INFORMATION NIGHT REVIEW
Notes from John McEachin's talk at the ABIA Information Night
held on 20th of March 1997
WHAT DOES ABA HAVE TO OFFER FOR OLDER CHILDREN?
Behavioral analysis has been around for some time back to the 1960's and in fact it had kind of a heyday in the late 1970's. I can't speak for what was happening in Australia at the time but certainly in America there were lots of places across the country and even in classrooms where ABA was kind of the rage of the day. And somehow that interest died out, the tide turned and people went in different directions. Some of that I think was due to some unfortunate things that were done or not done by practitioners in the field. ABA has changed a lot in 20 years and not a lot of people realise this. Many people today still have this notion of the late 60's-early 70's, like slamming the hand down on the table and yelling at kids and things like that. I can remember when I was an under graduate, I took a psychology course and they showed a video or a movie, a documentary illustrating the work of Lovaas, this was before I actually knew Lovaas. And there was one scene where they are working with this girl named Pamela. If you've ever seen this I'm sure you couldn't forget it; and they are showing her a crayon and asking her to tell what colour it is "what colour?" and she's fully engrossed in self stimulatory behaviour., looking quite autistic. After a couple of times of being asked "what colour?" and not getting an answer, this person jumps in, from off to the side of the screen, jumps in and gives her a little smack on the leg and says in this Norwegian accent "you tell!" and all of a sudden instantly, the autism would completely disappear and she says "yellow". And I remember when that happened, I literally jumped in my seat and I imagine a lot of people who saw that had a similar experience. And unfortunately that's what people today still think of when people talk about behavioural treatment or anything associated with Lovaas. But things have changed a lot. One of the most important things that has happened was Lovaas' publication of the outcome of the autism project showing just how far autistic children can go with intensive early intervention. It really represents the state of the art in terms of intensity, quality of treatment, and the extensiveness of the follow up of the treatment and the detail of the outcome as reported in the literature. The unfortunate thing about it is that it stands alone and, so the only thing that people have as a reference point is what was done in that study and in that study it so happened that the children who participated in the treatment were limited to those under the age of 4, in fact the average age was under 3 within that group of children.
So we have seen a study that demonstrates quite astounding results with young children, meaning pre-school age children. No one has done a comparable study looking at treatment outcome with children who are older than that. Some people conclude from that, that the research shows that ABA is not effective with older children. That's a very grievous fault in logic and interpretation of scientific research. What is correct to say is that the research does not show that ABA is as effective for older children as it is for younger children. All we can say is "we don't know" because its never been tested. It would be a very important study to do. I don't know if anyone is ever going to do it where two groups are compared and everything else is kept equal in terms of the quality of treatment, the number of hours, the level of parental involvement and all other subject variables being equal except for age. Our clinical experience shows us that with each year of increasing age from about age 4 on, one can expect a diminishing degree of possibility for full recovery. But that's not such a discouraging thing the way I look at it. I don't think that people should undertake an ABA program with the idea that this is a recovery program. I do think it's important to undertake it with unmitigated, enthusiasm and energy and seriousness. But I think it also needs to be tempered with realism knowing that probably the majority of children even those who get a start at the earliest ages are going to end up not being able to function completely independently. So we are talking about a lot of kids, not only those who didn't get diagnosed at a young enough age but those who did and were able to be exposed to this kind of intensive treatment but were not among those who had the most favourable response. So these kids are going to get older and something needs to be done for them.
ABA is clearly the most effective approach for teaching and educating not only autistic children but individuals with quite a variety of developmental disabilities. The question really is "how intensive, what do we teach, how long do we do it?" These are really tough questions but I'll take a stab at it and give you some of my thoughts about that based on our clinical experience.
Our clinic, The Autism Partnership, which is located in the Los Angeles area, got a reputation as being one that works with older children, so much so that some people don't realise we also work with younger children. Its just that we don't have any arbitrary cut off. We are willing to work with children of any age as long as they have needs that can be met using ABA. People have come to us and asked us "what do you do with an older child?" or "do you work with older children?" I would ask "well what exactly do you mean, how old are we talking about?" and people would say "5 years old" as if this is incredibly old!
