Don't under-estimate the beauty of the visual schedule

Although my last post has been long overdue, I felt the need to share my current experiences. First, I want to address the visual schedule as a behavior support. As mentioned before, one of the frustrating things about our field is the need for every speciated version of applied behavior analysis refusing to admit that their effective practices are behavior strategies and not something else. As a behavior consultant I incorporate visual schedules into a behavior support plan, i have been often told that ABA didn't invent visual schedules. But it doesn't matter who invented what. A visual schedule is an environmental modification that supports a child's understanding of their day, week, month, etc. If it is used to support appropriate behavior, it is appropriate in a behavior support plan.

Visual schedules can be incorporated in a child's day as pictures, words, symbols, etc. I currently have my typically developing 20-month daughter on visual schedules, and this is what I wanted to talk about today. Over the holidays, I noticed that with jumping around to the different houses and families all over the five boroughs and long island, that she didn't have a good understanding of what was going on. Although verbal, she was having a tough time with the travel and lack of predictability.

I purchased a dry-erase board, and created visual flow checklist for her of our day. EAch morning during breakfast, i brought out the board, and sketched one picture per activity of her day (e.g. for grandmas house it was a pic of a house and two people that i called grandma and grandpa), and included about 6-8 things that we were going to do that day. With each picture, i gave her buzz words to remember them. As the day went on, i referenced the checklist with her and we checked off the things that we had done (i didn't erase them as I wanted to reference them and refer to things that we had finished that day). She didn't understand all of it the first couple of times, but by the third or fourth day, we caught her referencing it and referring to the symbols.

Did it work? DAta indicates yes. Prior to using the schedule, i noted how she was able to retell what we did in a day and the number of correct utterances referring to our day. Following the implementation of this schedule, this number increased as did the comments in our car rides about where we were going, what we were going to see and who we are going to see.

The point is, visual schedule are not just for children with significant impairments or children with disabilities, although very important for these children as well. Recently at a team meeting i was told "but he is high-functioning and very verbal so he doesn't need a visual schedule." This statement is completely false.

1. All of us need visual schedules. Looking at our lives, how would we fair without a blackberry, planner, outlook etc to know what is coming up in our lives and in our day. That being said, it seems unrealistic and unreasonable to assume that our children wouldn't need a visual schedule as well.

2. For children with inhibition difficulties, autism, etc., predictability in their day is difficult to manage and fully understand. Although verbal ability may be high, maintaining a flow of the day covertly is another challenge that is an unnecessary requirement to place on our children. A visual schedule is a support that removes yet another task and allows the child to focus on more important tasks at hand (i.e. accessing learning and social opportunities)

3. When a child is anxious, although they may be verbal, the state of arousal takes over and makes it difficult to focus or retrieve information that under normal circumstances would be fine. Think of a typical adult in a fight with their significant other. While we may not have autism or a disability, and are fully verbal, in the state of anxiety and arousal of a fight, we may be inclined to yell and scream and throw things, forget chores that should have been done and forgotten events that we needed to attend. A visual support for a child in a state of anxiety and frustration will help direct them to what is going on.

One of the uses in the schools for high functioning children as well, is to keep that dry-erase board handy so that schedules can be mapped out as needed. When a child begins to get frustrated and seems confused, this is when a visual schedule can be used as a support for not only de-escalation but also as a proactive strategy.

Schedules do not have to map out the entire day or with the use of pictures. Words, symbols, sketches, photos can all be used. Uses can include:

- the entire day

- the school day or the afterschool day

- the events at a special event (birthday party, dentist, etc.)

- the big events over the course of a week (monday is dance, tuesday speech, etc.)

- holidays

- the weekend

- the month with pictorial cues of where the child will be,

- vacations

- the previous activity, the current activity, and the next activity

- the next few activities

- choices of activities

Goal: To become a living, breathing functional behavior assessment.

Functional behavior assessment (FBA) often carries a mysterious aura. Many professionals have an idea about FBA, think that they basically know what it is, but don't know how to begin to conduct an FBA, and nor do they want to. My goal in my consultation and teaching is to de-mystify functional behavior assessment. Teachers should become walking, living, breathing functional behavior assessors. FBA should not be something that is always formally conducted; rather, we need to keep the key questions of FBA constantly available to us and become fluent with asking ourselves these questions, so that when we observe a behavior, we can fluently functionally assess the behavior on the spot. 

