The World is Overwhelming Sometimes: ABA Sessions

So far in this journey of understanding ABA therapy, I have covered everything from emotions and basic prompting to larger applications like generalization.

Many people on the autism spectrum have difficulty processing sensory information. These sensory differences can affect learning and day to day behavior.

Sometimes an autistic person may behave in a way that you wouldn't immediately link to sensory sensitivities. A person who struggles to deal with everyday sensory information can experience sensory overload, or information overload. Sensory overload occurs when the brain and the nervous system  become bombarded with too much sensory input from one or more sensory systems and cannot process and sort out the incoming sensory messages. This can ultimately cause stress, anxiety, and possibly physical pain and can result in withdrawal, a meltdown and change in behavior and like not adhering to directions.

The main areas of processing difficulties are seen when a child is hypersensitive or hypo-sensitive to the seven senses which are sight, sound, touch, taste, smell as well as balance (vestibular) and body awareness. For example, a child with hypersensitive vision could have distorted vision when objects and bright lights appear to jump about. They may find it easier to focus on one spot of detail because the surroundings can be overwhelming especially if it is distorted, too bright and fragmented. They may avoid certain rooms, lighting, objects as it may increase their sensitivity.

To help someone on the spectrum with sensory overload, watch and be prepared. Take note of the environment at all times and keep it away from the triggers when possible. Watch for signs and sensory signals of possible overload and respond right then and there. Don't push through, and be there for them.

I hope you have all enjoyed these ABA sessions as much as I have!

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Applying What You Learn: ABA Sessions

What is the point of learning a new behavior or skill if it cannot be applied in different situations? Is a skill truly acquired if the student is unable to apply it outside the classroom or house?

Generalization is the “spreading” or “expansion” of teaching beyond what was directly or intentionally taught. It is the process of taking a skill learned in one setting like home and applying it in other settings like school or a store.  If anyone (on the spectrum or not) can do that, then they are exhibiting generalization.

Generalization is an integral part of ABA therapy and all learning. If you can teach a child to say "thank you" in the therapy room, but they never respond to other peers or adults out of the session then what is the point of that? How does the skill of saying "thank you" benefit that child? Ultimately, the goal of teaching any skill or behavior is that the child can apply it across many different environments and multiple people.

People on the spectrum tend to have a harder time generalizing. While they may be able to demonstrate a given skill, generalization is not automatically guaranteed if they are not being prompted or something about the presentation is a little different than it was when it was originally taught. Recently, one of the kids I have gotten a chance to observe is learning how to appropriately cross the street. Within a few weeks, he is able to demonstrate how to cross the street with play cars in the session. He will stop the play figure if a car is incoming and look left and right. However when taken outside to do the same thing with real cars, it is harder for him to apply the same skill. An open environment brings more distractions and stimuli than the inside.

There are many ways to generalize, including across time and people, across settings, and across stimuli.

1. Time- A child learns his numbers up to 20 last month. Today, he can still remember them.
2. People- A child can respond the same way to different people.
3. Settings- A child learns his numbers up to 20 in a ABA session. He can use those 20 numbers regardless of the environment (at home, on the playground, in class etc.)
4. Behaviors- A child learns his numbers up to 20 last month. Now he is learning numbers up to 50 and eventually 100. He’s also showing learning how to add and subtract. 

Generalization should be a part of any early intervention from the start. It’s not something extra; if it doesn’t happen, then behavior change is all but meaningless.

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Routines and Managing Change: ABA Sessions

Change affects us all. Anything from a delayed flight to a broken phone can bring frustration, panic and anxiety to the best of us. When times are chaotic and things go opposite of the norm, it becomes harder to cope and keep calm.  

Change is especially hard for a person with Autism.

Yesterday, the therapist was running late for the usual 4 o'clock session. The parents had already arrived and the child was waiting patiently until the clock hit 4. In a few minutes, the child started crying and asking where the therapist was over and over again. It was like their whole world had stopped. It was not until the therapist arrived had the child stopped crying.

Routines and rituals are important in the lives of people with Autism. The everyday hustle and bustle that most people view as normal can be overwhelming for those on the spectrum. A daily routine helps create stability and order and gives a clear expectation of what is going to happen everyday. These routines can be any big or small habits like eating at the same type of food for lunch to watching a movie at the same time everyday.

Sometimes even minor changes between these activities or routines can be distressing. Different people on the spectrum respond differently to change. Some exhibit withdrawal, repetitive behaviors, tantrums, or even aggression, while others shut themselves down completely. It is important to remember that these behaviors are typically the result of extreme anxiety and/or inability to communicate their emotions and desires.

