Beyond the B.A.S.I.C.S.
TIPS & TRICKS FOR PRESCHOOL SHADOWING
by Saundra Bishop, BCBA on 04/13/12Melissa Ruiz, BCaBA (edited by Saundra Bishop, BCBA)
THINGS YOU SHOULD DO:
- Be on time (this means following the school schedule, not your own)
- Respect the classroom rules (no gum for students = no gum for you!
- Respect the school dress code (if the teachers can’t wear jeans, you shouldn’t either).
- If your session overlaps lunch or snack time, bring your own food & drink
- Remember who you are working with: while peer interaction will be very important, you are responsible for your client and not the other children.
- Talk through the children (rather than to them) to facilitate communication with peers
- Be prepared to sit on the floor/a carpet square/a tiny chair/nowhere at all.
- Respect the teacher and his/her aides: you are not there to question what they’re doing; you’re there to help your client succeed under their rules (tell the BCBA if you see classroom practices that could be improved to help your student)
- Report back to your supervisor often.
- Maintain a professional attitude and relationship with school staff.
THNGS YOU SHOULD NOT DO:
- Explain yourself or your techniques to adults, students, or school staff who have not signed a confidentiality waiver (or who the parents have not authorized).
- Agree to “watch” the classroom while the teacher steps out. You are not responsible for the rest of the students in the class
- Use the office facilities (ie: printers, phones, computers, etc) unless you’ve been specifically authorized to do so.
- Expect the teacher to have time to discuss things with you during the school day. He’s a busy man with a classroom full of students
- Make changes to the treatment plan without talking to your supervisor (even if the teacher agrees that what you currently have in place isn’t working).
THINGS YOUR CLIENT MIGHT NEED TO WORK ON:
- Entering the classroom
- Getting to work immediately
- Routines for the end of class
- Self-Advocacy skills (ie: asking for the blue crayon or more time with the blocks)
- Listening to & responding to questions
- Telling someone they do/do not understand
- Group work
- Asking for help
- Knowing the day’s schedule
- What to do when you are done working early
- How to go to “specials” (music, library, etc)
- How to walk in the hall appropriately
- What to do when visitors enter the classroom
- What to do when the teacher leaves the room
- What to do if the student is suddenly sick
- Peer Communication
- Play
REMINDER LIST FOR SCHOOL BEHAVIORS
MANNERS:
- Greet friends
- Use polite words
- Use good table manners
- Take turns
- Share
- Don’t talk while others are talking
- Use tissues & napkins
- Ask first
WORK SKILLS
- Raising hand
- Keeping hands and body calm
- Walking quickly and quietly
- Working neatly
- Asking for help
FOLLOW DIRECTIONS
- Listen quietly
- Pay attention to what your classmates are doing
- Look at others when they are speaking
- Wait quietly
- Start and finish on time
- Put name on your work
- Keep desk/cubby/work area clean
- complete work
Strategies for Facilitated Play Dates -by Melissa L. Ruiz, BCaBA
by Saundra Bishop, BCBA on 03/30/12
1. Set goals for the play date. What’s the most important thing you want to accomplish? Some examples may include: appropriate touching, reciprocal conversations, turn-taking/following the rules, etc. Discuss with your supervisor whether to explain to your client what you’ll be measuring during the play date.
2. Ask your client, his caregivers, or his teachers for suggestions as to who to invite to the play date. If your client doesn’t know, or can’t answer, ask his teachers who he spends time with on the playground, or who he sits next to during free class time. Ask also for a list of activities the peer enjoys – this will help you plan a successful play date. Parents can also join local parenting listservs and ask if any children want to do a playmate with their child. There are lots of families that love doing this.
3. Help your client invite his peer to the play date. Use scripts for phone conversations & role playing if necessary. If phone communication isn’t possible, try having your client write a note to his peer inviting him to play. Remember to follow up with the peer’s parents to formalize plans, but be aware that doing so in front of your client may elicit a negative reaction.
