The seeds of the problem were sprouted and had grown strong roots before we had received any diagnoses past Tony’s sensory processing disorder. I, as a mother just trying to cope with an overwhelming array of challenges related to our son’s health had just been diagnosed with medication-induced liver disease. Andy was in graduate school, and I had been told I needed to loose all of that weight I had packed on living off of Papa John’s while trying to survive the first year of Tony’s life, being unable to cook most of the time.

So I loaded Tony, who was around 18 months at the time, into a stroller and walked up the main street in our subdivision, which heads uphill into the base of the White Tanks, making it more useful (in my opinion) from the cardio standpoint. I couldn’t safely leave Tony next to me to do any form of exercise at home, and at this point in time, I could still be holding him as many as six hours a night to keep him from being injured while he was trying to harm himself during middle of the night meltdowns. So I would blearily trudge up this hill before taking Hannah to school or after, if the temperatures were cool enough, 5-6 days a week.

By the time Tony was stable enough in his gait to walk independently around the community, we quickly realized: there was only one route and one way he was willing to walk…up that main street hill. Which was problematic, because we had other places in the community we wanted and needed to walk, and given the number and speed of the cars, it really wasn’t my preference for an initial route to expand his safety skills.

So, the first challenge was to try and get him to accept other routes. And what we quickly found with that was the way he walked on a certain street the first time was exactly the way he wanted to walk on it every single time after. We were at this time dealing with so much eloping (with an attempt to run off frequently occurring every few seconds), I know I have written about this before, but every outing at that time into our neighborhood was like a high speed chase wrestling match with a fair amount of self-harming when he was denied access to what he wanted (like someone’s yard) and we often had spectators. By the time elopement was reducing, he had learned the value of using all of his strength and body weight to try and push to where he wanted. So, we have been working simultaneously to eliminate pushing and expand his flexibility for walking directions and changes to routes, both expected and unexpected. Sometimes sidewalks are closed for branch trimming, for example, and we need him to walk safely and calmly around things like that.

As of this past spring, we were still having ongoing challenges with the pushing, and we were only able to get Tony to calmly accept 20 seconds of directional changes. A recent change suggested by a BCBA (to increase the length of the change if he pushed) was making him angrier and we were seeing dramatic increases in pushing. I recommended that we switch to differential reinforcement (that means only giving him a reinforcer or reward if he meets certain criteria as opposed to rewarding any effort), and the current BCBA team, who were new to working with Tony) agreed to try it. Previous BCBAs were hesitant to do so because they felt there wasn’t enough evidence to support Tony understanding differential reinforcement, but I have long felt it is clear he is more than capable of doing so. And, shortly after that, all community safety walks were moved to habilitation therapy hours and have not had any ABA team involvement.

So, what follows is where we stand with just me acting as the therapist for our son on community safety outings and the person currently making decisions about what to do and how to advance things.

*Tony now tolerates random and novel changes that can last up to 70% of the walk, with the first reinforcer not being given until the 50% mark. Combined changes have totaled as much as 95% of the route for recent outings. He does not need counting or timers to continue with a change, but will follow my verbal direction for when it is completed and when he can request a change himself if he wants to. I will advance the level of difficulty once he’s meeting the current goal for 2 days at 80% or above.

*Sometimes, Tony will now initiate changes to routes himself.

*Pushing of any kind is almost entirely eliminated, with no episodes on community safety for the past month, and nothing that required physical blocking for nearly 2.

*Reinforcers are being faded (reducing his dependence on them). Started out with french fries when we began with differential reinforcement, faded to cheetos within a couple of weeks, now will often use banana pieces, apple slices, and orange wedges during the evening walk. Some walks we do multiple changes, and I will only reinforce three that are calmly done (in a random manner if more than 4 changes are being done), and we have seen some walks with as many as 8 changes where all were well tolerated and only 3 were reinforced. Soon we will go to providing only 2 reinforcers.

*He will now sometimes calmly tolerate a no for his most preferred activities within the community without protest, pushing, or eloping…and I am fading reinforcement for that also.

In addition to what was noted above, there was a gradual tightening of standards when employing differential reinforcement. For the first couple of weeks, we only asked him to not push in order to be given the reinforcer. Then we started talking to him about how within a few days, he was going to need to also not be running or walking away from the direction indicated to be getting the reinforcer. Once implemented, I adhered 100% to the communicated expectations. And now I have tightened it further and informed him that any attempt to lay his hands on me when he’s upset about a change will loose him the chance to earn a reinforcer for that change. We are still expecting him to finish the change, even if he breaks one of the expectations. If Tony communicates a desire to go a certain direction partway through the change without running, walking away, prompting, or pushing, those requests were initially entirely honored, and now we are working him up to accepting a no some of the time for that type of request.

We also have added (as of this past May) a consequences component that is enforced by Andy when I am clocked in as a hab therapist working with him. If Tony pushes anyone, he looses use of his kindle for 2 minutes. He most certainly understands this type of consequence, and it is important that he does, because much of the world functions in this manner. Drive above the speed limit, you’re going to loose some money…drive drunk, you could loose your license, that sort of thing. Anyone being paid by DDD cannot implement such a consequence unless it is approved by an oversight committee (hence Andy gets to tell him that when I’m clocked in). While differential reinforcement did a lot to dramatically reduce the pushing, adding the consequence for his kindle had an immediate effect in virtually eliminating pushing in every environment, except for those moments where he’s gone into panic mode.

I was not sure how well this might transfer to our current ABA therapists if he resumes community safety with them at some point in the near future, and generalizing these abilities to others is extremely important. The principal behind everything I have been working on is gradually increasing his tolerance for not getting his way and then increasing the amount of time he can tolerate that, but he deeply loves me and is certainly at his most cooperative with me. Last night we were able to test out whether he would generalize these changes with Casandra, and he safely followed her as he has me these past weeks, with the final direction change profoundly altering the last half of the route. For weeks now, Tony has been showing me a great deal about how much he understands with his behavior through the changes he has made, and it was a high point in my week to see him be so willing to do that with someone outside of our family…and so I share it with each of you 😀