In our classrooms and homes, a full functional behavior assessment is not always possible. But it is important for teachers and therapists to learn to ask ourselves the key FBA questions to try and identify what is going on in order to inform intervention. So, some questions to keep on your mind....always...

1. Why do I think he is engaging in this behavior? A simple question, but at the crux of FBA. Function=Why. Why is the child engaging in this behavior? To escape the task? To get something he wants? To get my attention? Breaking it down and asking the question in the moment, helps us to think analytically about the behavior not only will help inform intervention, but helps the teacher take a step back and see the behavior for what it is, communicative, and not personal. 

2. Is there a setting that appears to occasion this behavior? Does it occur more during certain activities? AFter a transition? When leaving a preferred activity for a non-preferred activity? When there are more or less people in the room? After a long weekend or break? Identifying patterns in when the problem behavior occurs informs intervention as we can then develop a plan to work within that setting or activity. For example, if we identify that a problem behavior occurs during writing workshop, we can target writing workshop by a) breaking down the activities into smaller mini-activities within he workshop to make it more manageable, b) we can pair the environment positively and use the child's preferences incorporated into the workshop, c) we can make sure that writing workshop does NOT follow a preferred activity, but rather is followed by a preferred activity to act as a natural reinforcer, d) provide additional support during this activity, e) teach functional communication to replace the inappropriate behavior in this context. 

3. Is there a consistent antecedent to the behavior? Meaning, what usually happens just before the behavior? Identifying this pattern may also help to inform intervention. 

4. Is there a consistent consequence to this behavior? What usually happens after the behavior that may be maintaining the behavior? Is my behavior as a teacher maintaining the inappropriate behavior? How can I change my behavior while teaching my student/child a new behavior. 

These questions should be asked of ourselves as teachers with fluency when observing behavior. This is not to say that formal functional behavior assessment is not necessary; however it isn't always feasible. Working in a busy and active classroom, it isn't possible for a teacher to stop, complete every data sheet necessary, and observe behavior taking note of antecedents and consequences. It is however possible, with practice, to think FBA all the time. 

Off Topic: My Baby Girl

Hi Everyone,

I haven't posted in several months, but haven't forgotten the blog. I had a baby girl on April 14th. Her name is Ioanna (joanna but with an "I" instead of a "J") and she was born 5 pounds 15 ounces. She is now almost 12 weeks, smiling, laughing and giggling and is a joy.

I am however amazed at the social skills that she exhibits at this young age. Sustained attention for long periods of time, referencing, babbling, reciprocal babbling, and some precursors to joint attention. At 2.5 months, she is exhibiting these precursors to spoken language and it is amazing to watch.

As a behaviorist, it is also interesting to see how she has shaped my behavior and how my perspectives on some strategies have shifted somewhat. I wonder if as she grows, I would change as an ABA therapist, and if some of the techniques I have employed in the past (waiting out a tantrum, crying, etc.) would be acceptable now. We'll see.

I'll get back to posting soon.

Angela

Stereotypy in Children with and without Autism

A research review by Michelle Rodgers (CUNY Queens College)

Authors: MacDonald, R., Green, G., Mansfield, R., Geckeler, A., Gardenier, N., Anderson, J., Holcomb, W., & Sanchez, J.

Title: Stereotypy in young children with autism and typically developing children

Purpose of this study: The purpose of this study was to compare motor and vocal stereotypy in 2-,3-, and 4-year old children with autism and typically developing children within the same age group.

Participants: A total of 60 children participated. 30 were diagnosed with autism or PDD-NOS and 30 were considered typical. Each group was broken up into three subgroups, 2-, 3-, and 4-year olds, each with ten children.

Settings: The setting was a small testing room at the New England Center for Children. The testing room had books and toys as well as a table and chairs.

Target behaviors: The behaviors that were measured were vocal and motor stereotypy across the two groups of children and across the 3 age groups. Some examples of vocal stereotypy were: non-contextual giggling, vocalizing non-recognizable words and echolalia. Examples of motor stereotypy were rocking, hand flapping, tapping objects, more than 2 times in a row, spinning, and finger flicking.

