Other Related Disorders & ABA/VB

[Guest guest]

Hi,

I was wondering if anyone knows of, or is doing ABA/AVB/Discrete

Trial Training with children diagnosed with any of the following

disorders/syndromes and their results:

1. Angelman Syndrome

2. Prader - Willy Syndrome

3. Syndrome

4. Down Syndrome

5. Rett Syndrome

Thank you,

Dianne

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Hi Dianne,

My son is dx with the dual Down Syndrome/ASD and have started ABA/VB

at a late age of his 14 y/o last year. He is 15 going on 16 this

coming July, still undergoing ABA/VB Therapy at a private clinic

twice a week for an hour @

www.treehousepediatrics.com and benefits from this intervention

which has shown tremendous great results. He is starting to vocalize

as he was consider non-vocal, would only express by acting out which

was not a pretty site to deal with an older child. I also had him

evaluated for Sensory dysfunction and this is also being applied

with a sensory diet incorporated at school and here at home. The two

best interventions are ABA/VB & Sensory/Motor Activities that are

working for my son which has been a Blessing. I know your question

was aimed towards the ABA Therapist to see what results and of

course I'm just rambling on about my sons experience so I do

apolgize for sharing too much. Hope it helps out with your question,

though.

I'll add more notes below to review. I'm sharing this as I never

would of imagine that my son could learn anything and for 12 years

his behavior was getting worse, he was getting stronger/aggressive,

and he was getting older and I needed answers until I ran across:

http://www.disabilitysolutions.org/3-5.htm

http://www.kennedykrieger.org/kki_misc.jsp?pid=1986

http://www.cincinnatichildrens.org/svc/dept-

div/disabilities/down/default.htm

- all this information which has open the doors or my prayers have

been answered. I would hate any child to miss out as my son did at a

younger age. Then this is when I had done my research on ABA/VB and

when the private clinic had opened last year its been the best

program. I've recently attended to one of Dr. Carbone's 3-day

workshop and glad I did because it was a wealth of information that

just help build my spirits/strength towards this arena.

Irma

My son HAD once upon a time experienced the problems below and have

progressed in alot of these areas, not 100 % but at least to some

extent of relief, eat out at some restaurants, able to sit for a

hair cut, self-help skills like finally toilet-trained, working on

intiating to the restroom but out of wearing pull-ups to name a few:

- Does not use language effectively to communicate his own needs.

- Requires many trials to learn a task.

- Displays poor eye contact.

- Does not display age appropriate play skills.

- Difficulty consoling self, easily upset by difficult tasks.

- Failure to explore his environment.

- Dislikes baths and other age appropriate self-care or play

activities.

- Resists being held; dislikes being cuddled.

- Low muscle tone; seems weak or floppy.

- Clumsy/falls frequently.

- Does not enjoy jumping, swinging, or having feet of the ground.

- Displays stimulatory behaviors (visual, vocal, auditory, or

repetitive)

- Difficulties transitioning from one area/task to the next.

http://www.kennedykrieger.org/kki_misc.jsp?pid=2145

Changing Behavior & Teaching New Skills

by Naomi Swiezy, Ph.D.

Taking your child to a clinic for an evaluation is an intimidating

process. Often a variety of diagnoses or labels are discussed and

considered confusing the big picture you have of your child. You

leave with one question: " Now what do I do about it? " This article

will address this issue by presenting practical tips for managing

your child's inappropriate behaviors while also teaching some

appropriate behaviors and alternative skills.

Parents of children with Down syndrome and autistic spectrum

disorder (DS-ASD) are especially in need of these tips because there

is so little information available about this dual diagnosis for

parents or professionals. As parents, you become comfortable

accommodating your child's learning style based on information about

Down syndrome and your own experiences. Then the latter diagnosis,

autistic spectrum disorder, is superimposed on the first. At this

point many parents are overwhelmed. They feel as though all hope for

modification is lost. However, if you approach your child's

behavioral difficulties that are often associated with autistic

spectrum from a systematic, behavioral perspective, you will feel

renewed hope for not only behavioral management, but also for skill

development.

One methodology that has proven effective for children with autistic

spectrum disorders, including those with Down syndrome, is applied

behavioral analysis or ABA approaches. ABA approaches are based on

the idea that we know when children misbehave, they often have some

motivation to do so. We also know children learn from their

environments and adapt their behavior to gain access to what

motivates them the most. What becomes confusing is that each child

is motivated by different factors and sometimes more than one factor

at a time. To address this, ABA uses systematic and empirical ways

to assess the individual motivational factors of each child. With

this information, individual programs or plans are created

addressing both what happens before the behavior as well as the

consequences for the behavior itself.