4. Play dates should run approximately two hours or less. Consider starting with a significantly shorter date & adding time as your client becomes more skilled at social interaction. A successful play date is more productive than a long play date. If you’re time bound by a pre-set schedule, consider either beginning or ending the play date with a “down-time” activity: watching a short TV program, reading books, or listening to music. Playdates can be as short at 30 minutes.
5. BEFORE THE PLAY DATE:
a. Have your client choose three or four activities he enjoys and can play cooperatively. Remind him that he may play one, all, or none of these once his peer arrives. If turn-taking activities are problematic, consider using a visual timer or taking your client to a craft store to pick out an activity instead. Making a simple recipe can also work well. The play date will be most effective if activities are mutually reinforcing for both client and peer, so consider the peer’s preferences when helping your client choose activities.
b. Keep a few activity ideas in the back of your head as well – if you DO you probably won’t need them, but if you don’t, you can bet your client and his peer will rush through all 4 of your planned activities in the first ten minutes of the play date and you’ll be left wondering what to do for the last hour and fifty minutes.
c. Practice “being a good host” by having your client role play asking which activities his peer wants to do first/second/third. Consider using a visual schedule so that both client and peer can see what’s coming next.
d. Practice “being flexible” in case the peer doesn’t want to play any of the previously chosen activities. Practice “being a good winner/loser” if necessary.
e. Practice “reciprocal interactions.” Make sure your client knows if/when to respond to certain events (whether it be asking a question, making a comment, or helping his peer complete an activity).
f. Discuss with your supervisor how involved (s)he wants YOU to be during the play date. Consider:
i. Whether you will continue to run your client’s behavior plans during the play date
ii. How you will explain your presence to your client’s peers if they ask
iii. When/If you should intervene should things start go awry
iv. How your presence may affect any interactions (ie: will your role be that of an observer, a facilitator, or a participant in the activities?)
6. DURING THE PLAY DATE:
a. Make cooperation essential to the completion of any activity. For example, if you decide to make pudding, have your client hold the measuring cup while his peer pours the milk. For art projects, have your client cut out pictures and his peer glue them on the background.
b. Model appropriate social interactions.
c. Be flexible.
d. Be discreet.
e. If the children direct comments or questions towards the adults, redirect them to each other. (Talk through the kids rather than to them)
7. AFTER THE PLAY DATE:
a. Assess (either with or without your client, depending on your supervisor’s recommendation) your client’s progress toward meeting his goals.
b. Discuss how the play date went with your supervisor, your client’s caregivers and his peer’s caregivers.
c. Analyze any problems that arose and make a plan to address them during the next play date.
RESOURCES:
Koegel, et al. “The Effectiveness of Contextually Supported Play Date Interactions Between Children With Autism and Typically Developing Peers.” Research & Practice for Persons with Severe Disabilities 2005, Vol. 30, No.2, 93-102.
Kok, AJ, et all. “A comparison of the effects of structured play and facilitated play approaches on preschoolers with autism. A case study.” Autism. 2002 June;6(2): 181-96.
Ratner, Alison, LCSW. http://www.childtherapyinatlanta.com/
University of California, Santa Barbara’s Koegel Autism Center: http://www.education.uscb.edu/autism/behaviormanuals.html/
ABA and HIPPA
by Saundra Bishop, BCBA on 01/20/12
By Melissa Ruiz, BCaBA
What is HIPPA?
HIPPA, or the Health Insurance Portability and Accountability Act (1996), is a law consisting of a set of rules designed to protect and keep private individuals’ health care information.
What information is protected?
Any information that can specifically identify your client is protected under this act, including: patient demographics, past/present/future medical or mental health diagnoses or treatments, the provision of health care, health care payment information, names, addresses, birthdays, and social security numbers. Any information that can reasonably be used to identify your client is also protected (ex: via an internet search engine), so be careful about how specific you are.
How specific can I be without breaking the law?
OK: I have a 3 year old client in Del Ray (there are likely several 3 year olds in Del Ray, so the information you gave cannot specifically identify your client).
Not OK: I see a 3 year old boy on Mt. Vernon Avenue twice a week (there are likely very few 3 year old boys on any specific street, so someone could reasonably and easily discover the identity of your client with this information).