Procedure: Children were administered portions of the NECC Early Core Skills Assessment battery. These components covered motor and vocal imitation, matching, receptive and expressive communication, as well as instruction-following skills. Only a ten minute sample of the assessment was used, even though each student was given the entire battery. During the play portion, children were told to play with the toys but were allowed to move around the whole testing room. They were not prompted after the first directions were given. During the structured component, the children were administered tests for motor imitation, vocal imitation, and social questions. If the children engaged in stereotypy, it was not redirected.

Results: The results indicated that as the age increased for children with PDD-NOS, the mean percent duration of total stereotypy (vocal and motor) increased from 12% at 2-years old, 23% at 3 years old, and 39% at 4 years old. For typically developing children, the mean percent duration of total stereotypy decreased from 5% at 2 years old, to 3% at 3 years old and 2% at 4 years old. The children with PDD-NOS started with a higher mean percent duration than the typically developing students. The 4 year-olds with PDD-NOS displayed even higher rates of stereotypy than the 2 year-olds.

Implications: The study has several implications.

First, the optimal age for early intervention would be 2 years-old or earlier. Stereotypy is still relatively low at 2, that there may be more opportunities to teach appropriate behavior without having to compete with stereotypy.

Also, the fact that the four-year olds had higher rates of stereotypy implies that more should be done to limit the practice of stereotypy so that there is not much of a reinforcement history attached to these behaviors.

The types of stereotypy observed in the typical children and the children with PDD-NOS were also of interest. Children with autism tended to emit repetitive noises or non-contextual phrases, while rarely making eye contact. Typically developing children emitted contextually appropriate and identifiable words as well as made eye contact.

Stereotypy and social engagement : A Research Review

A research review by Jennifer Morrison (CUNY Queens College).

Lee, S., Odom, S. L., & Loftin, R. (2007). Social engagement with peers and stereotypic behavior of children with autism. Journal of Positive Behavior Interventions, 9, 67 – 79.

Purpose of the study: The relationship of social engagement and stereotypic behavior for children with autism, which looked particularly at if increased social engagement lead to decreases in stereotypic behavior, and finally if these decreases in stereotypic behavior generalized to other settings as well.

Participants: Three children diagnosed with autism who engaged in frequent stereotypic behavior. One child was 8 yrs old with moderate to severe mental retardation with severe delays in language. Another child was 7 hrs old and engaged in a variety of oral/vocal stereotypy and also would sometimes engage in self-injurious behavior to himself and also others. The other boy was 9 years old and had profound mental retardation; he could follow simple verbal commands from adults but also engaged in high rates of vocal and motor stereotypy. In addition to the three children diagnosed with autism, 12 (6 pairs) of children without disabilities also participated that were all in third grade classes that the three children that were part of the study were in.

Setting: The study was done in a 5 m x 4 play area in a special education classroom. The area was full of several different types of toys and objects that they could play with.

Target Behaviors: The behaviors that were mainly investigated in this study were initiations with a peer or stereotypic behavior. Initiations were defined as: any vocal/verbal or gestural behavior that a participant/peer directed to another peer and that was not preceded by a socially oriented behavior from that peer. Stereotypic behavior was defined as topographically similar behaviors that were performed repetitively. These could include vocal which was when children used their mouths or made vocalizations or sounds. Motor stereotypy was defined as when children used any of their body parts except vocal with or without manipulating objects (eg finger flipping, wiggling fingers, banging head, etc.)

Procedure: The experimenters used a multiple baseline across participants and settings. After the first participant had a stable baseline they then introduced the intervention. Once the first participant reached stable responding at intervention, the intervention was introduced for the next participant…so on. During the baseline phase, each child with autism was observed during structured free-play sessions with two peer buddies. No instructions were given to the children and lasted approximately 5 minutes. During training, the trainer taught the peers four social skills concepts (sharing, suggesting play ideas, assisting and being affectionate). Each training session began with a verbal discussion of the importance of playing with friends and/or a review of the previous day’s play. After this the teacher then modeled appropriate and inappropriate responses. In the using skills intervention the teacher reminded the peer to use the skills they had learned to get their friend to play, and the peer then got the child to play in a structured activity with them.

