Oct 5, 2010 ... three studies that compared Applied Behavior Analysis (ABA) with eclectic
approaches ...... and “Mama” and now is asking his mother for “Ball!
Diploma Nordhessen Europäische Hochschulen
Diplomarbeit im Rahmen des Diplomstudienganges Ergotherapie
Applied Behavior Analysis with Verbal Behavior (ABA/VB) Intensive Intervention in the Child’s Everyday Life
Vorgelegt von: Janina Menze Schmiedeweg 7 31855 Aerzen Institut Knospe-ABA
[email protected]
Erstgutachterin: Frau Prof. Dr. Link Zweitgutachterin: Frau Dr. phil. Steinbach
Aerzen, Oktober 2010
“Let us work to provide this educational service to all autistic children, regardless of age or severity of condition, and to all families, regardless of income.”
(Catherine Maurice 1993, p. 323)
II
Index of contents:
1. 2.
Introduction ........................................................................................................................ 1 Applied Behavior Analysis (ABA) .................................................................................... 3 2.1. Verbal Behavior (VB) ................................................................................................ 6 2.2. ABA Education .......................................................................................................... 8 2.2.1. Studying ABA .................................................................................................... 8 2.2.2. ABA/VB Education for Non-professionals.............................................................. 9 2.3. ABA Supply and Costs ............................................................................................ 10 2.3.1. Costs for the case study.................................................................................... 10 2.4 ABA/VB applied by Parents .......................................................................................... 11 3. Behavioral Strategies........................................................................................................ 13 3.1. ABC Paradigm ......................................................................................................... 13 3.2. The Purpose of Behavior.......................................................................................... 13 3.3. Consequences ........................................................................................................... 15 3.3.1. Reinforcement .................................................................................................. 15 3.3.2. Punishment ....................................................................................................... 18 3.3.3. Extinction ......................................................................................................... 19 4. Teaching Strategies .......................................................................................................... 20 4.1. Errorless Learning .................................................................................................... 21 4.2. Teaching Arc ............................................................................................................ 23 5. Seven Steps of Instructional Control................................................................................ 25 5.1. Step 1: Restriction of Reinforcement ....................................................................... 26 5.2. Step 2: Pairing .......................................................................................................... 26 5.3. Step 3: Being Contingent ......................................................................................... 27 5.4. Step 4: Positive Reinforcement ................................................................................ 27 5.5. Step 5: Variable Ratio of Reinforcement (VR) ........................................................ 28 5.6. Step 6: Differential Reinforcement .......................................................................... 28 5.7. Step 7: Extinction/ Negative Punishment................................................................. 29 6. ABLLS ............................................................................................................................. 30 6.1. The Categories of Language .................................................................................... 31 6.1.1. Category 1: Manding........................................................................................ 33 6.1.2. Category 2: Motor Imitation ............................................................................ 34 6.1.3. Category 3: Verbal Imitation............................................................................ 35 6.1.4. Category 4: Tact ............................................................................................... 35 6.1.5. Category 5: Intraverbal..................................................................................... 36 6.1.6. Category 6: Receptive Language ..................................................................... 36 6.1.7. Category 7: Feature, Function and Class (FFC).............................................. 37 6.1.8. Category 8: Textual .......................................................................................... 38 6.1.9. Category 9: Writing.......................................................................................... 38 7. Definition Autism Spectrum Disorder ............................................................................. 38 8. Diagnosis Martin .............................................................................................................. 40 8.1. Martin’s First ABLLS Assessment .......................................................................... 41 8.1.1. Cooperation and Effectiveness of Reinforcement............................................ 42 8.1.2. Visual Performance .......................................................................................... 42 8.1.3. Receptive Language (listening skills) .............................................................. 43 8.1.4. Imitation ........................................................................................................... 43 8.1.5. Vocal Imitation................................................................................................. 43 8.1.6. Manding (requests)........................................................................................... 43 8.1.7. Tacting (labeling) ............................................................................................ 44 III
8.1.8. Intraverbals....................................................................................................... 44 8.1.9. Spontaneous Vocalization ................................................................................ 44 9. Initial Consultation ........................................................................................................... 44 9.1. Initial Consultation at Home .................................................................................... 44 9.2. Initial Consultation in the Kindergarten................................................................... 45 9.3. Initial In-Home Program .......................................................................................... 46 9.4. Initial Learning Goals............................................................................................... 46 9.4.1. Effectiveness of Reinforcers ............................................................................ 47 9.4.2. Visual Performance .......................................................................................... 47 9.4.3. Receptive Language ......................................................................................... 48 9.4.4. Motor Imitation ................................................................................................ 49 9.4.5. Verbal imitation................................................................................................ 50 9.4.6. Manding ........................................................................................................... 51 9.4.7. Intraverbals....................................................................................................... 51 9.4.8. Behavioral Goal: “Give to me” Program ......................................................... 52 9.5. Initial Kindergarten Program.................................................................................... 53 10. Martin’s Teaching Goals in Progress ............................................................................... 53 10.1. Goals from December 2006 ................................................................................. 54 10.2. Goals from March 2007 ....................................................................................... 56 10.3. Goals from April 2007 ......................................................................................... 56 10.4. Goals from August 2007 ...................................................................................... 58 10.5. Goals from December 2007 ................................................................................. 59 10.6. Goals from May 2008 .......................................................................................... 60 10.7. Goals from July 2008 ........................................................................................... 61 10.8. Goals from October 2008 ..................................................................................... 62 10.9. Goals from February 2009 ................................................................................... 62 10.10. Goals from May 2009 .......................................................................................... 63 10.11. Goals from November 2009 ................................................................................. 63 11. Behavioral Goals .............................................................................................................. 63 11.1. October 2008 ........................................................................................................ 63 11.2 February 2009 ...................................................................................................... 66 11.3. May 2009.............................................................................................................. 66 12. Summary .......................................................................................................................... 68 13. Conclusion........................................................................................................................ 68 14. List of References............................................................................................................. 71 15. List of Abbreviations........................................................................................................ 74
IV
Index of appendices:
Appendix 1
ABLLS, Martin’s Assessment from September 2006 to November 2009
Appendix 2
Mand Sheet, September 2006, Initial Consultation.
Appendix 3
FFC Data May 2008
Appendix 4
Weekly Teaching Data, April 2007
Appendix 5
Token Chart
Appendix 6
Teaching Arc
Appendix 7
Studies Supporting ABA
Appendix 8
Assessment by Occupational Therapist, December 2004
Appendix 9
Diagnose, St. Olavs Hospital, February 2005
Appendix 10 Evaluation by the Local Commune, March 2005 Appendix 11 Report, Nic Waals Institute for National Health, June 2006 Appendix 12 Martin’s First ABLLS Assessment Appendix 13 Eidesstattliche Erklärung
V
1. Introduction “Autism is a spectrum disorder that affects an ever-increasing percentage of the population” (Schramm 2006, p.17). Autism Spectrum Disorder (ASD) contains the whole spectrum of autistic dysfunctions, such as the Kanner Syndrome, Aspergers Syndrome, A-typical Autism and high-functioning Autism, autistic disorder, childhood disintegrative disorder and Rett disorder (cf. Simpson 2005, p.1). ASD is a Pervasive Developmental Disorder (PDD: ICD-10, F84) that starts usually before the 30th month of life. As of yet, the origin and cause of Autism are not determined. Multi causative reasons, such as genetic aspects, environmental influences and vaccinations are suspected. The number of diagnosed cases is increasing. At the moment different sources are talking about six to fifteen in 10000 children (cf. Myers 2007). Since the number of ASD cases is growing, there is also an increasing need for effective interventions all over the world (cf. Myers 2007, p.1162). There are no clear statistics that show how many children are affected in Norway but also here the number is considered to be increasing. Occupational Therapy is one of the first therapies a child with Autism will receive when diagnosed. But most of the concepts used in the Occupational Therapy that address ASD lack a scientific proof of effectiveness. In 2007, The American Academy of Pediatrics states in the Clinical Report about “Management of Children with Autism Spectrum Disorders”, that occupational therapists promote self care and academic skills, develop play skills and modify classroom materials and routines to improve attention and organization. “However, research regarding the efficacy of Occupational Therapy in ASD is lacking”. Later it states that (…) “the efficiency of SI (Sensory Integration) therapy has not been demonstrated objectively” (cf. Stanislaw 2005, cf. Maurice 1996, p. 23). Sensory Integration is a therapeutic concept commonly used by occupational therapists to address perception disorders. The American Academy of Pediatrics suggests that sensory experiences can be helpful as a part of an overall program to reinforce desired behavior. The Clinical Report from 2007 explains that the efficacy of intensive behavioral programs has been well documented through 5 decades of research and proven in three studies that compared Applied Behavior Analysis (ABA) with eclectic approaches (cf. Myers 2007, p.1164, cf. Simpson 2005, p.94). The paper is also referring to studies regarding ABA that was based on the approach of Dr. Ole Ivar Lovaas that have been implemented in Norway (cf. Eikeseth 2002&2007). Applied Behavior Analysis (ABA) is a worldwide approved teaching method that is mainly common in the Autism intervention. ABA is the process of applying interventions that are based on the principles of behavior. The learning
strategies are based on experimental psychology research to systematically change behavior and to demonstrate that the interventions used are responsible for the observable improvement in behavior (cf. Myers 2007, p.1164). ABA has shown to be effective in increasing skill acquisition especially for children with ASD. Its teaching techniques are constantly improving and are becoming increasingly refined and sophisticated (cf. Simpson 2005, p. 94). This thesis will introduce the concept of a Norwegian Occupational Therapy practice that consults families, schools and kindergartens applying the ABA/VB teaching method for children with ASD and Pervasive Developmental Disorder-Not Otherwise Specified (PDDNOS). Occupational Therapy for children with Autism is usually applied one or two, sometimes as many as four hours per week. In Norway Occupational Therapy is usually provided within the educational system in schools and kindergartens. This concept will explain the efficacy of replacing individual therapy hours with one or two consultation days per month to provide the child’s entire social surrounding with a holistic concept that can be applied by the child’s family, teachers and therapists during most of the child’s waking hours (cf. Lynch Barbera, 2007, p. 18, 106 & 132). As an occupational therapist that was working in a practice for Occupational Therapy and later has been trained to work as an ABA/VB consultant, the author of this thesis saw the crucial difference that the ABA/VB teaching method represents in the early intervention of children that were diagnosed within the Autism Spectrum or with PDD-NOS. Occupational therapists who work with children with Autism usually apply Sensory Integration (SI), develop social and playing skills, and teach handwriting or typing skills and flexibility (cf. Simpson 2005, p. 183). They might use concepts like Floortime, which is a play-based interactive intervention approach, or play therapy to develop intellectual and emotional skills as well as physical skills. These concepts have not been scientifically demonstrated to be as effective as Applied Behavior Analysis. ABA/VB is a teaching method that would be a boost for occupational therapists who work with children with ASD and PDD. ABA/VB is providing exactly the kind of treatment to a child with ASD or PDD that is explained in the following definition of Occupational Therapy. On the website http://Autism.about.com (19th July 2010) it is explained that (...) “According to the American Occupational Therapy Association, Occupational Therapy is skilled treatment that helps individuals achieve independence in all facets of their lives. Occupational Therapy assists people in developing the 'skills for the job of living' necessary for independent and satisfying lives.”
2
Parents play a key role in effective treatment. ABA/VB is focused on training and enabling parents to be the best teacher of their own child and provide parents with the scientific knowledge to make them professionals in the field of Autism intervention themselves (cf. Lynch Barbera 2007, p. 27, 30 & 36; cf. Myers 2007, p.1174; cf. Maurice 1993, p. 50, cf. Maurice 1996, p. 4, 15 & 37). (…) “If left untrained, parents and teachers often inadvertently motivate and reinforce increasingly more problematic behavior” (Schramm 2006, p.17, cf. Eikeseth&Lovaas 1992). It is suggested that parents need to be supported by educating them about ASD, training and involving them as co-therapists within an in-home ABA/VB program (cf. Myers 2007, p.1174). This concept will show that ABA in the practice of Occupational Therapy is both outcome effective and cost effective (cf. Maurice 1993, p. 316). The introduced practice does not require practice rooms since the entire procedure of consulting will take place in the child’s family, school, kindergarten, natural environment and social surrounding. The consultations are suggested to take place at least once a month for at least two consecutive years. “After about two years of intensive intervention, research would predict substantial cost reductions for most children, significantly lower or no continuing special expenditures for many” (Maurice 1996, p.42). The history and science of ABA/VB, the possibilities to train parents and to enable them to implement an effective in-home program will be explained. Further, the Assessment of Basic Language and Learning Skills (ABLLS) as an assessment and skill tracking system, teaching strategies to achieve compliance and examples from the case study will be explained. The case study is the implementation of an intensive ABA/VB intervention for a family in Trondheim, Norway during the time frame of three years that can also be provided by a Norwegian praxis for Occupational Therapy in the future. The described boy Martin was four years of age at the beginning of the intervention in September 2006. He had the optimal age to start intensive behavioral intervention, which is suggested to be before the age of five. Still the best outcomes have been documented for children who started treatment at age two or three (cf. Maurice 1996, p.39; cf. Birnbauer&Leach, 1993; cf. Lovaas 1987; cf. McEachin et al. 1993, cf. Simpson 1005, p. 92).
2. Applied Behavior Analysis (ABA) The teaching method Applied Behavior Analysis is most commonly applied in the intervention of ASD. The basics of ABA are found in the discoveries of Dr. Iwan P. Pawlow, such as classic conditioning and in the works of B.F. Skinner (1938), the father of modern 3
behaviorism (cf. Schramm 2006, p.125). The basics of the theory of behavior analyses is that (…) “behavior is lawful, it is best studied scientifically as a branch of biology, and that everything an organism does is the product of the organism’s unique genetic and environmental history” (cf. Wyatt 2001, p.13). Ole Ivar Lovaas was a Norwegian scientist who used ABA teaching methods to apply them especially to the treatment of children with Autism in the seventies at the University of California (UCLA). In 1987 he published a study in the New York Times, showing that 45 percent of children of a comparison group obtained a changed diagnosis after intensive ABA treatment (cf. Maurice 1993, p.64; cf. McEachin et al. 1993). The UCLA research suggests that early intensive home-based behavioral intervention provides the best opportunity for a sizable proportion of children with ASD to have normal lives and that differential consequences can result in completely normal functioning for many (cf. Maurice 1996, p. 32&33). In his book „The autistic child“(1977) Lovaas describes the success especially by examples of speech development. The “Me book” (1981) by Lovaas was a practical guide, designed to implement intensive ABA teaching to children with Autism and a standard work and guideline for the first ABA institutes. Lovaas described ABA as the act of helping children to learn how to learn (cf. Maurice 1996, p.8). Because children with Autism seemed to be approached more scientifically than in an interpersonal educational way, ABA was criticized ever since for teaching techniques that some would call questionable or distasteful and was for a long time displaced from European educational and therapeutically systems, regardless of its effectiveness. In the year 1993 Catherine Maurice, a mother of two children that had a diagnosis in the Autism spectrum, published the book “Let me hear your voice” in the United States about the implementation of the so called Lovaas-ABA. She explained how she managed to help her two children to lose the diagnosis of Autism with the support of the scientific knowledge about ABA (cf. Maurice 1993, p.285, cf. Maurice 1996, p.37&39). The scientific case study by Perry et al. 1995 reported that both children were fully recovered from Autism. Maurice also used Lovaas’ “Me book” as guideline to teach her children (cf. Maurice 1993, p.70). In 1996 Catherine Maurice published the teaching manual “Behavior Intervention for Young Children with Autism: A Manual for Parents and Professionals” with many examples for teaching data sheets. In this book she explains that the “Me Book” did not include many new teaching techniques and refinements that have resulted from research conducted in the fifteen years since the “Me Book” was published. Maurice’s book lists and describes several studies of intensive ABA in-home programs that included the training of the children’s parents, such as the May Institute Study (Anderson, 1987) and the Murdoch Early Intervention Program (Birnbauer & Leach, 1993). These studies show that 4
ABA techniques have proven to be effective for improving a wide range of skills in children with Autism (cf. Maurice 1996, p. 31). Since the nineties the international interest is rapidly increasing and ABA has become a science that is developing fast. The methods described in the book “Behavior Intervention for Young Children with Autism” have been revised and replaced with more effective and more ethical teaching techniques since 1996 (see Verbal Behavior). Modern ABA programs facilitate relatedness and bonding. Aversive stimuli will only be used as a last resort for behavioral treatment of aggressive behaviors. The ABAmethod is not a mere „Autism therapy“, but can be applied for developmental disorders and learning disabilities. All children with ASD can benefit from ABA/VB, regardless of additional labels such as “high-functioning, “low-functioning” or “Aspergers” (cf. Lynch Barbera, 2007, p.162). Robert Schramm states that behaviors described by the labels Attention Deficit Disorder (ADD), Hyperactive Disorder (HD), Oppositional Defiance Disorder (ODD), Obsessive Compulsive Disorder (OCD), Apraxia, or Sensory Integration Deficits are in many cases valid issues that can be addressed with ABA (cf. Schramm 2006, p.101). Since ABA is the science of how people make learning experiences, the basics of ABA are even used in manager trainings, treatment of panic disorders, depression and anxiety, habit disorders such as smoking and overeating, drug addiction, AIDS prevention and in teaching relationship skills (cf. Wyatt 2001, p.25). ABA is the understanding of how antecedents and consequences affect behavior (cf. Schramm 2006, p.25). The behavioral principles can be found at work anywhere an organism gets in contact with its environment. Some institutions in Germany and Norway specialize in training parents, the children’s social environment, kindergartens and schools, to make the scientific knowledge useful for the affected child’s everyday life. The Ontario Study is recommending an intensive ABA treatment for twenty to forty hours per week (cf. Markham, 2006). For this reason many ABA programs are very expensive. When ABA can be applied by parents and all other people in the child’s surroundings, in all parts of the child’s life, a supervision of one – two days per month can be sufficient making more expensive ABA-Interventions unnecessary (cf. Robert Schramm, 2006, p.7-8; cf. Lynch Barbera 2007, p.133). Thus ABA can be very cost effective and costs are usually reduced after the first two years of regular consultations. Since the late nineties ABA is recommended as the only advisable intervention for children with ASD by the Surgeon General of the United States (cf. Schramm 2006, introduction; cf. Lynch Barbera 2007, p.9). It is the Autism intervention with the best scientific support of over three decades and has a large number of studies that demonstrate its effectiveness (cf. Eikeseth 2002 & 2007; cf. Maurice 1996, p.31; see appendix 7). Several scientific professional journals give 5
objective scientific evidence on research in ABA. Some of these journals are the Journal of Applied Behavior Analysis (JABA), Behavior Modification, Journal of Autism and Developmental Disorders, Journal of Behavioral Education and the American Journal on Mental Retardation (cf. Maurice 1996, p.20).
2.1.