It's all relative. For those people, 5 is considered old because they approached other clinics who limit themselves to children who are 4 and younger and they don't meet the criterion for inclusion in the program, so that means I guess 5 years is old.
What are some of the problems that you are going to encounter when a child is older? One of the problems is that as they get older, they get bigger and they get stronger and much more challenging simply to manage on a day-to-day basis. With a two and a half-year-old child, if he doesn't want to sit in a chair that's no problem, you just pick him up and put him in a chair. But if he's 6 or 7 and doesn't want to sit in the chair, that approach is not going to work, its definitely not recommended.
So often what that means is we have to, utilise intervention procedures, teaching procedures, that will be effective but would take longer, longer to accomplish the teaching objective. You know, we can get just about any child to come and sit in the chair one way or another if you can be patient enough and really the key thing in being effective is coming up with really good reinforcers. If you have a good enough reinforcer, then you can solve just about any behaviour problem and teach just about any skill. If you have a good enough reinforcer and you have enough time and assuming that the individual is not so severely impaired that they would be incapable of learning or remembering and there are very few individuals that fit that definition. One sub-group of people with pervasive developmental disorders for whom that is probably the case is Rhett syndrome, which is a type of autistic spectrum disorder that affects girls and its basically a degenerative disorder. Lovaas reported on case studies with two girls with Rhett syndrome for a period of about two years working very intensively with and despite all of that, they were basically not able to accomplish anything and their conclusion was that it probably does not make sense to undertake a program with someone who has that condition. In the last hundred or so children that I've seen, I've only seen one child who could not in one day learn to drop a block in a bucket in imitation and many kids can do it within two or three trials. So part of the trick is coming up with the response. If you are not having success teaching clapping hands or raising arms then you need to find something else that you can teach as a starting point to get the whole thing underway. You need to pick really simple responses to get it started so that you can get the behaviour under control. And once you can do that then you can move forward from there. And that one girl who was not able to put the block in the bucket and that I was feeling very depressed about after the initial workshop, three months later was on the verge of doing verbal imitation and had completely gone through all of the non-verbal imitations that were on the list and I was really quite astounded. It just goes to show that you really can't know on the basis of just an initial look how far any given child will go.
With older kids we've got the issue of physical size which is going to force us to use some different kinds of strategies where we're having to rely much more strictly on positive reinforcement as an inducement to get them to co-operate with the program because we can't really realistically overpower them. We have to learn very early on to avoid control battles. If you're not able to enforce what you're going to ask the child to do then there is really no point in making the request in the first place, in fact it's better not to. One of the things that's really important is to establish credibility and credibility means that if I say something then you can count on me backing it up, one way or another. And every time you give a directive or make a request and you don't follow through on it that undermines your credibility and will lead to ongoing difficulties in trying to establish co-operative behaviour and compliance. We've learnt to rely much more heavily on choices that the child makes for themselves and to utilise natural consequences as much as possible. The reality is that we can't control anything the kids do. It's a delusion if you think otherwise. A lot of times we start off a therapy program with these really grandiose ideas of I'm going to get her to do this and I'm going to get him to do that and then we'll do this and this and this. And we might like to think that we can control behaviour but the reality is we control nothing in the behaviour of the child. All we can manipulate is consequences. And so we can only be successful if the consequences, the meaningful consequences, are ones that we can control and that's why working with kids who are really hooked on self stimulatory behaviour is so difficult, because those stereotype behaviours that they engage in that give them various types of sensory feedback. It's like a drug, it's like opium, and they get high on it if you want to think of it that way. It's very reinforcing. And if we're going to try to get them to do things they're not presently doing, we've got to come up with something that can compete with that, something that is at least as attractive to them as the sensory effect that they can get from engaging in self stimulatory behaviour. So we have to either be able to suppress the self stimulatory behaviour or come up with really dynamite reinforcers.