When a situation goes out of hand or there is an unexpected change in routine, therapists recommend re-directing the person to a different activity as soon as possible and telling them that the situation cannot be changed. When the therapist was a bit late, the supervisor redirected the child to a different activity like reading a book and told them that “Ella will be here in a few minutes”. Every time the child would ask again, the supervisor would simply ask a question about the book or ask the child to read a page out loud.

Visual schedules and timers can also help prepare for change by clearly  laying out what is happening and when it is happening. These visual supports can help a child understand the order of daily events, the steps involved in daily living skills and any changes in routine that may occur throughout the day.

We cannot control change, but we can do everything to help those on the spectrum be more flexible and tolerant of change.

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"Practicing Errors Impedes Learning": ABA Sessions

Within an ABA program, a clinician usually employs different types of prompts to help a child achieve a desired behavior or skill. Prompting is extensively used in behavior shaping and skill acquisition. It provides learners with assistance to increase the probability of a desired behavior.

Prompts can be equally useful for helping people both with and without Autism. Have you ever pointed your finger to direct a person in the right direction? If so, you’ve prompted someone. Have you ever used an alarm clock to wake up? Then you have prompted yourself!

Lynn McClannahan and Patricia Krantz of Princeton Child Development Institute  describe prompts as: “Instructions, gestures, demonstrations, touches, or other things that we arrange or do to increase the likelihood that children will make correct responses.” When done correctly, prompting increases the rate of responding while lowering frustration, and helping the individual learn more efficiently. If your friend didn't know how to bake, you wouldn't give them a demand like "make me a cake" and then just stand back and watch them struggle. Practicing errors impedes learning. You would step in and help them succeed. This same idea is used in ABA therapy with prompts. 

Prompting is utilized in many ways during an ABA session , some of which are described below:

1. Gestural prompt- Pointing, nodding or any other type of action the child can watch the clinician do. 
Example: Pointing at an animal to make the child say cow.

2. Full physical prompt/Hand Over Hand (HOH)- Leading the child by the hand, or physically moving a child to guide them through the entire activity. 

3. Partial physical prompt- The clinician provides only some assistance to guide the child through part of the requested activity.

4. Full verbal prompt-  The clinician verbally models what the desired response of the child is. 

Example:“What is that toy?" 
                   "Say, block”

5. Partial verbal prompt- The clinician  provides the child with part of the response to the question asked or just says the first word or sound. 

Example: “What is that toy? Say, bl...”

6. Visual prompt- A video, photograph or drawing on a medium like paper, a whiteboard, or  an electronic device. 

Example: Clinician asks the child to “Clap your hands.”
Clinician prompts the child by playing a video of a person clapping his hands.

7. Auditory prompt- like an alarm or timer.

Example: Clinician asks the child to, “Clean up your toys in 5 minutes.”
Clinician prompts the child by setting a timer to go off in 5 minutes.

Ultimately prompts can become crutches; they’re a kind of artificial support. So, while prompts are a useful tool in teaching and the first step in helping a child fully learn a skill on his own, it’s important that the child is not always been prompted to perform a task.

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"To Be" or "Not To Be" That is Echolalia: ABA Sessions

While observing an ABA session this week, one of the things I found common in many children was the way they responded during conversations. They would constantly repeat certain words and phrases and only those phrases.

After the session, I learned that the term for this is Echolalia. This form of speech involves the repetition of words and sounds a person has heard or been asked recently.

Most children in early childhood mimic words and phrases that they hear their parents say or the people around them. Mimicry is an important stage in development that ensures a child is leaning core language skills.

However, what if this mimicry goes beyond early childhood? What does this mean for the child?

Echolalia is commonly seen as a “symptom” of autism. Parents usually point out that their child is "repeating what they say" during a diagnosis. There are two forms of echolalia called  immediate echolalia and delayed echolalia. Understanding the presence of echolalia helps understand how child is trying to process language.

Immediate echolalia refers to words or phrases echoed immediately after they are heard. For example, during the therapy session the clinician said, “time to go play,” and the child replied, “time to play”.  By repeating phrases the child does demonstrate that he or she can produce speech and efficiently reproduce it, but might struggle to comprehend what is being said.

For many on the spectrum, this form of echolalia is a way of communicating. The clinician explained that "sometimes immediate echolalia is necessary and for many  is a way to remain in a conversation and give an answer without feeling nervous or anxious”. It's like a desire to be included in a conversation without being sure of what to say exactly. While many parents feel frustrated and concerned for their child, immediate echolalia is still a good indicator that the child is trying to communicate.