Verbal Behavior (VB)
While ABA was nearly completely discarded in Europe since the late seventies, it has been adding teaching techniques and new alternative approaches to the traditional Lovaas system. Behavioral Analysts are progressively working on finding more ethical and more effective strategies to effective teaching and make ABA/VB a continuously developing science. “The Verbal Behavior (VB) approach builds on all of the ABA research but also enhances a child’s ability to learn functional language”. Language is seen as a behavior that can be shaped and reinforced while careful attention is paid not only to what a child is saying but why he is using language. Each function of the word is taught explicitly (cf. Lynch Barbera 2007, p.19&22). In Lovaas’ approach to ABA, expressive language is viewed more cognitively and the functions of words are ignored at least during the first months of the therapy. Speech is classified as either receptive or expressive by practitioners who do not use the VB approach to ABA. VB divides Language into functional categories that build communication skills to give the child a fuller concept of each word taught. These functions are all included in the “Assessment of Basic Language and Learning Skills” that will be explained later on, and are separated into manding, motor imitation, verbal imitation, receptive language, tacting, feature function and class (FFC), intraverbal, textural and writing (cf. Schramm 2006, p.128). The early development of effective communication skills is seen as the most important aspect in Verbal Behavior. The analysis of Verbal Behavior by Skinner, described in his book “Verbal Behavior” (1957) were applied first by Dr. Jack Michael and Mark Sundberg at Western Michigan University, to teach language to children with ASD and PDD in the late seventies (cf. Schramm 2006, p.125). They published their results in 1980, two decades before the VB approach became commonly used for children with Autism. Sundberg and Partington published the book “Assessment of Basic Language and Learning Skills” along with two other books in 1998 (cf. Lynch Barbera 2007, p.19). The ABLLS is crucial for VB since it breaks down language into nine different functions, including nonverbal skills, social and playing skills as well as motoric and academic skills in its 25 learning categories (see appendix 1). Robert Schramm characterizes ABA the equivalent to understanding how to use reinforcement consistently and systemically, while understanding VB is the knowledge about 6
how to capture and create motivation (cf. Schramm 2006, p.13). Schramm states that the goal of any good ABA/VB program is to identify the child’s naturally occurring motivation, to capture it and to use it to help the child learn (cf. Schramm 2006, p.15). In the Verbal Behavior approach “intensive teaching sessions include lots of opportunities for the child to practice giving verbal responses, instead of relying heavily on the nonverbal operants that hallmark standard ABA programs” (Lynch Barbera 2007, p.118). A Lovaas-ABA program usually starts focusing on nonverbal skills such as receptive skills, imitation and visual matching (Lynch Barbera 2007, p.104). A VB program is started by teaching manding skills. Manding is the ability to ask for things and integral to the VB approach. It is based on having a need met and it is predicted by motivation (cf. Lynch Barbera 2007, p. 21&72). Problem behavior is almost always caused by a mand defect. A child’s complete behavior will change positively, as soon as he can start to express his wishes and needs. If a child is non-verbal mand training will begin with augmentative communication such as signs or PECS (Picture Exchange Communication System) that will be used as a bridge to spoken language. The analysis of VB includes all sorts of non-vocal forms of communication including pointing, singing, writing and gesturing, even tantrums. Therefore it works for vocal and non-vocal children and for almost every child with developmental delays. Children use behavior as communication and by learning the language of their behavior, it is possible to employ strategies to decrease problem behavior and increase appropriate behavior (cf. Lynch Barbera 2007, p. 20&28). “Technically, VB is any behavior that is established and maintained by reinforcement coming from another individual” (Schramm 2006, p.126). A Verbal Behavior approach also focuses on pairing, strengthening the reinforcing value of teaching areas and teachers by presenting them in combination with reinforcers (cf. Lynch Barbera 2007, p.63). It is the goal that persons and not just snacks, toys and activities become conditioned reinforcers for the child (cf. Partington 2008, p.32). Everything that the child enjoys doing, has to be paired with the presence of the teacher first. As soon as the child experiences that the activity is more valuable together with that person, the teacher will implement a teaching arc (see appendix 6) and use the reinforcing setting as the teaching setting that allows the child to learn with a high motivation (cf. Partington 2008, p.39). As Catherine Maurice describes in her books, the Lovaas program often starts with making a child sit at a table, which lets the start of a program often become frustrating for the child (cf. Maurice 1993, p. 87). There are also VB approaches that start to teach children at a table but only if (…) “a child is happily approaching the teaching area” (Lynch Barbera 2007, p. 21&67). Robert Schramm recommends starting an ABA/VB program using those situations for teaching that 7
have the highest reinforcing value for a child. It can be taught everywhere, on the trampoline, in the swimming pool, at horse riding, playing on the floor with spinning toys or marbles or while watching a DVD. Before reaching school age the child will be taught to work at a table in small steps. It is one basic teaching philosophy of ABA/VB to break complex skills down in manageable chunks, not only language skills (cf. Maurice 1996, p. 8&30; cf. Schramm 2006, p.170). Mary Lynch Barbera recommends ABA/VB as the best approach for non-conversational children with ASD, Down-Syndrome and other developmental disorders. She states that it is never too early to start an intervention and that also teenagers benefit from VB (cf. Lynch Barbera 2007, p. 26&161). It is always worthwhile to investigate critically towards ABA and the different ways of application and institute philosophies, since there are crucial differences in actual application of ABA methods (cf. Maurice 1996, p.8). There can be big differences between Lovaas-ABA and ABA/VB programs. In this thesis the Verbal Behavior approach is supported and applied. In 2005 a four year old boy from Germany that received one year of intensive ABA/VB support lost his Autism diagnosis. His doctors, therapists and psychologists who had diagnosed the boy could no longer find one major symptom of Autism. He was the first medically documented case of Autism recovery in Germany (cf. Schramm 2006, p.111).
2.2.
ABA Education
2.2.1. Studying ABA Worldwide ABA can be studied at over one hundred master study courses in seven countries (cf. Schramm 2006, introduction). Examples for on campus programs in Europe are the Bangor University, Wales, UK; IDEIABA, LDA, Portugal and IESCUM in Italy. Board Certified Behavior Analyst (BCBA) The BCBA designs and supervises behavior analytic interventions, is responsible for behavioral assessments and interpretations of the results. He is able to effectively develop and implement appropriate assessments, behavioral plans and teaching plans, works together with pediatrics, physicians and psychologists and teaches others to implement ethical and effective behavior analytic interventions. It is the BCBAs task to supervise the work of Board Certified Assistant Behavior Analysts and others who implement ABA interventions. A BCBA is an Instructor in ABA and his work is based on published research. 8
Board Certified Assistant Behavior Analyst (BCaBA) The BCaBA designs and oversees interventions in familiar cases and obtains support from a BCBA for unfamiliar situations. Under the supervision of a BCBA, the BCaBA is able to make behavioral assessments, implements ethical and effective behavior analytic interventions for clients and is able to teach others to implement ABA Programs (cf. www.bacb.com, 20th of September 2010; cf. Simpson 2005, p. 91) 2.2.2. ABA/VB Education for Non-professionals Workshops for professionals and parents are offered mainly in the United States, some also in Europe. Examples for ABA/VB workshops are the workshops by Dr. Vincent Carbone, the workshops by Holly Kibbe, M.S., BCBA and Cherish Twigg, M.S., BCBA from Establishing Operations Inc., workshops by Dr. Patrick McGreevey, Dr. James Partington, Dr. Carl Sundberg, Dr. Mark Sundberg, Dr. Bobby Newman, Christina Burk and the workshops by Robert Schramm, MA, BCBA from institute Knospe-ABA. To attain these workshops it is not necessary to be a professional in the field of education or therapy. As this concept is supporting the “empowerment” of parents these workshops share the knowledge of ABA principles, teaching methods and techniques available to the people in the environment of the child (cf. Maurice 1993, p. 65&321). It is recommended that at least one parent of those families who receive ABA/VB consultations attend one of these workshops in advance of the initial consultation. The listed institutions also offer a variety of DVDs and books about ABA/VB. It is often helpful for parents to join an Autism internet group (cf. Schramm 2006, p.187). Families that receive consultations for their child will get a written manual with explanations of the individual ABA/VB programs for their child, along with teaching goals and teaching techniques after each consultation from their ABA/VB consultant. Step by step the family will be taught more ABA/VB principles while the child’s program is developing over time. As the parents support a quality ABA/VB program in their home, it is usually possible to fade the frequency of consultations after the first two years, while parents and professionals that surround the child will become confident and routined in the science of ABA/VB and start to apply their knowledge for new goals or occurring behavioral challenges. “The described program is designed so that with each subsequent visit the child’s parents and kindergarten or school staff are taught to be better tutors and teachers to the child and to need our direct supervision less intensively. The goal is to help the child and family achieve therapeutic independence while assuring that the child is getting the most ethical and effective education possible for as long as he is in need” (www.knospe-aba.com, 19th of July 2010). 9
2.3.
ABA Supply and Costs
There is no cost coverage for ABA in Norway, even though there are institutes like NOVA or TIPO that offer professional ABA treatment. Since the costs of ABA intervention are covered in Germany by more then 70 rural districts, it is the purpose of this scholarly piece to make ABA/VB available to Norwegian families with children with ASD or PDD regardless of income, by integrating ABA/VB into the practice of Occupational Therapy. “Norwegian citizens are entitled to get treatment, rehabilitation and technical aides paid by the Norwegian welfare system, which subsequently include Occupational Therapy. There is no tradition in Norway with private practice, but a growing number of occupational therapists are working with private counseling, ergonomics and health promotion” (http://old.netf.no, 19th of July 2010). The Norwegian institute TIPO is charging a fixed amount of $ 35.400 plus travelling cost for the counselor for one year Early Intensive Behavioral Intervention (EIBI) (cf. http://www.tipo-international.com, 19th of July 2010). In the U.S. good ABA programs average from $20.000 - $40.000 per year with many families paying much more (cf. Schramm 2006, p. 7). Simpson (2005, p.93) ranges costs for providing ABA services from $16.000 to $50.000 per year depending on the number of hours, number and qualification of therapists hired (cf. Simpson 2005, p.93). The American military service insurance carrier TRICARE ECHO covers full benefits for families of qualifying children with ASD up to $2.500 per month, which equals $30.000 per year (cf. Schramm 2006, p.237). The average program of the Institute Knospe-ABA, Germany costs less than 9.000 € (about $10.556) in the first year. Approximately 80percent of the German families are getting reimbursements for this service. The consultations are designed to start with an initial consultation of three days. After the initial consultation a frequency of one to two days per month or two days every second month are most often recommended. One consultation day includes about five hours of practical assessments, implementing and practicing programs and teaching techniques together with the child’s team and discussing the next steps of the holistic plan. Additionally three hours are needed for the consultant to write the child’s programs and to interpret the assessment results. Thus a consultation day is charged with eight hours. 2.3.1. Costs for the case study Since the beginning of the ABA/VB intervention Martin’s family accessed 30 days of ABA/VB consultation over a period of three years and two months. The ABA/VB principles were implemented by Martin’s family, teachers and therapists throughout the entire day. The 10
ABA/VB consultant in this educational process is not the child’s daily teacher or therapist but a program developer, trainer, counselor and supervisor. The ABA/VB consultations for Martin’s family were $99 (78 €) per hour, so $920 (624 €) per day. Martin’s family had to pay $7.942 (6.240 €) per year for ten days of consultations. In three years and two months they paid $23.828 (18.720 €) all together for 30 consultation days. This amount is much lower than the average yearly costs of $20,000 - $40,000 per year for consulting services. Recommended are 12 consultation days for each of the first two years that would cost $9.531 (7488 €) per year. This was not possible since the family paid for their expenses privately. Additionally they had to finance travel costs for the ABA/VB consultant who flew from Germany for each consultation. Each flight ticket varied from $318 to $447 (250 to 350 €). Hotel costs can be averaged with $115 (90 €) for a standard Norwegian hotel. A practice for Occupational Therapy that would operate from Trondheim or Oslo effects less travelling costs. More regular consultations like once per month or two days every two months can be more effective than three days in a row with several months in between. Yet, even in this less than ideal circumstance Martin has shown very good progress. A practice for Occupational Therapy in Norway can operate more regularly and thus provide a more appropriate service to Norwegian families.
2.4 ABA/VB applied by Parents Parents are their children’s advocates and should always insist on knowing everything about their child’s treatments (cf. Schramm 2006, p.111). Parents of children with ASD are often told to enjoy the time the child is attending school or therapy for themselves. Some are instructed to stay away from educational or therapy approaches. In most cases parents want to do something to support their child. Many parents do not know anything about their child’s therapy and are not given any support for their challenging home environment. Families often report the frustration of knowing that the child is responding well in a professional structured school program and at the same time demonstrates the worst behavior at home. The American Academy of Pediatrics states that “parents, teachers, or other caregivers may inadvertently reinforce maladaptive behaviors, and in such cases, the most appropriate and effective interventions are behavioral” (Myers 2007, p.1170). Without a firm understanding of the basic principles and procedures of ABA/VB, inappropriate behavior is often encouraged by the child’s family and teachers and aggressive behaviors are often accidentally reinforced (cf. Schramm 2006 p. 250).
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In this concept the parents are seen as the most important teachers of their children. Robert Schramm suggests that the main reason of the success of VB teaching is the inclusion of parents (cf. Schramm 2006, p.7&269). Because they can apply the principles in nearly every natural situation, they can supply their child with an intensive ABA/VB program of more than the twenty to forty hours a week as recommended in the Ontario study and in the Stanislaw study (cf. Markham 2006; cf. Stanislaw 2005; cf. Schramm 2006, p.14). An individual ABA/VB program will be adjusted to the child’s and family’s current needs, goals and capacities to avoid excessive demand on both the child and family. Some families start a program earning instructional control and introduce three signs for manding (the ability to ask for things), other families start with 30 signs, words or sentences for manding and will additionally start working on a variety of teaching goals. A lot of literature about ABA/VB was written by parents of children with Autism like Catherine Maurice, Shira Richman and Mary Lynch Barbera. Dr. Juliet Burk, founder of Autism Teaching Tools™, compiled and edited an autism educational video about ABA/VB called "The Early Learner at Home", which is the most often sold ABA/VB teaching DVD in the United States. A very important part of consulting is to reinforce and encourage parents for their work and dedication to the child. Parents need a lot of positive feedback since consultation days can often give parents the feeling that they make a lot of mistakes. Understanding the family’s emotional state is a large part of effectively working clinically with a child (cf. Lynch Barbera 2007, p. 159). Providing a professional consultation includes the ability to supply the child’s parents with all available information about newest research next to the ABA/VB approach. Parents have the right to receive as much information as possible about approaches like biomedicine, RDI™, Floor Time, SI, TEACCH and PECS that are commonly applied in the Autism intervention. The book “Autism Spectrum Disorders” by Richard L. Simpson (2005) that introduces a resource of effective methods for individuals with ASD, can be helpful to this challenge. Parents should be their child’s advocates, so they need to be enlightened about the therapeutic interventions available, need to gather all the information they can get and then choose what it is best for their child (cf. Schramm 2006, p.274). Many parents of children with Autism are told that their child will never improve or recover from Autism (cf. Maurice 1993, p.66). They often have to overcome expensive treatments, social isolation and have much higher divorce rates than families without a child with Autism (cf. Schramm 2006 p. 253). Even if recovery is not possible for all children, teaching in the direction of recovery with high expectations, love, understanding and support makes it possible to teach a child with Autism to his true potential (cf. Schramm 2006 p. 239&275). 12
3. Behavioral Strategies 3.1.
ABC Paradigm
The ABC Paradigm is an analytic tool used to help identify the purpose or the function of a behavior. If an inappropriate behavior needs to decrease, it has to be clear what the child wants to achieve through this behavior. Then it is possible to teach the child a more appropriate alternative behavior that helps the child to achieve the same reinforcing outcome. ABC describes the antecedent (activator, anything that is presented in the environment of a child before the behavior occurs), the behavior (any measurable change observed in a person) and the consequence (anything that happens in the environment after the behavior has occurred (cf. Schramm 2006, p. 32 & 118; cf. Lynch Barbera 2007, p. 31). When the behavior is identified (B), data has to be collected to find out what usually happens before the behavior (A) (cf. Lynch Barbera 2007, p.34). Everything that usually follows the behavior (C) will either be a form of reinforcement, punishment or extinction to that behavior. Antecedents can be instructions (SDs= discriminative stimulus), Prompts and Motivating Operations (MOs). An SD can be an instruction and has established a history of evoking a specific behavior. It also signals the availability of reinforcement. A Prompt is anything added to an instruction (SD) that increases the likelihood of a correct response from the child. An MO is an environmental set of conditions that makes the reinforcer more valuable and a prompt is anything added to an SD that assists in evoking a target response (cf. Vail 2002, p.8). Next a plan is implemented that avoids allowing anything to follow the behavior that might have reinforced that behavior in the past. If a behavior has been reinforced in the past and is not reinforced anymore this is called extinction. It is not enough to put an inappropriate behavior on extinction to reduce the use of that behavior. As the ABC paradigm has shown, the child uses that behavior to meet a certain purpose. Now we need to find a more appropriate way for the child to meet the desired purpose.
3.2.
The Purpose of Behavior
The purpose of any behavior can be divided into three categories (cf. Lynch Barbera 2007, p.37). It can be the purpose of attention which also includes the access to items. This function of behavior is also called socially mediated positive reinforcement (cf. Schramm 2006, p.30). Skinner mentioned that (…) “only people who are attending to us reinforce our behavior” (cf. Wyatt 2001, p.29) 13
The second function is escape or socially mediated negative reinforcement. The child finds a reinforcing value in the act of escaping or avoiding an instruction, demand or an unpleasant situation (cf. Lynch Barbera 2007, p.42). The third function is sensory stimulation, also called stimming or automatic reinforcement. There are three purposes of behavior and thus also three strategies to improve behaviors (cf. Lynch Barbera 2007, p.38; cf. Schramm 2006, p.33). It is important to understand that the ABA approach is not addressing an inappropriate behavior but the function of that behavior. One example is a child clapping his hands in his classroom. To be able to implement strategies that lead to a decreasing use of clapping, we need to know what the intention of this behavior is. If the child shows this behavior because he experienced a recurring attention (consequence = positive reinforcement) in the past and hopes for someone to turn to him, then attention is the purpose of this behavior. It is possible that a teacher turned to the child every time he clapped his hands and told him to stop or even offered him something to distract the child. If this consequence leads to the fact that the child showed this behavior more often in the future, the attention was the reinforcer to this behavior and the lack of attention would be the extinction. The teachers have to make sure now to ignore this kind of behavior and if necessary implement strategies to remove the child from the classroom for a period of time after he claps. Ignoring is not always the same as extinction. Only when attention is the reinforcer would not giving attention or ignoring the behavior be the matching extinction. It is important that the child always wants to stay in the classroom and that being sent out does not have a reinforcing value for him. If being sent out of class leads to less attention and is something the child likes to avoid it can be useful as extinction in this case. Because the classroom has been paired with a lot of reinforcement in the past, being sent out ensures the lack of attention and becomes a form of negative punishment. The desire for attention in a child with ASD is normally something that we want to support and instead of just removing the behavior, we try to find alternative appropriate behaviors for the child to meet his need for attention. We could teach him to raise his hand every time he is bored in the class. Then he could use this new behavior to get the teachers attention. We can also make sure to provide the child with regularly occurring attention for as long as he is showing appropriate behavior in the classroom. Thus we can supply the child with the attention he desires, avoid inappropriate behavior and reinforce appropriate behavior choices at the same time. 14
If the child mainly shows this behavior when he was given a worksheet to complete (antecedent), it could indicate that behavior is escape motivated. It has to be investigated to see if the child was able to skip or to delay the task by clapping in the past. If so, the experience of less work is likely reinforcing the behavior of clapping. The matching extinction plan would be an intervention that did not allow escape or delay of the task after clapping. Since escape in this situation would be considered inappropriate all the time, we would not teach the child an alternative behavior to meet his desire of avoiding tasks. We can focus, instead, on strengthening the child’s compliance in the classroom by reinforcing this behavior. We would try to raise the reinforcement value of the tasks themselves by pairing them with outside reinforcement. In other words, we would offer reinforcement to the child intermittently while he is working on the tasks. It is also possible that the clapping is automatically reinforced because the child experiences a reinforcing value in the sound of the clapping and in the stimulus of clapping his hands together in a rhythm. The purpose now is self-stimulatory and the only extinction we can use to make the behavior useless for the child is interrupting the clapping without giving attention or to increase reinforcement when he is not clapping. If the child is seeking a lot of sensory stimulation, we can enrich the child’s environment with more sensory stimulation as long as it is not distracting to the rest of the class. An example would be a seat cover made of plastic bristles or cushions filled with beans. We can also use clapping as a reinforcer for appropriate behaviors (cf. Lynch Barbera 2007, p.44).