Another problem that you'll have to contend with is that kids who are older have been practising these behaviours that we don't like for a long time and the longer they've been practising it the more ingrained the habit is, the more difficult it's going to be to retrain them, to undo those habits. And a lot of times it just means you're going to have to be more patient, and you're going to have to just proceed in a very systematic, step by step fashion. Your going to pick your battles carefully and your going to prioritise what you work on. And the basis for prioritising what you work on should include things like; dangerousness of the behaviour in other words the immediate impact the behaviour has from a safety stand point, including both the safety of the autistic child and others around them. Another factor is how teachable a certain skill might be. For example, toilet-training is something that would be pretty high on most parents list of priorities, but that's not the only consideration. We know that there is really no point in undertaking a toilet-training program until the child has readiness for that. We know that there are certain prerequisite skills that need to be in place before you can hope to be successful in doing that. So those are really the factors; the safety, the teachability and the importance in daily life. There's a psychologist from Wisconsin (Lou Brown) who probably would hate intensive ABA therapy, but he has got some good ideas in other respects. His definition of an important skill or important behaviour is if it's something that someone would have to do for the person if they can't do it for themselves, then that's something that's important to teach. So obviously things like dressing, feeding and toileting would all be things that fall in that category. Learning 2+2 and your times-tables does not fit in that category. There may be some priority behaviours that need to be dealt with and because the kids are older and bigger those behaviours are a much graver concern.
Behaviours like running away, self injurious behaviour, extreme aggressive behaviour and again if children are older and we have not been successful in teaching more adaptive skills and getting behaviours under control, this is going to be a much bigger challenge. But often that would have to take precedence over any other goals that you might want to set, including things like toilet-training. On the other hand, often the key to treating behaviour problems is to teach adaptive skills. For example, a lot of times behaviour like aggression exists because the child has no effective means of communicating what they want or they don't understand what we're trying to do with them or for them. So if we want to be able to successfully reduce the disruptive behaviours then we have to come up with some effective means for them to be able to communicate. So you really can't do one without the other and in actual practise you've got to proceed on both fronts at the same time. Teaching adaptive skills, important functional skills like communication and leisure skills which is another very common area of need can overcome a lot of inappropriate behaviours that you have to contend with. We have to avoid overreliance on reactive strategies. Reactive means when misbehaviour occurs we implement some kind of consequence. You also have to work proactively, meaning teaching things ahead of time and trying to prevent the occurrence of behaviours in the first place as well as having a plan in place for what to do when the behaviour occurs.
Another thing that becomes more pronounced as kids get older is splintering skills. Developmental profiles tend to be quite uneven generally for autistic children and this is more so as the kids get older. By splintering what they mean is that the child has very good skills in some areas and extremely deficient skills in other areas. So if you tried to map out the developmental profile it would look like the Sierra Nevada, mountain peaks and valleys. And this kind of profile makes it difficult to make any kind of generalised statement of an individual's overall level of functioning.
What is the true measure of what a child's IQ is? Do we look at the peak, do we look at the valley, do we average it out and put a line through the middle. Actually it seems like the most useful way to interpret it is to look at the peaks as indicative of what the potential is of the individual, rather than taking the average or looking at the lowest level of performance. But, for example, we'll have kids who can read but can't talk. It's a very unusual combination of skills. Often we'll see kids with incredible memory skills particularly good visual memory and yet extreme difficulty with social behaviour, reasoning and judgment and anything that's abstract. What that means is that in designing your curriculum you have to take a balanced approach. Certainly the greatest area of need is in the areas of greatest deficit. But if we design our curriculum to overly focus on those areas we're going to end up with kids that get extremely frustrated.
