"Not to me either. It's not as if someone were tying him to the chair," Kevin agreed."
"Viki! Don't tell me you're going to agree to this?" Blair protested, sharply.
"You are? Aren't you!" Sam's was accusing more than asking.
"I don't know. I have to think about it. I honestly don't see that much harm in him being held in a chair for a second or two," Viki knew this was not what Sam wanted to hear. She had to think of Adam first.
"To start! Viki! Didn't you hear Doctor Hanen say, 'to start!' Before we know it they will be strapping him down to the chair the same way they do in the bed." Blair was genuinely horrified to think of that very young child being subjected to that.
"So, even if he's crying you will still hold him in the chair?" Téa asked. She was not comfortable with this part of the treatment, but if it were necessary she would participate.
"Yes, at the beginning. He would still be praised and reinforce, even if he were crying. He needs to make several associations. He needs to understand that crying will not get him out of achieving his goals and that coming to the chair can get him what he wants. Once he realizes this we can expand the lesson. At the beginning we will use powerful reinforcers, things that he really likes to help him start to get the idea. After a while we would only use powerful reinforces for compliance without a prompt and then only when he is behaving appropriately. This means without any inappropriate behavior like crying or stimming. We would also use a powerful reinforcers when teaching a new skill, or fading the prompt."
Susannah could see that they all looked confused and uncertain.
"Susannah, I'm sorry, I'm not following. After a while you will only use things that are just so-so to him?" Kevin wanted clarity.
"He would still get powerful reinforcers, but they would be contingent on his completing a task or learning a new one or fading a prompt. If I say 'do this' and touch my nose and he imitates correctly without being prompted and without any crying or any maladaptive behaviors he gets a powerful reinforcer. If he touches his nose, but he is crying, stimming or needs to be prompted, he would get a less powerful reinforcer. You also have to be very careful with the delivery of the reinforcer. You have to observe him very closely while he is doing the task for any maladaptive behavior or any behavior you don't want reinforced. If you don't, you can end up reinforcing that inappropriate behavior along with the appropriate response. Let's say as he's about to comply and his face itches and he scratches his cheek or he stims or makes stereotypic sounds while complying. If you reinforce at that moment you may also be reinforcing any of those behaviors. Observation of every nuance of his behavior is crucial. He needs to be sitting quietly, without crying, stimming, acting out, self-abusing, or engaging in any behavior you don't want reinforced."
Susannah could see they were getting nervous. They were afraid that they'd never be able to do this program as exactingly as she described it. "I know it sounds complicated. I think you'll find it will begin to come naturally after a few sessions. If you make a few mistakes at the beginning don't panic. It should not cause any long lasting problems."
"If we reinforce the wrong behavior at the beginning it won't cause him to think that's what we want him to do?" Viki asked, nervously.
"It's highly unlikely that reinforcing this behavior once or twice will do that. It is also unlikely that you would mistakenly reinforce a subtle behavior like the example I gave of him scratching his cheek more than once. If he had some kind of problem, such as an allergy that caused this, we would be aware of it and know to look out for this behavior. I don't want you all to become so afraid of doing the wrong thing that you become stiff and fearful when you work with him. Keep in mind that most families and beginning professionals feel exactly as you do. It is a normal reaction. This is complicated and there are always mistakes made at the beginning. I've never known a child to have lasting effects from the kinds of typical mistakes made by families and beginning professionals who are conducting ABA programs. Try to relax and make it fun for both you and Adam."
Susannah could see some of the tension leave Viki, Téa and Kevin. Sam and Blair still looked anxious and upset. She understood how intimidating this could all be. Susannah continued. "Okay, so if he complies correctly and with appropriate behavior you reinforce immediately. He has to associate the reinforcer with his compliance. In addition to the task being asked of him, you also reinforce any spontaneous desirable behavior, like eye contact or speech and good attending. What you are doing is catching him at being good. If you do, you reinforce. If before you've had a chance to offer a reinforcer his behavior turns inappropriate you hold back and wait for a correct response with appropriate behavior. Keep in mind, at the beginning, we are more flexible with the reinforcers. Even if he's displaying some maladaptive behavior he would still be reinforced for complying," Susannah once again emphasized.
So far, nothing that was said helped to change Sam's opinion of this program. "What kind of way is that to treat a child? Not only does he have to do exactly what you say, but also if he's miserable doing it and cries he's denied something he really likes. I can't believe parents actually go along with this." Sam looked at Viki when he said this. He could not understand how she was going to allow this.
Susannah knew it was common for parents and family members to react this way at first. She realized they would not be comfortable with the program until they started seeing Adam make progress and see that he is surviving the demands placed on him.
"Then you do expect him to cry a lot at first." Kevin asked, nervously.
