Currently, our ABA programs are focused on skills that are being both practiced inside and outside of the home. This week, I am going to give a brief overview of the in-home therapy programs. Although everything we are working on matters, the bulk of our time is spent working on skills necessary for Tony to function safely outside of the home…so those areas of his programs are going to get multiple posts in December. Many of you have heard me say this before, but it won’t matter to anybody what he can do or what he knows if he can’t acquire certain safety skills in the public domain.
One of the biggest challenges we have in any setting is the overall lack of joint attention our little man has. Joint attention is essential for learning many things, and it is necessary for a conversation that lasts longer than a request for a particular item. A little over three years ago, when our son was first diagnosed with ADHD, his developmental pediatrician and I hoped that the medications would help increase his attention span. Unfortunately, that really wasn’t a benefit that materialized for us, so we are needing to target the development of joint attention therapeutically.
Initially the task was just to get Tony to request a fun activity that he could do with the therapist and then make eye contact. We are currently working on the next step of that, which is a three point gaze in which he looks at both the therapist and then the item being used. For this therapy goal, we are starting with preferred activities because he is most willing to cooperate and practice the appropriate skills with those.
Another critical program revolves around tolerance for being told “no” and teaching Tony an acceptable tolerance response. When the anonymous BCBA and I consulted about this need, this person gave us a recommendation for a program that initially began with directing our son to say “OK” on his AAC device. The request to give that as a response was given randomly across all of his activities, with the goal of helping him to feel like it was an automatic response. Initially he had to be shown and verbally prompted every time. Now when he is asked to say “OK,” he will hit this button on his speech device independently. I worked on teaching to him what “OK” meant, because typically he prefers to use “yes” and “no.”
We have now advanced this program to giving him a “no” for 25% of his requests in-home during a therapy session. What we are looking for is for him to either say “OK” or to respond calmly without pushing towards the item desired, having a tantrum, or self-harming behaviors. As his tolerance for this grows, we will increase the percentage of “no’s” he’s getting and move to have therapists give him a “no” in the community. Right now, I’m the only one who’s got a chance of giving Tony a “no” in public and having him tolerate it calmly…but as we’ve discussed, even for me that’s iffy. But as a mom, sometimes a “no” must be given, and what we are trying to do is teach safe responses and reactions when his first impulse is to try and push his way to what he wants.
We are also, as I mentioned last week, working on helping Tony tolerate tooth brushing and learn some self-brushing skills. Because of the deficits he has in motor planning, we are having to teach one plane of one tooth quadrant at a time, and it can take a few weeks for him to master each plane. We are also working on asking him to keep his clothes (and sometimes a mask) on in-home for longer periods of time when a therapist is present.
Tony also has an ongoing program for labeling certain items. The goal is to integrate these items in ways that expand his conversational or requesting skills. So an example of how we are implementing this is to pick an item, such as a straw, that we want him to label with others independently. Once he has achieved mastery, we prompt him to ask for it as an item he needs to drink his smoothie. The straw is withheld until he asks. After the first couple of times, Tony doesn’t need the prompt any longer, and he will move automatically to independently request the missing item. We will do this for clothing items when we need to go out in public, any item that starts out being taught under tacting (labeling).
While we are running the other programs in-home, we have items we have asked him not to touch that are spread about the living room, and as mentioned in a previous post, he’s rewarded with skittles every time he refrains from touching the items for the designated time period. We also have programs for imitation and cooperating with instructions given by someone who is not me. For the cooperation, we started with tasks he felt happier about, moved on to tasks he felt neutral about, and now Casandra is focusing on asking him to cooperate with requests for things he doesn’t really want to do.
For the new ABA RBT that is working in the mornings, she is performing all of the same programs with Tony, because what he needs most is practicing generalizing tasks with others. One of the more challenging deficits for our son is the difficulty he has in generalization. He can learn a skill under the direction of one person, and be unwilling or unable to do it in a new environment or for a different person. Typically it will take him attempting the task for several different people before he will exhibit first time cooperation with something he has learned for an entirely new to him person. However, for a new therapist, we make modifications initially to have that person ask him to cooperate with requests he prefers more initially and then advance him as tolerated.