What we need to do is also tap into the areas of strength and in fact look at ways of helping them with areas of strength to compensate for areas of weakness. Kids have difficulty with abstract reasoning and figuring out what to do in different situations. We just make up lots of rules. They may be really good at simply memorising rules. So that would be one way to help them learn what to do in social situations. If you've got a child who can read, you could teach him to type on the computer and then you've got a practical means of communicating back and forth, for a child who is non-verbal. You also have to look at, as I was saying, the importance of reinforcement. You can't accomplish anything if you don't have effective reinforcers. Just one example, you can't pick a 7-year-old up and toss them in the air as a positive reinforcer. You are a little more limited in certain ways. You also have the consideration of age appropriateness. Some people are fanatic about insisting that anything that a developmentally disabled person is encouraged or allowed to do be something that is age appropriate. I don't take such an extreme view. I think that, first of all, that's not based on science, that's based on religion and I don't belong to that church. But I do think that there is a valid concern over stigmatisation. If you've got an adolescent who walks around wearing a goofy hat with long floppy ears" (you know you go to Disneyland and they have these hats with goofy on the front and its got long floppy ears)"maybe many of us could wear a hat like that and get away with it but a child with disabilities doesn't need that extra attention being called to them. Now they may love goofy and that may be the biggest reinforcer in the world, but if he takes it outside of the home he will be subjected to ridicule. So you've got to think about that, or if he is carrying around little big bird dolls or things like that. I can't really say though that reinforcement is any more important for kids that are older than it is for kids that are younger. I mean it's equally important. The issues you will be looking at is how the reinforcers may be different at different ages and what's "normal" for a certain age. If you look at what's reinforcing to a typical 2 or 3 year old as compared to what reinforcing to a typical teenager, they're radically different. What's tricky about it is, you've got a person in the body of a 10-year-old with a developmental age of maybe 4 years old. And so it's kind of difficult to reconcile that discrepancy. One of the things that we had to learn to do earlier on once we moved away from the university clinic where we were just working with these cute adorable little 3 year old kids was to be flexible and creative. Working in the university setting was kind of like a fantasy world. There was never anything that we couldn't do because of shortage of funds or at least that's how it seemed. There seemed to be fully adequate resources, not the least of which was manpower, person-power to do the work with the kids. At UCLA, Dr Lovaas taught an undergraduate psychology course in behaviour modifications. He taught it twice a year and he got an average of 200 or more students each time he taught it. From that class students who got an A or a B or a C if they really begged a lot could then sign up to take up a lab course and often there were 40 or more students at a time that were involved in this laboratory course. They were the therapists that worked with the kids. I think that college students are the best therapists in the world.
Looking for demographics on what to look for in recruiting therapists, I would say go to the local colleges and universities. I think the reason for that is that you've got people who are young and energetic and incredibly naïve. They'll do anything you say. They don't know any better. They work hard and the reinforcer for them is not money, although it does take money to pay the rent and buy gas for the car. The reinforcer is getting the work experience and working with the kids and seeing the kids progress. People who have that as reinforcers are the best people to work with your kid. Outside academia, it seems to be a lot harder to find the bodies that you need to make a program work. So we had to look at other ways of motivating people and looking for other places to recruit staff.
But I must say that even now we still rely extremely heavily on students. Another thing we did that was kind of a radical departure from what we had done at UCLA was to consider working with the school as allies rather than trying to always avoid them. The view of the school system was basically that you did not want your child anywhere near anybody that had anything to do with the public school system. Now that attitude came to exist because of experiences, accumulation of experiences but it's important not to indict everybody and not to indict the whole system. The reality is that this system represents a potentially very important resource. If you are going to avoid it or eliminate it as an option, then you are ruling out, at least in America, one of the most valuable potential resources that exist, and I think that's true in any country. There is a difference though in that, in America, there is a Federal standard and many states have standards that are even higher than the Federal standard which mandates the public schools to provide a certain level of education that is deemed appropriate or even optimal. That has been the legal basis for many parents to obtain funding for an ABA program for their school age autistic child. That is not quite the standard that exists in Victoria, as I understand it, so you will have to come up with even more creative approaches, in identifying resources to solve this problem.
There are lots of other things that we did, that we tried, to be more flexible in implementing the programs. One of the things was that we agreed to work with families who were not going to do a 40 hour a week program which is some ways is like heresy but less than 30 hours is not necessarily worth nothing. So far there has not been enough research done to clearly point out to us what the dose effect is of ABA at different levels.
