When a Client’s Behaviors Interfere with Delivery of Effective Treatment: Evidence-Based Behavioral Approaches

Christine_MaulMaul_BPCD

By Christine A. Maul, PhD, CCC-SLP, co-author of Behavioral Principles in Communicative Disorders: Applications to Assessment and Treatment

A 3-year-old child badly in need of one-on-one language stimulation clings to his mother and cries inconsolably whenever she tries to leave the clinic room. An adult being seen for elective accent reduction therapy asks numerous questions that increasingly consume valuable therapeutic time. An elementary school-aged child being treated for a fluency disorder with a token economy system coupled with response cost reacts with torrents of tears whenever a token is taken from her. All of these are cases of behaviors that interfere with the effective delivery of therapy, taken from real-life clinical situations. In all of them, the behaviors were reduced through behavioral techniques: for the 3-year-old, a modified version of extinction was applied; for the adult, questions were reduced using differential reinforcement of low rates of responding; and for the elementary school-aged child, a modification was made of response cost, which is often coupled with conditioned generalized reinforcement, such as a token economy.

Extinction. After consulting with the mother of the 3-year-old child with delayed language, it was decided that a modified version of the process of extinction should be utilized to decrease the child’s crying behavior. Extinction removes the reinforcing contingencies for a person’s undesirable behavior. Ideally, a clinician should work with a board certified behavior analyst (BCBA) to identify the exact reinforcing contingencies for a targeted behavior. In this clinical case, however, the clinician, in consultation with the mother, determined that the mother’s continued presence and the attention she gave the child in the clinic room was probably reinforcing the child’s crying behavior.
Therefore, for the next clinic session, the clinician arrived with a bagful of toys and books she hoped would be appealing to the child. The mother agreed to take the child into the clinic room and then leave. The expected tantrum behavior occurred. The clinician positioned herself in front of the door, blocking the child’s “escape” path, with her back to the child and began pulling out toys, one by one. The clinician played with each toy, remarking about how much fun she was having, but keeping her back turned toward the child. She engaged with each toy for only a brief amount of time, and, if there was no reaction from the child, she would exchange the toy she was playing with for another item. She did this with several items, none of which seemed to interest the crying child. Then she pulled out a pop-up book that made a “ding-dong” doorbell sound every time she turned the page and began reading it. The child continued to cry, but every time he heard the doorbell sound, he cried less and less, and began to approach the clinician. The sobs subsided more and more as he peeked around her back to look at the book. Finally, to the delight of the clinician and the mother observing through a one-way mirror, the child crawled into the lap of the clinician who gently started evoking one-word productions from the child through her storybook reading. The whole process took no more than 10 minutes, from the time the clinician turned her back to the time the child approached her, and the child went willingly into the clinic room for all subsequent sessions.

There are important things to remember if a clinician wants to try extinction, or this modified version of extinction. First, the process must be thoroughly explained to the parent, and the parent must be in agreement with the procedure. Second, the first time extinction is applied, an “extinction burst” is likely to occur, when the undesirable behavior escalates to even greater heights. When this happens, the procedure of extinction should continue to be applied; if not, all the client will have learned is how much of the undesirable behavior must be displayed before reinforcement is given. Third, extinction should never be used for physically aggressive or self-injurious behaviors.

Differential reinforcement of low rates of responding. In the case of the adult being seen for foreign accent reduction, the clinician suspected that the excessive question-asking behavior was probably negatively reinforced by providing escape from therapeutic tasks. Sometimes, maybe even often, clients find therapy to be aversive, and if a behavior puts off the hard work involved in therapy sessions, it is likely to increase.

The clinician decided that the rate of question-asking was so high, the most that could be done at first would be to employ a technique designed to reduce, but not entirely eliminate, the question-asking behavior. In differential reinforcement of low rates of responding (DRL), the client is warmly reinforced for performing an undesirable behavior at a lower rate. The clinician in this case explained to the client that the amount of time spent responding to her questions was seriously interfering with the effectiveness of treatment. She asked the client to limit her questions to only three per session. The clinician kept her responses to the questions very brief, and kept a tally of the number of questions asked during each session. If the client met her goal, the clinician warmly congratulated her and let her know how much her cooperation was appreciated. If the client had been a child, the clinician could have reinforced the reduced rate of undesirable behavior by offering a small prize at the end of the session; for adults, however, just warm acknowledgment of a job well done is usually enough.