3.3.
Consequences
In the ABC paradigm the consequences (C) are usually the key to better ways of teaching appropriate behavior. There are three different kinds of consequences: reinforcement, extinction and punishment. The consequences that a VB program tends to focus on are positive reinforcement, extinction and negative punishment. 3.3.1. Reinforcement Reinforcement is defined as anything that occurs after a behavior and makes a repetition of that behavior more likely in the future (cf. Schramm 2006 p.15). Positive reinforcement involves adding something to the environment that is being experienced as pleasant by an individual person causing a repetition of the behavior reinforced in the future. Less often recommended is negative reinforcement which describes the termination of a displeasing situation, the removal of something aversive from the environment to increase the use of a 15
behavior. If something is added to the child’s environment after a certain behavior but this does not lead to an increase in the behavior in the future, then what was added does not qualify as reinforcement for this behavior, for this child. A reinforcer will only be identified a reinforcer if it increased a behavior. Praise and reinforcement are not the same thing if praise does not lead to an increase of behavior (cf. Lynch Barbera 2007, p. 70). To some people even yelling or stimuli that are usually experienced as displeasing can have a reinforcing value. As positive reinforcement both reinforces the behavior and motivates the child toward further interaction with his teacher, it should always be used in preference to negative reinforcement that increases behavior but also motivates escape (cf. Schramm 2006, p.77). Both kinds of reinforcement however are effective to establish new behavior skills. Reinforcement takes the most important role in establishing compliance and motivation with a child. For every individual person different things, situations and activities serve as effective reinforcement (cf. Maurice 1996, p. 186; cf. Vail 2002, p.7). Some children have reinforcers that appear strange to us such as kitchen tools they like to hold, lining up toys, spinning in circles, pushing an office chair round the house or pressing buttons on the coffee machine (cf. Maurice 1993, p. 245; cf. Lynch Barbera 2007, p. 60). As long as the reinforcer is not encouraging the child to avoid contact with people, these reinforcers can and should be used for teaching. If a family desires to develop new reinforcers for the child, it is possible to pair items that have a known reinforcing value to a child with neutral items (cf. Partington 2008, p. 20; cf. Schramm 2006, p.117). This way also tokens, smileys or stickers can become effective reinforcers. For children who do not react to social praise, hugs or cheering, effectively pairing these consequences with powerful existing reinforcers can lead to them becoming reinforcing (cf. Partington 2008, p. 42). Every behavior, whether appropriate or not, has at least one reinforcer and has been reinforced in the past. There is no behavior we show today that has not been reinforced in the past. Reinforcement can be found everywhere an organism is exposed to its environment (cf. Partington 2008, p. 21). When a child that screams, gets a cookie, he is more likely to scream again if he wants to have a cookie in the future (cf. Vail 2002, p.8). For the same reason a person will return to have a long bath in the sun when this behavior has lead to a reinforcing outcome in the past. In this case tanned skin leading to compliments will be the reinforcement that leads to the fact that the person will show this behavior more often in the future. Here some examples of negative reinforcement: A baby is crying because of the uncomfortable wet diaper. The removal of the soggy diaper will negatively reinforce the child’s crying. An addict will experience the reduction of uncomfortable stimuli such as stomach cramps and 16
depressions by taking another hit of his drug. A drug addiction is the process of engaging in a form of negative reinforcement (cf. Wyatt 2001, p.21). Another example: A sheep on the meadow in the middle of a summer day is feeling very uncomfortable because of the heat. In the shade of a tree the sheep finds cooler grass and a moderate temperature. Experiencing a subtraction of the unpleasant stimulus of heat or of being exposed to the sun is a form of negative reinforcement to the sheep’s behavior. This kind of reinforcement will lead to an increasing occurrence of the sheep’s behavior under similar conditions. Reinforcement can also be applied purposeful by another person when intrinsic motivation is too little to enable a person to make new learning experiences and better behavior choices. The goal is always to replace the extrinsic motivation with intrinsic motivation (cf. Schramm 2006, p.118). Most typical children see their parents as generalized reinforcers and show new behaviors and skills every day for the reinforcing interaction with their parents. This is what allows those children to be typical. Most children with Autism do not experience that kind of reinforcing value in the presence of their parents (cf. Schramm 2006, p.41&171). Therefore a relationship has to be developed that allows the child to see the adult as a source of good things and not as a barrier to preferred items such as the person who is constantly giving instructions and interrupting the child’s most reinforcing activities. For many children with developmental disorders it is often impossible to understand which behavior we consider to be appropriate or inappropriate based solely on our words. As long as the child achieves his goals by using a certain behavior, this behavior will be a meaningful and appropriate behavior in the child’s view, since it leads to reinforcement. Through systematical reinforcement of alternative and more appropriate behaviors, we can teach the child that showing the alternative behavior is more worthwhile. At the same time we can pair ourselves with the reinforcing value of preferred items and become reinforcers ourselves. “Pairing is a behavioral principle that states when two items or activities are constantly experienced together the perceived value of one will influence the perceived value of the other” (Schramm 2006, p.40). It should be avoided to use „If… then…- phrases” so that reinforcement does not blend with trading or bribe. Those statements invite the child to negotiate and do not translate into better choice making. A child would only be willing to cooperate if he considers the item offered as being good enough and this would take the control in this situation out of the adults hand and gives the control back to the child (cf. Vail 2002, p.5). It is recommended to use surprise reinforcers in an unpredictable way. This will build up the trust in the child that by 17
cooperating he can always count on the teacher to be there for him with something that makes him happy (cf. Schramm 2006, p.53). There are four main factors that influence the effectiveness of reinforcers. The first one is immediacy. In the beginning of an ABA/VB program, reinforcement needs to be delivered immediately after the behavior, preferably within three seconds (cf. Schramm 2006, p.115). The second factor is size and suggests that reinforcers need to be large enough to overcome any competing desires (cf. Schramm 2006, p.116; cf. Partington 2008, p.28). The third factor that makes reinforcement effective is contingency and the fourth is satiation (cf. Partington 2008, p. 39). Primary reinforcers meet basic needs and have not been conditioned or learned to be reinforcers. Basic needs of a human being are for example food, fluid, warmth, social contact and sexual satisfaction. Most of us show all kinds of behaviors to meet these needs every day. Usually food items serve as powerful primary reinforcers for a child’s behavior. Conditioned reinforcers have been paired with other reinforcers in the past and obtained their reinforcing value that way. They are also called secondary or learned reinforcers and can be toys, praise, smileys used as tokens and activities (cf. Partington 2008, p.19-20 & 42). Money is the best example of a conditioned reinforcer since money does not have a reinforcing value to humans when they are born. Being paired with a variety of reinforcers over time money becomes reinforcement itself. 3.3.2. Punishment Scientifically, punishment is defined as a change in the environment of an individual person after a behavior, which decreases the use of that behavior in the future (cf. Schramm 2006, p. 82). Positive punishment is anything added to an environment that decreases the use of a behavior in the future. Usually it is adding a stimulus that the person likes to avoid. The use of positive punishment should be the exceptional case because it strengthens the motivation in a child for refusing interaction and encourages escape (cf. Wyatt 2001, p.22). An example of positive punishment is a teacher giving a student some additional pages of writing for the behavior of smoking in school. Also social work for a person who was convicted a crime is positive punishment if it leads to a decrease of criminal behavior. Negative punishment is anything removed from the environment after a behavior occurs that decreases the likelihood of the use of behavior in the future. It includes removing a pleasant stimulus from a person or removing a person from a reinforcing environment. Moving a child from a current activity to a less reinforcing one for a short period of time is called a removal procedure (cf. Schramm 2006, p.108). A ticket for fast driving is some kind of negative punishment because something valued (money) is taken away from a person after inappropriate behavior.
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Someone who is imprisoned experiences some kind of negative punishment because goods like freedom, access to friends, family and social activities are taken away from him. Punishment also occurs naturally without another person being the punisher. If someone is lying in the sun too long, his skin will get sunburned. This experience is often painful and some kind of positive punishment to the behavior of lying in the sun for too long. This person will be more likely to avoid the sun, or to lie in the sun for shorter periods of time. If someone falls off his bike after driving too fast, that experience can be positive punishment for fast cycling causing the person to choose to cycle less fast in the future. Some kind of negative punishment is someone losing a lot of money at the casino. But it is important to remember that it is only declared punishment if the consequence leads to a decrease of the behavior, in this case to a decrease of gambling (cf. Lynch Barbera 2007, p.40). When it comes to gambling the very little reinforcement, that people experience by winning small amounts of money every once in a while, is a much more effective reinforcer to gambling than losing twice as much money is a punisher for the same behavior. This is only one example of how much more effective reinforcement can be compared to punishment. If the same behavior is punished one hundred times by losing money and reinforced only once by winning a percentage of the lost money, the behavior of gambling was still reinforced effectively and the person is likely to show the same behavior again in the future. A good ABA/VB program focuses on reinforcement to increase appropriate behaviors. This often leads to a reduction in the use of punishment procedures. “The widespread use of positive reinforcement procedures such as differential reinforcement of other behaviors (DRO) has replaced the aversive techniques of early ABA” (Schramm 2006 p.261, cf. p.110). Positive punishment procedures implemented by another person can harm the interpersonal relationship and can be counterproductive to pairing. There are differences of what is experienced as punishment that varies in every individual person. Positive punishment should only be discussed after other procedures have been ineffective with aggressive or selfinjurious behavior and should be always combined with the development of alternative appropriate behaviors by using reinforcement. Punishment procedures that cause pain, fear or nausea, should be dismissed since they operate against the right of self-determination. 3.3.3. Extinction Extinction is one of the most effective strategies to decrease the use of inappropriate behavior and to maintain motivation and compliance (cf. Schramm 2006, p.73).
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Extinction means to not reinforce a behavior that has been reinforced in the past. It is the lack of reinforcement and thus it is a neutral consequence. Every behavior that is no longer reinforced will lose its function or purpose and will be used less in the future until it is not used at all anymore. No organism will repeat a behavior that does not lead to some form of reinforcement. Unsuccessful behaviors are reduced and replaced by more successful ones in achieving the same goals. If a behavior is no longer leading to the desired reinforcement, this will usually evoke an extinction burst. An extinction burst is the period in which a behavior on extinction will intensify or increase before decreasing (cf. Schramm 2006, p.73&107). One example is magpies that try to get access to the core of a walnut. The magpies try to open the nut with their beak first because they have learned that using their beak usually solves the problem of getting access to food items. Usually this behavior will not be effective on walnuts and is not reinforced with the access to the nut core, so it is put on extinction. The magpies will start to use new behaviors to serve the same function. The extinction burst will evoke new behaviors. One new behavior the magpie can try is to fly up umpteen meters to let the nut fall onto asphalt. This behavior is often reinforced and this is the reason why magpies all over the world repeat this kind of behavior every year. Some magpies are still not reinforced by behavior attempt number two and try to place the nuts on a street where cars will cross from time to time. This behavior finally leads to reinforcement, when the cars roll over the nuts and crack them. The magpies will happily skip behavior number one and two in the future to get quick and easy access to the inside of walnuts. Extinction burst behavior can naturally evoke a learning process but can also evoke inappropriate behavior as explained in step number seven of instructional control (cf. Schramm 2006 p. 182). In the ABC paradigm we could see that each behavior is used to serve at least one of 3 functions. If the function of behavior is attention, then ignoring or not giving attention will be the extinction. If the function is escape, we have to make sure that this behavior will no longer lead to avoidance and escape. If the function is stimming then the lack of sensual stimuli is the appropriate extinction for that behavior. Extinction though should always be combined with the reinforcement of alternative more appropriate behavior at the same time (cf. Schramm 2006, p. 62-84).
4. Teaching Strategies The teaching strategies are scientific guidelines that teachers apply to teach new skills most effectively, fast and/or as ethically as possible. These strategies are continuously upgraded and replaced with strategies that have proven to be more effective, fast and/or ethical to teach 20
children. These guidelines make it possible to teach a child new behaviors and individual teaching goals.
4.1.
Errorless Learning
Errorless learning is “pairing new demands with the lowest prompt (support) necessary that evokes a target response in order to create a pattern of reinforcement for that target response” (Schramm 2006, ABA/VB Terms). An SD has to be supported with enough prompts to make the child’s response successful. During following trials prompts need to be systematically reduced to help the child to become more independent over time. Errorless learning will not only teach a skill quickly to a child, it will also make the learning process itself a reinforcing event (cf. Schramm 2006, p.152). One of the biggest challenges parents experience, is teaching their child a new skill that he is not naturally interested in. This often ends in the child throwing tantrums or trying to escape the situation. Mary Lynch Barbera experienced that these behaviors occur because of the fact that the work is too hard and reinforcement is too low (cf. Lynch Barbera, 2007, p.42). “Although it is true that many people learn from their mistakes, the study of VB shows us that mistakes are not a necessary ingredient of learning” (Schramm 2006, p.151). With least-to-most prompting, the child often is left to struggle toward the correct answer while being incorrect several times before receiving the help needed to be successful. It often happens that adults move onto giving demands too quickly. In the beginning the child should not know that he is working and should experience the situation as being as playful as possible. If the child is not even approaching the puzzle happily, why would he be willing to do the whole puzzle? (cf. Lynch Barbera, 2007, p.67). The first thing is to break down every task into smallest manageable units (cf. Maurice 1993, p.120& 257; cf. Vail 2002, p.3). We are not lowering the expectations, since we still want to teach the child the whole skill. We only use a strategy that allows the child to learn in small steps and without frustration by using most-to-least prompting (cf. Schramm 2006, chapter 11). At the same time the child will build up more compliance for further learning skills because he will connect the teaching situation with reinforcement. Errors lead to frustration and people with Autism tend to frustrate easily if they are not successful with a certain skill within the first few trials. This is why mistakes have to be prevented by using a zero-second prompting in the beginning (cf. Lynch Barbera, 2007, p.141). Errorless learning is a Motivating Operation (MO) that increases the value of learning. In the Teaching Arc section to come it will be explained how to build up motivation before presenting the SD and how to reinforce the response. Errorless learning is the understanding 21
of how to use prompts after we gave an instruction. There are different types of prompts, prompt fading and correction procedures (cf. Lynch Barbera, 2007, p. 93). For every skill there is a prompt hierarchy to identify prompts from the most to the least invasive. We need to find the right prompt in a situation that is least intrusive but still allows a child to be successful. The rule should be: as much as necessary, as little as possible. The nine different types of prompts are divided in the two categories of physical and verbal prompts. The physical prompts include 1. full physical prompt, 2. partial physical prompt, 3. model or imitative prompt, 4. gestural prompt, and 5. positional prompt. The last four are verbal prompts: 6. full echoic prompt, 7. partial-echoic prompt, 8. direct verbal prompt and 9. indirect verbal prompt (cf. Schramm 2006, p. 148). There are also visual and textual prompts used in a VB program. A prompt has to be immediately added to the SD if there is even a small chance that the child is going to give the wrong answer. Beginning teaching a puzzle we will not expect the child to perform the whole skill but only one piece at a time. One technique of errorless learning is backward chaining (cf. Jerome et al. 2007, cf. Lynch Barbera 2007, p.157). In this case the puzzle is put together completely, only the last piece is missing. If the child has never placed a similar puzzle piece before, we will use a zero second, full physical prompt. The child places the piece into the puzzle frame and will be reinforced highly. During the next trials we will teach the same puzzle piece using less and less prompts until prompts can be faded. Prompts should be faded as soon as the child begins to understand the task (cf. Lynch Barbera, 2007, p.97). Fading is the act of giving a certain amount of initial support and then systemically reducing that support. This allows the child to remain successful while becoming increasingly more independent (cf. Schramm 2006, p.149; cf. Maurice 1996, p.30). If prompts are not faded quickly enough, this can create a prompt dependence (cf. Vail 2002, p.3). Fading them too quickly can lead to incorrect answers and decreased motivation to participate (cf. Schramm 2006, p.153). The child is taught to put in the first puzzle piece until he is able to do so independently. Then we will leave two pieces out of the puzzle the next time (cf. Lynch Barbera 2007, p.116). The inset of one puzzle piece is one task that has to be mixed and varied with other teaching goals in the teaching session. One task should never be repeated more than three times in a row because this also would decrease the value of learning. As soon as the child can perform a task unit independently, the reinforcement will be faded for this unit using an increasing variable ratio (VR). The child will be reinforced after an average of two responses (VR=2), later after three or four responses and so on. Using a higher 22
VR of reinforcement will strengthen the child’s responses. The VR will be increased slowly over days and weeks along with the child’s increasing cooperation. Finally the child will be able to put all the puzzle pieces in and will respond to some additional SDs before the reinforcement is delivered. If possible, the VR will be increased throughout the ABA/VB program until the child is able to work independently in a regular school setting, for the same time that is acquired from other children. The more successful a child is, the more he will be cooperative in the future and the more he will learn. When the teaching is good, the child will spend most of the day being correct and the behaviors that are leading to success will be shown more often. The more successful the child feels, the more time he will want to spend with his teacher and in the learning process (cf. Schramm 2006, p.122). This way the child learns that compliance brings him rewards (cf. Lynch Barbera 2007, p. 97).
4.2.
Teaching Arc
Children with Autism will learn many skills which they have a strong interest or desire for. Many children learn the names of all the dinosaurs, flowers or birds, countries and their capitals, some know all of the flags or street maps of big cities or prime numbers. Many children learn to read and to write before they can speak and many have a strong interest in math, computers or music. But to be able to teach a child with ASD all the other skills in which they show no interest, we need to systemically manipulate the antecedents and consequences that will give the child the strong desire he will need to learn the skills we decide to teach him (cf. Schramm 2006, p.119). To teach Martin new skills that he is not naturally interested in, we need to capture and use his naturally occurring motivation. Thus we give him a good reason to attempt a new skill from the beginning (cf. Schramm 2006, p.135). The VB approach to ABA prefers to make the desired task the most interesting and enjoyable option in the environment. It is based on making teaching more reinforcing than escape (cf. Schramm 2006, p. 83&136). “If you want your child to learn everything he can as fast as he can, his desire to learn from you must be greater than your desire to teach him” (cf. Schramm 2006, p. 230). Older ABA methods suggested a bare room as a teaching setting where the teacher would sit opposite of the child at a table with his legs wrapped around the child’s chair. The teaching room had little stimuli to limit distraction and usually one or two edible reinforcers were used for teaching (cf. Schramm 2006, p.158). In these teaching settings children often made good 23
progress but were seldom able to apply the learned skills in different environments. The teaching arc provides effective teaching everywhere in the child’s environment while liberating the child from a teaching room (cf. Schramm 2006, p. 160). What follows is a description of a teaching arc that is usually given to families with their program after the initial consultation. “Remember to use a teaching arc when you work with Martin. A teaching arc is designed to make learning as reinforcing as possible. A teaching arc always starts and ends with pairing. 1. Start by pairing with Martin. This means getting involved in some fun reinforcing activity that he wants you to be a part of. In the beginning you try not to give any directions or SDs to the child. 2. Next, begin to incorporate a few small and easy SDs into the playing. They should be tasks that your child is most likely to do without thinking. Be sure to reward those responses appropriately with more or better playing. 3. Then begin teaching new skills. Mix in new or more difficult skills with easy ones and keep reinforcing with the activity. 4. Before the child begins to have enough of the activity, begin to ease off on the difficult demands and begin using a higher ratio of easy SDs and more pairing. 5. Always finish the activity with a period of pairing alone. 6. Try to be the one who ends the activity before the child can decide that he wants to leave it. In other words, leave Martin wanting more.” (Janina Menze, Knospe-ABA database, September 2006) A teaching arc is designed to ease the child into learning and to leave him with a memory of the teaching process as fun and something the child wants to do again (cf. Schramm 2006, p.195). About 70 percent of all SDs should be easy ones to provide ongoing success experiences to the child. Only 30 percent should be new or harder SDs. It is important to end the teaching arc with pairing before the child gets satiated of the activity. Therefore the adult has to end the reinforcing activity while the child is still having fun to avoid satiation and then finds another activity that will have a reinforcing value (cf. Partington 2008, p.62). In the teaching arc we will build up the child’s motivation, so he will want to attempt this skill this time. Additionally reinforcement will be the reason why the child will want to engage in the skill again in the future (cf. Schramm 2006, p.137). The SDs giving in the teaching arc should be a good mix of all the verbal operants (see the categories of language), even with 24
children who are not vocal yet. At least 50 percent of all trials should include verbal responses (for non-verbal children signs). To teach Martin, most valued activities were used to pair teachers with reinforcement. Then teaching arcs were implemented to teach the first skills. These activities were rough play, jumping on the sofa, tickles, ball games, spinning tops, swinging, a rocket launch, jumping on the trampoline, train, DVD, making tunnels and his marble run game. Over time, his interests changed and activities were used such as bowling, fishing, throwing stones in the water, a computer flight simulator, dancing with loud music, and many other activities for teaching. Before entering school Martin was taught to understand delayed reinforcement and to accept a token system. In school he could earn tokens and redeem the tokens against favored activities after school (see appendix 5: Token chart). Appendix 6 shows a design of a teaching arc example. The curve represents the motivation of the child for the activity. A teaching arc can last a few seconds or up to several hours. But it is recommended to not use most activities for longer than 20 minutes to avoid satiation (cf. Partington 2008, p.61).