All we have is isolated studies done in different ways and we have to try and extrapolate between the studies. For example, the Murdoch study done in Perth provided children with 20 hours a week of therapy. Now kids improved, there is no question about that, and the improvement was statistically significant and I would imagine that many of the families involved in the study would deem it also to be clinically significant in terms of improving the quality of life for the kids in the study, but none of the kids in that study achieved outcomes like Lovaas achieved in his study where the kids got an average of about 40 hours.
There were other differences between the studies and that sort of makes it fuzzy in trying to sort out exactly what those findings mean. It's not as simple as saying 20 doesn't work and 40 does work. But it is at least an indication that its very likely that 20 hours is not sufficient to get the optimal response. Dr Lovaas is very consistent and very adamant in his assertion that 40 hours is the recommended amount. But there are lots of people who can't do that, and there are lots of kids who can nevertheless benefit from ABA at more limited number of hours and I think it makes sense to try and help them to be able to do that.
Let me talk a little bit about curriculum issues as pertaining to all the children. This is an area where there is considerable difference in the approach that one would take as the kids get older. What really needs to happen is that as the kids get older and if they have not advanced to the point where they can participate meaningfully in academic activities, then what we need to do is put greater and greater emphasis on what we call functional skills. It's kind of a funny word that people use, in America functional skills is the euphemism for anti-academic. Often the people who promote teaching functional skills to kids act as if learning to read is not something that is practical for kids, not functional, which amazes me because I can't think of anything that's more functional than being able to read. And I think its very problematic if you take kids who are 6 years old and (What would be the equivalent of WalMart in Melbourne?) fill up their time doing "community based instruction" so these little kids are going out every day and are making purchases at WalMart, (you know, it's like K-Mart or Target). So they're learning practical skills, how to get along in the world, how to cross a street safely, that money gets them things, that if you have a little money you can get a few things, if you have more money you can get more things Okay, that's practical and that's functional, but for a 6 year old child, aren't we sort of rushing things just a bit. There is plenty of time to learn some of those lessons although I certainly would agree that crossing the street is an important skill, even at a very young age. It's not so much that there is anything bad about teaching them skills like that but is that using up so much of their day that there is no time left to give them an opportunity to perhaps learn to read and to communicate via speech. Certainly for kids who aren't going to learn to talk, something like the Picture Exchange Communication System or assistive technology, you know, computerised devices that allow kids to communicate are very very important.
But if a child could potentially learn to talk, really isn't that where we ought to first be working and then if it looks like we're not going to be successful, taking that route, then let's fold, let's go with the backup of communication needs. So I think its important not to sell the kids out too soon and I think one of the really important lessons from Lovaas' work is that you can accomplish a lot; don't underestimate what these kids are capable of. If you are going to accomplish it, you've got to be willing to work very intensively. If you think about the usual prescription that a parent gets upon receiving a diagnosis of autism it will include a recommendation for some kind of developmental preschool, the speech therapy, probably some occupational therapy of the sensory integration variety. Actually there may be some wisdom to that. Actually speech therapy in the hands of a competent practitioner can be extremely beneficial, but why 2 hours; or lets put it this way, if you think 2 hours is a good thing, how much better would it be if you could get 20 hours or 30 hours of speech therapy. So I think that the mistake that people have made is not so much, what they're recommending, I don't have problems with that, but it's how much it's failing to recognise that there is an incredible difference in the outcome that will be achieved if you multiply the effort radically. It wouldn't be justified to put in 30 hours per week of 1 to 1 teaching if you were not going to get substantially better outcome. Given that there is a decent chance that we can make vastly better outcomes then it makes sense to do it. But as the kids get older though, we do have to put a lot more emphasis on teaching practical functional skills for kids that are not going to go on to College, for kids that are not going to be able to be competitive in the usual sense in the workplace, we need to work on the other important aspects of daily living like how to operate a washing machine and how to fix meals for yourself, so that they can learn to be as independent as possible. So that's the direction it goes. I wouldn't be worried about teaching a 12 year old colours if earlier attempts have been made and they just didn't happen; there are probably more important and useful things.