"Yes, I won't lie to you," Susannah admitted. "As I've said before, he may cry and possibly tantrum for quiet some time until he starts to make those associations I mentioned. I'm hoping that when he goes back inside he will retain what we've taught him and carry it over to the following lesson the next time he comes out."
Another question occurred to Viki. "Are there any set lesson plans that will be used for Adam?"
"Yes, I will go into the specifics when they have been drawn up. They will be based on the goals that we have set for him,"
"Doctor Hanen, he's just a little boy. Aren't you expecting too much from him?" Téa spoke up. She didn't realize how structured Adam's days would be.
"When Adam is out we don't want him to isolate, self-abuse or stim all day. The goals I have for him, for now, are attending, imitation, following commands, matching, appropriate play, point response and functional communication. Please understand these goals are broken down into the most basic steps. He will have as long as he needs to learn each step. If he seems to have trouble with one particular aspect of a skill it is our job to figure out how we can get him to learn. He will never be spoken to harshly for not understanding something. We would go on to something we know he can do. The most important thing is to make him succeed. That is why if he is unable or unwilling to do a task we will physically prompt the correct response, hand-over-hand if necessary, so that he can succeed and be rewarded. It is also important that he begins to see his lessons as fun and not as punishment. To that end it is up to us to make them fun for him." Susannah was hoping they would all begin to see that ABA was not as hard on the child as they imagined it be.
"And how do you propose to make him see that it's fun when he already seems to hate what you are trying to do?" Blair asked.
Sam looked her way and nodded. Susannah once again repeated, "It is expected that he will cry and even tantrum when we place demands on him. Most children with autism are very resistant to intrusion and the kinds of demands we place on them. This behavior may persist for days or even weeks until he makes the connection that this isn't so bad. We ask him do something he does it and gets something he wants. Eventually the crying and tantruming decrease because we are not addressing them at all. We only address the appropriate behavior. He is getting nothing from crying and screaming and kicking, but as soon as he complies he gets something he enjoys."
Both Sam and Blair thought how much like training a puppy this seemed to be and both found the thought of using those techniques on Adam repulsive. It wasn't that ABA didn't strike Téa, Viki and Kevin that way, to some degree. However, they understood that this was the way this child needed to be taught.
"That is not at all the way Starr was raised. Todd and I paid attention to her when she cried. She turned out all right. She didn't have to earn every last thing we ever gave her," Blair commented.
Susannah did not think Blair was just trying to cause problems. She appreciated how difficult this was to understand.
"Adam does not perceive things the way Starr does. He can't learn from his environment the way a typical child does. Most of us learn incidentally. The teacher tells you something once or twice and you start to get it. The teacher may give several instructions at once like stand in a circle, clap your hands and touch your head. Children with autism usually can't do this. Each skill has to be broken down into single elements and each part of that one element has to be taught. For instance, first we need to get him to pay attention to us. If we are teaching at the table then the first thing would be to get him to come to the table. That skill alone could take days or even weeks. We shape his behavior. We can't expect a child who knows nothing about paying attention or sitting or even standing at a table to comply, so we physically prompt him when the instruction or Sd, discriminatory stimulus, is given."
Susannah paused again for questions. When there were none she realized that it was most likely because, at this point, they were too intimidated by the program to think of any. She continued to carefully explain. "At the beginning of each new skill we expect to have to use physical prompts, like leading him to the table by his shoulders, forming his finger into a point, sitting him in chair, assisting in a skill hand-over-hand, if necessary. Then we begin to fade the prompt. Like in the case of forming his hand into a point, just lightly touching his elbow may be enough, and then eventually the physical prompt is not used at all. We may go to a gestural prompt, which might be a slight motion of our hand or eyes to give him a clue as to what he's expected to do. Once we document that a skill has been done successfully, without a prompt and generalized, in different places with different people, eighty percent of the time we consider it a successfully learned skill. These skills are placed on maintenance so that the child does not regress in them as new skills are introduced. A maintenance schedule allows for periodic revisiting of learned skills, every week or two. This will help to keep them fresh while the day-to-day progression of new skills continues."
"So he may know a skill at the table but not be able to do it in the playroom?" Kevin sounded confused.
"Yes, Adam may not be able to do that skill anywhere else or he may be able to do a skill with one of us and with no one else. He may be able to label a juice box or his sippy cup, 'ju' or even say the word 'juice' at the table, but not be able to request juice by saying the word. He may respond to 'hi' but not 'hello.' It is not uncommon for learning to be very uneven. That is where incidental teaching comes in. We need to get him to generalize his skills. Once we see that he gets something in isolation, meaning at the table, in this little corner of the room, we take it out of isolation. We try it in another room or with him sitting on the floor and with different people. We would introduce some distractions. We try combining that skill with other learned skills. The skill has to be generalized for true learning to take place. If he can point to his sippy cup and/or say 'ju' while at the table, we ask him to do that whenever he wants a juice, wherever he is. We maximize every learning opportunity."