There are several general guidelines you can use to improve behavior-

related problems without conducting a formalized assessment. These

strategies will improve your child's behavior regardless of the

specific motivation behind them. . However, we first need to look at

some general facts about children with Down syndrome and autistic

spectrum disorder (DS-ASD) that form the basis for working

effectively with your child:

Children with DS-ASD do not misbehave because they are mean-spirited

or obstinate. All behaviors serve a purpose. That purpose may be to

communicate wants and needs. Particularly children who are nonverbal

or just learning to communicate will communicate in whatever method

is most effective and successful in getting what they want, whether

it is appropriate or not.

Children with DS-ASD can learn. Learning may take longer and you may

need to use different teaching strategies that are more explicit and

direct than for other children, but they do learn.

Children with DS-ASD have three major areas of concern:—

communication, socialization, and interests or activities. A child

with DS-ASD may or may not have a different amount of language,

socialization, and leisure behaviors from other children her same

age. What is distinct is they way interactions vary from what is

expected from other children their same age and developmental

ability, particularly in the area of communication, socialization,

and activities.

Common behavior problems such as aggression, tantrums,

and " noncompliance " are not part of DS-ASD. For instance, it is not

necessary for a child to have these behaviors to meet diagnostic

criteria for the DS-ASD. However, children with DS-ASD tend to

respond with aggression, tantrums, or " noncompliant " behavior as a

way of communicating a frustration or need. The behaviors are the

result of the syndrome, not a symptom of it. Some suggestions

regarding how to respond to these behaviors are discussed later in

this article.

A comprehensive, individualized program is the most effective way to

affect behavior. A comprehensive program will not only address

consequences for inappropriate behaviors, but also focus on training

appropriate alternatives such as functional communication and play

skills. If you seek only to reduce inappropriate behavior, you may

be decreasing the only effective form of communication your child

has. It is as important to teach a child what to do as well as what

not to do.

Helping Your Child Achieve Her Potential

The most effective approach to shaping appropriate behavior for

children with DS-ASD is to create opportunities in the environment

for the behavior you want to occur. It is equally important to

respond to inappropriate behaviors with effective management

strategies. Below are some general guidelines that address both of

these angles. If you are overwhelmed or faced with behaviors that

are very difficult or pervasive in nature, please consult a trained

behavioral specialist who is familiar with ABA strategies. A trained

ABA specialist will work with you and your family to build specific

recommendations and plans for your child.

Environmental Controls

Do not set expectations too low. Your child is capable of learning.

However, she may learn many essential skills such as functional

communication, toileting, social skills, play and engagement more

effectively by using explicit teaching than by picking the skills up

naturally. Regardless, your child will develop skills. Expect

progress and growth.

Do not set expectations too high. Set goals that are realistic. It

helps to break tasks down into separate steps that you prompt and

respond to independently. This encourages success and reduces the

stress or frustration and, ultimately, behaviors, that arise when

expectations are too high.

Change activities often and always try to end with success. Just as

it is important to set reasonable expectations, it is important to

know when and how to end a teaching session or change activities.

When you are teaching your child a new skill, take a break before

she becomes fatigued or frustrated and misbehavior arises. If

possible end the activity at a point where she has achieved some

success. As much as possible, plan to end any specific teaching time

on a positive note. This will build your child's positive feelings

about her abilities, and yours too. Consistently working until she

is fatigued is frustrating for everyone; she feels she has lost

control of her situation and will act out accordingly.

Use things your child enjoys as reinforcement. When your child has

done something that you want to encourage, it's important she sees

your response as a worthwhile reward. Keep in mind many children

with DS-ASD may take particular pleasure from some things that

others would not find particularly reinforcing or gain pleasure

from. That's OK. What is important is that your child sees the

reward as a reinforcement for her behavior or work that she has

done.

Allow choices whenever possible. If your child does not feel she has

control over her environment, she will be frustrated (and misbehave)

as a result. Provide the illusion of control by giving her choices

regarding aspects of the task without lowering your expectations.