There is one other thing, it's kind of unrelated to this topic that I wanted just to tell you about and it's very exciting and it's some research that's just come out in the last year and I don't know if people have heard much about it. It involves children with language learning impairment and the thing that's very exciting about it to me is the potential for this to be of assistance to autistic children who are having great difficulty understanding language. I'm talking about the kids who can't make sense out of the command "clap hands", vs. "stand up" or "apple" vs. "shoe" vs. ball. What the research found, they sort of stumbled on to this when they were looking at kids with dyslexia which is a reading problem, they found that some of these kids with language problems had an auditory processing delay; for these kids it takes them longer than normal to process sound.
For some of these kids it took them 100 milliseconds to process sounds like speech sounds. That's a problem because many sounds in the English language and probably in lots of other languages have a duration that's less than 100 milliseconds. Some sounds are as short as 60 milliseconds and basically they're not getting those sounds - it's just being missed. So that could explain why autistic kids who are able to make these receptive discriminations are having such difficulty. We know they can hear, and we know that they can process some speech to a certain extent and we know that they're intelligent and they are able to learn visually but there is something wrong with the auditory processing channel. Well, the ingenious approach that they took to solving this problem is that using computer technology, they artificially lengthened the duration of the sounds and effectively recorded speech that was artificially manipulated and they created computer games where the kids are hearing speech that's been altered and learning to make discriminations and by making it into a game, its something that's inherently reinforcing.
And they start out with making the duration 100 milliseconds and then after the child then meets a certain criteria, then they decrease the duration to 90 milliseconds and then after a time, then down to 80 milliseconds. That sound familiar doesn't it, like prompt fading and stimulus fading. It's exactly what they did and they found that they ended up with the kids being able to fully understand speech that was just presented in a normal fashion.
Autistic children were not the target population for these initial studies but it looks promising. They've done preliminary clinical studies with about 20 autistic children and are reporting that the results are very encouraging. So we intend in our clinic to get access to this technology and do some trial with kids. One of the things that remains to be determined is whether this is going to be able to work for kids who would be regarded as lower functioning or how much sort of prerequisite common skills does it take to be able to participate in this computerised game process, but I wanted to mention that because I think it's an important development and even if the first approach that they've come up with does not work for the kind of kids we're looking at, surely there is another way that we can go about this. I can imagine having a little black box with a microphone on it and you just give your instructions into the black box and it alters the sound and the kids put little headphones on. What you can do is go on the Internet and look for, go to the address "scilearn.com". In order to have access to the software, you have to consult a professional who's been certified by the people who own this program. Unfortunately, it's become a commercial enterprise now. But as a psychologist or as a speech therapist that qualifies you and you need to take their workshop and get trained and then that entitles you to make this computer program available to clients that you work with. You'll have to get them to come over here to do a seminar. I'm sorry I don't remember the names of the researchers. But if somebody will go to that address you'll get it there and you can access it through more traditional means like journal articles. The most interesting article was published in the JAMA (Journal of American Medical Association), around January 1996- Jan to Feb. If you want to try to hunt it down.