5. Seven Steps of Instructional Control The seven steps of instructional control were designed by Robert Schramm to establish a positive learning relationship with the child. The goal of this plan is to teach the child that the fastest and easiest way to get what he wants is to follow our directions and to use appropriate behavior and language. The child will learn that following directions is easy and worthwhile. Instructional control will be achieved when the child is happily following instructions in everyday situations as well as in intensive teaching sessions with a high motivation that resembles the learning motivation of a typical developed child or even more. This plan is designed to manipulate the environment in a way that makes traditional escape extinction unnecessary. Escape extinction is the process of not letting a child escape or delay an instruction. The child is physically prompted stay in the area or to complete the task, which often leads to a forceful situation that is harmful for the positive relationship between the child and the teacher. This is the main reason to avoid escape extinction (cf. Schramm 2006, p.41). The seven steps are taught to parents intensively during every initial consultation and are adapted to each child and his environment individually (cf. Schramm 2006, p.75). The basics of the seven steps will now be described.
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5.1.
Step 1: Restriction of Reinforcement
The first step suggests that parents should be in control of all reinforcing items and activities in early stages of instructional control. By blocking access to reinforcers, the child has more reasons to show more appropriate behaviors and to use language. The restriction of favored items should never leave the child in a situation where he experiences the adult as the person that is in the way of reinforcement but the giver of reinforcement. Restricting the items in boxes and closets gives the adults the opportunity to generously give reinforcing items to the child frequently throughout the day. When the child has no free access to the reinforcers, he has to get in contact to the adults to maintain access. This strategy gives the adults endless opportunities a day to reinforce the child’s appropriate behavior choices. The goal is that the adult is experienced as the giver of reinforcement and thus is paired with a reinforcing value. Reinforcing items should never be taken out of the child’s hands, as long as the child is showing appropriate behavior, but should be restricted in a moment after the child has put the item down and is no longer using it, behaves inappropriately with the item or ignoring a direct instruction. In the end the child should experience that he has more access to reinforcers than before. The difference is now that the child will always get these reinforcers out of the adults hand and always after good behavior choices (cf. Schramm 2006, p.44, cf. Lynch Barbera, 2007, p.64).
5.2.
Step 2: Pairing
Pairing is the process of strengthening the instructor’s relationship to a child and providing the child with ongoing positive experiences. Instructions and questions are reduced to a minimum by using more declarative language (cf. Schramm 2006, p.46; cf. Lynch Barbera 2007, p. 63&135). Every interaction with the child has to be an enjoyable experience; so that the child wants to follow the first easy instructions to earn more time sharing these positive experiences (cf. Vail 2002, p.5). At least 75 percent of the time an adult spends with the child should be reserved for the process of pairing. Pairing should always be led by the child’s motivation. If a child for example likes to play with a ball right now, the teacher should engage in that game in a way that makes the child enjoy this activity even more with that person than playing alone with the ball. Even though ABA is rated a skill based intervention, the implementation of 75 percent Pairing makes modern ABA a more relationship based treatment. Pairing is included in many known ASD interventions such as Floor Time or the Son-Rise Program (cf. Simpson 2005, p.25). Bonding with a child, building up a relationship 26
that is lead by acceptance and love should be the base of every therapeutic intervention. ABA knows that Pairing builds up trust and motivation that is necessary for teaching new skills and behaviors.
5.3.
Step 3: Being Contingent
By saying what we mean and by meaning what we say, the child will learn that we can be trusted. The child will learn to pay more attention in what we say if we always give our words the corresponding meaning. If an instruction is given to a child, the adult has to make sure that the child follows the instruction, if necessary with prompts. Instructions should only be used 25 percent of the time. If a question is asked, the child should answer. If the child cannot answer a question, this question should not be given to the child (cf. Vail 2002, p.5). To teach the child that everything we say has a meaning, we cannot allow the child to ignore instructions or questions. Many parents give more than 500 instructions a day without even realizing, while the child is responding to maybe ten. If we allow the child to ignore instructions we teach the child that the words we say are not important and that ignoring what we say is worthwhile. If an adult asks the child: “Do you want to come and play?” and the child responds with “No!” this reaction should be respected, since the meaning of a question like this is, that the other person has a choice to answer “No!”. Instructions should be very easy in the beginning and only be given in situations of high motivation, when there is a high chance that the child wants to respond (cf. Lynch Barbera 2007, p.38). Parents have to learn to give fewer instructions per day, make them easy to follow and make sure that the child follows all of them. By using errorless learning the child can always trust in us to give him enough prompts to respond successfully. By reinforcing every response the child learns to associate instructions with positive outcomes (cf. Schramm 2006, p.48).
5.4.
Step 4: Positive Reinforcement
In every situation the child should experience that following directions is beneficial. (cf. Lynch Barbera 2007, p.58). Easy directions should be given throughout the day as often as possible. Then new or more difficult SD’s are faded in, over time, as the child continues responding. Everything that the child finds of reinforcing value can be used as reinforcement unless the parents decide that they do not want to allow the child a certain activity, food or item. If a child is not responding to verbal praise or other social reinforcers, these events can be paired with known reinforcers in the hopes they will become reinforcing over time (cf. Maurice 1993, p.71). If the child wants to have access to a reinforcer this should be seen as an 27
opportunity to give the child an easy task. The SD can always be something natural and useful. If the child wants to have a cookie, the SD could be to sit on a chair for a moment. If the child wants to go out, the instruction could be to put the last toy back into the box. The instruction can also be to use more or better language. If the child is capable of saying “Ball!” and “Mama” and now is asking his mother for “Ball!” she can prompt him to say: “Mama, ball!”, before getting the ball for him. It is always a good choice to have surprise reinforcers ready for better responses that the child can have additionally to the item he asked for (cf. Schramm 2006, p.52; cf. Partington 2008, p.18). Soon skills such as receptive language, imitation and visual performance will be given as SDs in those situations that have shown an increase in a child’s compliance.
5.5.
Step 5: Variable Ratio of Reinforcement (VR)
In the beginning, the child should experience consistent reinforcement after every positive response. Throughout the following days and weeks, the VR will be increased slowly. No reinforcer should be used consequently for only one defined skill, because this would lead to unrequested learning conjunctions, which have to be avoided. Scientific study indicates that using a VR of reinforcement schedules is more effective in evoking strong and consistent responding than set or predictable schedules of reinforcement (cf. Schramm 2006, p.55; cf. Wyatt 2001, p.19). Reinforcers should be varied and combined unpredictably. Variation of reinforcement and the restriction of access to reinforcers (step 1) for a period of time are also strategies to avoid satiation. One reinforcer should never be used so long that the child loses interest. If the child has only a few reinforcers that can be used for teaching, new reinforcers have to be developed (cf. Schramm 2006, p.116; cf. Lynch Barbera 1993, p.68).
5.6.
Step 6: Differential Reinforcement
The adult should demonstrate to the child that he knows the child’s priorities as well as his own. The child will experience that he will receive highly valued reinforcers without the need to ask for them. Differential reinforcement means to apply different amounts of reinforcement to different types or levels of behavior. We vary the level of reinforcement depending on the child’s response (cf. Vail 2002, p.3). Better behavioral decisions are being reinforced more intensive, less satisfying reactions are reinforced less. Thus the child will receive clear feedback as to whether the demonstrated behavior is appropriate or not (cf. Schramm 2007, p.56). For this purpose different reinforcers can be combined and varied.
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5.7.
Step 7: Extinction/ Negative Punishment
Extinction is the most effective way to reduce inappropriate behavior that is currently being reinforced and was already explained earlier in detail. Inappropriate behavior can be any kind of behavior that we would not like to see again in the future. It can be defined as any behavior that will get in the way of teaching or in the way of including a child into social life (cf. Schramm 2006, p.30&62). The strategy behind extinction is to no longer continue reinforcing inappropriate behavior. In this VB program the restriction of reinforcement allows us to let the child leave in every situation he chooses not to respond to a SD or whenever he cannot accept “No”. However, effort is put into place to assure that the child will not find any reinforcement available while he is showing inappropriate behavior (step 1). Therefore we do not need to physically prompt him to stay away from reinforcement or to use escape extinction. In the beginning of the program the house will be structured in a way that does not allow the child to gain access to any kind of reinforcement during extinction. The goal is that the child will quickly get bored and will make the decision to come back to the teacher. In the moment the child shows motivation for something, the teacher will repeat the former SD. Thus, the child will learn that the adults are in control of the reinforcement and the only way to get access to reinforcement is getting in contact with adults. We show him that we mean what we say (step 3) and stick with the instruction we gave before. We show the child that the easiest and quickest way to reinforcement is to follow instructions and to show appropriate behavior (step 4). This last point will be the hardest part of the behavioral program and should always be done together with the ABA/VB consultant, because it has to be discussed in detail what kind of extinction burst behaviors the child could show. It has to be sure that the child, other people and things in the environment are safe as the child will likely become upset during extinction (cf. Schramm 2006, chapter 6). If a child experiences that a behavior was reinforced in the past but is not leading to reinforcement anymore, the child is likely to show extinction burst behavior to achieve the same goal. A child with Autism will more likely use inappropriate behaviors such as threatening to break items, hitting, biting, scratching, selfinjurious behaviors but also laughing and pretending not to care. Children with Autism often have a history of reinforcement for those behaviors since they have experienced that these behaviors are effective in punishing an adult’s behavior and to regain dominance and control in a relationship. It often happens that parents reinforce during an extinction burst when the child is using more severe behaviors (cf. Schramm 2006, p. 228). Here is one example of how a typical child learns to use more inappropriate behavior. In every supermarket there will be a variety of sweets offered in the waiting queue. The child asks his mother if he can have a 29
piece of candy and his mother says “No!” This would be extinction to a behavior that was reinforced in the past. Now that the behavior of asking is not reinforced, the child will show other behaviors to get his need met (extinction burst). First, the child will start to complain and to whine. If this behavior does not lead to reinforcement, the child is likely to start to cry loud and will finally throw tantrums. If now the child’s mother is experiencing the child’s behavior as some kind of positive punishment, she is more likely to give in and to allow her child to have some candy. If the child receives his reinforcer right after he was lying on the floor, beating the ground with his fists, this will be the reinforced behavior. The child is more likely to skip earlier behavior attempts and skip straight to the most successful behavior right away in a comparable situation in the future. Extinction bursts can evoke new learning experiences, both in positive as in negative ways. If the mother would have been consequent with her first statement (step 2) and would have endured the extinction burst behavior, the child would not have made a new inappropriate learning experience. Children with Autism make comparable learning experiences every day. Since they are learning behaviors every day by the reinforcement from their environment, this means that they are also able to learn appropriate behavior. Parents need to have a clear guideline and have to be supported while helping their children through extinction burst behaviors without reinforcing them.
6. ABLLS The Assessment of Basic Language and Learning Skills were published as one of three books by Dr. Mark Sundberg and Dr. James Partington in 1998. The ABLLS describe 25 learning categories (categories A-Z) and include 476 specific skills; the ABLLS-Revised which was published by Partington in 2006 contains 544 skills which are sequenced from simple to more complex skills. The ABLLS is the most complete list of skills presented in a developmental sequence available to assess children with Autism (cf. Schramm 2006, p. 213). Each skill is additionally divided in two to four levels. The four broader categories are: basic language and learning skills (A-I), academics (J-T), self help (U-X) and motor skills (Y-Z). The 25 ABLLS categories are A= cooperation & effectiveness of reinforcement, B= visual performance, C= receptive language, D= motor imitation, E= vocal imitation, F= requests/mands, G= labeling/tacts, H=intraverbals, I= spontaneous vocalization, J= syntax & grammar, K= play & leisure, L= social interaction, M= group instruction, N= classroom routines, P= generalized responding, Q= reading, R= math, S= writing, T= spelling, U= dressing, V= eating, W= grooming, X= toileting, Y= gross motor and Z= fine motor. This assessment is a tool to identify critical learner skills, helps to locate skill deficits and can assess the skills of all children with and without developmental delays. The ABLLS provide potential targets for the 30
child’s teaching program and allow tracking the child’s progress in detail. “The more color that is filled in across each skill item, represents a greater amount of competence in that skill area (...) The various shading of the scoring grids represents changes in the skills of a child (...) The non-shaded sections represent skills in need of further development” (Partington 2008, p.6). As an example Martin’s ABLLS assessment (see appendix 1) shows 10 colors representing 10 different assessment dates beginning September 2006, ending November 2009. The color grey represents the skills that Martin had achieved before or within the initial consultation, light blue represents the skills that Martin could now perform as of November 2009. The first nine ABLLS- categories have been chosen for the first assessment, because of their significance for childhood development, since they supply the basics for further learning skills. The results of Martin’s first ABLLS assessment can be found in a developmental report under “Diagnosis Martin”. Thirteen additional categories have been chosen for Martin’s assessment over time because of Martin’s individual teaching plan. Three categories have not been assessed. Because the ABLLS provide goals from 25 areas it enriches the Occupational Therapy practice as a standard assessment for children with developmental disorders. The ABLLS help a new therapist to quickly check a child’s skills after a therapist change and it can function as a tool for detailed developmental reports. The ABLLS are a tool that provide the therapist with a detailed guideline of what to teach to a child but not how to teach those skills. Here the knowledge about ABA principles is crucial to understand and to apply ABA teaching techniques, to understand how to motivate a child and to find strategies to develop the wish in the child for cooperation.
6.1.
