks also offers a detailed task analysis for toothbrushing. As is the case with every task analysis, this should be individually tailored to target the child’s needs, skills, and deficits.

University of Washington’s Fact Sheet for Professionals.  This fact sheet put together by the Washington State Department of Health, and University of Washington’s DECOD outlines the symptoms of ASD, commonly associated comorbid conditions, and strategies for dental professionals to manage patients with autism. This resource offers guidance for promoting cooperation in the dental chair and specific tips on techniques to use before and during the appointment. In addition, seizure management during treatment, and ways to handle visible signs of trauma are briefly summarized. This is important given that many individuals with autism develop seizure activity. An analogous Fact Sheet for Dental Professionals has also been developed for ADHD, Down Syndrome and cerebral palsy.

National Institute of Child Health and Human Development Resource Center (NICHD)’s Practical Oral Care for People with Autism. This is a handbook for oral care physicians created by the NICHD in collaboration with the National Association of Dental and Craniofacial Research. The booklet is one in a series on providing oral care for people with developmental disabilities including ASD, Cerebral Palsy, Downs Syndrome, and intellectual disability. The autism handbook lists the issues and oral health challenges common in individuals with ASD and provides care strategies for them. Specific ways to prepare for patients who present with “unusual and unpredictable body movements” and sensitivity to sensory stimuli are offered.

Dental Care – Continuing Education course. Dental Care offers a free continuing education course for dental professionals, with an aim to promote understanding of ASD and prepare learners to serve patients with this diagnosis. The course content is extensive and provides modules on creating a sensory friendly office, developing an office protocol for patients with ASD, utilizing a visual schedule, and behavior management strategies to increase appropriate behavior. The course is intended for all types of dental professionals as well as dental students, and is self-instructional.

Dental Exam Tolerance with Dr. Kelly McConnell — ABA Inside Track. This 1 hour and 22-minute podcast with Dr. Kelly McConnell by ABA Inside Track showcases recent behavior analytic research to help children with autism better tolerate dental appointments. It mentions strategies that could be considered when children with autism meet with their dentists, as well as things to avoid. A distinction is made between desensitization and graduated exposure as the latter may be a more accurate description of the procedures typically used.  As shared throughout many of the resources described in this article, it was discussed that adjustments and increased demands should be made gradually.

We hope you will find these resources beneficial whether you are an individual with autism, a family member to someone with autism, an education or behavioral professional, or a dental care professional. We will continue to update this annotated list and reshare with our readers as new resources become available. Together, we can help to make dental visits successful for people with autism. Please consider sharing this article with clients, friends, and colleagues.

References:

Bai, N. (2020, February 24). For patients with special needs, any dentist is hard to find.    https://www.ucsf.edu/news/2020/02/416726/patients-special-needs-any-dentist-hard-find

Dao L. P., Zwetchkenbaum S., & Inglehart M. R. (2005) General dentists and special needs patients: Does dental education matter? Journal of Dental Education, 69(10), 1107-15. PMID: 16204676.

Citation for this article:

Celiberti, D., Sivaraman, M., & Gupta, Y. (2021). Consumer Corner: An updated and annotated list of online resources for promoting dental hygiene and success with dental care. Science in Autism Treatment, 18(5)

Please also see other related ASAT articles:

• Interview with Dr. Purnima Hernandez, DDS
• Clinical Corner: Cooperating with dental exams
• Clinical Corner: What are some essential skills in a COVID-19 era?
• ASAT Responds to West-info.eu’s Special dental care for children with autism
• A Review of Healthcare for children on the autism spectrum: A guide to medical, nutritional, and behavioral issues

A Non-exhaustive list of recent research in the area:

Allen, K. D., & Wallace, D. P. (2013). Effectiveness of using noncontingent escape for general behavior management in a pediatric dental clinic. Journal of Applied Behavior Analysis, 46, 723-737. https://doi.org/10.1002/jaba.82   

Altabet, S. (2002). Decreasing dental resistance among individuals with severe and profound mental retardation. Journal of Developmental and Physical Disabilities, 14, 297-305. https://doi.org/10.1023/A:1016032623478  

Appukuttan, D. P. (2016). Strategies to manage patients with dental anxiety and dental phobia: Literature review. Clinical, Cosmetic and Investigational Dentistry, 8, 35-50. https://doi.org/10.2147/CCIDE.S63626   

Blitz, M., & Britton, K. C. (2010). Management of the uncooperative child. Oral and Maxillofacial Surgery Clinics of North America, 22(4), 461-469. https://doi.org/10.1016/j.coms.2010.08.002   

Carter, L., Harper, J. M., & Luiselli, J. K. (2019). Dental desensitization for students with autism spectrum disorder through graduated exposure, reinforcement, and reinforcement fading. Journal of Developmental and Physical Disabilities, 31, 161-170. https://doi.org/10.1007/s10882-018-9635-8   

Chandrashekhar, S., & Bommangoudar, J. S. (2018). Management of Autistic Patients in Dental Office: A Clinical Update. International Journal of Clinical Pediatric Dentistry, 11(3), 219–227. https://doi.org/10.5005/jp-journals-10005-1515

Cuvo, A. J., Godard, A., Huckfeldt, R., & Demattei, R. (2010). Training children with autism spectrum disorders to be compliant with an oral assessment. Research in Autism Spectrum Disorders, 4, 681-696.

Delli, K., Reichart, P. A., Bornstein, M. M., & Livas, C. (2013). Management of children with autism spectrum disorder in the dental setting: concerns, behavioural approaches and recommendations. Medicina Oral, Patologia Oral y Cirugia Bucal, 18(6), e862–e868. https://doi.org/10.4317/medoral.19084

Du, R. Y., Yiu, C. K., & King, N. M. (2019). Oral health behaviours of preschool children with autism spectrum disorders and their barriers to dental care. Journal of Autism and Developmental Disorders, 49(2):453-459. https://doi.org/10.1007/s10803-018-3708-5.  

Fakhruddin, K. S., Yehia, H., & Batawi, E. (2017). Effectiveness of audiovisual distraction in behavior modification during dental caries assessments and sealant placement in children with autism spectrum disorder. Dental Research Journal, 14(3), 177-182.

Ferrazzano, G. F., Salerno, C., Bravaccio, C., Ingenito, A., Sangianantoni, G., Cantile, T.  (2020). Autism spectrum disorders and oral health status: Review of the literature. European Journal of Paediatric Dentistry, 21(1):9-12. https://doi.org/10.23804/ejpd.2020.21.01.02.