Results: During baseline, all three children did not engage with peers at all in any type of play situation. After training with peers, the mean percentage of social engagement increased to, 69%, 79%, and 56% for all three children. More importantly, this behavior continued through the reimplementation period and also for generalization probe trials with children that were not trained. At the same time, the participants’ engagement was more variable during the generalization phase which took place at snack time. In addition, during baseline each of these three children engaged in high rates of stereotypy (87%, 47%, and 89% respectively). When the peer initiation intervention was introduced not only was social engagement increased but stereotypic behavior decreased in all three children.

Implications: This study had several important findings. First of all, this study showed the importance of training peers to initiate social interactions with children diagnosed with autism. This study also showed how effective training with a peer model can be in increasing social engagement in a child on the autism spectrum. More importantly it was shown that the percent of self-stimulatory behavior also decreased with all three children. This shows the importance of the relationship of a set of social skills in comparison to stereotypy. If a child is engaging in a conversation with another child, this gives them less of a chance to engage in vocal stereotypy especially. The other really nice thing about this study is that it was naturally done with peers of the children that were their age. This study ultimately shows the importance of peer modeling and peer assistance to children diagnosed on the autism spectrum. One thing I thought was a strong point of this study was that they also used children that were not on the high functioning side of the autism spectrum. When reading studies similar to this, there are a lot of studies done with children with Asperger’s or related symptomology, but very little with children with more severe deficits and higher rates of self-stimulatory behavior.

Research Review: Physical exercise as a Reinforcer

Research Review by Michelle Rodgers (CUNY Queens College)

Azrin, N.H., Ehle, C.T., & Beaumont, A.L. (2006). Physical exercise as a reinforcer to promote calmness of an ADHD child. Behavior Modification, 30, 564-570.

Authors: Azrin, N.H., Ehle, C.T., &Beaumont, A.L.

Title: Physical exercise as a reinforcer to promote calmness of an ADHD child

Purpose of this study: This study had several purposes. One purpose was to determine if scheduled exercise could serve as a reinforcer for a child remaining calm for a certain period of time. Next, the authors wanted to determine if the exercise would result in calmness even if it wasn’t based on being a contingent reinforcer, if specific praise could result in calmness, or whether contingency was necessary to promote calmness.

Participants: The subject was a 4 year old boy that was diagnosed with autism and ADHD.

Settings: During baseline, the child was observed in his classroom setting. During the procedural component, the child was observed in a separate roomTarget behaviors: Calmness was the target behavior and was defined as sitting calmly and attentively and looking at the assistant.

Procedure: The procedure had several components. These procedures were given on separate days and alternated over the course of 5 days. The reinforcer would be 1 minute of play in an outside playground that contained gymnastic equipment and other climbing structures. The child would engage in activity for the full time and would not be prompted.

Shaping was the first component and the purpose was to attempt for the child to display calmness according to the definition. The time for the child to sit calmly increased from 1 second and after several trials eventually reached 60 seconds. Specific verbal praise was given throughout the session as well as after each successful session. After each successful session, the child was allowed to play.

The descriptive praise was the component in which only specific praise was given for the target behavior and the playground was not used as a reinforcer.

The noncontingent reinforcement phase allowed the child to use the playground every 60 seconds regardless of calmness and no praise was given.

The reconditioning phase allowed the child 60 seconds of playground activity contingent on 60 seconds of calm behavior. Descriptive praise was included at the end of each successful session.

The baseline component was the phase in which the playground was not given as a reinforcer and no descriptive praise was given. The child was seated in the chair and was returned to it when he arose from it.

Results: Prior to the intervention, the child was out of his seat for 100% of the time. The shaping and reconditioning phases had the most dramatic results. In these two phases the child was able to display 60 seconds of attentiveness which lasted for 50 minutes of the session. Descriptive praise, noncontingent play, and the baseline phase resulted in about 3 to 5 seconds of calm behavior.

Implications: Although this study was conducted on only one boy, it is interesting to see that vigorous activity served as a potent reinforcer. For children with ADHD, engaging in exercise at scheduled times may allow for more attentive behavior in the classroom. While the teachers noted how calm the boy was during the intervention, he was in a separate room. It would be interesting to see how attentive he would be in the classroom if he was able to “work” towards use of the playground as a reinforcer. This study offers another possible reinforcer that could be paired with the usual token economy that is often implemented in the classroom. A feasible schedule would need to be worked out to obtain maximum attentiveness in the classroom, while appropriately allowing for playground activity time.