The Categories of Language
The Behavioral Classification of language into categories is crucial for the Verbal Behavior approach. Skinner organized language into categories to ensure that a child is not using language as a trained behavior but that the child develops functional communication. To become conversational a person needs to be able to produce a variety of complex sounds. He needs to order his thoughts, gauge what he wants to say and needs to have a concept of theory of mind to find out what his partner might be interested in hearing. He needs to line his words into a specific order, needs to be able to ask questions and to answer them. He needs to be able to understand the meaning of words, needs to use and read body language. This amount of complex skills is usually mastered by the age of five (cf. Schramm 2006, p. 169). It is the 31
function, the intent of a word or behavior (making a sign for example) and not the form that defines a language category. Breaking language down into categories allows to better understand a child’s skills and to teach every functional area of communication separately (cf. Lynch Barbera 2007, p.47). A child will need to be able to use each word he learns across most, if not all, of these functions (cf. Schramm 2006, p. 127). In older forms of ABA receptive language was often taught through intensive teaching methods while expressive language was expected to develop on its own. “Consequently, many children with Autism in these programs would develop a strong repertoire of receptive language skills but might never learn to talk!” (cf. Schramm 2006, p.126). Instead of dividing language in expressive and receptive language, it is further divided into manding, motor imitation, verbal imitation, tacting, intraverbal, receptive, feature function and class (FFC), textual and writing. All language categories are included in the ABLLS curriculum. Every good VB program will start with and have a special focus on manding (cf. Schramm 2006, p.125). If a child can say “Apple!” we have to look at the intention. We need to know why the child says this word to be able to sort it to one of these categories. Did he say it because he can see an apple or can smell apple sense and says this word, it is a tact. If the child wants an apple right now and says this word in hope of receiving an apple, it is a mand. Does the child say the word because he just heard the word “Apple” in a song on the radio, it is a verbal imitation. Does someone ask: “What is a fruit that is sometimes red, green or yellow and grows on a tree?” and the child says “Apple!” this is an intraverbal response. All these functions are different skills that often need to be taught separately. If the child can use the word “Apple” in the function of manding this does not mean that he can also use the same word as a tact, FFC or intraverbal. Understanding the Behavioral Classification of Language will help to develop more systematic teaching, to be more complete in the meanings we teach and it will help the child to become a more effective communicator (cf. Schramm 2006, p.131). In the Employee Training Manual from the Mariposa School (2002) it is written that (…)“conversations are typically a combination of mands, tacts and intraverbals with occasional receptive responses” (cf. Vail 2002, p.11). To plan a VB program, it is important to know how the child uses language, how often and when he uses those words (cf. Lynch Barbera 2007, p.48). The book “Teaching Language to children with Autism and other Developmental Disabilities” by Dr. Mark Sundberg and Dr. 32
James Partington gives more detailed information on how to use Skinner’s Behavioral Classification of Language in the context of an ABA/VB program (cf. Schramm 2006, p. 131). 6.1.1. Category 1: Manding Manding is the ability to request items, activities or information and is found in the ABLLS under category F. Because manding is always preceded by motivation and ends with the child receiving what he requested, this is the most important operant of language (cf. Lynch Barbera 2007, p.48). Manding is integral to VB, since it is based on having a need met. It is recommended to create hundreds of opportunities for the child to mand throughout his day during natural environment teaching (NET) on the move teaching (OTM) (cf. Lynch Barbera 2007, p.135; cf. Schramm 2006, p. 165&178). A child must be motivated by an MO (Motivating Operation) to ask for something; otherwise he will not learn to ask (mand) (cf. Schramm 2006, p.139). The MO is anything that temporarily alters the value of a reinforcing consequence and is often the deprivation of a reinforcer, also hunger for a food item. It is a motivation that makes something temporarily more or less valuable to a person (cf. Schramm 2006, p.13). For Example thirst is an MO that makes a glass of water more reinforcing to a person. Since manding is always reinforced immediately, manding has an immediate positive benefit. This is the reason why manding is the easiest function of language for a nonverbal child to start to develop expressive language skills. It is also considered that most problem behaviors are caused by the lack of manding abilities. Children who are taught how to express their desires and needs will show less inappropriate behavior since they do not need to employ inappropriate behavior to express their needs or to maintain access to reinforcing items (cf. Lynch Barbera 2007, p.72). Nonverbal children will be taught signs or PECS for first manding skills as a bridge to spoken language (cf. Lynch Barbera, p. 82-84; cf. Schramm p.173). In the mand process with PECS or signs the child’s response and the delivery of the reinforcer will be always paired with the spoken word of the item or activity. Pointing to a favored item or leading mother’s hand to an item the child wants are ways of manding that a lot of children with Autism already use. The main factor of a mand is not what the child does or says but the intention of what he does or says. Even tantrums are considered a mand if the child uses that behavior to get access to favored items, persons or activities (cf. Schramm 2006, p. 128). The understanding of VB teaches us that all children can mand because they all show behavior to get access to reinforcers. It is the goal of the VB program to replace inappropriate behavior with alternative behavior to meet the same need. Also the ability to point to things or to lead mothers hand will be replaced with more advanced manding skills. 33
The Manding Levels from the Institute Knospe-ABA suggest that every individual has manding skills of at least one of the described ten levels. The first level is crying to get a wanted item, the second is crying near a wanted item, the third is taking someone’s hand to the wanted item, the fourth is pointing to a wanted item and the fifth is the use of augmentative communication (signs or PECS) to get a wanted item. The sixth level is the behavior of using a sound or part of a word to ask for an item, the seventh is the use of an entire word, level eight the use of multiple words including carrier phrases like “I want..!”. Level nine includes manding by using describing words and at level ten a person can have a discussion about the wanted item (cf. Schramm p.172). The manding program starts with the most valued reinforcers and is started with several mands at once (cf. Schramm p.176). Those items and activities are chosen that the individual child values the most. The child should be taught an exact mand such as “bubble”, “tickle”, “juice”, and “pizza” instead of non-specific mand like: “yes”, “no”, “I want”, “again”, “more”, “please”, “drink” or “eat” (cf. Lynch Barbera 2007, p.74 & 83; cf. Schramm p.175). Appendix 2 shows Martin’s mand sheet from the initial consultation with 36 vocal mands that his parents started to teach him every day in NET, including 11 mands for food items, two mands for favored drinks and the rest containing items, toys games and activities. At the second consultation all of these listed vocal mands were mastered. 6.1.2. Category 2: Motor Imitation A motor imitation is any attempt to copy the action of other persons and is found in category D in the ABLLS. This skill is one of the big fundamentals of a child’s development and extremely important to non-verbal children who learn sign language as a bridge to vocal language. Copying mouth and tongue movements will be acquired for verbal imitation. Typical children at age three involve motor imitation skills in 80-90 percent of all learning behavior. It is due to the lack of motor imitation skills why many children with Autism become developmentally delayed (cf. Schramm 2006, p.128). This skill is usually begun by teaching imitation using objects or objects in discrimination, especially when a child is starting to learn his first signs for manding. Mary Lynch Barbera usually starts with gross motor and toy/object imitations, so play skills can be taught and new reinforcers can be developed at the same time (cf. Lynch Barbera 2007, p.112). The SD is usually “Do this!” and the teacher will perform the movement with or without objects. The teacher will use errorless learning for imitation skills, will reinforce every single response, also the prompted ones and then fade the prompts before also fading reinforcement for the skilled imitation. More complex imitations are the imitations of sequences, speed of a movement, delayed imitation 34
and spontaneous motor imitation, which will enable the child to copy everyday and leisure skills in the kindergarten. The child will be more easily integrated in a group if he can imitate dance movements to nursery songs and imitate play sequences in the dolls corner, at the wooden train track, in the Lego corner or play kitchen. 6.1.3. Category 3: Verbal Imitation A verbal imitation or “echo” is an operant whose antecedent is behavior of another person saying a sound, word or phrase. The behavior is the child repeating what the other person said. It is found in the ABLLS under category E and can be an approximate or exact echo, immediate or delayed. Getting echoic control can open the floodgates to a child’s language skills, since the ability to imitate verbally increases the ability to learn (cf. Lynch Barbera 2007, p.51 & 124). If a child with Autism is using language mainly in an echoic way, this can be a great opportunity to teach further language skills since the ability to echo is an early important step in learning to speak (cf. Schramm 2006, p.222). Verbal and motor imitation are considered to be very fundamental skills that have to be taught to a child with Autism in the beginning of a VB program, since children with Autism often do not have the natural skill of imitation. Verbal imitation is a skill that helps developing manding, tacting and intraverbal skills since an echoic prompt can be used on all those skills and can easily be faded. On the other hand it is impossible for a child to learn vocal tacting, manding and intraverbals when he can not verbally imitate. 6.1.4. Category 4: Tact A tact is the ability to label an item, person or activity if you can see it, sense it by hearing, tasting, smelling or touching. It is represented by ABLLS category G. Young children usually build their vocabularies to thousands of tacts before they reach school age. Flashcards and real items are used to teach the child more than 100 tacts in the beginning of a VB program. The child also needs to identify several different examples of the item (cf. Lynch Barbera 2007, p.48). Very important considerations while teaching tacts are to build up the child’s ability to discriminate between different stimuli and generalization. If a child can tact “Cow!” it is still possible that the child will over generalize this skill if the first tact was not varied with other SDs and then also tacts a horse “Cow!” Discrimination means that the child can tact a “Cow!” and a “Horse!” correctly when it is presented different visual stimuli (item or picture). Generalization means that the child can also perform a certain behavior under conditions other than for which it has been previously reinforced. One example of generalization is when the child can tact a cow when he sees a real cow in the countryside, in the zoo or on TV and is 35
also able to tact new examples of a cow, pictures of cows and cow figures without further training. Additionally the child has to be able to perform this skill when asked by different people and in new environments (cf. Partington 2008, p.32-33). Nonverbal children can develop tacting skills using sign language. A real tact is when a child points out to something and labels: “Cow!” but also the ability to answer the question “What is it?”, while presenting a stimulus is considered a tact. Also a carrier phrase can be used: ”This is a...!” More complex tacting includes the use of prepositions and pronouns and sentences that include nouns, adjectives and verbs: “Look Mama, my red balloon hangs in the tree!”. This complex sentence would be both a tact and a mand for attention. Receptive identification skills are taught usually before or with the corresponding tacting skills (cf. Lynch Barbera 2007, p.119). 6.1.5. Category 5: Intraverbal Intraverbals are the first step to develop conversational skills and involve the ability to answer questions with the goal of maintaining conversations. The adapted ABLLS category is H. It is different from an echo in so far as what another person says to a child in the antecedent affects what a child responds, but this time the response does not mirror the antecedent. As an example, we ask Timmy: “How old are you?” and Timmy responds: “Old are you!” this would be considered a verbal imitation. If Timmy is able to respond: “Six!” to the same question, this is considered an intraverbal (cf. Schramm 2006, p. 130). To teach a child the first intraverbals the child is usually taught to fill in the blanks to songs and nursery rhymes: “Twinkle, twinkle, little.....!” The child responds, or fills out blank with: “Star!” (cf. Lynch Barbera 2007, p.51 & 125). More advanced intraverbals include answering what, who, where, how and why questions, answering questions about the future or past and telling stories (cf. Schramm 2006, p. 130). 6.1.6. Category 6: Receptive Language Receptive language, also called “listener skills”, includes the ability to respond to directions and to follow instructions. In the ABLLS it is represented by category C. Children with Autism usually do not perform strong listener skills when they are diagnosed. The first goal in the category of receptive language is the ability to respond to one’s name, when a child is called by his name (cf. Lynch Barbera 2007, p.54 & 106). The child will be taught to perform some simple motor actions on request, like: “Clap hands!”, “Stand up!” or identification skills, like “Show cow!” or “Touch belly!” in the beginning (cf. Barbera 2007, p. 110). This procedure often appears strange to parents and teachers since the language used in the SDs is very short and appears to be “not natural”. But this is the only proven way to 36
build up the first listener skills in a child while working toward more natural and complex receptive language until a child can react to an SD like: “Can you please bring me Daddy’s hat from under the chair?” It is most effective to teach a skill by breaking it down into tiny units (cf. Partington 2008, p. 3). It is important to start teaching a child to respond to SDs of only one or two words in the beginning. It is recommended to use words clear, concise and consistent in the beginning of a program, since the child will feel more comfortable as we react consistently and predictably, comparable to a computer game (cf. Schramm 2006, p. 23). Mary Lynch Barbera states that children could find it confusing if adults speak quickly, so she is recommending to fill the child’s environment with single words (cf. Barbera 2007, p.89). As people in the child’s environment become more confusing, the child will likely choose to spend more time withdrawn in his own world (cf. Schramm 2006, p. 24). This is one reason why single words are used during Pairing while we use declarative language to a child with little receptive language skills. A child is more likely to build receptive language skills when we comment actions with single words like: “Swinging” or “Cookie” instead of using complex sentences like: “We are swinging very high into the sky!” or “These cookies are your favorite ones with chocolate chips!” Discrimination and generalization have to be addressed also with receptive language skills (cf. Lynch Barbera 2007, p. 107). 6.1.7. Category 7: Feature, Function and Class (FFC) FFC is the ability to identify, to tact or answer intraverbally about a specific item or picture of an item, when given a description of its function, feature or class. Most objects have more than one function, feature or class and thus this skill is one of the hardest to teach (cf. Schramm 2006, p. 130). It is usually necessary to implement a data sheet with a collection of FFCs for items (see appendix 3: FFC data). As a pre-condition to this goal, the child needs to be able to receptively identify all items that will be used for FFC when asked: “Where is the...?” or “Show me the...!” If a child is able to identify at least 50 items by pointing, touching or giving (ABLLS goal C-14-15), these items can be placed on a list and for each item some FFCs can be found. If the item the child can already discriminate receptively is a cow, the features could be the tail, udder and fur. A cow’s functions could be to say “mooh”, to eat grass and to give milk. The cow would be sorted to the class of farm animals or animals. If the item is chocolate, its features could be that it is sweet and brown. Its functions are the fact that it is eatable and that it can melt. The class can be food, sweets or candy. Appendix number three shows a FFC data in Norwegian language that was collected for Martin.
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Learning FFCs the child will be taught how to respond not only to the SD: “Show the cow!” but also to: “What has a tail?” The child’s response will be pointing to the picture of the cow or answer “Cow!” with or without a picture or a cow in the environment. In the beginning errorless learning will be implemented. This new skill will be mixed with various mixed SDs of other learning categories. Intermixing between the types of tasks we teach will keep the child from becoming bored with the repetition of an instruction (cf. Schramm 2006, p.141). As soon as the child can perform the correct responses, new SDs to the picture of the cow will be introduced: “What has fur?” or “Show me something that eats grass!” Next, new questions will be generalized to other pictures since the SD “What has a tail?” also fits to a cat, a dog and many other animals. According to the ABLLS assessment for receptive FFCs, this has to be mastered with the functions of at least 25 items, at least two features of 25 items, for each fife items from four classes, which are 105 receptive responses all together. Then these items have to be taught across the tact and intraverbal operants as well. The new introduced FFCs will be taught in the natural environment the same time. Building up a strong FFC repertoire helps the child to become a much more functional communicator (cf. Schramm 2006, p.130; cf. Lynch Barbera 2007, p.128). 6.1.8. Category 8: Textual Textual language is the ability of reading written words and goes with ABLLS-Q. 6.1.9. Category 9: Writing This category describes the ability to handwrite or to type words and can be found under ABLLS category S= Writing and T= Spelling.
7. Definition Autism Spectrum Disorder Autism is a spectrum of dysfunctions with a variety of different symptoms. The ICD-10 (F84.0) and the DSM-IV describe three main abnormalities that are significant for Autism: Deficits in social interaction, restricted communication skills, severely limited interests and stereotype behaviors (cf. Simpson 2005, p.3). Boys are affected five times more often than girls, but girls are usually affected more severely. There is no such thing as classical Autism, since individual occurrences differ and vary in every single person. People with ASD show a range of abilities ranging from severe mental retardation and an absence of spoken language up to near or above average intellectual and communication abilities (cf. Simpson 2005, p.1). Many people with Autism study at university, like Temple Grandin (USA) and Nicole Schuster (Germany) and are scientifically 38
involved in the science of ASD themselves. Many persons with ASD like Martin MøllerNordbye from Norway (2009) publish their autobiographies. In Denmark there is a business concern, called Specialisterne that offers training for people with ASD and that hires professionals with ASD referring to their outstanding skills of organisation, reliability and focus (cf. www.specialisterne.dk, 5th of October 2010). Perceptual disorders, the inability to filter stimuli, hyper- and hypo- sensibility affecting all human senses can go hand in hand with Autism. About 40 percent of children with ASD do not develop functional language skills. Inappropriate behaviors can manifest in a way that children need to be institutionalized or treated with behavior managing medication. Often certain types of medication or homeopathic treatment are used but still experimentally since there is no standardized medication to ASD (Maurice 1996, p.53). Some affected people learn to compensate their socio-emotional deficits through cognitive skills. Approximately 10 percent of all adults with ASD are able to lead an independent life, 40 to 50 percent are dependent on an institutionalized support. There are documented cases about children with ASD that have recovered from Autism by the reduction of relevant symptoms. Catherine Maurice describes for example that her two children no longer met the criteria for the diagnosis of Autism by the ages of 39 and 53 months (cf. Maurice 1996, p.37). There are a few people who achieved a crucial development without professional intensive treatment. Also documented are cases of children who have been given a bad diagnosis, which obtained an extremely well development (cf. Markham 2006). The most important test standards for the diagnosis of ASD are: ICD-10, DSM-IV, the Autism Diagnostic Observation Schedule (ADOS), The Autism Diagnostic Interview Revised (ADI-R), Childhood Autism Rating Scale (CARS) and the Autism Behavior Checklist (ABC). Empirically confirmed methods to Autism intervention are behavioral treatments such as ABA/VB, TEACCH (Treatment and Education of Autistic and Related Communication Handicapped Children), Incidental Teaching and the Picture Exchange Communication System (PECS). Also supporting therapies like Occupational Therapy, speech and physiotherapy are frequently indicated.
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Additionally there is a variety of alternative methods that have not proven to be effective or that still need to be scientifically evaluated like Biomedicine, Relationship Development Intervention (RDI), Pet/Animal and Dolphin Therapy, Option Method (Son-Rise Program), Floortime, Music Therapy, Auditive Integration Treatment, Neurofeedback, Montessori, Affolter, Tomatis and Facilitated Communication (FC). Various methods that are commonly used in the Autism intervention are listed and explained in the book “Autism Spectrum Disorders-Intervention and treatment for Children and youth” by Richard L. Simpson (2005).
8. Diagnosis Martin In September 2006, at the time of the ABA/VB initial consultation, Martin was four years old and the eldest of two boys. His mother is German, his father Norwegian. He lives with his family in a well structured apartment in a suburb area in the middle of Norway. The appendices 8-11 show three developmental reports in Norwegian and a report from a German practice for Occupational Therapy. In December 2004 Martin was assessed by a German occupational therapist who gave the family several recommendations of how to support Martin by implementing Sensory Integration (appendix 8). She assessed deficits in the areas of tactile, proprioceptive and vestibular perception. She also listed socio-emotionally retraction tendencies, avoidance of interaction, reduced spontaneity, lack of eye contact, non-age analogical speech, repetitive playing behavior, few emotional facial expressions and a lack of emotions concerning nonverbal communication. Martin was officially diagnosed in February 2005 at age two and a half. The report from the children’s hospital (appendix 9) states that Martin’s family realized a lack of social contact when he was aged one. Martin was a bad eater, had no words, could produce only a few sounds and had weak eye contact but demonstrated some receptive language. The Diagnose Autism (F84.1 – ICD-10) was given by the senior physician. To diagnose Autism, the ICD-10 (World Health Organization-WHO, 1992) is the standard diagnostic tool in Norway (cf. Møller-Nordbye 2009, p.11). In March 2005, another report (appendix 10) was a versed evaluation by the local community. It stated that Martin had contact deficits and was motorically delayed. Martin was attending the kindergarten 12 hours per week with a variety of special pedagogical submission. There he was learning sign language. A one-to-one help for the kindergarten was suggested and the attendance of a small group of children. He had hypotonia and problems with motoric coordination. He showed repetitive playing behaviors and often forgot everything around him when he was focused on something stimulating. He was able to point to his mother, his father 40
and a car in a picture book on request but he was not able to understand simple directions like “Get your shoes!” He was able to imitate some playing behaviors. Martin enjoyed cuddling with his parents, liked ball games, trampoline and building blocks. He did not show much interest in other children and little interest in his brother. Martin would escape if other children would sit next to him and he would not let them touch his toys. He was described as a joyful and sweet child. Another report (appendix 11) was written in June 2006 by the Nic Waals institute for national health within the ABC study (Autism Birth Cohort). The Institute used the ADOS (Autistic Diagnostic Observation Schedule), Mullen Scales of Early Learning and Stanford-Binet 5 as assessment tools. Martin’s parents were interviewed with the diagnostical standards ADI-R (Autism Diagnostic Interview-Revised), Vineland Adaptive Behavior Scales and PAPA (Preschool Age Psychiatric Assessment). Martin was described as developmentally delayed. He had a few words but instead used a few signs to communicate. He liked to play with water and small stones. He responded well in the structured test situation but had problems in an unstructured play situation and performed the same playing behavior repeatedly. The Institute strengthened the Diagnose of ASD but stated that he performed better functions than children with typical Autism, like better contact and his interest in using sign language. The Institute diagnosed Martin with atypical Autism or PDD-NOS. The diagnosing psychologist mentioned how impressed he was with Martin’s mother’s warmth and support that she showed communicating with Martin. During the diagnostic process Martin’s parents were told that he would most likely never use spoken language to communicate, become potty trained and that he would most likely never be able to learn social skills.
8.1.
Martin’s First ABLLS Assessment
Within the three days of initial ABA/VB consultation in September 2006, Martin was assessed by his ABA/VB consultant with the ABLLS assessment (Assessment of Basic Language and Learning Skills). Appendix 12 shows Martins first ABLLS assessment containing nine ABLLS categories. These nine ABLLS-categories were chosen for the first assessment since they provide the basic skills for further learning and are crucial for the entire development of a child. Further categories of the 25 learning categories of the ABLLS were assessed during the follow up consultations (see appendix 1). The skills of the first assessment were all assessed at the initial consultation in September 2006 and match the color grey in Martins ABLLS. The first assessment is done in almost every initial consultation to assess the child’s current level of functioning in detail. Based on the outcome of each ABLLS 41
assessment, the new learning goals are chosen to fill in missing learning skills and to build upon lower skills in the direction of typical development. If a categories panel would be completely filled with color, this would represent the skills of a typical developed child within the age range of fife to eight years, although there has been no attempt to age reference the ABLLS. 8.1.1. Cooperation and Effectiveness of Reinforcement Martin already had basic cooperation skills at the time of the initial consultation. Sometimes he needed further prompts to look at an item when he was asked to. He was taking reinforcing items from adults but would often refuse to take things he was not interested in. Martin got upset and frustrated easily if he could not have or do something he liked. He could not accept “No!” and threw himself on the ground several times per day in a tantrum. Martin was in many cases not willing to give back a reinforcing item, and would fight for the item. Martin was very motivated with tasks he knew and liked, such as visual matching and dancing games in the kindergarten but refused new games or skills. He was able to work for fifteen minutes on matching or computer games. In a lot of routine situations he would not follow instructions because of the lack of motivation both in the kindergarten as well as at home. Martin was showing different stereotypical behaviors such as grinding, rolling a ball around his body and rolling balls along surfaces. He was extremely attracted to spinning tops and other turning and rolling toys. He spent hours in front of the computer playing pre-school PC games but had few, if any, social games he could play. These are the reinforcers that were motivating enough for Martin that we chose to use them for teaching: Primary Reinforcers (food and drink): apples, bananas, raisins, pancakes, ice cream, bread balls, cookies, chips, sausages, pasta, yogurt, squash and juice. Secondary Reinforcers (non food): computer, music, rough play, tickles, ball, spinning tops, letters, swinging, rocket launch, trampoline, train, watch others writing, DVD, lights, mobile phones, books, balancing and marble run. 8.1.2. Visual Performance Martin had good visual skills but insisted on repeating the skills he liked, such as matching. He was able to match all kinds of picture-cards, including matching items to pictures. He was usually not willing to try new visual skills when offered. He had a strong interest in numbers and letters, liked to look at them and match them and he liked to see others write.