Friedlander, A. H., Yagiela, J. A., Paterno, V. I., & Mahler, M. E. (2006) The neuropathology, medical management and dental implications of autism. Journal of the American Dental Association, 137(11): 1517-1527. https://doi.org/10.14219/jada.archive.2006.0086  

Hernandez, P., & Ikkanda, Z. (2011). Applied behavior analysis: behavior management of children with autism spectrum disorders in dental environments. Journal of the American Dental Association,142(3):281-7. https://doi.org/10.14219/jada.archive.2011.0167

Jaber M. A. (2011). Dental caries experience, oral health status and treatment needs of dental patients with autism. Journal of Applied Oral Science: Revista FOB, 19(3), 212–217. https://doi.org/10.1590/s1678-77572011000300006  

Loo, C., Graham, R., Hughes, C. (2008) The caries experience and behavior of dental patients with autism spectrum disorder. Journal of the American Dental Association, 139, 1518-1524. https://doi.org/10.14219/jada.archive.2008.0078.

Marion I. W., Nelson T. M., Sheller B., McKinney C. M., & Scott J. M. (2016). Dental stories for children with autism. Special Care in Dentistry, 36(4):181-6. https://doi.org/10.1111/scd.12167.

McConnell, K. L., Sassi, J. L., Carr, L., Szalwinski. J., Courtemanch, A., Njie-Jallow, F., & Cheney, W. R. (2020). Functional analysis and generalized treatment of disruptive behavior during dental exams. Journal of Applied Behavior Analysis 53(4), 2233-2249. https://doi.org/10.1002/jaba.747   

Ming, X., Brimacombe, M., Chaaban, J., Zimmerman,-Bier, B., Wagner, G. C. (2008). Autism Spectrum Disorders: Concurrent Clinical Disorders. Journal of Child Neurology, 23, 6-13. https://doi.org/10.1177/0883073807307102

Nelson, T., Chim, A., Sheller, B. L., McKinney, C. M., & Scott, J. M. (2017). Predicting successful dental examinations for children with autism spectrum disorder in the context of a dental desensitization program. The Journal of the American Dental Association, 148(7), 485-492. https://doi.org/10.1016/j.adaj.2017.03.015  

Nelson, T. M., Sheller, B., Friedman, C. S., & Bernier, R. (2015). Educational and therapeutic behavioral approaches to providing dental care for patients with Autism Spectrum Disorder. Special Care in Dentistry, 35(3). 105-113. https://doi.org/10.1111/scd.12101

O’Callaghan, P. M., Allen, K. D., Powell, S., & Salama, F. (2006). The efficacy of noncontingent escape for decreasing children’s disruptive behavior during restorative dental treatment. Journal of Applied Behavior Analysis, 39(2), 161-171

Stark, L. J., Allen, K. D., Hurst, M., Nash, D. A., Rigney, B., & Stokes, T. F. (1989). Distraction: its utilization and efficacy with children undergoing dental treatment. Journal of Applied Behavior Analysis, 22(3), 297–307. https://doi.org/10.1901/jaba.1989.22-297

Virdi, M. S. (2011). Application of contingency management in pediatric dentistry practice. Journal of Innovative Dentistry, 1(1), 1-4.

About The Authors

On my first day returning to the office after over a year of working from home and Zoom, I felt as if I had lost all of my leaving-the-house skills. What shoes did I wear? What could I pack for lunch? Did I have time to drink my coffee at home or would I need to bring a travel mug? Where I used to be able to make it out the door 45 minutes after waking up, I suddenly was running 20 minutes late. What had been years of routine was now completely unfamiliar.

Many of us will probably be feeling the same way, including our students with Autism. How do we possibly ease this transition? Below are a few suggestions, and we’d love to hear any you may have as well. 

• Offer choice whenever possible. Access to choice is motivating for many kids, and can be a balm in instances where so much is out of their control. You can provide choices with what they pack for lunch, what outfits they wear, or what fun activity they can do when they return home from their first day back to school.
• Create alerts and schedules. Have your kid participate in creating a basic schedule, setting alarms, or putting alerts in your smartphone for new activities added to the schedule. Another benefit of creating a schedule is that you can add fun events/activities in with the new required activities.
• Identify supports within the school. Many schools and teachers are creating their own plans to ease the transition. Find out what your school and/or your child’s classroom teacher are doing, and see what you can do to support that plan or carry it over into your home.
• Practice the new transitions. Role-play the new routine as much as possible. This could be as simple as setting the alarm for the new wake-up time; or it can be more complex in that you wake up, go through the morning routine, and practice the drive to school. Practice will help your child adjust to the new routine, but will also alert you to any potential problems without the added stress of having to complete the routine in its entirety.
• Prep what you can in advance. Set out clothing the night before, prep lunches in advance with your child, or set a time with a fellow parent for children to meet prior to walking into the school.
• Use tools that have been successful in the past. Reflect on transitions that have been challenging in the past for your child. What strategies worked in those instances? How could those strategies be implemented now to ease this transition?
• Prepare your child for additional changes. There are many changes that will be outside of your control. It’s possible the school will change (or has already changed) its re-open date, or that it will close again after re-opening. It can be helpful to state this possibility for your child, and tell them what you’ll do if plans change.
• Check in. Set aside time to check in with your child. One game that can be fun for check-ins is “high, low, buffalo.” Here, you and your child each share a high point of your day (high,) a low point of our day (low,) and a something else funny or fun or interesting about your day (buffalo.) Providing this structure can be a great way to normalize check-ins and ensure that you are addressing any issues that may arise during the transition.

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. 

According to Harvard University social skills are the top factor in getting a job. Is your teen or young adult prepared? Social skills are especially difficult for individuals on the autism spectrum, however many of these skills can be learned, and with practice, can become habit. Social skills are critically important to make friends, get and keep a job, get along with co-workers, and live a fulfilling, independent (or as independent as possible) life.

I created the Smile & Succeed for Teens Online Course as an engaging, easy and fun way for teens and young adults to learn and master valuable social and job skills. The content is quick and easy to learn with no wasted words, perfect for short attention spans.

"Smile & Succeed for Teens is a fantastic resource to help teens be successful at work." —Temple Grandin, One of Time Magazine's 100 most influential people in the world, leading autism advocate, author, Thinking in Pictures, The Autistic Brain

At-Home Learning
The pandemic has negatively affected many teens and young adults’ social skills. Smile & Succeed for Teens Online Course is perfect for at-home, in-class or remote learning, self-paced or instructor led. This flexible course provides an ideal resource for all young people, including those in transition and autism support programs, to gain the social and job skills necessary for success. The course is mobile friendly and can be viewed on a cell phone, tablet, laptop, or desktop computer.