For example, if you would like her to sit down, you can say, " you

need to sit—do you want to sit in the big chair or the little

chair, " or " you need to get dressed—do you want to put on your pants

or shirt first? "

Incorporate structure and routine into the environment. Children

with DS-ASD often do not pick up on vague cues that others do to

detect changes in rules, expectations, or events. Therefore,

building predictability through structure and routine encourages

appropriate responses and increases the chance of success while

decreasing frustration and resulting inappropriate behaviors .

Plan ahead for transitions. Children with DS-ASD have difficulty

with changes or new activities. You can help your child by allowing

for adequate time and using prompts that are effective for your

child about the change as it is about to occur. This may mean

specific verbal cues, a visual schedule, or physical cues (a touch

or gathering specific items) that communicate what is coming next.

Make eye contact. Children with DS-ASD may not pick up on verbal

cues even though they understand the request or comment. Achieving

eye contact in any interaction, spoken or visual, will increase the

chance your child is attending to the interaction.

Be as concrete as possible. Using abstract ideas, analogies,

exaggerations, or sarcasm may only serve to confuse your child. She

may take your comments literally or thoroughly misunderstand. Keep

your comments simple, clear, and concise to encourage her

understanding. For example, give short, direct,

instructions: " Alice, turn off the T.V. " Then follow the guided

compliance procedure described below. This will be more effective

than saying, " Why are you watching T.V. when you're supposed to be

getting ready for school? "

Use more than verbal instruction. Use a combination of verbal,

visual, modeled, and physical prompts to get your point across.

Be consistent in every way. Your child will be most successful when

the environment is predictable in terms of structure, routines, and

expectations.

Use these ideas and methods to set the stage for your child's

success and encourage appropriate behavior. It takes planning, but

it is an important part of shaping your child's behavior. Once this

is done, take a look at teaching your child what it is you would

like them to do.

Using Prompts to Teach New Skills

Children with Ds-ASD may do better using specific teaching methods

for new tasks. Your child must understand the request, what action

to take to follow the direction, and then do those things. To do

this, your child new skills or to follow particular directions may

need a variety of cues (visual, verbal, and physical) for her to

understand and then follow-through with action. In addition, her

interest in repetitive or other behaviors may interfere with her

ability to follow your direction. Teaching your child to follow

simple commands is a basic tool for managing your child's behavior.

If your child is not attentive or receptive to your demands then

this will limit your child's ability to learn more adaptive ways of

responding.

One way to present new directions and teach the requested response

is called, guided compliance procedures. This method is effective

with gaining compliance in most cases. There are three basic steps

to the procedure:

Verbal prompt: Give your child a clear instruction and wait five

seconds. If she follows your direction (complies), praise her in a

manner that specifically and concisely details what she did well.

(e.g., state " That's good for….. " and insert the task completed). If

she does not comply, move to the next step: a gestural and verbal

prompt.

Gestural prompt: Show your child the exact response you desire. As

soon as you complete the task, return things, or yourself, so they

are exactly the same as before you gave the prompt. Tell her, " now

you do it. " Wait five seconds without providing any other cues. If

she complies, praise her specifically for her actions. If she does

not comply, move to the next step: a verbal prompt with physical

prompt follow-through.

Physical prompt: Take your child hand-over-hand through the entire

response as you say, " you need to (repeat instruction). " No praise is

issued if you must utilize this step.

Important Pointers:

The basic premise behind this procedure is that sometimes your child

may not be attentive, may not hear you, or may not understand what

is being asked of her. The middle step is added to provide the

benefit of the doubt. Even if you are convinced that these things

are not occurring, attempt this strategy and observe behavioral

change. You will learn more about your child in the process.

The timing of 5 seconds between each step allows for some

opportunity for compliance and keeps the pace moving. However, for

some children, this processing time is not long enough and the time

interval may be expanded to more like 10 seconds. If the interval is

too much longer, the procedure is not as smooth and allows too much

for diversions and task evasion.

The way you say things when talking to your child is very important.

Your child is more likely to do what you ask if you avoid some

common pitfalls of giving instruction. These include: giving long or

multiple requests at one time, providing vague requests such as " Be

a good girl, " issuing questions rather than statements, repeating

instructions, giving instructions when there is not enough time or

energy to follow through, and failing to achieve eye contact. Use

one-step, concrete instructions as much as possible.

When using the physical prompt, it is important to demonstrate the

exact response you want. This is where you are teaching your child

what is expected of her. It is important to teach it correctly the

first time.