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8.1.3. Receptive Language (listening skills) Because of the lack of motivation in many daily routines and activities, Martin would not respond to many instructions. He was not continuously responding to his name. He was able to point to six body parts and could receptively identify more than fifty items or pictures of items. In playful situations he responded to many SDs such as “Jump!” or “Press the button!” but would seldom respond to some SDs of daily demands. Very often he would say “No!” to daily demands and try to escape. It could be suspected that he had the ability to understand a lot of SDs. The ABLLS goals however were only filled in with color, when Martin was both understanding the SD and also following the SD. As soon as instructional control improved, Martin became more motivated to perform certain receptive skills without direct teaching of those skills. Still Martin was considered to be delayed in the field of receptive language and was provided with ABLLS goals concerning receptive language. 8.1.4. Imitation Martin’s basic imitation skills gave an excellent basis for further learning, since the skill of imitation effects the learning process of all other teaching areas. He was able to imitate many movements with items and toys after request and was also motivated to imitate a variety of fine motor and gross motor movements. Martin was taught in kindergarten to imitate about 40 signs. Martin’s first in-home teaching plan included a lot of imitation skills. The first reason was to use easy and motivating skills to gain instructional control and the second reason was to strengthen his ability to imitate even more to give Martin the best basic skills for further learning. 8.1.5. Vocal Imitation Martin was able to imitate about 15 sounds clearly when he was motivated and demonstrated six approximations to words. Martin’s mouth tonus was low which made his speech sound blurry. He did not have good control of his salivation and received speech therapy to strengthen his mouth muscles. In everyday life Martin imitated verbally less than fife times per week spontaneously, but using motivating teaching settings as described in the teaching arc, he was motivated to verbally imitate almost every word. This skill was trained along with manding. 8.1.6. Manding (requests) Martin could use about 20 signs for manding and was able to point to things he wanted. The signs he already knew provided good basics for further expressive and receptive language 43
skills but have been completely dismissed during the initial consultation and were replaced by spoken language (see appendix 2: mand sheet). Verbally he was able to spontaneously call “Mama”, to ask “Help” and to answer “Yes!” and “No!” 8.1.7. Tacting (labeling) Martin could use 20 signs without prompts to label things. Martin’s ability to label things vocally was poor because he did not learn how to respond to the question: “What is this?” He used six words to label things and persons less than ten times per week spontaneously. 8.1.8. Intraverbals The first teaching programs that were given to Martin’s family built on the existing skills to fill in some blanks of songs and sayings. As soon as Martin was able to fill in the blanks of a variety of songs and sayings, we could start to teach him to answer his first simple questions. 8.1.9. Spontaneous Vocalization Martin vocalized speech sounds for about five minutes per hour. Sometimes he started to hum along with a song in the radio, but only with about one word per song.
9. Initial Consultation 9.1.
Initial Consultation at Home
The initial consultation took place over three days in September 2006, mainly in the family’s home. Martin’s parents, aunt and grandmother had attended an ABA/VB workshop approximately fife month before the initial consultation and already had a basic knowledge about the main ABA/VB principles. In the first two hours the consultant played with Martin to assess his interests, his behaviors, language and social skills. The consultant asked the family about his usual play and free time behavior, how long and intensive he would play with items and how the parents were able to pair themselves with those activities. After this pairing phase the parents sat down with the ABA/VB consultant to discuss their main concerns, problems, goals and expectations for Martin. In between, the consultant filled out parts of the ABLLS assessment. The parents explained their daily challenges with Martin when he refused to follow daily routine instructions. Anytime he had to put his shoes on but did not want to go out, he would throw tantrums. There were only few situations in which he was willing to follow his parent’s instructions without showing avoidance behaviors. Another problem the parents mentioned was that Martin was not willing to give back his toys. This often led to physical fights. The parents described the development of spoken language as 44
their main goal along with the goal of getting Martin potty trained. In the initial consultation it was possible to work on nearly all of the described goals but potty training. This is a skill that is best taught to a child who already accepts instructional control, is easily following daily demands and is showing little inappropriate behavior (cf. Schramm 2006 p. 202; cf. Lynch Barbera 2007 p. 145). This skill was taught the following year after the initial consultation. In the afternoon the seven steps of instructional control were discussed and Martin’s reinforcers were collected and written down in detail. Martin’s parents received a ten page detailed description of the seven steps of instructional control. The parents had the opportunity to ask their questions to the steps of instructional control and the ABA/VB consultant showed them practical examples of how to implement this plan with Martin in everyday life. The consultant and parents structured the environment according to the plan and the parents had the opportunity to try to implement the first steps themselves. On the second day the first ABLLS assessment was completed by interviewing Martin’s parents and by testing Martin in his home environment. According to the results of the ABLLS assessment his first teaching goals were chosen. The ABA/VB consultant and parents practiced teaching those goals with each other at the table, implementing strategies like errorless learning, prompt fading, reinforcement and the teaching arc. As soon as the parents felt comfortable to teach the first goals, they implemented a teaching arc to teach the new skills to Martin, mixed with very easy demands. The ABA/VB consultant had the opportunity to help Martin’s parents to apply the teaching strategies in a more effective way. Martin’s parents got many teaching goals in the initial consultation, since they were able to implement the teaching plan quickly. Since Martin’s parents were immediately able to capture Martin’s motivation using teaching arcs on his favorite activities, the last day took place in Martin’s kindergarten.
9.2.
Initial Consultation in the Kindergarten
In the kindergarten the ABA/VB consultant assessed Martin’s behavior and routine skills and discussed the possibility of concentrating on spoken language with his teachers. The consultant demonstrated some examples by motivating Martin to verbally mand for tickles, ball and jumping. The teachers had the opportunity to discuss teaching goals and the possibilities of combining the kindergarten concepts with the ABA/VB principles. Since some teachers expressed their concern about ABA/VB, the consultant worked directly with Martin giving practical examples while explaining the science behind each teaching strategy. The 45
kindergarten team agreed on implementing first smaller, over time larger parts of the ABA/VB program in their daily routine with Martin. The time until Martin left the kindergarten his kindergarten team and the ABA/VB consultant worked closely and effectively together, changing thoughts, ideas and developing strategies together. During consultations in the kindergarten it was common to have up to one-hour team meetings where Martins parents were also participants.
9.3.
Initial In-Home Program
The Following is from the teaching program that was given to Martin’s parents after the initial consultation: “Martin is a child with lots of interests and motivators. When his motivation is used appropriately during teaching combined with reinforcement he learns new skills quickly. He has a good sign vocabulary and is able to echo many speech sounds, uses some mands in the form of proper speech spontaneously for his favorite reinforcers. To be able to teach him advanced skills and appropriate language, we need to focus on establishing instructional control from the beginning. We need to give him good reasons to follow our instructions and to use appropriate language as often as we can. In the beginning we will use very easy instructions as often as we can and reinforce the correct responses and good attempts immediately with a large amount of reinforcement. The main thing he needs to learn right now is that participating is always worthwhile and always paired with fun! (see instructional control).”
9.4.
Initial Learning Goals
Along with the seven steps of instructional control the family got following ABLLS and behavioral goals, which were practiced with them during the initial consultation. These goals are described in a way that the family can easily understand and remember how to teach them. Behind each given ABLLS goal the date of completion is noted along with the accordant color of the date of completion as it is found in Martins ABLLS assessment in Appendix 1. Some goals were taught even though they were considered mastered in the ABLLS. These goals still needed repetition and generalization. Easy goals are also needed for the beginning process of establishing instructional control (cf. Schramm 2006, p.54).
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9.4.1. Effectiveness of Reinforcers “ABLLS Goal A-6 Child responds to a variety of reinforcement settings Goal: Martin will be able to work happily and consistently for more than 15 different nonfood reinforcers for a period of 20 minutes or more. Martin currently works for: computer, music, rough play, tickles, ball, spinning tops, letters, swinging, rocket launch, trampoline, train, see others writing, DVD, lights, mobile phone, books and balancing. Spend time and effort, trying to find or develop enough new reinforcers to fill up this list. Every week you should try to find or develop a new one or two. When you do so, add it to this list and share this list with everyone working with your child. (Mastered September 2009 – grey) 9.4.2. Visual Performance ABLLS B- 6 and 7 Form designs on and from a picture Goal: Martin will be able to look at a picture of a form design and then replicate the design with the forms that are in front of him. First on the picture, then on the floor or table in front of the picture. Start by showing Martin a picture of two forms. SD: Ask him to “Put it on” Prompt (if necessary): full and partial physical, gestural (pointing). Reinforcer: Any known reinforcer. When he can do it without prompts, show him pictures of form designs with three forms and again ask him to “Put it on”. The skill B-6 will be considered mastered when he can put on many combinations of six forms with more than the necessary forms available to him. The skill B-7 will be considered mastered when he can put many combinations of six forms with more than the necessary forms available to him in front of the picture. (Mastered August 2007 – blue) ABLLS B- 8 Matching a sequence Goal: Shown a model of a sequence of objects, Martin will be able to match that sequence with similar objects in front of him. Use items like nuts, coins, Legos and spoons. For example shown a sequence that looks like this: XCXCXC or XXCCXXCC Martin will be able to take the items in front of him and match the sequence by putting the matching pieces under the sequence. Once he can perform this skill without difficulty, he should be able to match sequences with three or more objects that look like this: XAOXAO or XXAAOO or XXAOXXAO (Mastered December 2006 – red) 47
9.4.3. Receptive Language ABLLS C- 1 Child responds to own name Goal: Martin will consistently respond to his name when he is called. One or two people with strong reinforcers like a favorite toy will wait for a moment, in which Martin is not paying attention to them. SD: One person calls: “Martin!” Prompt: Physical prompt by the second person or volume prompt (speak very loud). Behavior: Martin looks at you. Reinforcers: Give Martin the reinforcer. When he has it, pair with praise. Slowly you can begin to extend the distance and eventually you can use reinforcers that are more social. Try to offer surprising reinforcers that he has not seen in a while. The goal is to get him used to wanting to look or come when he hears his name called. As he gets used to doing it, you can start to only deliver a reinforcer every other time he looks or comes when you call his name. This will strengthen the response. (Mastered August 2007 – blue) ABLLS A-4 and C-6 Child takes and touches common items Goal: Martin will take and touch a common Item when asked to. Hold up one common item and ask him to take it from you. SD (Antecedent): “Take the spoon!” or “Touch the Spoon!” Prompt (if necessary): Positional prompt = move item towards him. Behavior: Takes or touches the spoon. Reinforcer: Immediate reinforcer, one of the above listed reinforcers. Only reinforce “Take” when he takes the item and only reinforce “Touch” when he touches the item. Later: Add discrimination. The process is the same, but hold up another item as well. Do this until he can take 15 to 20 (or more) common items. * Always use errorless learning and expect fluency. (Mastered December 2006 – red) ABLLS C-8 Child follows directions in everyday situations Goal: Martin will be able to follow simple everyday instructions without the use of prompts Examples: “Throw that away!”, “Put this on the table!”, “Wash your hands!”, “Put on your shoes!”, “Pick up your blocks!”, “Take off your jacket!”, “Go upstairs!” and so on. This goal will be considered met when Martin can follow at least fife different daily instructions without prompts. (Mastered September 2009 – grey)
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ABLLS C-17 Touches own body parts Martin will be able to touch his own body parts when asked to (nose, head, ears, elbow, foot, knee, etc). SD: “Touch head!” Later: “Touch your head!” Prompt: Use imitative prompt if necessary. Martin does not need physical prompts for this goal, since his imitation skills are strong. Behavior: Child touches head. Reinforcer: Use known reinforcers and pair with praise. (Mastered December 2006 – red) 9.4.4. Motor Imitation ABLLS D-1 and D-2 Motor Imitation using objects Goal: Martin will be able to follow simple motor imitation directions using objects SD: “Do this!” or “Try this!”, then demonstrate a motor movement. Example: Push car, kiss doll, walk shoe along table, pretend to drink from an empty cup, turn cup upside down, turn car upside down, etc. Prompt: Full or partial physical prompts. Behavior: Martin imitates the same action. Reinforcer: Use known reinforcers. Do not forget to pair with praise! * Always use errorless learning and expect fluency. (Mastered September 2009 – grey) ABLLS D-2 Motor Imitation with objects and discrimination Later do the same as in D-1, but have him use and discriminate between two objects. Example: Put sock in shoe, feed doll with spoon, put block in a cup, cover block with upside down cup, uncover block with cup, cover doll with blanket, push car around Lego, put block on top of upside down cup, etc. (Mastered September 2009 – grey) ABLLS D-3 Motor Imitation with gross motor movements Goal: Martin will be able to follow simple imitation directions when they involve making gross motor movements. SD (antecedent): “Do this!” and “Try this! “, „ Now do this!” (use all three and more). Prompt: Full physical and partial physical prompts. Behavior: Standing up, sitting down, turning around, running, jumping, hopping, (add more) Reinforcer: Use known reinforcers (tickles, music, apples etc.) Goal is considered mastered when Martin can imitate about 10 different actions on request. (Mastered September 2009 – grey)
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ABLLS D-6 and D-7 Motor Imitations using head, mouth, and tongue Goal: Martin will be able to imitate motor actions using his head, mouth and tongue. SD (antecedent): “Do this!” and “Try this! “, „ Now do this!” (use all three and more) Prompt: Full physical and partial physical prompts. Behaviors: Shaking head no, shaking head yes, turning head to side, dropping head all the way back, sticking out tongue, smiling, making an “O” with his lips, licking his lips, and so on. Come up with at least 4 head actions and 4 mouth or tongue actions. (Mastered September 2009 – grey) ABLLS D-8 Motor Imitation with speed discrimination When Martin can successfully demonstrate all of the above imitation skills, you can begin to work on the speed of actions. Go back to the easiest imitation skills and teach him to “Do this!” not only copying the action but also the speed of the action. Example: Arms up and down slowly or arms up and down fast. The SD should remain, “Do this!” or “Try this”. (Mastered December 2006 – red) ABLLS D-9 Motor Imitation of fine motor actions Goal: Martin will be able to imitate fine motor actions. Ask Martin to “Do this!” “Try this!” etc. but this time make the skills fine motor skills such as: Pointing his index fingers together, clasping his hands with his fingers interlaced, putting his thumb together separately with each of his fingers on one hand, making a V-sign etc. * In addition to this you should find a way to practice things like stringing beads, doing buttons, and lacing shoes. Put large holed objects on a thick piece of yarn. When he gets better at this, use smaller objects with smaller holes and use thinner thread. (Mastered December 2006 – red) 9.4.5. Verbal imitation ABLLS E-1 Imitation of sounds Goal: Martin will be able to imitate almost any individual sound on request. Start by getting Martin involved in a very reinforcing activity (like a favorite video, jumping on the trampoline or spinning tops). Then turn off or stop the activity and deliver an SD: “L” or “B” or “D” or “F”. The first few times you should reinforce any sound he makes. This way he is learning that it is a sound you are looking for. Once you are sure he knows you are looking for a sound, use whatever sound he tends to make easily as your first SD until he can readily do it on command. Then you will begin to change the SD to other sounds you think he can do. At this point you will begin to only reinforce sounds that are similar to the SD you delivered. 50
Reinforce by immediately turning the video on letting him jump or give him another bead to string etc. Just like manding, we will reinforce more for good strong responses and less for weaker or no attempts. *This is an important skill and in the beginning should be taught when he is motivated and happy. It is often helpful to save Martin’s very strongest reinforcers for this goal. This is the beginning stages of learning to talk. To keep this skill fun and easy, you should only give the SD three to four times. If Martin is unable to respond, reinforce his effort anyway. But be ready to reinforce immediately when he makes a good response. Also look for accidental sounds that are just like the SD. Reinforce these “accidents” a lot. They are great teaching opportunities. Keep track of the sounds you are working on and which ones he is able to make on command. Good sounds to start with are vowel sounds: E, O, A, etc. and consonant sounds from words like: B, T, P, H, R. Later we will add Be, Bi, Bo, Ba, Te, Ti, To, Ta and Mama, Papa etc. Continue to work on Martin’s current skills by giving him hundreds of opportunities a day to make sounds on request. (Mastered May 2008 – pink) 9.4.6. Manding ABLLS F-2 and F-3 Requesting with reinforcer present Goal: Martin will be able to ask for an item with a word when the item is present and a prompt is given. When you know that Martin wants to have something (and only when you know that he wants it at that moment) you should say the word for the item like “Juice” to be echoed. When he echoes part of or the entire word, reinforce with the item the child wants. SD (antecedent): Make the item available and wait for Martin to reach for the reinforcer. Prompt: Full echo prompt. Say the whole word: “Juice!” Later a partial echo prompt: “Ju...!” Behavior: Martin says approximation of the word or says the whole word. Reinforcer: You must reinforce with the item he asked for. (Mastered December 2006 – red) 9.4.7. Intraverbals ABLLS H-1 Fill in words from songs Goal: Martin will be able to fill in at least three different phrases from at least six different songs. Example: “The wheels on the bus go round and ... (round)” or “Old McDonald had a farm, E I E I ... (O)” To teach this, you need to get him singing a song along with you and then stop when you get to the word or phrase he knows, so that he can complete it for you. Eventually he should be
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able to fill in several words from several songs. “The wheels on the bus go … (round and round)”. (Mastered April 2007 – green) ABLLS H-2 Fill in Missing words from fun activities Goal: Martin will be able to fill in the missing word or words at the end of a phrase that involves a fun activity. Example: You can teach the phrase “Ready, set, go!” while playing spinning tops. SD: “Ready, set... Behavior: Martin says: “Go!” Reinforcer: Start the object (spinning top) that the child said “Go!” to have started. Later you can move to SD: “Ready... Behavior: “Set, Go!” Additional Examples And now we go up and … (down) Hoppe, hoppe, hoppe and … (crash) etc. (Mastered December 2006 – red) 9.4.8. Behavioral Goal: “Give to me” Program This program should in the beginning be used with items that have some reinforcing value. Eventually moving up to all of his most valued reinforcers. Goal: To build up enough trust in us that Martin is willing to give us his reinforcing items and eventually leave reinforcing activities when we ask him to. Set up: Give Martin a reinforcing object or activity. SD: While he is playing with his reinforcer, tell him “Give it to me!” or “Give it back!” Part A: If he gives you the item when you ask Hold the item for a very short amount of time (one to two seconds) and then give it back to him. Be sure to pair giving it back to him with positive praise for “Good listening” or “Nice giving back!” You can also reinforce him with some additional reinforcement, like a favorite ball or a piece of apple. Let him play with it again for a while and repeat. Slowly increase the amount of time you wait before you return it or reinforce. Remember that the SD is “Give it back!” not “Can I have it?” The first time it is for one to two seconds then three to fife, six to ten and so on. Then one minute, two to fife minutes, and so on. It is important that you pair returning the item to him with praising him for “Good listening” or “Thank you!” every single time. * Part A is the part of this program we would like to see Martin using. We are trying to build up his trust in us so that he will give us things that he likes and can learn to wait for reinforcement for longer and longer periods of time. 52
Part B: If he doesn’t give you the reinforcer when you ask Count to three and quickly but safely, scoop the item away from him and put it behind your back. Then give Martin a direction or two to follow before giving it back to him. We are trying to teach him that giving us an item when we tell him to, is reinforcing itself and if he does not give us an item when we tell him to, he will lose it anyway and then he has to do more to earn it back.” (Janina Menze, Knospe-ABA, September 2006)
9.5.