Now is a perfect time for your son or daughter to learn or refresh vital social and job skills. The online course mirrors the content in my Teachers' Choice Award and Mom’s Choice Gold Award-winning book, Smile & Succeed for Teens: Must Know People Skills for Today's Wired World. The seven modules in the online course correspond to the seven chapters in my book. Your young adult will learn the same life-changing skills.

KEY TAKEAWAYS FOR TEENS:

• How to interview effectively, land a job and keep it!
• How to make friends.
• Electronic etiquette.
• The important life skills your first job can teach you.
• Customer service, sales and fundraising skills to excel.
• The many benefits of volunteering.
• How to handle stress.
• Job skills that make you stand out.
• Improved confidence and self-esteem.
• What colleges are looking for in applicants, and a lot more.
  
  The online course is perfect for middle, high school and college students and all young adults.

Course Benefits

• Quick and easy to implement. Simply log in and begin using!
• Straightforward, simple and extremely user-friendly.
• Bookmarks and highlights. Users can bookmark, make notes and highlight key points.
• Search function to refresh skills and for quick and easy reference.
• Interactive questions and answers make learning fun.
• Curated videos reinforce concepts.
• Mobile friendly.
• “Wired Tips” remind students of the benefits of face-to-face communication and electronic etiquette.
• ADA (Americans with Disabilities Act) compliant.
• Compatible with free Read&Write extension for Google Chrome.
• Lexile: 720L (4^th grade reading level)

A Solution for Schools and Students
Many students are struggling with “soft skills” (social skills). This online course provides instructors with an easy way to teach students these powerful skills. There are opportunities for comprehension testing along the way.

For school purchases with multiple users (instructor(s) and students), the instructor(s) will receive the instructor version of this online course that includes an embedded teaching guide with differentiated activities and lesson plans that make it easy to teach the content and provide additional learning opportunities.

Prep time is very minimal. A teacher can purchase and implement the same or next day. Results from quizzes automatically populate into the gradebook with the gradebook export feature.

The specific curriculum for customer service skills in this online course meets Customer Service Standards as outlined by the Ohio Department of Education.

Note: This course is a content delivery system. It can stand alone or fit inside your Learning Management System (LMS). It can even integrate with your video conferencing tools such as Zoom or Microsoft Teams.

Course Benefits

• User-friendly common-sense approach to people skills.
• Written in an upbeat manner that holds the interest of young people.
• Entertaining graphics with educational captions enhance the content.
• Reaches a wide variety of teen and young adult abilities.
• Allows for independent use.

Excerpt from the Online Course

Once you land a job you will want to work hard to keep it.

HERE’S HOW

• Follow directions
• Communicate clearly
• Be on time
• Be enthusiastic
• Practice self-control 
• Take responsibility for assigned tasks
• Be able to work without supervision
• Be respectful
• Accept instruction eagerly

Why do most young people lose a job?

• Being late or being absent
• Not making an effort to get along with others
• Slow to learn good work habits

Whether they are looking for a job, already working, starting their own business, volunteering, or applying to college, Smile and Succeed for Teens Online Course is ideal for young adults. Packed with indispensable tips, proven techniques, and “must-do-now” strategies, this course generates results.

Parts taken from “Smile & Succeed for Teens: Must-Know People Skills for Today’s Wired World” Copyright © 2014-2021 by Kirt Manecke. Kirt Manecke is the award-winning author of “Smile & Succeed for Teens: Must-Know People Skills for Today’s Wired World” online course and book, and “The Teaching Guide for Smile & Succeed for Teens”.

Editor’s note:  Autism Awareness month is becoming a call to action from the autism and neurodivergent communities for change from the rest of society. In this edited excerpt from their upcoming book with Different Roads, co-authors Shahla Ala’i-Rosales and Peggy Heinkel-Wolfe offer a specific call to action to both parents and professionals—to seek and maintain joy’s radiating energy in our relationships with our children.

Parents have the responsibility of raising their children with autism the best they can. This journey is part of how we all develop as humans—nurturing children in ways that honor their humanity and invite full, rich lives. Ala’i-Rosales and Heinkel-Wolfe’s upcoming book offers a roadmap for a joyful and sustainable parenting journey. The heart of this journey relies on learning, connecting, and loving. Each power informs the other and each amplifies the other. And each power is essential for meaningful and courageous parenting.

Ala’i-Rosales is a researcher, clinician, and associate professor of applied behavior analysis at the University of North Texas. Heinkel-Wolfe is a journalist and parent of an adult son with autism.

Joy gives us wings! ― Abdul-Baha

“Up, up and awaaay!” all three family members said at once, laughing. A young boy’s mother bent over and pulled her toddler close to her feet, tucking her hands under his arms and around his torso. She looked up toward her husband and the camera, broke into a grin, and turned back to look at her son. “Ready?” she said, smiling eagerly. The boy looked up at her, saying “Up . . .” Then he, too, looked up at the camera toward his father before looking back up at his mother to say his version of “away.” She squealed with satisfaction at his words and his gaze, swinging him back and forth under the protection of her long legs and out into the space of the family kitchen. The little boy had the lopsided grin kids often get when they are proud of something they did and know everyone else is, too. The father cheered from behind the camera. As his mother set him back on the floor to start another round, the little boy clapped his hands. This was a fun game.

One might think that the important thing about this moment was the boy’s talking (it was), or him engaging in shared attention with both his mom and dad (it was), or his mom learning when to help him with prompts and how to fade and let him fly on his own (it was), or his parents learning how to break up activities so they will be reinforcing and encourage happy progress (it was) or his parents taking video clips so that they could analyze them to see how they could do things better (it was) or that his family was in such a sweet and collaborative relationship with his intervention team that they wanted to share their progress (it was). Each one of those things is important and together, synergistically, they achieved the ultimate importance: they were happy together.

Shahla has seen many short, joyful home videos from the families she’s worked with over the years. On first viewing, these happy moments look almost magical. And they are, but that joyful magic comes with planning and purpose. Parents and professionals can learn how to approach relationships with their autistic child with intention. Children should, and can, make happy progress across all the places they live, learn, and play–home, school, and clinic. It is often helpful for families and professionals to make short videos of such moments and interactions across places. Back in the clinic or at home, they watch the clips together to talk about what the videos show and discuss what they mean and how the information can give direction. Joyful moments go by fast. Video clips can help us observe all the little things that are happening so we can find ways to expand the moments and the joy.