When using the physical prompt, it is important to be sure that your

child is fully involved in the task and is not just loosely held

while you complete the task. That is, even if the task may be

completed with one hand, if physical guidance is necessitated, then

you should hand over hand from behind the child and guiding both

hands.

Initially, you may want to practice this prompt sequence within the

context of one specific task (e.g., dressing, eating). That way, you

can practice the sequence in a natural, time-limited situation and

your child will master a new skill that makes life a little easier.

Establish a standard schedule and routines for your child. The more

predictability your child has in her day, the less often you will

need to guide her through specific tasks.

Large tasks such as cleaning her room, are best broken into several

smaller tasks for better success. This presents more opportunities

for praise and is reasonable for everyone if she needs gestural or

physical prompts.

Do not give an instruction unless you are willing to provide follow

through. Consistency in follow-through to the gestural or physical

prompt as needed, is more important than giving the instruction

alone.

Set up situations so your child earns more attention for compliance

than for noncompliance.

Misbehavior during the three-step procedure should not allow escape

from the task—rather, this behavior should be ignored and the

sequence continued.

Behavior Management Strategies

Understanding what motivates your child's behavior and deciding how

to approach it can be a daunting task. Although a formal, functional

assessment is the most thorough method, there are some general and

effective strategies to consider as a starting point. It is

important to individualize them for your child. Some of these

techniques, such positive reinforcement and planned ignoring, are

straightforward and intuitive in theory, but will prove to be quite

difficult to implement. Therefore, remember to set reasonable

expectations for yourself and your child and seek the support of a

trained professional.

Differential Responding

Children typically enjoy receiving attention. If they do not receive

enough positive attention for their good behaviors, they will often

resort to behavior that results in negative forms of attention

(e.g., yelling, nagging, " time out " ). They would prefer to receive

this negative attention than to do without attention all together.

Over time, they learn which actions are the most effective in

getting a response--positive or negative. This is called,

differential responding.

It is important to show your child more attention for acting

appropriately than for acting inappropriately. This will motivate

her to continue with positive behaviors. When used along with

procedures to reduce inappropriate behaviors, such as ignoring (see

below), it will encourage her to discriminate which behaviors will

gain approval. It is important for children to learn that only

appropriate behavior receives a response.

This makes sense to most people. When your child engages in

appropriate behavior, she should receive a positive and heightened

response; when she misbehaves, attention should be

limited.Unfortunately, it is natural to respond opposite to what is

effective and aggravate the situation. That is, when your child acts

appropriately, you (the parent or teacher) tend to ignore her good

behavior fearing that if you respond it will " rock the boat. "

Conversely when she behaves negatively you respond dramatically. In

reality, the best way to teach your child how to act appropriately

is to attend to the positive behaviors and ignore the inappropriate

behaviors. Particularly for children with DS-ASD, the easier it is

to discriminate between responses to positive and negative

behaviors, the quicker she will learn that the best (and only) way

to get any form of attention is through good behavior.

Differential responding is most effective when both positive

attention and ignoring are implemented. In this way, your child

learns inappropriate behaviors result in no attention and acceptable

behaviors result in positive attention. This eliminates at least one

motivation for inappropriate behaviors such as attention seeking.

The components of these strategies, positive attention and ignoring,

are detailed below:

Giving positive attention effectively:

Make eye contact with your child and speak enthusiastically.

Be specific about the behavior that you liked.

For instance, " Good being quiet " or " Nice hands to self, " instead

of: " Good girl. "

Keep praise statements simple

For instance, " Good picking up toys " instead of, " That was good

picking up your toys so that no one would trip on them. "

Give attention immediately following the behavior that you liked.

Delays in rewards make it more difficult for her to determine what

she did to receive attention.

Withhold attention to an inappropriate behavior (or anything

following it) occurring within the last 30 seconds.

For example, your child should exhibit at least 30 seconds of good

behavior before you praise her with positive attention after a

negative behavior. This helps her discriminate between the behavior

being rewarded as the most recent positive behavior rather than a

previous misbehavior.

Give the type of attention that your child enjoys.

Children with DS-ASD find different things pleasurable than other

children. Make note of the type of attention your child enjoys such

as tickles, hugs, or a specific touch. It is important that the

attention you give to reward appropriate behavior is positive to

your child.

Catch your child being good.

The gains you see in your child seem like small improvements or

behaviors which would only be expected due to chronological age.