Initial Kindergarten Program
The kindergarten was given the seven steps of instructional control. Since it is not possible to restrict reinforcers in the kindergarten to the same degree as in the home, the seven steps were adapted to the kindergarten environment. Since the kindergarten teachers had their own teaching goals such as games and materials for visual performance the kindergarten did not work on the ABLLS goals initially. “Martin enjoys being in the kindergarten, has a good relationship to his teachers and chooses to spend time with them rather than being alone. His teachers were able to teach him a variety of skills in the past. This shows me that they have done a good job applying motivation and reinforcement in appropriate ways to teach him new things. But still Martin is the one who chooses what he wants to learn. If he is not willing to learn a certain skill, he uses inappropriate behavior effectively to avoid demands. Sometimes he chooses to follow instructions, other times not. To create his willingness to participate and to give him the desire to participate consistently across tasks, I recommend to you to focus on the seven steps to instructional control. Everyone who works with Martin has to develop instructional control with him first, before teaching him advanced skills. When he is finally always choosing to follow your instruction regularly due to learning that it will be worthwhile, we can start to teach him advanced skills. In the beginning we want to show him that following instructions is easy and always leads to fun and reinforcement. Only use easy skills in the beginning.” (Janina Menze, Knospe-ABA, September 2006) The kindergarten got a copy of the in-home program after every consultation but often also got special suggestions for the Kindergarten routine.
10. Martin’s Teaching Goals in Progress The following is a list of the ABLLS goals and some behavioral goals that were given to Martin’s team after each of the eleven consultations, from September 2006 to November 2009. The goals that are given in a consultation do not have to be mastered by the following 53
consultation. Each family tries to teach what is possible to teach. If a family has problems with a certain goal, they call or mail their ABA/VB consultant or send a video of the teaching sessions. Some goals will be mastered after a few days, other goals will stay in the program for month and teaching techniques will be adapted to the child’s needs and to the families teaching skills if the teaching attempts were not successful. All the goals, especially speech goals, were taught through intensive teaching arcs. As soon as the skill became easy for Martin, the skill had to be generalized in everyday life and in natural situations. In the beginning of each follow up consultation a new ABLLS assessment was done by the ABA/VB consultant, new goals were chosen and taught to Martin’s parents and co-therapists. Some behavioral goals are shortly explained for every consultation. Later on a few behavioral goals will be explained more detailed. The ABLLS goals show how the teaching program started with many basic skills. After the first year there were fewer goals but the goals became more complex. With every listed ABLLS goal it will be noted when the certain goal was mastered in the ABLLS. It will also be listed the color of the ABLLS master date (see appendix 1: ABLLS). Some ABLLS goals were given even though they were considered mastered by the ABLLS. These goals were estimated to be in need of more examples, giving more training to understand the concept of the skill or better generalization. Some ABLLS goals were mastered without being taught. The first explanation for this is the increase of instructional control. As soon as Martin experienced that cooperation is worthwhile, he performed much better to demands that he would have ignored before. His intrinsic motivation grew fast throughout the first year, so he gained many skills only by observing and imitating. Many skills were also taught by parents and teachers through a natural good teaching instinct that developed as their skill level increased. The more basic ABLLS skills are taught to a child the easier it will be for that child to learn new skills without intensive teaching.
10.1.
Goals from December 2006
The second consultation took place in December 2006 over three days. Martin was highly motivated for the teaching sessions; instructional control was greatly improving. Some social programs were developed to teach Martin to use language to communicate with other children. A program was written to address his fear of the shower, for getting dressed more independently, to teach him to accept situations in which his little brother was crying without hitting him and to accept “No”. The family was taught new teaching strategies and received new teaching goals that will only be listed but not further explained. 54
ABLLS B-5 The ability to sort items into categories. (Mastered April 2007 – green) ABLLS B-16 Delayed identification. The ability to pick one of three items that was shown fife seconds before and then hidden. (Mastered April 2007 – green) ABLLS B-15 Pattern Sequences. The ability to put three items into the right order, when the right order was shown fife seconds before. (Mastered April 2007 – green) ABLLS B-18 Replication of 3-D Objects with up to six Legos, wooden blocks or other items. (Mastered August 2007 – blue) ABLLS A-4 and C-6 The ability to respond and discriminate correct between the SD “Take!” and “Touch!” combined with common items. (Mastered December 2006 – red) ABLLS C-11 The ability to touch an item versus a distracter after the SD “Show me…!” or “Where is…?” (Mastered April 2007 – green) ABLLS Goal C-16 Understanding varied directions like: “Take…!”, “Touch…!”, “Give…!”, “Hold…!”, “Pick up…!”, “Put down…!” or “Go to…!” (Mastered April 2007 – green) ABLLS C-25 and 26 Selecting items or pictures from a larger group of ten and more. (Mastered April 2007 – green) ABLLS C- 32 Demonstrating pretend actions with objects. (Mastered August 2007 – blue) ABLLS C- 33 Demonstrating pretend actions without objects. (Mastered August 2007 – blue) ABLLS C- 34 Selecting pictures representing actions. (Mastered April 2007 – green) ABLLS D-10 Motor imitation of a series of actions. (Mastered April 2007 – green) ABLLS E-3 Verbal imitation of consonant blends. (Not yet mastered) ABLLS E-6 Verbal imitation of number sequences up to five numbers. (Mastered April 2007 – green) ABLLS E-7 Prosody. The ability to imitate words and sounds with the same speed, volume and/or pitch as the person speaking. (Mastered May 2008 – pink) ABLLS F-6 Requesting others to perform actions. (Mastered April 2007 – green) ABLLS F-8 Manding for missing items that are outside of vision. (Mastered August 2007 – blue) ABLLS F-10 Requesting using whole sentences. (Mastered August 2007 – blue) 55
ABLLS F – 12 Requesting for others to stop. (Mastered April 2007 – green) ABLLS F- 14 Requests information using “Where” (Mastered April 2007 – green) ABLLS G – 2 and 4 Labeling up to 100 common items and pictures. (Mastered April 2007 – green) ABLLS G- 5 and 6 Labeling ongoing actions and pictures of actions. (Mastered December 2007 – yellow) ABLLS H-5 Answering questions about personal information, like: “What is your name? (Mastered August 2007 – blue) ABLLS H- 6 Filling in words for common activities, like: “We are washing our … (hands)!” (Mastered August 2007 – blue)
10.2.
Goals from March 2007
Martin’s family had one video consultation in March 2007. A video that was taken from home and kindergarten activities was analyzed by the ABA/VB consultant. The kindergarten team sent some written questions about teaching strategies to the ABA/VB consultant. The family received a written program with suggestions for more effective teaching and for prompting social play along with three new ABLLS goals. Martin’s parents were encouraged to proceed videotaping teaching sessions right from the beginning of the ABA/VB intervention. Videos are the best evidence for insurance companies, government agencies and schools of the benefit of ABA/VB (cf. Schramm 2006, p. 215). ABLLS C-27 and C-28 The ability to give an item to a person or place after SD. (Mastered December 2006 – red) ABLLS C-29 The ability to go to a person or place and to get an object from there. (Mastered December 2006 – red) ABLLS C-30 The ability to go to a person or place and perform an action. (Mastered December 2006 – red)
10.3.
Goals from April 2007
In April 2007 there was the third consultation for three days. A toilet training program was introduced as the level of instructional control was now estimated to be high enough. The kindergarten focused intensively on the toilet program. In this program Martin’s family got a 56
weekly teaching data to document what they taught throughout the week (see appendix 4). This kind of data enables the parents to keep track of which goals they need to teach more frequently and to make sure that no goals are being forgotten. The weekly teaching data contained not only the new goals but also former goals that still had to be taught. ABLLS B-17 Continue a pattern sequence like XOXOXO... and later: XOMXOM... (Mastered August 2007 – blue) ABLLS B-19 Seriation. The ability to put up to four objects or pictures in the right order. Examples: ABCD, 1234 or pictures of a flower from small to big. (Mastered August 2007 – blue) ABLLS B-20 Picture sequences. The ability to put up to four pictures of real situations in the right order. Example: Daddy takes a glass, fills in juice, drinks and puts the empty cup down. (Mastered August 2007 – blue) ABLLS B- 21 The ability to draw the right way through mazes. (Mastered August 2007 – blue) ABLLS C–10 The ability to perform simple motor actions on request, like: “Jump”, “Sit down”, “Stand up”, “Turn around”, “Walk”, “Run”, “Hands up”, “Fold your hands”, etc. (Mastered December 2006 – red) ABLLS C-20, 21, and 22 Identification by Function, Feature and Class. (C-20&22 mastered May 2008 – pink, C- 21 mastered December 2007- yellow) ABLLS C-36 Selecting pictures of at least four community helpers and jobs. (Mastered May 2008 – pink) ABLLS C-40 Selecting different items by at least 20 adjectives. (Mastered August 2007 – blue) ABLLS C-41 Selecting single items with two specific characteristics: “Give me the small blue...!” (Mastered August 2007 – blue) ABLLS C-42 Selecting a set of items with one specific characteristic: “Give me all soft...!” (Mastered August 2007 – blue) ABLLS C-46 Selecting two items that are “Same” or “Different”. (Mastered August 2007 – blue) ABLLS C-47 Receptive at least six prepositions. (Mastered December 2007- yellow)
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ABLLS D-13 Delayed imitation of actions up to four hours delayed. (Mastered May 2008 – pink) ABLLS F-13 Requesting information using “What”. (Mastered May 2008 – pink) ABLLS F-15 Manding information using “Who”, “Whom” and “Whose”. (Mastered May 2008 – pink) ABLLS G-10 Labeling parts or features of objects. (Mastered December 2007- yellow) ABLLS G-18 Labeling using “Yes!” and “No!” when asked: “Is this a...?” (Mastered December 2007- yellow) New category Math: ABLLS R-8 Matching cards with numbers to cards with dots and amounts. (Mastered April 2007 – green)
10.4.
Goals from August 2007
In the fourth three day consultation Martin received new programs to extend his use of expressive language interactions with other children including how to invite children to play. He received one program to develop creativity as he insisted on creating pictures or Lego structures as an exact copy from a model. He received a “waiting” program, since he had problems to wait for reinforcers or activities that he wanted to have or do. Also this time Martin’s family received an updated weekly teaching data form. ABLLS G- 12, 13, 14 and H -7, 8, 9, 10, 11, 12 Answering FFC questions without cards as visual prompt. The questions are concerning feature function and class. Martin’s answers are just the items. Feature: “Wheels belong to the … (car)”, “What has lights … (car)”, Function: “You throw a … (ball)”, “What can you wear … (jacket)” Class: “A dog is an … (animal)”, “What is clothing … (shirt)” (In steps mastered May 2008 – pink, July 2008-dark green, May 2009-black) ABLLS C-48 The ability to receptively identify at least eight pronouns. (Mastered October 2008 – brown) ABLLS C- 49 Selecting non-examples: “What is not an animal?”, “What is not for playing?” (Mastered May 2008 – pink) ABLLS C- 50 Selecting pictures representing a location or activity represented in a scene. (Mastered May 2008 – pink)
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ABLLS C-51 Selecting pictures representing at least four emotions. (Mastered December 2007- yellow) ABLLS C-52 Selecting pictures representing at least four social scenes. (Mastered December 2007- yellow) ABLLS F-22 Requesting using at least four adjectives. (Mastered December 2007- yellow) ABLLS G- 19 Labeling items that are missing or incorrect. (Mastered October 2008 – brown) ABLLS H – 15 Opposites. The ability to answer at least 10 questions like: “What is the opposite of cold?” (Mastered May 2008 – pink) ABLLS H-16 Answering 50 “What”-questions. (Mastered December 2007- yellow) ABLLS H-18 Labeling items previously observed after the question: “What did I show you in the kitchen?” up to one hour delay. (Mastered May 2008 – pink) New ABLLS category Z: Fine motor, ABLLS Z-10 String beads (Mastered August 2007blue) ABLLS Z-18 Color in large areas and connecting dots. (Mastered December 2007- yellow) ABLLS Z-19 Connecting dots as a pre-skill for copying shapes and patterns. (Mastered December 2007- yellow)
10.5.
Goals from December 2007
The fifth consultation took place over two days. Martin was taught to accept a token program as preparation for school. He received a program for sensory stimulation and muscle training for the mouth. The program for accepting “No” had to be updated since Martin was still whining when he could not get what he wanted. In this program many skills that have been in earlier programs were re-taught to prevent Martin losing skills that he already had. This time there was no consultation in the kindergarten. ABLLS H – 13 Multiple responses with categories. “Tell me three fruits!”. (Mastered July 2008-dark green) ABLLS H – 14 Gives class when given examples “Where does a chair, bed, and sofa belong to?” (Mastered July 2008-dark green) ABLLS F-16 Manding information using “Which”. (Mastered July 2008-dark green) ABLLS F-17 Manding information using “When”. (Mastered October 2008 – brown) ABLLS F-23 Using at least four prepositions while manding: “Can I have the game on the board?” (Not yet mastered)
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10.6.
Goals from May 2008
The sixth consultation took place for three days. Martin was given a role-play program and an updated token system. With the new co-therapists it was discussed how they can keep the data on the weekly teaching data forms more effective. Programs for inappropriate behavior were developed to teach Martin not to put his hands in his pants in public and to stop pressing his index finger into his mothers face. Teaching strategies were discussed and explained to the new co-therapists. The kindergarten received suggestions to teach Martin how to ask and to answer questions to the other children. Since Martin was not able to sit for 20 minutes in circle time, his teachers received suggestions on how to reinforce time frames of five minutes and extend them up to 20 minutes as a preparation for school. The cooperation with a school assistant started at this consultation. The assistant started to visit Martin in his kindergarten half a year before school started. This way the assistant could get familiar with the ABA/VB teaching program and had the opportunity to ask questions about Martin’s program. ABLLS F-25 Manding with whole sentences and pronouns. (Not yet mastered) ABLLS G-24 Two component labels with carrier phrase “It’s a train and a dog!” (Mastered July 2008-dark green) ABLLS G-26 and 29 Using noun - adjective labels “This is a large spoon!” (Mastered May 2009-black) ABLLS G-25, G-29 Using noun - verb labels with carrier phrase „I see a sleeping monkey! “ (Mastered May 2009-black) ABLLS G -30, H-17 Labeling at least 10 prepositions and answering “Where” questions. (In steps mastered May 2008 – pink and May 2009-black) ABLLS G-39 Labeling at least four emotions of others. (Mastered July 2008-dark green) ABLLS G-40 Labeling own emotions and events. (Mastered October 2008 – brown) ABLLS G-41 Labeling at least ten social interactions. (Mastered May 2009-black) ABLLS H-19 Answering “Who” and “Whose” questions. (Mastered May 2009-black) ABLLS H-21 Answering ”When” questions. (Not yet mastered)
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10.7.
Goals from July 2008
Consultation number seven took place two days. Martin had just begun attending classes in the local regular school. In the end of 2007 Martins parents found a class in a special school with six children with Autism that would start the following summer. The consultant discussed the possibility of integrating Martin into a regular school since he was able to develop more appropriate behavior every day. Appropriate behavior is a key indicator to successful integration. Children with ASD have shown to persist or to improve when placed in regular classrooms with typical developed children (cf. Maurice 1996, p.39). Robert Schramm states that all children deserve access to the same social and educational advantages. “Children with disabilities may need more systematic teaching, but excluding a child, based simply on an IQ test or a diagnostic label is unequivocally wrong” (Schramm 2006, p. 244). With the support of ABA/VB consultations it is possible to give the regular education teachers the best methods to teach a child (Schramm 2006, p. 246). The school received suggestions on how to make the classroom a reinforcing setting for Martin so that being removed from the classroom might be an effective consequence for inappropriate behavior choices. The token system was introduced to the school. Some suggestions were given as to how to teach Martin to read and the considerations necessary to be able to teach him the same goals as his classmates. A plan was developed with Martin’s teachers to strengthen his concentration and improve his fine motor skills. The school received a school program and a copy of the in-home program after every consultation. School visits were now structured in a way that the consultant had the opportunity to see Martin for four hours in school each visit. After school Martin’s teachers met for one hour with the ABA/VB consultant to discuss goals and strategies. During the first weeks after school start, teachers from the kindergarten visited Martin in school to give him some additional support in this new environment. ABLLS G- 32 Tacting at least eight pronouns. (Mastered May 2009-black) ABLLS F-18 Manding Information using “How”. (Mastered November 2009-light blue) ABLLS G-21 Labeling obvious problems. (Not yet mastered) ABLLS H-22 Answering at least 50 “How” questions. (Not yet mastered) ABLLS H-23 Answers at least 50 “Why” questions. (Not yet mastered) ABLLS H-37 Answering at least 20 academical questions. (Mastered May 2009-black)
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10.8.
Goals from October 2008
At the eighth consultation, which took over three days, Martin received a school contract that that addressed behaviors like clapping hands in class, hitting or kicking others or lying on the floor. Also, a time-out plan was implemented to address inappropriate behavior. His teachers received suggestions on how to implement strategies toward better instructional control in school. The social interaction plan, concentration program and token system were updated. Some teachers were observed working in school with Martin one-by-one and had the opportunity to discuss their teaching strategies with the ABA/VB consultant after school. Each of the teachers received some written suggestions on how to teach more effectively. Martin received a social program to help him understand that all people like different things and activities; he received a creativity program to learn how to invent new creative stories and a “raise hand” game as preparation for answering questions at school. There was only one new ABLLS goal given at this time, since a lot of former goals were very complex and still needed to be taught. ABLLS G-34 Describing things and pictures using different parts of speech. (Mastered May 2009-black)
10.9.
Goals from February 2009
The ninths consultation was a three-days consultation. The school received suggestions on how to motivate Martin to work more independently on his task sheets. A program was implemented to teach Martin to stay seated in the group teaching setting, even when he wanted to see something interesting. Some sport games were suggested for sport class and leisure activities. Martin and his teachers made a new time-out contract for school. Martin’s family got behavioral programs to teach Martin to behave more appropriately at the bowling center, in church and in other social surroundings. The token system was updated. Since Martin received many teaching goals from school, the ABLLS goals have been reduced. ABLLS R-12 Receptively identifying and tacting coins. (Mastered October 2008 – brown) ABLLS X-8 Folding toilet paper on his lap. (Not yet mastered) ABLLS Z-27 Folding paper. (Mastered October 2008 – brown) ABLLS Z-22 Cutting shapes of paper with scissors. (Not yet mastered)
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10.10.
Goals from May 2009
Consultation number ten was two days long. Martin received programs to learn how to ask peers to give back toys, how to read similar written words, such as “den”, “der”, “dar” or “det”. He received programs on how to be more independent in solving task sheets, how to pay more attention during group teaching and to stop grinding his teeth. Many ABLLS goals were repeated.
10.11.
Goals from November 2009
The eleventh consultation took place for three days. Martin was showing more inappropriate behavior in school, such as clapping in the classroom and making sounds, so behavioral strategies were discussed in detail with his teachers. Social skills programs were suggested for the time after school, when Martin has contact with children in the school yard. Social stories were implemented to teach Martin alternative behavioral strategies in situations that are hard for him to understand. Social stories give Martin suggestions of what he could do or say in difficult social situations. These stories are taught so Martin knows in theory what to do in similar situations. He needs to be reinforced and encouraged to apply the learned theory in the everyday life.
11. Behavioral Goals Only a few of Martin’s behavioral goals will be explained. Some of these goals were developed for behavior that was either disruptive in that it stood in the way of teaching or social integration. Others were developed to teach Martin to the next level of cooperation, interaction and rule compliance.