Clinicians should be aware of the disadvantages of this technique. First, the technique will only serve to reduce a behavior. After the behavior has been reduced through DRL, further techniques will have to be employed to eliminate it. Second, a phenomenon known as generalized suppression of a behavior may occur. Consider the fact that asking questions is not an entirely undesirable behavior. People ask questions to seek out new information and to clarify that which is already known. If the client in the scenario provided eventually ceases to ask a reasonable number of well-considered questions altogether, generalized suppression has occurred.

Response cost and conditioned generalized reinforcement. A token economy system, such as the one employed by the clinician treating the school-aged child with a fluency disorder, is based on the behavioral principle of conditioned generalized reinforcement. People learn to work for conditioned generalized reinforcers that provide access to many other tangible reinforcers. In the natural environment, money is the most commonly sought after conditioned generalized reinforcer. In the clinic room, tokens such as poker chips, stickers, points, or happy faces can be given to a child to reinforce correct responses. The child can then exchange tokens earned at the end of the session for a prize in the clinician’s “treasure chest.”

A token economy can be even more effective when coupled with response cost, a corrective technique in which a token previously given for a correct response is taken away for an incorrect response. Children will usually work hard to keep the tokens they have earned, but sometimes, as is the case in the given scenario, a child may react emotionally when a token is taken away for an incorrect response.

Sometimes clinicians decide to simply cease administering response cost as a corrective technique when a child displays such emotional reactions. The clinician in this case, however, decided to adapt a slightly modified version of response cost. Each fluent response the child made was lavishly reinforced with three or four tokens, placed in a plastic cup. When the child exhibited a dysfluency, the clinician took one token out of the cup but did not remove it from the child’s view. Instead the clinician held the token over the cup, gave the child an expectant look, and encouraged the child to try again—“Come on, I know you can smooth it out!” Almost always, the child was able to produce the utterance fluently, and the token was plopped right back in the cup. Administering response cost in this way increased the child’s production of fluent utterances and eliminated undesired emotional reactions.

These are but a few examples of cases in which the application of techniques based on behavioral principles resulted in the reduction of undesirable behaviors that were interfering with the delivery of effective treatment. There are many other techniques that can be employed to decrease undesirable behaviors and to increase the desirable communicative behaviors SLPs seek to teach their clients. Much more detailed information regarding these and many more techniques, accompanied by protocols for session planning and recording data, are provided in Behavioral Principles in Communicative Disorders: Applications to Assessment and Treatment.

 

Attacking Social Interaction Problems Across the Lifespan

Autism: Attacking Social Interaction Problems

Autism: Attacking Social Interaction Problems by Betholyn F. Gentry, Pamela Wiley, and Jamie Torres-Feliciano

By Pamela Wiley, Ph.D., co-author of Autism: Attacking Social Interaction Problems

In my private practice, we are often asked by our funding sources when our children with ASD will no longer need social skills instruction. I often feel a sense of “indirect or subtle” pressure to discontinue our service and declare that a child is socially competent and basically cured of what is essentially the hallmark feature of ASD: impaired social interaction. However, given what I know and have observed with this population it is difficult both ethically and morally to do so.

As professionals we know that social skills are the foundation for getting along with others. We also know that there are social skills milestones which develop along a continuum. For example, one of the early skills focused on for our young children is “how” to make friends and join groups. Many are successful and with parental support during the preschool years engage in playdates and develop friendships with their typically developing peers. However, around 8 or 9 years of age the terrain shifts and children reportedly become more discriminating and scrutinizing as they select their friends. Labels such as nerd, cool and loser become important in the selection process. Our children with ASD often fall into the category of nerd.

As a result, many of them experience rejection and bullying and are left confused and hurt when their only friends abandon them. Social skills continue but our focus evolves to include discussions and skill steps to facilitate their understanding of “who” should be their friend and “how” our friends make us feel and accepting loss and changes in life. The need for social skills training into middle school and beyond can have a profound effect on the quality of life for these children.