Can my partner/significant other drive me to work?
Not if you work at a client’s home; divulging your client’s address is a violation of HIPPA law.
Can a taxi drive me to work?
As long as you do not tell the taxi driver why you are going to a specific location, you may take a taxi to work.
Can I leave my Autism Awareness bumper sticker on my car when I’m at work?
Unless you also identify yourself as an ABA therapist (via a uniform, etc), neighbors have no way of knowing why your car is at your client’s home. Some clients prefer not to have any identifying objects visible in or around their home, so although your bumper sticker is legal, it may not be in your client’s best interest. If you have highly visible Autism Awareness paraphernalia, talk to your client about his/her preferences.
My client’s grandmother is babysitting during my session and she’s asking a ton of questions about the curriculum. Can I answer her?
According to HIPPA, if your client has identified grandma as family AND if you think that sharing information with her is in the best interest of your client, then YES, you may answer grandma’s question. For example, if you see grandma giving your client raisins but know that raisins are a very special reinforce reserved for a specific task, you should probably tell her. She does not, however, need to know how your last team meeting went or how your client’s sessions are submitted to insurance. When in doubt, tell grandma you’re not allowed to discuss program information and refer her to your Program Consultant.
KEEP IN MIND that although you are legally allowed to share relevant information with grandma, your client may not want you to do so. Ask your client if and what you are allowed to discuss with other family members, and if you have doubts, refer grandma to her son or daughter.
You can often side-step the issue by offering general information about autism treatment. Most of the time family members want to understand more but don’t know the right questions to ask. So, instead of telling grandma which programs your client is running, tell her that ABA programs try to teach from several different angles, and that we ask the same question several different ways to make sure our kids know and understand the answers. Instead of trying to answer her query of whether or not her grandchild will ever live an independent adult life, offer her examples of adults on the spectrum who do fabulous things.
KEEP IN MIND ALSO that the above strategy ONLY WORKS with identified family members. If you encounter a stranger or a neighbor on the street who asks you a similar question, discussing even general facts about autism will reveal to that person that you treat people on the autism spectrum, which will in turn “out” your client if she is with you, and you could go to jail. WHEN IN DOUBT, SAY NOTHING.
My client’s neighbor approached us at the park and asked how my client was doing. I know she is friends with my client and knows all about his diagnosis and treatment program. What can I tell her?
Legally, you can’t tell her anything. Answer her questions as honestly as possible without offering any treatment-specific information. For example:
Q: You’re one of Johnny’s therapists, right? A: I’m (insert name here).
Q: How’s he doing today? A: We’re having fun!
Q: Jane was telling me he’s working on potty training. How’s that going? A: We’re swinging right now.
Q: Do you know if his OT is canceled this week? I was supposed to babysit. A: I don’t know.
Q: When is his next psych evaluation? A: His mom knows his schedule better than I do!
Most of the time friends and neighbors will realize you are dodging their questions, and most of the time they’ll figure out why rather quickly. Occasionally you will come across someone who does not understand. DO NOT tell this person you’re not allowed to discuss it with them – you are implying that the information is medically related and you may be inadvertently violating HIPPA law. If you can’t think of a good answer, or you’re confused about what you’re allowed to say, simply leave the situation. Talk to your Program Consultant about what you can do in the future.
What if I run into a client at the mall? Am I allowed to say hello?
If you are off work and see one of your clients in a public place, it is a good idea to let your client make the first move. If you are with other people, allow your client to make the introductions and follow her lead – DO NOT tell anyone how you know your client unless your client offers the information first. It may be obvious to the people you are with (your friends likely know your career and could easily figure it out), but confirming your friends’ suspicions is a HIPPA violation.
I’m trying to teach my client to grocery shop, but people ask me a lot of questions when I’m at the store. What should I do?
Say as little as possible and be as honest as possible. Don’t offer any information. Don’t be rude and don’t lie, but get out of the conversation as quickly as you can. Here are some examples:
Q: Are you his therapist? A: I’m helping him right now.