11.1. October 2008 “Inappropriate behavior: Martin wants to ignore your SDs as long as it is possible, so he starts trading and arguing with you. When he has to stop his computer game and he complains “No!” many times you offer him another minute or two. But this is reinforcement for Martin complaining “No”. We want that Martin is willing to leave the computer when necessary without complaining and that he does it because he can trust us. Please prevent bribing sentences like “If…. then…!” For example: When you tell him to help you in the kitchen and he is refusing. Do not tell him that if he helps you now, he can have his 63
computer back. You need to be very consequent one or two times when Martin refuses your demands. Usually he learns quickly that following the SD is worthwhile and that complaining will lead to no reinforcement at all. When you just switch off the computer without another warning, after he said “No!” he will be upset this time. But tomorrow, when you give the same SD again, he will remember, what could happen if he complains “No” to your SD. When he follows your SD without complaining, reinforce highly. Do not forget to praise him: “You did it! Well done, you deserve your favorite game!” Do not forget to teach Martin an alternative appropriate behavior. When you tell him to switch the computer off and he does it even though you can see that he does not like to do it, you can prompt him to say: “Mama, please two more minutes!” Only prompt him to say this, when he was calm after you asked him to switch off the computer. Asking using the word please is a normal and appropriate way for Martin to express what he wants. As soon as he uses this new sentence regularly, sometimes you reinforce, sometimes not, because this is what he has to learn for the real life. Classroom: Create a reinforcing setting in class, so it would be a real consequence for Martin to be taken out of the class room after inappropriate behavior. You have to reinforce good responses with tokens and other reinforcers such as raisins, apple, favorite books, and whatever motivates him to stay in the classroom. Always pair with praise. If you do this, Martin will learn that only in the class room he has the chance to earn reinforcers and that being outside is boring. Make sure to ask a question only when Martin is allowed to choose yes or no and that you give him a clear instruction like: “Come into the class!” when he has to do it. When he shows inappropriate behaviors in the same situations you have to make sure first, that you reinforce more, when he does not show inappropriate behavior in similar situations. So it will be easier for him next time to choose to attend. Social interaction: When Martin tells you something spontaneously during play, for example: “I have a red car!” reinforce and prompt him to tell it to another child. If he does, reinforce right away with a token and praise “Well done, you told the child that you have a red car!” When he shows this behavior unprompted you can ask the child to respond: “Tell Martin what you drive!” For example child tells Martin: “I drive a fire truck!” Next step: Ask Martin what the child has said (what he drives). If he responds correctly: “Fire truck!” reinforce even more. When he asks other children for information or items, reinforce with a high reinforcer. Create situations where you send Martin to ask another child, when he comes to you with a question, that the children can also answer. He has to learn, that he can 64
get information as well from other children and not only from adults. Ask the children to ask Martin questions that you know he can answer. Then reinforce Martin for answering the question to a child. This can be a FFC question as well as another intraverbal. When the child explains a game and Martin pays attention to it and does it (for example the child says: “Here is the airport and you have to land here!”) reinforce Martin for the spontaneous reaction of attending to this game. When he says “Your turn!” to another child reinforce him. Create situations where you let the children give reinforcing items to Martin. He should not make the experience that reinforcement only comes from adults. Concentration: Often Martin answers incorrectly and then realizes that the answer is wrong, because you do not react (you do not reinforce). The missing reaction is also a prompt. Then he will give you the right answer. But doing this he will always guess and not concentrate and think about the question. Example: We asked him: “What is daddy: woman or man?” He usually answered “Woman!” Because we didn’t react he then said: “Man!” The reinforcement that came after the right response was not high enough to motivate Martin to concentrate next time and to give the right response first. He would guess again. What we reinforced was the behavior of guessing. If you have a new question, please work on this new question as your goal and do not teach other new questions the same time. Use the correction procedure: Ask the new question, prompt right away the correct answer, now ask the question again so Martin can answer it without prompts, and reinforce. Give one to three distracter trials (easy questions). Then ask the question again with less prompts and so on. When he knows the right answer three times in a row (with distracters and pairing in between), the goal is considered mastered for today. Repeat this skill tomorrow. Martin will learn that he always has to repeat questions that he answers wrong. This will also motivate him to concentrate, because repetitions of SDs can be very boring. Sometimes you give an SD and Martin does not react. Most of the time he does not react, when he already has everything he wants (a toy, apple….). You should wait for a moment, until Martin has no reinforcers left (when he is finished eating), or let him hand you the reinforcer first, so he will be motivated to answer you. If you have given him an SD, while he still has reinforcers, you should take his reinforcers at least after four seconds after your SD. Always make sure that he answers your questions. Do not let him go if he ignores you. This is step three of the instructional control: Mean what you say and be contingent!” (Janina Menze, Knospe-ABA, October 2008)
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11.2. February 2009 “Circle time: Martin stands up in circle time often, when it is inappropriate. You need to reinforce when Martin does not stand up in situations where he usually would stand up inappropriately. For example when the teacher reads a book to the children and he would like to see the pictures, when he wants to touch the board, or tidy up things that he likes to see in order. He should not be allowed to stand up because it is written in the contract. For this behavior he is not getting the time-out but use other consequences first to see whether that motivates him to sit during circle time. Consequence 1: You go with him in the classroom to teach him 1:1 when he stood up. Tell him immediately that you will go out with him, because he cannot be in the circle time when he stands up. If you apply consequence 1, it should be described in your contract. Consequence 2: If step 1 doesn’t reduce the behavior of standing up in circle time, you should do this: Martin will be sent in the small room alone to read but the toys have to be restricted. If you apply consequence 2, it should be described in your contract. Consequence 3: Third possibility should be the time-out if the first steps do not reduce the behavior of standing up in circle time. If you apply consequence 3, it should be listed in your contract. Use every consequence at least for two weeks before you use the next step. If consequence 1 works, of course the other steps are not needed. Start to reinforce less and less as soon as a behavior occurs as often as you expect Martin to show it. You can then instead use reinforcement for other advanced skills. For example Martin might still need some reinforcement for raising his hand spontaneously in circle time.” (Janina Menze, Knospe ABA, February 2009)
11.3. May 2009 “Asking for toys back: Martin needs more prompts in situations when he wants to have a toy back from someone. When you see him that he approaches a child and puts his hand out for the toy, prompt him to say: “Can I have it back?!” Then reinforce, also with tokens. Martin is mostly playing by 66
himself or with an adult during classroom break. Sometimes other children join him, but never for more than fife minutes. We will find some more play settings with other children by using the token system in school. Martin now has to pick a child to redeem his ten tokens to get a reinforcer. He is also not allowed to enjoy games like marble run alone; instead, he has to invite another child. Grinding teeth: The grinding is still severe, so we have concerns about Martin’s dental health. Martin shows this behavior mostly when he is excited, when he plays computer for example. We will now use the high motivation to reduce that behavior. First we will offer him an alternative, like chewing gum or a chew toy in his free time to provide him with the sensual stimuli that he might need. Flight simulator: Martin grinds a lot when he is playing with his flight simulator. Now we tell him that every time he grinds, we will turn off the computer screen for one minute, before he can have it back. The consequence is an annoying interruption of the game. Please put this rule on the contract and make sure that Martin knows and understands the new rule before we apply it. You will have to turn off the screen every time you hear Martin grind. When Martin stays calm after you have turned off the screen, praise him for being calm and for nice waiting. We want to show him that we are proud of him when he does not show frustration, but do not reinforce him with an edible or other reinforcer. If he starts to whine and complain he will have to go out of the room for one more minute. Please keep data of how the behavior of grinding reduces over time. School or homework: Here we cannot use consequences for grinding because if we just quit work for one minute, Martin might use the behavior to get rid of the task. Instead, please write in your contract that Martin will have to go to time-out every time you can hear that noise during work, writing, school tasks and so on. Talk to Martin about the new rules before you apply them! Because the consequences applied to the flight simulator worked so well, we are convinced that Martin can easily control the behavior of grinding. Please reinforce every once in a while for not grinding: “Wow, you are so quiet, that is great!” After a few days the behavior should reduce, after one week you should start to reduce the reinforcement.” (Janina Menze, Knospe-ABA, May 2009)
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12. Summary In this thesis the history and basics of ABA/VB were explained to give the reader a basic knowledge about the ABA/VB teaching concept to Autism intervention that will be integrated into a practice of Occupational Therapy. Afterwards a practical ABA/VB intervention was described based on the theoretical principles of ABA/VB. Martin’s initial ABLLS assessment, his learning goals and the documented data of their achievement show a strong development in all learning categories. The ABLLS gives a very detailed impression of Martin’s progress and thus support the effectiveness of the described intervention. Usually occupational therapists do not use a comparable detailed assessment and curriculum tool nor can the other concepts of Occupational Therapy prove to be as effective as the approach detailed in this concept. Martin did not only achieve his parent’s goal of being able to get toilet trained and to use spoken language, he is also conversational. He can ask and answer a variety of new questions, he asks for information using “What”, “Why”, “Where”, “Who” and “How”-questions. He remembers jokes that he tells his family at home. He can play role-play games and understands the difference between fantasy and reality. His theory of mind is brought to light when he is cheating in parlor games or when he is using white lies as typical children do. He is flexible in a way that his parents can take him to holiday trips to foreign countries more than two times a year without problems. He reached a level of social competence to be able to join a scout group. Martin is attending the regular school, can write, read and calculate on the same level as his peers. It is reasonably expected that he will continue to make this progress with ongoing consultations.
13. Conclusion For children with Autism there is no other approach that has proven itself nearly as effective as ABA (cf. Schramm 2006, p. 237; cf. Maurice 1996, p. 7&29). Because of this fact and because ABA/VB intervention in financially supported by, for example, the German government, it is necessary and justified to make ABA/VB services available to Norwegian families with children with ASD and related disorders by financing ABA/VB consultations to families with children with ASD and PDD-NOS. In the long-run ABA is cost effective because fewer individuals have to be institutionalized. A place in an institution in Norway for a person with ASD costs about one and a half million Norwegian Kroner per year, which equals $238.350. With one-by-one attendance the costs would be up to two million Kroner
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which equals $317.800. It is not acceptable that parents in Norway have to pay privately for a scientifically supported and effective intervention for their child. Most parents have the desire to help their child effectively in everyday life. The goal of this concept is to enable parents and the persons in the child’s environment to be the best teachers and experts for their child with ASD and to fade consultations over time. This thesis explains a concept that is designed to increase the reinforcing value of teaching and to decrease the value of escape (cf. Schramm 2006, p. 42). The goal of ABA is to teach toward recovery even though full recovery is only possible for some children. The goal should be “a gradual fading out of autistic symptoms, a gradual increase in social and linguistic competence, a gradual acceleration in our children’s ability to learn normally from the environment” (Maurice 1993, p.288). Good teaching also includes enabling the child to become spontaneous, affectionate, sensitive to others feelings and able to play cooperatively with other children. The child with his unique abilities and challenges sets the steps of education. The child has to feel coherent, a full valued member of his family and society, accepted as a personality, loved and supported throughout the intervention process. This thesis shows that supplying a child’s family with scientific knowledge about ABA supports the child with high quality early intervention in his everyday life, instead giving a few hours of one-to-one Occupational Therapy sessions a month. New goals are chosen when the former steps are mastered and the family and the child is given all the necessary time, respect and support to develop their teaching and learning skills. All teaching plans are established in a way that ensures a continuing motivation in the child for cooperation and the willingness to learn new skills in the future. Motivation is the key to teaching a child with Autism skills that he is not able to learn in a typical way. By capturing the child’s motivation in the natural environment and by using reinforcement we give the child a substitute to the intrinsic motivation that typical children experience when they are learning. By using errorless learning we avoid frustration and make sure that the child knows exactly what to do. The teaching arc builds up ongoing motivation, avoids excessive demands and makes teaching an enjoyable event that the child likes to repeat. Fading prompts and differential reinforcement strengthen the child’s responses. The concept of an Occupational Therapy practice is dependent on the financial coverage by the Norwegian welfare system. The borders of this service could be that only occupational therapists can be trained to work as ABA/VB consultants in this practice and not psychologists, social workers and social pedagogues like in other ABA/VB institutions. 69
Therefore it is necessary that ABA itself will be acknowledged and financed by the Norwegian government to support families all over Norway and Scandinavia with this intervention. It is about time that Applied Behavior Analysis finds its way into the master study courses of Norway’s Universities. In many countries professionals face the challenge of making ABA/VB services available to families. Integrating ABA/VB into the study of Occupational Therapy might be the fastest and most economical approach. Occupational therapists apply concepts like Bobath, Affolter, Castillo Morales and Sensory Integration for their different groups of clients. Sensory Integration techniques are very commonly used by occupational therapists that work with children with ASD, but its benefit lacks a scientific proof (cf. Maurice 1996, p.49, cf. Simpson 2005, p.176). Working with children with ASD and PDD-NOS, ABA/VB should be one of the concepts of choice for Occupational Therapy. In Oslo there begins a pilot project in September 2010, where within the timeframe of one year the family of a 13 year old girl with Autism will receive the financial coverage of an ABA in-school program that is supervised by a Behavioral Analyst and Psychologist that will be working as a part of the Norwegian educational system. At the moment it is discussed if, after this pilot, ABA could become a financial supported intervention within the educational system in Norway for all children with Autism. ABA in Norway can be done via outside agency or through the currently existing field of Occupational Therapy.
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14. List of References Anderson, S.R.; Avery, D.L.; Di Pietro, E.K.; Edwards, G.L.; Christian, W.P.: Intensive home-based early intervention with autistic children. Education and Treatment of Children. 10, p. 352-366, 1987 Birnbauer, J.S., Leach, D.J.: The Murdoch early intervention program after 2 years. Behaviour Change. 10, p. 63-74, 1993. Eikeseth, S.; Lovaas O.I.: the autistic label and its potentially detrimental effect on the child’s treatment. Journal of Behavioral Therapy and Experimental Psychiatry, 23, p. 151-157, 1992 Eikeseth, S.; Tristram Smith, Erik Jahr, Sigmund Eldevik: Intensive behavioral treatment at school for 4-7- year- old children with Autism: a 1-year comparison controlled study. Behavior Modification. Sage Publications, Vol. 26, p. 49-68, 2002. Eikeseth, S.; Tristram Smith, Erik Jahr, Sigmund Eldevik: Outcome for children with Autism who began Intensive behavioral treatment Between Ages 4 and 7, a comparison controlled study, Behavior Modification, Sage Publications, Vol. 31, Nr. 3, May 2007. http://online.sagepub.com Jerome, J.; Eric P Frantino; Peter Sturmey: The effects of errorless learning and backward chaining on the acquisition of internet skills in adults with developmental disabilities, Journal of Applied Behavior Analysis, 40, p.185-189, 2007. Lovaas, O. I.: The Autistic Child. Language Development through Behavior Modification. Irvington Publishers, New York, 1977. Lovaas, O. I.: Teaching Developmentally Disabled Children, The Me Book. Pro-ed, Austin, Texas, 1981. Lovaas, O. I.: Behavioral treatment and normal educational and intellectual functions in young autistic children. Journal of Consulting and Clinical Psychology, 55, p. 3-9, 1987. Lynch Barbera, M.: The Verbal Behavior Approach – How to Teach Children with Autism and Related Disorders, Jessica Kingsley Publishers, London and Philadelphia, 2007. Markham, Ontario Study, National Post, 11. Nov. 2006 Maurice, C.: Let Me Hear Your Voice, A families Triumph over Autism. St Edmundsbury Press Limited, Suffolk, 1993, ISBN 0 7090 6346 6
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Maurice, C.: Behavioral Intervention For Young Children With Autism- A Manual for Parents and Professionals. Pro-ed, an international publisher, Austin Texas, 1996. McEachin, J.J., Smith, T., Lovaas, O.I.: Long-term outcome for children with Autism who received early intensive behavioral treatment. American Journal on Mental Retardation, 4, p. 359-372, 1993. Myers, S.M.: Management of children with Autism Spectrum Disorders, The American Academy of Pediatrics, Clinical Report, Elk Grove Village, IL, Vol. 120, Nr. 5, November, 2007. Møller-Nordbye, M.: Martins Verden, Hertervig Forlag, Stavanger, 2009. Partington, J. W.; Sundberg, M.: Assessment of Basic Language and Learning Skills (The ABLLS): An Assessment for Language Delayed Students. Behavior Analysts, Inc. Pleasant Hill, CA, 1998. Partington, J.W.; Sundberg, Teaching Language to Children with Autism or Other Developmental Disabilities. Behavior Analysts, Inc. Pleasant Hill, CA, 1998. Partington, J.W.: Assessment of Basic Language and Learning Skills-Revised (The ABLLSR): An Assessment, curriculum guide and skill tracking system for children with Autism or other developmental disabilities. Behavior Analysts, Inc. Pleasant Hill, CA, 2006. Partington, J. W; Capturing the Motivation of Children with Autism or other Developmental Delays, Behavior Analysts, Inc. Pleasant Hill, CA, 2008, ISBN: 0-9745151-6-7. Perry, R., Cohen, I., & DeCarlo R. (1995). Case study: Deterioration, autism, and recovery in two siblings. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 232237. Richman, S.: Raising a Child with Autism, A Guide to Applied Behavior Analysis for Parents. Jessica Kingsley, Publishers, UK, 2001, ISBN: 978-1-85302-910-3 Schramm, R.: Educate Towards Recovery. Turning the Tables on Autism. Hespe: Pro-ABA, 2006. Skinner, B.F.: The Behavior of Organisms. An Experimental Analysis. Appleton-CenturyCrofts, New York, 1938. Simpson, R.L.: Autism Spectrum Disorders. Interventions and Treatments for Children and Youth. Corwin Press, Thousand Oaks, California, 2005
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Stanislaw, H.; Howard, J.; Sparkman, C.; Cohen H.; Green G.: A comparison of intensive behavior analytic and eclectic treatments for young children with Autism, of Research and Developmental Disabilities, TURLOCK, Calif., August, 2005. The article can be purchased online at: www.sciencedirect.com . Vail, T.; Freeman, D.: Employee Training Manual – The Mariposa School, Verbal behavior Training Seminars,
October 2002,
available at:
www.MariposaSchool.org,
email:
[email protected]. Download: http://www.mariposaschool.org/sites/default/files/TrainingManual.pdf World Health Organization: The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, Switzerland: WHO, 1992. Wyatt, J.W.: B.F. Skinner From A to Z – Brief quotations on everything from Approval to Zen. Third Millennium Press, Hurricane, WV, 2001, ISBN: 0-9663622-2-5
Resources: www.knospe-aba.com www.pro-aba.com www.MariposaSchool.org www.DrCarbone.net www.establishingoperationsinc.com www.BACB.com www.webablls.com ablls.blogspot.com www.autismteachingtools.com Autism.about.com www.abainternational.org www.specialisterne.dk
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15. List of Abbreviations ABA
Applied Behavior Analysis (also: Autism Birth Cohort)
ABC
Antecedent, Behavior, Consequence
ADI-R
Autism Diagnostic Interview-Revised
ADOS
Autistic Diagnostic Observation Schedule
ABLLS
Assessment of Basic Language and Learning Skills
ADD
Attention Deficit Disorder
ASD
Autism Spectrum Disorder
BCaBA
Board Certified Assistant Behavior Analyst
BCBA
Board Certified Behavior Analyst
DRO
Differential Reinforcement of Other Behaviors
DSM
Diagnostic and Statistical Manual of Mental Disorders
EIBI
Early Intensive Behavioral Intervention
FC
Facilitated Communication
FFC
Feature Function Class
HD
Hyperactive Disorder
ICD
International Classification of Diseases
JABA
Journal of Applied Behavior Analysis
MO
Motivating Operation
NET
Natural Environment Teaching
OCD
Obsessive Compulsive Disorder
ODD
Oppositional Defiance Disorder
OTM
On The Move Teaching
PAPA
Preschool Age Psychiatric Assessment
PDD-NOS
Pervasive Developmental Disorder-Not Otherwise Specified
PECS
Picture Exchange Communication System
RDI
Relationship Development Intervention
SD
Discriminative Stimulus, Instruction
SI
Sensory Integration
TEACCH
Treatment and Education of Autistic and related Communication Handicapped Children
UCLA
University of California
VB
Verbal Behavior
VR
Variable Ratio of Reinforcement
WHO
World Health Organization 74