High school brings yet another level of complex social interactions and negotiations especially when dealing with the opposite sex, changes in hormone levels, sexual maturation, and peer pressure.

The final phase is the transition process from high school to college and the world of work. The need for continued social skills training is essential and should address core clusters of skills critical for promoting independence and fulfilling lives: vocational, independent, and personal development. Social skills taught may include relationships and how to discriminate between a friend, a colleague, and an acquaintance, the importance of good hygiene, executive functioning, workplace conversation, nonverbal communication, unwritten social rules, and workplace idioms such as “hit the ground running” to name a few.

Based on decades of working with this population and the long-term relationships experienced with many of the children and families in my practice and more importantly the positive outcomes we have achieved, in response to the question, how long should children with ASD continue with social skills treatment, my short answer is, “Across the Lifespan.”

That having been said, based on the positive comments and requests from our colleagues following several ASHA presentations on social skills, my colleague and I have developed a series of social skills workbooks, Autism: Attacking Social Interaction Problems to cover the lifespan of children with ASD from 4 years to adulthood.

Our books contain clear and concise objectives and instructions on how to introduce and implement the lessons. Our approach is fun yet structured and each unit builds on previously learned skills to assist in the generalization of information across boundaries and contexts which include home, school, and the community while incorporating parent and teacher input.

Our newest additions are the teen and prevocational books which are fresh and relevant to today’s youth and include the use of social media and issues facing young people today such as sexting, texting, and TMI. The goal is to assist our students to develop a full range of interpersonal social competencies that can help them ultimately achieve acceptance in the workplace and develop a meaningful existence.

To learn more about our series of workbooks, visit Plural Publishing at www.pluralpublishing.com or our website www.speakla.com.

Reflecting on Autism Awareness Month: Why Is Awareness Important?

Zenko, Catherine

By: Catherine B. Zenko, MS, CCC-SLP

During the rush of activities on April 2nd for World Autism Awareness Day, a journalism student interviewed me to discuss upcoming events at our center and to learn more about Autism Awareness Month. One of the first questions she asked me was, “Why is awareness so important for autism?” It seems like such a simple question, but when I had to put into words why I do what I do every day to promote awareness, it took me a moment articulate the importance of awareness. My response sounded something like, “Ideally, the more people know and understand what autism spectrum disorder (ASD) is—how individuals think, process, and learn differently—the more understanding they will be when they see a person on the spectrum acting ‘out of the ordinary.’”

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, autism spectrum disorder consists of deficits in two domains: (1) social communication and (2) restricted, repetitive, and stereotypic interests and activities (APA, 2013). ASD presents in a myriad of ways, thus inspiring the expression, “once you’ve met one person with autism, you’ve met ONE.” Generally speaking, people with ASD have difficulty communicating: some cannot use speech to communicate; some use a combination of speaking, sign language, pictures, or augmentative/alternative communication (AAC); and some speak too much, not understanding the social rules that a conversation involves two people and both people get to talk. Understanding spoken and written language is also difficult and takes more time to process for most people on the spectrum.

The DSM-5 outlines the diagnostic characteristics of the domain of restricted, repetitive patterns of behavior, interests, or activities as the following: repetitive speech, motor movements, or use of objects; inflexible adherence to routines and/or ritualized patterns of verbal/nonverbal behavior; restricted, fixated interests (intense focus); and hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of environment (APA, 2013). All of the diagnostic criteria translate into people who:
• Are literal interpreters of language and concrete thinkers;
• Have difficulty processing all of the sensory information around them and can have both gross- and fine-motor challenges;
• Are visual learners;
• Have a strong sense of logic that is black and white, not much (if any) room for gray;
• Prefer routines and become extremely upset when a routine is disrupted and are sometimes compelled to finish a task they have started, even when the allotted time has expired;
• Have difficulty taking the perspective of others which makes them appear egocentric;
• Are detail-oriented but have trouble seeing the big picture;
• Have difficulty with attention, starting with joint-attention and engagement with others as well as trouble shifting their attention away from their intense interest area (Janzen & Zenko, 2012; Quill, 1997; Rydell, 2012; Zenko & Hite, 2013).