The last thing that I want to say a little bit about and then we can end it up with questions, is the whole problem of developing a cadre of para-professionals and professionals who will help make ABA more widely available for kids. One of the things that I've found over the last couple of years that looks to me like a smart thing to do is something that's actually pretty easy given that you have some consultations going on. When you have, as you do here in Melbourne, clusters of families that are doing ABA program and people are bringing consultants in to train therapists and provide periodic supervision and these are people who have extensive experience, who are qualified to really do a proper job of designing and running a program, you want to capitalize on that fully. One way to do that is to have therapists sit in on workshop sessions with kids other than the ones they're working with. It doesn't cost anymore, the consultant's time is exactly the same. And you could double or triple the amount of training experience that interested therapists get if you all just simply work out some sort of co-operative arrangement among yourselves where you invite therapists to sit in on each others workshops. Now, apparently not all workshop providers are willing to go along with this kind of arrangement but at least some, and I would hope most, will be. Personally, I don't think that there is any legitimate reason not to let people sit in on workshop sessions. It's really, the way I see it, it's up to the parent. If the parent is comfortable with it, the only real issue is confidentiality. There's really, I don't see any other legitimate reason not to let this happen. In places where I've gone where people have done this, I've seen a very impressive degree of acceleration in the development of skills among the therapists. The thing about doing an ABA program is that it takes a couple of years to accumulate sufficient experience to be able to, to really effectively design a program for kids. Now, someone who had 6-9 months experience often could get a program going for a child who's starting at the basic level of non-verbal imitation, matching, receptive commands level. A lot of kids actually start at that point. Often this is relatively straight forward, especially if the new child has learning characteristics and behaviors similar to children the therapist has already worked with. But if your going to guide the child along the entire curriculum it takes time to see how his development progressed. And one of the things that is important in developing skills of therapists is that they be exposed to children at different levels of the program. And also more than one child. If you work with one child, you'll get to be a good therapist toward that child. If you work with two or three kids you'll start to become a good behaviour analyst and that's really what it takes to learn, sort of the generic process rather than the specific concrete steps of, you know, do these 10 non-verbal imitations and then call me when you get done with them. Also, in terms of developing skills, people do need to know the basics of ABA. This is something that could be accomplished in course work, it can be done through reading, in many cases it can be done through attendance at workshops and really there's no reason why it couldn't be done by just watching a course on a video tape. Basically, get a series of video tapes that would cover the basics of ABA and people can go through it at their own pace. I think the reasons for learning the basics of ABA because this is not a program that really should be implemented in cookbook fashion. By cookbook I mean, you look up in the index under - throwing blocks - and you turn to page 80 and it says - throwing blocks; make him go pick it up and bring it back to the table. You can't solve behaviour problems in that fashion. The A in ABA stands for analysis and analysis means that we make an intervention and we evaluate the outcome and then we make changes if needed. So if we want to solve the problem of throwing blocks we have to come up with a hypothesis as to why is he throwing the blocks in the first place. What's the pay off that he's looking for. And once you've figured what the pay off is, you're going to know whether you should have him go pick up the blocks or just keep him sitting at the table and go right on and reach down to the bucket and pull out two more blocks. So you have to understand how behaviour analysis works and that will make the difference between a technician and a therapist. One other recommendation in terms of recruiting not only potential therapists, students to be potential therapists, but also and perhaps starting to win over professionals and the people who shape future professionals is to offer to make a presentation at university courses that are covering either developmental psychology or behaviour modification or psychopathology or abnormal psychology or. Invariably at some point during that course, autism is on the syllabus and some professors might be quite agreeable, in fact they may go out and play golf for the day, have a guest lecturer and there's nothing more impressive and nothing would do a better job of selling this program then bringing in a child. It's a little bit of a risky thing, it's not something you would do with just any child but it's incredible how people respond to seeing an actual child. That emotional appeal is strong. But even if you don't do that at least you could make a video tape presentation. And what would be very impressive is a before and after demonstration. This is what the child was like a year ago. This is what he can do today. And when the professors start to see that it may start to open the door and make people a little more receptive to what your trying to help them understand, the terms of what contemporary ABA really is and what it has to offer the kid.
There may be some cultural differences that I haven't yet totally been able to sort out. Some described to me the "tall poppy" phenomenon . Have I got that right? And that's something that's definitely Australian that we don't really have to contend with in America. I think that comes into play in getting therapists to learn from each other. One of the processes or tools that we use is weekly or bi-weekly clinic meetings, where everyone gets together, everybody takes turns working with the child. Basically, get critique by their peers. And that process works, we can make that work well in America. I'm not sure if this "tall poppy" thing (that it's not ok to look too good because you will get chopped down) will get in the way too much of getting people to speak up in meetings.