Q: What’s wrong with him? A: He can’t find the spaghetti sauce.
Q: Does he have autism? A: I’m sorry, we don’t talk to strangers.
Q: Why does he have that book thing/talking device/computer/helmet? A: He’s using it.
Q: Why isn’t he talking? A: He’s trying to shop.
I know that teachers and doctors are legally obligated to report suspected child abuse and/or neglect. Am I?
Yes. Start by discussing your concerns with your Program Consultant.
Where can I find more information about HIPPA and Mandated Reporting?
http://www.hhs.gov/ocr/privacy/index.html
http://www.dss.virginia.gov/family/cps/index2.cgi
PROACTIVE STRATEGIES FOR AVOIDING PROBLEM BEHAVIORS (and a few for when you just can’t prevent the tantrum)
by Saundra Bishop, BCBA on 12/13/11
By Melissa Ruiz, BCaBA
SCENARIO: Your client consistently displays negative behaviors when you run a certain program.
SOLUTION: Give your client as much control over the situation as you can.
Let’s say your client LOATHES his drawing program and throws a tantrum each time you run it. Let him escape the program by offering him a choice – he can either do the drawing program OR a different program-related task. Eventually you’ll have to come back to the drawing program, but sometimes avoiding it for a minute or two (or ten) allows your client to feel some control over the situation.
If you HAVE to run an unpopular program, ask your client if he wants to do it *now* or *later,* or, in the case of drawing, if he wants to use crayons or markers, paper or a coloring book, chalk or paint, etc. Let your client feel that HE is in charge of the program – everybody likes to be in charge, and, at the end of the day, it probably doesn’t matter if he draws on the back of your data form instead of in his journal; the important part is that he’s drawing (without a tantrum)!
SCENARIO: Your client refuses to come back to the work area.
SOLUTION: Again, give your client the control.
Teach her to say, “I need a minute, please.” If she’s non-verbal, teach her a gesture (a raised index finger works well) so she has a way to tell you she’s not ready to do something. Be careful not to create a behavior chain here – don’t ALWAYS allow her to escape – but every so often, don’t you avoid doing your work, too?
SCENARIO: Your client has his own agenda.
SOLUTION: Say “YES” as often as you can.
If your client really, REALLY wants to watch YouTube videos, instead of saying, “NO, you need to do your work first,” say, “Oh, sure! Let’s watch a video RIGHT AFTER we finish washing our hands!” Instead of saying, “NO, it’s not time to go see mom yet,” say, “YES! We ARE going to go see mom just as soon as the timer beeps – let’s write our name while we’re waiting.” Instead of saying, “NO, we can’t go to the park today –it’s raining,” say, “Oh! Great idea! I LOVE going to the park! Let’s pretend the park is right over there by the couch! Come on!” ***Note: Your enthusiasm will make or break this strategy, so try your best to be genuine.
SCENARIO: You’ve tried all of the above strategies (plus a few of your own), but your client ended up in the middle of an epic meltdown anyway. Now what?
SOLUTION 1: Model appropriate self-calming strategies.
Lower your voice, even to a whisper if you have to. Take some deep breaths (it’ll help both you and your client stay calm) and ask your client to do the same. After they follow s simple direction, offer some sensory input, but let your client keep the control here – ex: “Do you want some squeezes or to turn the lights out?” If your client says “no,” DON’T DO EITHER. If your client can’t answer, continue modeling your calming strategies. Deep breaths work great, but you could also model counting to ten, hugging/punching a pillow, or even curling up on the couch. Some clients react negatively to being touched while tantruming, and others the opposite – once you get to know your client you’ll have a pretty good idea of which will work best for you and your client.
SOLUTION 2: Model appropriate language.
Chances are you have a pretty good idea why your client is in crisis (perhaps you forgot to give him a choice over the drawing program). Model some language that he can use next time to avoid the undesirable activity (Ex: “I don’t want to color.”). Non-verbal kiddo? Remind him about his break card, PECS, or whatever gesture he uses to tell you he’s done or he needs a break.