I like to view autism spectrum disorder more like a difference rather than a disability. The term “neurodiversity” is gaining steam lately and illustrates that just because people on the autism spectrum think and learn differently, they are not disabled. One of Temple Grandin’s most famous quotes embodies this idea of “different, not less.” One social media campaign currently trending is #AutismUniquelyYou. This campaign highlights and celebrates each individual with ASD’s unique personality, instead of lamenting it. Another great campaign is #MakeATinyChange that encourages people to make a difference in the lives of individuals with disabilities through any one of 25 small changes.

There have been several stories circulating this month about how a small gesture of openness and understanding can make a huge difference. One that stood out was a story by ABC News about a man who put away his work and played with a little girl with autism sitting next to him on a plane. The man did not understand why “playing Ninja Turtles with the little girl was a big deal,” but to her mother—who was so relieved when her daughter was met with kindness and acceptance, not pity and annoyance—it meant the world.

Circling back to the question of why awareness is so important, if more people take the time to learn how someone with autism thinks and experiences their surroundings, the more people may embrace the neurodiversity, rather than shy away from the differences and get to know some truly interesting people.

References
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, DC: American Psychiatric Publishing.

Janzen, J. E., & Zenko, C. B. (2012). Understanding the nature of autism: A guidebook to the autism spectrum disorders (3rd ed.). San Antonio, TX: Hammill Institute on Disabilities.

Quill, K. A. (1997). Instructional considerations for young children with autism: The rationale for visually cued instruction. Journal of Autism and Developmental Disorders, 27(6), 697–714.

Rydell, P. J. (2012). Learning Style Profile for children with autism spectrum disorders. Retrieved from http://itunes.apple.com

Zenko, C. B., & Hite, M. P. (2013). Here’s how to provide intervention for children with autism spectrum disorder: A balanced approach. San Diego, CA: Plural Publishing.

About the Author
zenko_hhtpicasdCatherine B. Zenko, MS, CCC-SLP is a Florida-licensed speech-language pathologist who has worked with individuals on the autism spectrum for over fourteen years. She is an adjunct lecturer at the University of Florida Dept. of Speech Language Hearing Sciences since 2008 teaching a graduate-level Autism and Augmentative and Alternative Communication (AAC) course and has worked at the University of Florida (UF) Center for Autism and Related Disabilities (CARD) since 2000. While at CARD, Catherine has helped hundreds of individuals with ASD, their families and educators by providing consultation or training opportunities on a myriad of topics relating to best practices and ASD. In addition to her work at CARD, Catherine has co-authored Here’s How to Provide Intervention for Children with Autism Spectrum Disorder: A Balanced Approach, a timely resource for speech-language pathologists working with children on the autism spectrum as well as graduate students preparing to work with this demographic.

April is Autism Awareness Month!

Lynn Adams has been at the forefront of working with children with autism over the past two decades. Plural’s Autism bundle includes all three of her titles: ‘Group Treatment for Asperger Syndrome: A Social Skills Curriculum’, ‘Austism and Asperger’s Syndrome: Busting the Myths’, and ‘Parenting on the Autism Spectrum: A Survival Guide’. Buy all three and save 20%.

Are you a Parent?

If you are a parent with a child who has hearing problems or autism, then check out one of these three titles: Cochlear Implants: What Parents should know, Your Child’s Hearing Loss, and Parenting on the Autism Spectrum. Each of these titles offers easy-to-follow guidance and help for parents. They help parents be proactive with their children, giving them the necessary information and tools to come alongside their children through these difficult times. Plural is proud to supply the best and most useful resources for parents.

Great Deal On This Bundle!

Check out this Autism bundle package which includes three amazing titles from author, professor and researcher Lynn Adams! The package includes her three titles: Group Treatment for Asperger Syndrome: A Social Skills Curriculum, Autism and Asperger’s Syndrome: Busting the Myths, and Parenting on the Autism Spectrum: A Survival Guide. Lynn Adams currently works as an autism and behavior consultant, and is deeply involved with autism and the education system. Adam’s background makes these textbooks essential for anyone in the field. And, at this price, it’s an unbeatable deal!