"I see what you mean about making him beg for food," Blair commented under her breath.
"No one is making him beg for food, Blair! He's learning to ask for what he wants. Don't you want him to be able to do that!" Téa spoke angrily.
"Of course I want him to do that, but I would be happy that he just wanted the juice. I wouldn't expect him to have to work for it. He's just a baby. I didn't withhold bottles from Starr because she wasn't asking for them."
"Blair, Susannah is trying to explain that Adam is not like Starr. You didn't have to teach her this way. She learned to say ba and then ba-ba when she wasn't even a year old. Adam is at least three years old and he can't do that," Viki tried to keep her tone patient.
"Using Viki's example of Starr going from saying ba to ba-ba," Susannah went on, "one thing does not necessarily lead to another with many of these children. Learning to say 'ju' for juice many never lead to the full word, hopefully it will. Even if it does, that does not mean he will make the connection that this is how you ask for juice. Adam has to be taught everything one small step at a time. This is called Discrete Trial Training, DTT. It consists of several parts. There is the instructor's presentation or instruction, meaning the Sd. There is the child's response. The response can be correct, prompted, incorrect or no response. Then there's the consequence, meaning the reinforcer to the appropriate response or what's called a no-no-prompt for an incorrect response. The consequence is what gives the child feedback and lets he or she know if what they did is correct or not. The no-no prompt is simply saying something like 'nope,' or 'no try again' in a dull monotone voice so that it doesn't have the reinforcing quality of the highly animated voice you use when reinforcing correct behavior. Keep in mind the consequence or feedback has to be unambiguous. Don't smile when you say 'no' or 'nope' and don't frown or look unhappy in some way when you say 'great job.'"
"Susannah what about allowing him to play. You said there would be almost as much playtime as work time at the beginning?" Viki reminded her.
"Yes, he would get frequent breaks. The length of each break depends on the amount of time he's spent doing trials. It should be proportionate to the length of work just completed. If we just did three quick trials then the length of the break would be about a minute. If the trials lasted for three to five minutes the break would last about two to three minutes. For ten minutes of teaching he would get a five minute break and so on. It doesn't have to be exact. We would use some of the time during these breaks to record data and prepare materials for the next trials. You would still monitor him while he's at break and if you catch him being good, meaning he's not engaging in stereotypic behavior or he is playing with toys appropriately you reinforce that. At the beginning he would be allowed to engage in stereotypic behaviors or to pretty much do whatever he wants during a break. We want him to understand that this is a reward and it is his time and it's free of demands. Later on the break will end if he engages in stereotypic behaviors."
"So in other words even during his break time he won't be allowed to do as he pleases." Blair emphasized the word pleases.
"At the beginning he will. We will not take anything away from him without giving him something to substitute for it. Once he has activities that substitute for behaviors like stimming he would be encouraged to engage in them," Susannah spelled it out more clearly.
"Does he ever get longer breaks?" Kevin inquired.
"He does get eating and nap breaks?" Tea stated more than asked.
"Oh yes, absolutely! There would longer lunch and nap breaks. There would also be longer breaks during work time. During longer breaks we would try to engage him in appropriate play without infringing on his break time. That means we would not ask him to come to the table or to play with something he does not seem interested in. Every hour or so he would get a longer break, about ten to fifteen minutes. During this break we would take him outside, to the hallway or the day room or playroom, so he can have a change of location and engage in some physical activity. This is important in maintaining his interest level and attention. Breaks would also be used to shape appropriate behavior. We would give let him take a break when any kind of inappropriate behavior is on the decrease, rather than when it's increasing."
"Wouldn't he need the break more if he were upset or fussing?" Téa wasn't sure about the seemingly backward way of working with Adam.
"No, if we reward him with a break while he's fussing it would reinforce it. At the beginning we have to think about everything we do with Adam. In many ways we can't use methods used with typical children. Adam's brain will not interpret things the way a typical child's brain would. Even time-outs can be a problem. Especially when the child wants to stim. You would not use a time-out then, because that is exactly what he would want. Going off to a quiet place by himself would afford him the perfect opportunity to stim to his heart's content."
Sam, Viki and Blair realized how different things would have to be with Adam than they were with the children they had raised.
Kevin took a deep breath. Like the others he was feeling a little overwhelmed by the complexity of this. Even though Susannah had explained some of this before it was still hard to grasp. "Susannah, when do we prompt him? Before or after we say 'nope' or 'try again?'"