Let’s imagine another moment. A father and his preschooler are roughhousing on the floor with an oversized pillow. The father raises the pillow high above his head and says “Pop!” To the boy’s laughter and delight, his father drops the pillow on top of him and gently wiggles it as the little boy rolls from side to side. After a few rounds, father raises the pillow and looks at his son expectantly. The boy looks up at his father to say “Pop!” Down comes the wiggly pillow. They continue the game until the father gets a little winded. After all, it is a big pillow. He sits back on his knees for a moment, breathing heavily, but smiling and laughing. He asks his son if he is getting tired. But the boy rolls back over to look up at his dad again, still smiling and points to the pillow with eyebrows raised. Father recovers his energy as quickly as he can. The son has learned new sounds, and the father has learned a game that has motivated his child and how to time the learning. They are both having fun.

The father learned that this game not only encourages his child’s vocal speech but it was also one of the first times his child persisted to keep their interaction going. Their time together was becoming emotionally valuable. The father was learning how to arrange happy activities so that the two of them could move together in harmony. He learned the principles of responding to him with help from the team. He knew how to approach his son with kindness and how to encourage his son’s approach to him and how to keep that momentum going. He understood the importance of his son’s assent in whatever activity they did together. He also recognized his son’s agency—his ability to act independently and make his own choices freely—as well as his own agency as they learned to move together in the world.

In creating the game of pillow pop, parent and child found their own dance. Each moved with their own tune in time and space, and their tunes came together in harmony. When joy guides our choices, each person can be themselves, be together with others, and make progress. We can recognize that individuals have different reinforcers in a joint activity and that there is the potential to also develop and share reinforcers in these joint activities. And with strengthening bonds, this might simply come to mean enjoying being in each other’s company.

In another composite example, we consider a mother gently approaching her toddler with a sock puppet. The little boy is sitting on his knees on top of a bed, looking out the window, and flicking his fingers in his peripheral vision. The mother is oblivious to all of that, the boy is two years old and, although the movements are a little different, he’s doing what toddlers do. She begins to sing a children’s song that incorporates different animal sounds, sounds she discovered that her son loves to explore. After a moment, he joins her in making the animal sounds in the song. Then, he turns toward her and gently places his hands on her face. She’s singing for him. He reciprocates with his gaze and his caress, both actions full of appreciation and tenderness.

Family members might dream of the activities that they will enjoy together with their children as they learn and grow. Mothers and fathers and siblings may not have imagined singing sock puppets, playing pillow pop, or organizing kitchen swing games. But these examples here show the possibilities when we open up to one another and enjoy each other’s company. Our joy in our child and our family helps us rethink what is easy, what is hard, and what is progress. 

All children can learn about the way into joyful relationships and, with grace, the dance continues as they grow up. This dance of human relationships is one that we all compose, first among members of our family, and then our schoolmates and, finally, out in the community. Shahla will always remember a film from the Anne Sullivan School in in Peru. The team knew they could help a young autistic boy at their school, but he would have to learn to ride the city bus across town by himself, including making several transfers along the way. The team worked out a training program for the boy to learn the way on the city buses, but the training program didn’t formally include anyone in the community at large. Still, the drivers and other passengers got to know the boy, this newest traveling member of their community, and they prompted him through the transfers from time to time. Through that shared dance, they amplified the community’s caring relationships. 

When joy is present, we recognize the caring approach of others toward us and the need for kindness in our own approach toward others. We recognize the mutual assent within our togetherness, and the agency each of us enjoys in that togetherness. Joy isn’t a material good, but an energy found in curiosity, truth, affection, and insight. Once we recognize the radiating energy that joy brings, we will notice when it is missing and seek it out. Joy occupies those spaces where we are present and looking for the good. Like hope and love, joy is sacred.

"When there is so much hate and so much resistance to truth and justice, joy is itself is an act of resistance." ― Nicolas O’Rourke

Photo Credit: Bruno Nascimento c/o Unsplash

The importance of parental/caregiver involvement cannot be overstated. Parents are not only our children’s first teachers, they are the one teacher that remains with them throughout their infancy, childhood, and through adulthood. ABA practitioners and teachers may have a positive and substantial impact on a child’s life, but nothing compares to the impact parents/caregivers have. Parents/caregivers are their child’s forever teacher and just as we as practitioners and teachers need training and resources, so do parents/caregivers.

The R.E.A.L. Model (Terzich-Garland, 2020) incorporates parent involvement from the very start of programming, encouraging parents to become independent with utilizing techniques to increase independence, generalize and maintain skills across environments. In this must-read for practioners, there is a specific parent generalization section in each chapter, which discusses how practioners can involve parents at each level of programming utilizing the R.E.A.L. Model.

Acceptance and Commitment Therapy (A.C.T.) can also be integrated along with The R.E.A.L. Model into parent and caregiver training. Parents must believe in their own abilities to set up children up for success. Practitioners must give them the skills necessary to be as independent as possible right from the start.

Different Roads to Learning, along with The R.E.A.L. Model will be hosting an upcoming 1-hour webinar on Wednesday, April 21^st, at 11am (pst). We will discuss getting real with the R.E.A.L. Model, A.C.T. and parent/caregiver training. Please join us. Free to attend. 1 BACB CEU will be offered for a $10 processing fee. Our objectives will be:

1. Utilizing the R.E.A.L. Model in planning for generalization within ABA program with parents and caregivers by remaining in the present moment, identifying values, and defining committed actions in a strategic manner.
2. Determine motivating factors that increase the likelihood parents will participate in ABA programming.

We hope to see you on April 21^st! Register today!

WRITTEN BY MARI UEDA-TAO, MA, BCBA

Mari is the Chief Clinical Officer for Applied Behavior Consultants, Inc. (ABC) CA. Working in the field of ABA for almost 20 years with students with Autism Spectrum Disorders and other developmental delays, Mari has worked across ten different countries, spreading Behavior Analysis globally. She is also a parent of two amusing young children!

This month’s ASAT feature comes to us from Lesley Shawler, PhD, BCBA and David Celiberti, 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!

"My student Molly is nonvocal. Whenever I assign independent worksheets, Molly will often refuse to work by ripping up the assignment, throwing her pencil, or putting her head down. There are also times when the students are working and I have to take a phone call or am helping another student, and she screams. I am not sure why she does this, but I am concerned she is not completing assignments and disturbing her peers. She seems to show these behaviors only during academic times or when I am busy and cannot immediately respond to her. What is the best way to respond in these situations? My district recently hired a Board Certified Behavior Analyst who mentioned something about a procedure called Functional Communication Training."

Answered by

Lesley Shawler, PhD, BCBA and David Celiberti, PhD, BCBA-D
Association for Science in Autism Treatment

It can be difficult to know how best to respond when a student, such as Molly, becomes disruptive or engages in potentially harmful behavior. It is important to remember that her behavior serves a functional response, and, in all likelihood, is effective for her in achieving a desired outcome (escape from demands or access your attention). If these behaviors are successful in meeting her needs, they will continue to occur in similar situations until they are no longer successful. Fortunately, this also means that these behaviors are modifiable, and you can teach new, replacement behaviors, particularly those that are communicative in nature and serve the same function (i.e., purpose) as the challenging behavior.