SOLUTION 3: Use simple language.
Humans, neurotypical or otherwise, have difficulty processing language when they are upset. Don’t waste your time explaining the seven reasons your client can’t have TV time – chances are she’s not going to process what you’re saying anyway. Instead, acknowledge her feelings and move on to your self-calming strategies (Ex: “I’m really sorry you’re feeling mad/sad/angry, but it’s not time for TV right now.”). Don’t negotiate. Don’t give in – if you do you’ll have reinforced the tantrum. Keep your language to a minimum until your client is calm, THEN offer explanations and alternatives if appropriate.
***Remember: even the most experienced ABA therapist has bad days, and even the best-behaved child occasionally throws tantrums. You can’t avoid every negative behavior, but using the above strategies will help you decrease their frequency. Keep your client safe, keep your cool, and keep trying different strategies until you find the ones that work best for you and your client.
Sleep Issues
by Saundra Bishop, BCBA on 11/26/11
Does your child have trouble falling asleep? Does she have trouble staying asleep? Is sleep a battle at your house? I just attended the MABA conference in Baltimore and was amazed at how much I learned1 I attended a great sleep workshop given by Dr. Gregory Hanley http://www1.wne.edu/faculty/index.cfm?selection=doc.3040&uid=568. I was nervous about it because I feared it would be a long presentation on extinction (cry-it-out) which is a procedure that I do not typically implement for sleep problems. I was so thrilled to see that it was filled with great information. I am going to summarize it below:
Small Changes:
1. If a child is fighting sleep for a long time, instead of putting them to bed at the desired bedtime, write down the time they usually fall asleep. Put them to bed one hour later than that time for 2 days. This will make sleep more valuable and hopefully they will fall asleep right away. After they are falling asleep within 15 minutes, move the bedtime back in 15 minute increments.
2. Make sure the child has had a healthy snack that does not contain caffeine, sugar, or a food that may cause discomfort (gassy foods, allergens, etc)
3. Build in a predictable, consistent bedtime routine. This routine is more fun when they are complying but is always present.
4. Make sure you aren’t expecting them to be in bed longer than is biologically realistic. If you put the child to bed at 6:30pm, you can’t expect them to stay in bed until 8:30am.
5. Use a sleep cue that will always be present like white noise and let it play constantly.
6. Ensure your child is not too cold or too hot. A bath right before bed can change the body’s core temperature so it might be a good idea to do the bath early in the routine.
7. If the child is afraid, offer them some tools to empower themselves. I have heard of clients successfully using a night light, “monster spray”, and/or a phrase like “I am safe in my bed”. Social stories can be used here as well.
8. If your child is engaging in self-stimulatory behaviors in bed which prevents sleep, it might be worth setting up a video-monitor and going in to block all “stim” attempts for a few nights in a row. Also, make sure all “stim” objects are put away.
Big Changes:
Extinction (I don’t recommend this): The parent completes the night-time routine and then closes the child into the bedroom. The parent does not re-enter and the child will often tantrum or cry themselves to sleep. This can also be done by repeatedly outing the child back to bed every time they get out.
Pass: The child can be given a set number of passes. Each pass can be exchanged for a visit with mom or dad, a drink of water, etc
Timed Visits: This is when a parent enters the room after a set time of quiet to praise and give a kiss. This allows the child to receive parent attention for appropriate behavior and they often fall asleep while waiting for the time to elapse.
Dr. Hanely discussed a small study that he conducted where he used the three different interventions. His study found all 3 methods were equally effective. What was unique about this study was they rated what the parent preferred and what the child preferred. He found that the parents didn’t choose extinction as their favorite intervention but there wasn’t a clear pattern for preference otherwise. They did find that the children preferred the pass and none of them ever preferred extinction.*
The Pass-model is something we often use during the day in my practice and it is very effective. It appears to be effective at night and preferred by the children so it is certainly worth trying!
It is really important to find out why the child is having trouble sleeping or staying asleep and address it from that direction.
*They determined this by pairing each intervention with a card color and then allowed the children to choose the card and then observed the pattern.