There are huge regional differences in America in the accessibility of ABA. There are regions in America where it's just not accepted and so you're not necessarily any worse off here in Australia. What parents have to do, the most efficient way to do it, I think, is with a workshop. Use that forum to train as many people as possible when you've got the experts in. Look at video taping in fact design it in such a way that you can put it on videotape for training future therapists. Volunteers is one way to make it happen. But let me comment, there is some inherent difficulty in running programs with volunteers. You know, in some cases it's your only option, so I'm not saying that you shouldn't do it. But volunteers have a tendency to fizzle out. There's lots of people who start out with kind of , good intentions, church members, neighbors, family members and people like that. But it takes a lot more than good intention to stay with this and I think that one of the reasons why college students work out so well is that these are for the most part, people who are intending on a long term career path where tutoring an autistic child fits in with that. It's not just a little sideline. But the kind of workshop model that I would envisage for families over here would really not be any different than what I would do in America. The workshop has got to have two components: it's got to have the didactic component, something that can be video taped and actually could even theoretically be gotten by reading. But the second part and perhaps even more important is the hands on experience. It is not sufficient to merely to talk about it.
At age six can a child be in a half a day program at school. And then the other half of the day doing discrete trials. Or he can spend the whole day at school. That's a question of integration or mainstreaming. What we do is look at the, basically, the daily schedule for what the kids are doing and we identify those periods of activity that the autistic child can meaningfully participate in with assistance. And we trial these periods of time for mainstream and then other times we do one on one discrete trials or in some cases, small group activities. For example, there are kids who, whose one of the greatest areas of need is to be able to listen to a story, follow along what's happening and if we put them in the big circle with 20 or more kids they just space out. It just doesn't work. What we need to do is take a child like that and go off in a very small group, away from the large, all the hubbub, and we may also need to be using different stories. Stories that the language is a younger level but we put him there with a couple of other kids who serve as distraction so that he learns to attend with distractions. So that would be one kind of modification that goes beyond doing only one to one discrete trials but it depends on how far the child has progressed in the program. Clearly, for older kids, the ideal is to have ABA incorporated in what happens at school. And one way to do that is to have, if there's a one to one aide being provided, get that aide trained.
And not only get the aide trained, don't just train them at the beginning of the school year and then say good-bye but have them join in every week in the team meetings so that there is an on-going process of collaboration.
You know there's, I've actually only met one person who, one parent who was able to be the primary provider of therapy to their autistic child and not burn out. And she's in this room here. Sitting right in the front row. It is almost an inevitable set up for burn out, if you take on primary responsibility. Now I do think that it's really good for parents to be able to do a little bit of discrete trial teaching. It's a wonderful way to learn behaviour management skills. The structure that exists within the discrete trial will set the stage for you to be successful and for your child to be successful. Realistically, it's something that's very difficult to sustain especially if you've got other kids, you know, you've got to work, you've got to maintain the house, you know.
Or look for someone with a high "Ma" on the MMPI, (that's the mania scale). There's lots of therapists in this room here who have no problem being abundantly zany.
The other important question to ask, is are we talking about someone who would be regarded as fairly high level with verbal skills or someone who has significant cognitive difficulties. I think that for someone who's, you know, in adolescence/ early teens who has a diagnosis of autism but who has also a fair amount of developmental delay, at that point we're looking at a person whose needs are beginning to look more and more like that of a person with mental retardation, like people in general who have a developmental disability but is not autistic. There are certain things that are unique to autism (like tendencies for fixation), but the biggest needs will be communication skills and functional skills as far as being able to get around in the community. For example, for a person that age I wouldn't at all be thinking about a 40 hr a week program. I would be working with the people at school, trying to get them to implement a behaviourally sound educational program with him at school. I might consider doing a couple of hours a day after he gets home from school, working on some of the things they're not going to be able to do in school. And possibly also spending additional time working on some of the things that they are working on in school. Knowing that that extra time will help him more through the curriculum.
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