Based on the details that you shared, we wanted to shine a spotlight on functional communication training (FCT). FCT is an evidenced-based intervention that teaches an appropriate replacement behavior that should replace the interfering behavior (Carr & Durand, 1985). FCT has been supported through decades of research to decrease problem behavior and increase functional behaviors (e.g., Tiger, Hanley, & Bruzek, 2008; Hagopian, Boelter, Jarmolowicz, 2011). An important component of FCT is the removal of reinforcement for the inappropriate behavior (i.e., extinction). Essentially, the child should learn that the old methods (i.e., the unwanted behavior) are ineffective, and that in order to achieve his/her desired outcome, he or she must engage in a new response (i.e., the communicative alternative). For example, if Molly has learned that refusing to work and/or destroying her materials will end or delay the difficult task, we need to teach her that this behavior does not lead to that outcome, and instead teach her a more acceptable way to achieve the very same goal (ending a task). This could be a response such as requesting a different task, or asking for a break. Similarly, if she screams to gain attention, a replacement behavior such as raising her hand, or tapping her desk, could be taught. The most important take-away is the new communication skill must serve the same function as the unwanted behavior.

Given that, it is very important to clarify what the underlying motivation is for the behaviors in question. The process should begin with a functional behavior assessment (FBA) in which the function of the problem behavior is assessed (a board certified behavior analyst can assist you with this effort). This can start with an open-ended interviews with those who are familiar with or have knowledge of the student in question. Some questions may include, “does the behavior typically occur when work is given and students are working independently? Is the typical reaction that the teacher reminds the student to get back on task?” Assessment could also be conducted through direct observations of the student in which teachers can determine what may commonly precede (antecedents) and follow problem behavior (consequences). These data are documented in an A-B-C (antecedent-behavior-consequence) format which involve recording events that preceded and followed the behavior. By observing repeated occurrences of the problem behavior, the purpose of Molly’s behavior may become clear (i.e., she wants attention from the teacher, she does not want to complete the work) This information can then be used to formulate hypotheses about why the behavior is occurring. These types of direct methods are the most important, and should be relied upon over indirect methods. In some cases, a behavior analyst may need to directly manipulate certain variables that are thought to maintain the problem behavior, in an experimental functional analysis (LaRue, 2009).

Taken together, the results from the FBA will provide information pertaining to the function of the behavior(s). The possible functions include: escape from non-preferred/aversive situations, demands, or people (social negative reinforcement), attention from others (positive or negative forms) or access to preferred items/activities (social positive reinforcement) and sensory stimulation often in the form of repetitive or stereotypic behaviors (automatic reinforcement). Once identified, the behavior analyst and teacher should work together to identify appropriate functional communication skills. In Molly’s case, one would likely hypothesize that throwing and ripping up material and putting her head down are maintained by escape or avoidance from demands and screaming may be maintained by attention from the teacher. As such, teaching an appropriate method to ask for a new task, a break, attention, or other similar concepts may be best.

Selecting a replacement behavior is of utmost importance and various factors should be considered. Not only should the response match the purported function, but the new response should initially be easy to teach, not too effortful for the student, highly likely to be noticed by others, and consistently and immediately reinforced. If the replacement behavior is too difficult, the student may rely on their previous history of behavior, which to this point has been effective. This explanation supports the necessity of choosing a relatively simple response. Replacement behaviors can also come in various forms, whether for vocal or non-vocal students. For students like Molly, as she is nonvocal, you would need to teach her a nonvocal response. You also want to consider her current skill set and select and target a response that is feasible for her. Bear in mind that teaching new skills, especially those replacing behaviors that have received considerable reinforcement previously, will require the teacher to deliberately focus on the student as the process may take time. If she has a communication system in place (e.g., PECS, iPad application), you could teach a response that is within that system so she could ask for a break or attention. If she does not have a system in place, a simple card touch response may be appropriate. This response will serve as her communication method, and each time she touches the card, she will be immediately given a break, and/or provided with attention. This type of response will not be disruptive to those around her, but does require the teacher to attend to her more intensively, in order to immediately reinforce the newly taught response.

Once the function is determined, and a replacement behavior is selected, it is time to teach! The best method to teach the response is through a set of steps that provides Molly with repeated practice in asking for what she wants and showing her that problem behavior is ineffective (i.e., behavior skills training; Sarokoff & Sturmey, 2004) or prompt fading. This could be done with a brief explanation, modeling the card exchange using most to least prompting, and then role-playing. Continue to practice this while gradually fading out prompts over time until she is exchanging the card with less and then no prompts. Continue practicing until Molly can reliably demonstrate the card exchange without prompting. Following teaching this response, multiple opportunities to practice in more natural settings should occur. Try to create opportunities that appear natural but allow you to observe her engaging in the response. For example, when a worksheet is provided, as soon as she touches the card, immediately offer her a break. If she is doing another activity, act like you are attending to another student, then following the card touch, provide immediate attention to her. Should she engage in other responses in order to gain a break or attention, these behaviors should not provide her with those respective outcomes. Continue to encourage her to complete her assignment, even providing additional copies if she needs them. Allow her extra time to finish assignments even if it means missing out on a preferred activity she may enjoy. Similarly, do not provide attention following disruptive behaviors. Once she learns that these behaviors are no longer effective, she will start to engage in those behaviors that have recently been reinforced. However, often times we warn that when using extinction (i.e., removing reinforcement for behavior), the behavior often gets worse before it gets better. If this occurs, do not panic. Consistency and patience are key, as are the strategies being used to teach the alternative. Over time, with repeated practice, she will learn how to obtain the desired outcomes and problem behaviors will begin to reduce.

Eventually, once Molly becomes more consistent with the card touch, the complexity and effort level can also be increased. Molly may have to hold the card up, or walk over to the teacher and hand them the card before reinforcement is provided. It is also important to plan for generalization and maintenance of this response by slowly and systematically increasing the delay to which the response is reinforced and to eventually teach the child that his/her request for a break will not always be reinforced. Try modifications such as using the card in different settings, with different adults, and different responses. It is also important to plan for generalization and maintenance of this response by slowly and systematically increasing the delay to which the response is reinforced and to eventually teach the child that his/her request for a break will not always be reinforced. However, consistency and independence of the card touch response initially should occur prior to any changes in expectations. Ideally generalization will occur, however, if not, try practicing again either in a novel setting, with a new person, or with other modifications to the original context. These changes may be more likely to promote generalization (Stokes & Baer, 1977). Remember to maintain a vigorous schedule of catching Molly using her skills to ensure that the hard work that has been done will continue to be rewarded. If carefully implemented, these types of modifications may promote enduring success in the natural environment.