If a child continues to repeat phrases for a longer period of time, then it is referred to as delayed echolalia. The phrase is repeated a day, month or even a  year after it was originally heard and can may pop up at any time or place. For example, the child I was observing loves to talk about nursery rhymes. Thus, he’d repeat “clap your hands” randomly as if he was watching a video at the moment.

The clinician explained that this other form of echolalia was a way to sometimes express mood. If a child is feeling happy and excited he’ll say something like “clap your hands” which is something he associates with a happy situation. This helps kids on the spectrum join in conversations without fully understanding the context. They will pick up on the mood of the conversation and repeat sentences that they associate with that mood.

To improve speech and prevent constant echolalia, therapists recommend PEC Cards (like cards with different pictures). Picture cards can provide visual cues that can help formulate different conversations. For delayed echolalia, redirecting conversations help bring the child back on topic.

See you next week with another topic from an ABA session!

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Distractions and Eye Contact: ABA Sessions

“I really don’t understand why it's considered normal to stare at someone’s eyeballs” - John Elder Robinson

Many children with Autism struggle with eye contact. Making eye contact is an important skill because it lets someone know we’re engaged and interested in the conversation and that we acknowledge their presence. This makes it one of the first concerns of many parents and one of the biggest goals they want to see their child accomplishing through a treatment program like ABA. Much of ABA instruction also involves specific demands, and if a child is not properly attending then it can be difficult to provide the most effective treatment.

What someone believes to be indicators of “paying attention” (which for many is constant eye contact) can actually be challenging behaviors for a child with Autism. Some situations and behaviors can make paying attention difficult. For example, yesterday I sat in an ABA therapy session that was focused on how frequently the child made eye contact during different activities. Because the activity was one of the child’s favorites (Legos), he had difficulty paying attention to the therapist. The therapist  had to give him demands like “can I have a Lego piece?” multiple times to get the appropriate response. To get him to eventually move on from the activity, the therapist set a timer that provided the right structure.

Social difficulties also correlate with lesser eye contact. For some children, looking directly into someone’s eyes can make them feel anxious. Even standing in close proximity to someone can be a very uncomfortable which makes it harder to pay attention.

The Autism Guide advises that for families with kids who struggle with Autism one of the first steps is to request eye contact daily in some form. “Each day, say your child’s name followed by “look at me.” Do this every five minutes for one hour and note whether or not the child makes eye contact. When you say the child’s name and the phrase “look at me,” only say it one time in a firm voice, but do not shout, or have a pleading tone in your voice.” Another way is to make sure the activity is child specific. By giving them options like “should we play with the cars or the train?” the child is involved in the structure of the session and more inclined to pay attention.

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ABA: The Scientific Approach to Autism Treatment

Throughout the last few weeks, I have been hinting at a broader form of Autism therapy known as ABA or Applied Behavior Analysis. Recently, I have talked about PRT which is a form of ABA. ABA is the science devoted to the understanding and improvement of human behavior. “Applied" means practice, and "behavior analysis" is the application of the different principles of learning and motivation. It might seem odd to use the word "behavior" when talking about basic life milestones like talking or following directions but with ABA all “behaviors” can be taught and encouraged.

Usually as we grow and develop, we learn and evolve with our environment. Our surroundings, cultures and situations help us learn different social skills and the “rights” and “wrong” of behavior. Someone diagnosed with Autism has difficulty communicating and learning from our daily environment. That does not mean they cannot learn from their environment, but that it takes a very structured routine and arrangement where conditions are optimized for them to acquire the same skills that are considered "natural" and “normal”. ABA is all about how to set up the environment to improve behaviors that are the most meaningful for the individual and those around them.

The word “behavior” sometimes carries a negative connotation in society. What exactly is a behavior? A behavior is anything that is observable and measurable. A behavior is not an type of emotion, a state of mind or feeling and definitely not something that is undesirable. With ABA, therapists teach and monitor behaviors that can represent emotions and that are important to the quality of life.

There are many important components to ABA therapy. To teach ABA methods, a behavior needs to be isolated and controlled. Therapists aim to work on one behavior at a time, because changing many behaviors can confuse what exactly caused the change in the individual. These changes to behavior need to last over time as well. The child must be able to general the skill outside the realm of the clinic or session or working not that behavior is ineffective. For example, if a child is toilet trained at a clinic, but is unwilling to use the restroom at home or school then the behavior is not generalized. The results also need to effective and practical as well.

In later blog posts I will explain the different ABA based interventions as I observe them during sessions, and provide examples of what this form of treatment looks like. For anyone still confused about this type of treatment, I have attached a video that gives a brief introduction to the basic concepts of ABA.

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