However all gains and appropriate behaviors are important and should

result in positive attention . Statements such as, " Nice sitting on

the toilet " or " Nice brushing teeth " are important for your child to

hear.

Provide positive attention for behaviors that cannot occur at the

same time as inappropriate behaviors.

For example, if your child tantrums often, praise her for playing

quietly and using a normal voice during her play. If she is

disruptive to others frequently during her independent play, praise

her when she is playing independently and not being disruptive.

These methods will teach her acceptable alternatives for

misbehaviors.

Get in the habit of catching good behavior and providing positive

attention at least once every 5 minutes.

You will know you are praising your child enough, when you feel you

are doing it too much or too often

Be sure that good behaviors receive more attention than

inappropriate behaviors.

Provide many opportunities for positive attention. It is easier to

promote appropriate behaviors when your child is doing something she

likes to do and you are both focussed on that one activity (instead

of cooking dinner, correcting homework, or folding laundry while

your child plays). The more you arrange the environment to be

conducive to appropriate behavior the better the chance she will

learn how to act appropriately.

Using Planned Ignoring

Determine what is " ignorable behavior. " Ignorable behavior is

typically defined as behaviors that are not harmful to the child,

others, or others' belongings. It is important that all family

members and caregivers be aware of the definition to be consistent

in their response.

Ignore as soon as the behavior occurs. Delaying your response

(ignoring) will confuse your child if too much time passes between

her action and your response.

Ignore consistently. Whenever ignorable behaviors occur, be

consistent in your response. The best way for your child to learn

the limits to her behavior and to determine which behaviors will

result in the desired attention is through consistent responses.

Make ignoring obvious. To have an impact on behavior, your child

must be aware that attention is being removed because of specific

behaviors she has done. This is particularly challenging for

children with Ds-ASD who are less aware of social cues. Therefore,

ignoring must be made obvious by:

looking away,

keeping a neutral facial expression,

talking with others in child's presence,

restricting physical contact,

tuning the child out, or

engaging in household tasks.

Expect behaviors to escalate.

Things often get worse before they get better. This is because your

child increases the frequency of behaviors to receive the attention

she is accustomed for them. This does not mean that ignoring is not

working--quite the opposite--she is merely testing the new rules

that have changed.

Distract yourself from attending to difficult behaviors.

When your child's behaviors escalate, it may be best to leave the

room, turn on the radio or TV, pick up a magazine, or call someone

on the phone to prevent you from reacting to your child's behaviors.

Keep an ear out for situations that require your immediate

attention, however.

Do not allow your child to escape a task due to ignorable behaviors.

If you are working on a task, such as putting toys away, continue to

follow through with the task even if behaviors you have defined

as " ignorable " occur.

Ignoring is a very active strategy that requires that you withhold

eye contact and make no verbal response to the child. However, it

does not mean to stand back and allow destructive or other behavior

to occur. It is important at times to prevent and block behaviors as

well as removing or diverting a child from an area or situation. It

is important to keep everyone and everything safe.

Conclusion

Children with Down syndrome and autistic spectrum present a unique

blend of characteristics. The dual diagnosis also complicates

intervention strategies, particularly from a behavioral standpoint.

Parents and professionals are often unsure what to do for behavioral

issues when the dual diagnosis is present.

A practical approach is to use teaching strategies and behavior

management methods that address the specific needs of your child and

your family. Although this is best done with the assistance of a

behavior specialist, some of the strategies described in this

article are effective in helping you begin to make progress with

your child.

Once you understand the main areas of need for your child and your

family, the individual motivations for behavior, treatment of

behavioral issues your child with Down syndrome and autistic

spectrum is less mystifying. The core to effective teaching and

appropriate behavior is consistency, consistency, and consistency!

Naomi Swiezy, Ph.D. is a Clinical Assistant Professor of Psychology

in Psychiatry in the Autism Clinic at the Riley Hospital for

children at Indiana University Medical Center. Prior to this she was

the director of the Autism and Pervasive Developmental Clinic and

behavioral consultant to the Down Syndrome Clinic at Kennedy Krieger

Institute.

The article above is reproduced from the September/October 1999

issue of Disability Solutions, Volume 3, Issue 5 & 6. Permission was

granted for its use on this web site. In accordance with federal

copyright restrictions, the contents of this article may not be

reproduced by photocopying or any other means without written

permission from the copyright holder. © 1999 Disability Solutions

For more information on this valuable resource visit their web site

at www.disabilitysolutions.org.