"If prompting or modeling the appropriate response is necessary it would be done after you quickly deliver the no-no prompt and give the Sd again. Remember that you never use the no- no prompt with a new skill. With a skill that has already been taught, you give him two tries at a correct response and you prompt on the third. You also want to watch to make sure he doesn't start responding before you finish the Sd. If he does then it could mean you are being too predictable. If this were the case you would vary the order of the presentation so he could not anticipate your pattern. It may also mean he is guessing. You would not want to reinforce a guess. That would only encourage him to guess in the future. It could also mean he is not paying attention and you would not want to reinforce a response under that condition."
Susannah looked around at everyone. She was happy that none of them had that "glazed eye look" that some family’s had when all the instruction became too much for them. "Are there any questions about what I just explained?"
They all shook their heads and Téa brought up a good point. "I think I'll have to let all of this sink in before I can even get to the point of asking all the questions I need to ask."
Viki and Kevin nodded in agreement. Sam sat stone faced and Blair sat there looking frightened.
"I think you will all need to do as Téa is doing. You need to let all of this sink in and then make notes about everything you don't understand. I also want you to realize that once you actually start working with Adam it will be easier to understand what it is you are supposed to do."
"He's not a guinea pig!" Blair interjected, "Are we supposed to practice on him!"
"Blair, none of you will be doing DTT alone in the room with Adam at the beginning. I or someone else well versed in it will be guiding you. In a sense yes, you will be 'practicing.' It will not be in any way that will hurt Adam. Actually working with Adam is the only way for any of you to really learn." Susannah could see that Blair was still apprehensive and not at all happy with what was being asked of her or expected of Adam.
"How many times do we show him something, like touching his nose?" Kevin asked.
"There is really no set amount of trials. The average is about ten. There can be as many as fifty. We sometimes do what is called errorless learning instead of the no-no prompt. Some children are very sensitive to the no-no prompt and it upsets them. Errorless learning will prevent the child from making a mistake. With errorless learning the correct response is modeled or prompted from the first Sd and continues to be modeled or prompted until the child can do the skill independently. There are also massed trials. Here the skill is taught up to fifty times if necessary. Massed trials are sometimes used when we first teach a skill or when the child is absolutely not getting what is being modeled or prompted. There is some controversy over the use of massed trials. Some believe that it the best way to get a child to learn a new or problem skill and some believe massed trials can lead to the child guessing or patterns being formed or boredom and frustration. We have to see what works best for Adam. No two children with autism are exactly alike."
Viki posed and important question, “How do you determine if Adam is a child who needs massed trials?"
"We would do three or four trials of a new skill to see what his baseline is for that skill. If he doesn't have too much trouble with it we would do ten discrete trials. Then if he is having difficulty with it we would go to massed trials for that skill. If he doesn't seem to get it at all when we test his baseline skill we would go right to massed trial. If it turns out that massed trials are having a negative effect on his learning then we would discontinue them."
"Doctor Hanen, I want to make sure I'm understanding this. Each trial will not last very long and he will have frequent breaks." Téa was still very concerned that this would be too much for him.
"Yes, the trials will be short. At the beginning they will be very short," Susannah responded.
"So in some cases the shorter the trial the better?" Téa inquired.
"Not necessarily. At the beginning the trials will be very short. After Adam has acquired some attending and imitating skills and has gotten used to the program, and us, we will go to longer trials. We don't want the trials to be too short because that can reduce learning opportunities and can break the momentum. Another thing, the short breaks that go with short trials might not be sufficiently reinforcing," Susannah replied.
"What if even after all that he just doesn't get something?" Viki was worried.
"We would most likely let it go for a while and reevaluate the way we are teaching it to him. We would have to find a different way. It is also sometimes helpful to sandwich a more difficult task in between two easier ones."
Blair sighed. She was still having a really hard time with this, as was Sam. The only difference was that Sam was having a difficult time following everything Susannah was saying. He couldn't seem to concentrate.
Susannah continued. "There is also something called the between-trial-interval. This is a short pause between the consequence, meaning the feedback, and the next instruction or Sd. The between-trial interval lasts about five seconds. It will help Adam to understand that one request has ended and a new one has begun. It will also give him time to process the information he just received. That information would be that the response he gave was either correct or needs to be changed. It also would give us time to process what has just occurred and to collect data. This is when you would jot down a few notes. It also teaches Adam to wait. This is more naturalistic to everyday life. We would also gather the materials needed for the next trial. At the beginning you do not want to keep any material that is not part of the current trial where he can see it. It can become distracting and confusing. It can also give him a hint as to what is coming up next and may cause guessing or the forming of patterns. During this pause Adam would still be receiving praise and allowed to enjoy his reinforcer."