It is always appropriate to make individual adjustments and changes as related to your specific situation.

Good luck!

References

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

Hagopian, L. P., Boelter, E. W., & Jarmolowicz, D. P. (2011). Reinforcement schedule thinning following functional communication training: Review and recommendations. Behavior Analysis in Practice, 4(1), 4-16.

LaRue, R. (2009). Clinical Corner: What is meant by functional analysis? When should this be done and who should do it? Science in Autism Treatment, 6(2), 16-17.

Sarokoff, R. A., & Sturmey, P. (2004). The effects of behavioral skills training on staff implementation of discrete-trial teaching. Journal of Applied Behavior Analysis, 37(4), 535-538.

Stokes, T. F. & Baer, D. M. (1977). An implicit technology of generalization. Journal of Applied Behavior Analysis, 10(2), 349-367.

Tiger, J. H., Hanley, G. P., & Bruzek, J. (2008). Functional communication training: A review and practical guide. Behavior Analysis in Practice, 1(1), 16-23.

Citation for this article:

Shawler, L., & Celiberti, D. (2019). Clinical corner: What is functional communication training? Science in Autism Treatment, 16(12).

Lesley Shawler is currently a research post-doctoral fellow at Kennedy Krieger Institute and Johns Hopkins University School of Medicine. She recently completed a clinical post-doctoral fellowship at Kennedy Krieger Institute working in the Neurobehavioral unit treating individuals with severe challenging behavior. She is a Board Certified Behavior Analyst who received her Ph.D. in Applied Behavior Analysis from Endicott College – Institute for Applied Behavior Studies in 2019. Lesley has worked with individuals with developmental disabilities across the lifespan focusing on decreasing challenging behavior as well as teaching language and other adaptive skills. Her clinical and research interests center around promoting generalization of treatment outcomes for increasing language and decreasing challenging behavior, as well as identifying efficient and practical methods for caregivers to effectively manage challenging behavior.

David Celiberti, PhD, BCBA-D is the Executive Director of ASAT and Past-President, a role he served from 2006 to 2012. He is the Editor of ASAT’s monthly publication, Science in Autism Treatment. He received his PhD in clinical psychology from Rutgers University in 1993 and his certification in behavior analysis in 2000. Dr. Celiberti has served on a number of advisory boards and special interest groups in the field of autism, applied behavior analysis (ABA), and early childhood education. He works in private practice and provides consultation to public and private schools and agencies in underserved areas. He has authored several articles in professional journals and presents frequently at regional, national, and international conferences. In prior positions, Dr. Celiberti taught courses related to ABA at both undergraduate and graduate levels, supervised individuals pursuing BCBA certifications, and conducted research in the areas of ABA, family intervention, and autism.

Compassion requires three actions: listening, understanding, and acting. ABA is a compassionate practice by definition, because behavior analysts are trained to do each of these actions in very specific ways.

Listening is necessary for consent. Behavior analysts are required by ethical and professional guidelines to ensure informed consent prior to implementing assessment or intervention. Informed consent includes demonstrating that you understand what you are agreeing to, so behavior analysts should be listening to clients and their parents/guardians to determine if this understanding exists. If they are really consenting, clients or their parents/guardians will always be in control of the goals targeted and strategies of intervention.

Understanding occurs through the functional perspective taken by behavior analysts, which means that they take the time to learn and understand why behavior is happening or not happening. After listening to what is important to and for the client, the next step is to assess behavior. Put simply, the behavior analyst endeavors to get into their client’s shoes and figure out why they are acting the way they are acting. The assumption is always that the individual has good reasons for their behavior, and if those actions are going to change, we need to figure out how to replace them or make them less necessary, more efficient, or easier. We assume that people are right about their interactions with the world. If anything needs to change, it is the world, and not the person.

Acting is done through the development of interventions designed to improve the client’s situation and experience, based on the priorities established by the client through listening and consent. Behavior analysts hold social validity to be a very important value, in that not only should behavior change be meaningful and helpful to the individual who is changing their behavior, but the ways in which behavior is changed must also be acceptable. Behavioral interventions are not done to people, but with them, to help them meet their own goals in ways that they find reasonable.

Consent, assessment, and intervention meet the three requirements for compassionate care in ABA - listening to someone to hear what is concerning them, attempting to understand or feel their distress, and then doing something to alleviate their problems. Failure to take steps to listen to concerns and understand behavior takes the “analysis” out of the practice and reduces it to a collection of tricks that sometimes work but often don’t, and sometimes even make things worse. Unfortunately, sometimes poor training or supervision, or simple unethical practice, results in behavior analysis that is not compassionate and that reflects badly on the whole field.

Consider two scenarios that could happen when a well-meaning behavior analyst meets a new client for the first time, and finds that the client engages in high rates of stereotypy:

● Behavior analyst A draws upon her experience and determines that the levels of stereotypy that the client engages in will likely be disruptive in school and other community environments. She informs the family that stereotypy is inappropriate and teaches the parents to implement a comprehensive plan that includes environmental enrichment, positive reinforcement for periods of time when stereotypy does not occur, and asks them to collect data throughout the day on levels of stereotypy. Then she leaves with a promise to return in a week to evaluate their progress. The parents call the agency and say that they don’t think ABA is for them.

● Behavior analyst B has a lengthy conversation with the family about their preferred activities as a family. She asks them what they love to do with their child, and finds that they all enjoy going to the playground but that they usually reserve that activity for chilly days or early evenings and that they have been going less and less. When this is explored a bit further, they share somewhat reluctantly that both parents are uncomfortable when other parents and children stare when their child engages in stereotypy. The behavior analyst asks what they would like to do about this, if anything, or if they feel that their current strategy is working for them. The parents ask if they can think about it, and the behavior analyst agrees to discuss at next week’s meeting. In the meantime, she leaves them with some websites about functional assessment to look over. At the following week’s meeting, the parents say that they would like to prioritize other issues over stereotypy at this time, but they would like to learn more about functional assessment to see if it could help them to understand stereotypy a bit better.

In these scenarios, behavior analyst A provided a set of interventions that are not aversive and potentially not difficult for a trained professional to implement, but perhaps overwhelming to a family newly introduced to compassionate ABA. She prioritized the goals for intervention based on her experience rather than the family’s needs and preferences, without taking the time to listen to them and ensure consent. She also did not assess or attempt to understand the behavior and instead attempted to swiftly take action to reduce it. In addition, she did not attempt to determine if the interventions were acceptable to the parents or the child. If the family did choose to continue with her plan, it is possible that stereotypy might have decreased, but it is also possible that her plan would fail to meet the function of the behavior, resulting in unnecessary stress and a poor experience for the child. Ultimately, the family decided that this approach did not fit with their needs and they lost out on all of the potential benefits of well-implemented ABA for other areas of their child’s life, such as improving communication and independence.

By contrast, behavior analyst B moved slowly. She did not start by trying to identify problems, but by listening to the family by exploring their strengths and reinforcers, providing her with knowledge about how to connect with the child and parents and how to create a fun, warm, and enjoyable experience for everyone. She allowed them to share what makes it difficult for them to enjoy those reinforcers, and she opened the door to helping them with this issue if that is what they want. She did not provide a solution without consent or assessment, however. She left them with information and time to think, and the family was comfortable to have her return and continue to explore what would be best for their child in the context of their family. Ultimately, by listening and assessing, this behavior analyst has a chance of eventually acting and providing truly compassionate ABA service and care to this client and family.

Both behavior analysts mean well. Both want what is best for their client. Neither behavior analyst wants to frighten families, make children cry, or take away what they enjoy. Both have rich resources at their disposal, but only one will likely be able to share those resources and meet her goals and the goals of the family. Practicing with compassion keeps communication open, but failure to demonstrate compassion by not listening and not understanding can result in a closed door and a great loss for the family and the field.

When practiced correctly and compassionately, ABA includes several features. First and foremost, there is a continuous emphasis on client and family input. Goals, strategies, and outcome measures are determined in consultation with the individuals who will be affected by the intervention. This includes not only the individual person receiving services, but those who love that person as well. Taking a broad viewpoint that includes the whole family is an important part of compassion.

Next, not only should behavior analysts obtain consent as mentioned earlier, but they should also be sure to get assent from clients who are not able to legally consent. Assent is a less formal version of consent that can be given by children or individuals who have cognitive differences that make it impossible for them to truly consent. Due to the extreme nature of the behavior of some individuals who receive behavior analysis services, at times assent is not obtained for safety reasons. This should only occur during times of crisis when the individual and/or those around them is in true danger. Any such occurrence should be immediately followed by obtaining consent and then conducting assessment and analysis of ways to prevent crises from occurring in the future. Interventions should be acceptable to all parties, including the individual receiving services. Again, many individuals who receive ABA services cannot verbally express assent, but the behavior analyst should be skilled enough to recognize behavioral indicators of assent or lack of assent, and adjust their actions accordingly.

Compassionate behavior analysts are also flexible. They recognize that there are changing circumstances in clients’ and their families’ lives, and that sometimes even effective plans need to be adjusted. They also recognize when sometimes despite their own best intentions, their efforts are not working well and they are willing to step back, reevaluate, and adjust approaches as needed. Behavior analysts should also be honest about what they can offer, their competence and comfort level with what is being asked of them, and how clients and families can best participate in their own services. Finally, it is crucial for behavior analysts to make human connections with the families they serve. Many behavior analysts find it easy to connect with their clients through their reinforcers and successes, but it is also important to maintain a connection with the rest of the people in their clients’ lives by showing interest and concern for them.

One final thought is that compassion can be a two-way street. Behavior analysts can most successfully connect with the client and family when the effort to connect is reciprocated. Although it is up to the behavior analyst to attempt to make the family comfortable in sharing their needs and preferences, sometimes we don’t know what we don’t know. Even the most compassionate and skilled professional might miss something, so families and if possible, clients, should speak up and let them know if that is the case. It is also important to be clear about whether or not consent and assent are being given. If the behavior analyst is not asking for consent, it is perfectly acceptable for the client or family member to pause the interaction and discuss what the limits of implied consent may be in any individual situation. Finally, families who demonstrate flexibility, connection, and honesty in return and who are open about any reservations or discomforts are allowing for the maintenance of a longer-term and more productive relationship, which will only help their loved one more.

References Consulted

Behavior Analyst Certification Board. (2014). Professional and ethical compliance code for
behavior analysts. Author.

Callahan, K., Foxx, R. M., Swierczynski, A., Aerts, X., Mehta, S., McComb, M. E., Nichols, S. M., Segal, G., Donald, A., & Sharma, R. (2019). Behavioral artistry: Examining the relationship between the interpersonal skills and effective practice repertoires of applied behavior analysis practitioners. Journal of Autism and Developmental Disorders, 49(9), 3557-3570.

LeBlanc, L. A., Taylor, B. A., & Marchese, N. V. (2019). The training experiences of behavior analysts: Compassionate care and therapeutic relationships with caregivers. Behavior Analysis in Practice, 13, 1-7.

Taylor, B. A., LeBlanc, L. A., & Nosik, M. R. (2018). Compassionate care in behavior analytic treatment: Can outcomes be enhanced by attending to relationships with caregivers? Behavior Analysis in Practice, 12(3), 654–666.

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).

This month's ASAT feature comes to us from Amanda Marshall, MEd, BCBA and Nicole Stewart MSEd, BCBA, LBA-NY. 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 a parent of a 6-year-old girl with autism. She used to be very cooperative, but recently, every task is a battle leaving us exhausted. She doesn’t want to do things that I know she can do like taking a bath or getting dressed in the morning. My child’s teacher offered a variety of suggestions which we are putting into action. She also mentioned a technique called the High Probability Instruction Sequence. What does this particular technique involve and how can it be used to address my current struggle?

Answered by Amanda Marshall, MEd, BCBA
Brighter Outcomes and
Nicole Stewart, MSEd, BCBA, LBA-NY
Solutions for Exceptional Children

Lack of cooperation with non-preferred tasks is a very common challenge for all parents. It can be draining and can leave you grasping at straws to figure out the path of least resistance. We suspect that each time you know you have to encounter these situations, you’re probably bracing yourself because you are anticipating a less than desirable outcome.

At a time when parents are spending more and more time with their children, these battles are becoming more frequent. It is common for frustration to mount on both sides. To add to that challenge, a lot of interventions are time or labor intensive, which are both scarce commodities in the current environment. We understand how challenging it can be to make changes with everything that a parent has on their plate on any given day.

Even with the stress of parenting, a pandemic, and other personal situations, positive outcomes are something we all want to see for ourselves. It could be passing an exam, baking a cake that rises, or having our children do as we ask. We want our parenting strategies to work for ourselves, as the parents, and for our children. When either of us experiences a positive outcome, we feel good. Because it feels good, we’re both more inclined to do the same thing in the future to contact the same positive reinforcement again.

Let’s turn to your question. Think about when you’ve asked your daughter to do something for you. What has the outcome been? Was it positive or downright negative? Were you successful at asking her to complete the task? Or was it a significant battle with no winners, just a lot of unpleasantness lingering in the air? We know many of our personal outcomes with our own children have consisted of the latter. It often goes like this – “It’s time for a bath!,” swiftly moving to a tantrum because our child is avoiding getting in the bathtub. Oh yes, you say, we’re familiar with that unpleasant experience!!!

We are very glad that you are working with your daughter’s team to address this issue. It would be important to look closely at each situation and ask questions like:

1. Is the resistance related to skill deficits that could be addressed?
2. Is there a sensory hypersensitivity in place such as the smell of the shampoo or discomfort with water on her face?
3. How is cooperation currently being reinforced and is that reinforcement adequate? We don’t necessarily mean an actual reward (although you could!) but think about what is in it for your daughter – what is her positive outcome?
4. Are demands happening at times in which a competing reinforcer is in play (e.g., siblings playing with a game system)?
5. To what extent is your daughter’s day predictable?
6. Is there any opportunity to use choice-making?
7. Is sufficient time allotted for the task such that it is less of a “battle?”
8. If it’s something your child can’t yet do on their own, are you providing the necessary teaching and/or support?Is the context for the task oriented for teaching to ensure near-errorless performance?

The answers to these questions will guide your next steps. As you learned from your daughter’s teacher, there is a behavioral procedure that many parents find breaks the ice when it comes to those unpleasant “must do” tasks. It’s called the High-Probability Instructional Sequence. While there are many ways to address the issue at hand, this one is free, requires limited forethought, and can thread a little laughter and fun into those previously challenging moments.

The High Probability Instructional Sequence is often used when you need your child to complete a task or follow an instruction. Cooper, Heron, and Heward (2020) define the High Probability Instructional Sequence as “a non-aversive procedure for improving compliance and diminishing escape-maintained problem behaviors.” In other words, the child is more likely to listen and complete the demand because you are creating a fun and more conducive environment beforehand. We’ve all experienced escape-maintained problem behaviors when our children continuously do things to get out of doing what we need them to do. Examples of common scenarios that many parents struggle with could be getting homework done, getting dressed, or picking up toys. As parents, we know that many of these non-preferred tasks often lead to aversive interactions, which negatively impact both parties.

The High Probability Instructional Sequence involves the teacher or parent presenting a series of approximately 3 to 5 easy to follow (high probability) instructions for which the child has a history of compliance. What do these high probability requests look like? It could be many simple, short, and easy to achieve tasks like touching their nose, a high five, running on the spot, clapping, doing a wiggle dance, or growling like a lion. Think about what’s fun and easy for your child to do! These requests are delivered fairly rapidly, followed immediately with powerful and positive reinforcement for each instance of compliance. Lipschultz and Wilder (2017) recommend a time interval between 1 to 5 seconds between each instruction. Reinforcement could be in the form of verbal praise, hugs, high fives, dancing on the spot, or some cheering. Use whatever form of positive reinforcement your daughter will respond to positively and will increase the likelihood of repeating the behavior in the future.

Once your daughter has completed the sequence of high probability requests that you’ve given, it’s time to add in the target instruction (low probability). What does a low probability request look like? A low probability request is an instruction that requires compliance from your daughter. It is the type of instruction that you would, as we stated in the beginning, brace yourself while delivering and anticipate a less than desirable outcome. Below is an example of how it might look to incorporate this strategy at bathtime.

Sample Instruction sequence:

Parent: “Touch your nose.” (high – probability request)
Child:   Touches nose.
Parent: “Good job!!” “High five” (high – probability request)
Child:   Slaps parent’s hand.
Parent: Dancing and cheering on the spot “Take this duck and throw it in the bath.” (high – probability request)
Child:   Takes duck and throws it in the bath
Parent: “Woohoo, you rock!!! Now step in the bath and let’s save that ducky!!!” (low – probability request)
Child:   Climbs into the bath.

  
This procedure may take a lot of practice and persistence for parents to master. That’s ok, keep at it, be creative, and remember – you’re the one in control. Always be sure to vary your requests and don’t use the same sequence each time because it will become less effective over time. Above all, reinforcement is essential to the success of this procedure! If your child is not engaging in the “easier” or more fun tasks, try different ones or talk to your team about which ones they think are most likely to get the ball rolling for compliance.

What we want to stress here is that parenting is downright one of the most challenging jobs in the world, so please don’t be hard on yourself. You’re not a bad parent. Your little ones don’t come with a manual. We encourage you to look for small ways to incorporate the High Probability Instructional Sequence into your time with your child. We also recommend this sequence for the ease of use: you don’t need materials, pre-planning or to prepare your child for a change. When you feel yourself mentally prepare for a challenging situation (as we know we do whenever we have to get kids to school!), take a moment to try this tactic out!

There is so much assistance out there to guide you along a more positive path as a parent by using simple scientific evidence-based strategies. The High Probability Instructional Sequence is just one of many. For instance, you and your team can also try incorporating Functional Communication Training, modeling, or shaping, as well as addressing missing prerequisite skills. You’ve got this!!!

References:

Cooper, J. O., Heron, T. E., & Heward, W. L. (2020). Applied behavior analysis. Pearson Education, Inc.

Lipschultz, J., & Wilder, D. A. (2017). Recent research on the high‐probability instructional sequence: A brief review. Journal of Applied Behavior Analysis, 50(2), 424-428.

Mayer, G. R., Sulzer-Azaoff, B., & Wallace, M. (2013). Behavior analysis for lasting change (3rd ed.). Sloan Publishing.

Rosales, M. K., Wilder, D. A., Montalvo, M., & Fagan, B. (2020). Evaluation of the high‐probability instructional sequence to increase compliance with multiple low‐probability instructions among children with autism. Journal of Applied Behavior Analysis. https://doi.org/10.1002/jaba.787

Citation for this article:

Marshall, A., & Stewart, N. (2021). Clinical Corner: What is the High Probability Sequence and how can it help increase responsiveness to everyday tasks? Science in Autism Treatment, 18(2).

About The Authors 

Amanda Marshall is a BCBA with a Graduate Certificate in Early Childhood Education and a Masters in Inclusive Education. She is currently the Owner/Behaviour Analyst for Brighter Outcomes, an early childhood behaviour intervention consultancy in Brisbane Australia. Having also worked in the education system for 10 years as an Inclusion Support teacher, she is passionate about advocating for her clients to ensure their successful and meaningful participation within mainstream schools and has authored blogs on a wide array of topics. She discovered the field of ABA 6 years ago identifying multiple opportunities to use ABA to support children with autism and other developmental disabilities in the Australian school system.