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The Errors we See- Discrimination challenges in children with autism and Learning Disabilities – Part II

The author is a Board Certified Behavior Analyst working with Behavior Momentum India. The views in this blog are his own. I  hope to keep in mind parents and therapists as I write and will try to keep the jargon to a minimum. Do feel free to contact me via smbehavioranalysis@gmail.com

In Part 1 of the series we saw the types of discrimination challenges and issues we run into when teaching children with autism or other learning disabilities.  These are often a part of larger error patterns that children acquire inadvertently because of the way materials are used, the way responses may be prompted or the way they are reinforced. In this second part, we will look at inspecting and understanding error patterns. In part III we will look at strategies to avoid and overcome them.

Most of the receptive language tasks involve :

  • the teacher presenting an array of 3 or more items, asking for one of them
  • prompting and fading prompts if the child does not know the correct response
  • and rewarding ( reinforcing)  correct responses and ignoring incorrect responses.

Several potential errors creep in depending on how the training procedures are run.  Step one, in most cases, we must recognize that the student may not really interested in acquiring the discrimination between purple and Red or Tall and short. We believe, these are useful and functional and set up the teaching environment while the student could only aim to get a reward with minimum effort. The reward can be a preferred item or activity given by the therapist for correct responses or just completing the task as fast as possible and getting away from it all ( Technically. these are called reinforcers that increase future occurrence of the behavior that they follow) !! Behavior Analysts, both researchers, and practitioners have, in studies since the 1960s documented the kind of errors that could happen and newer and newer strategies are still being researched for improving outcomes. Laura & Grow ( 2013), have published a great article which details the type of errors that occur in teaching receptive language and strategies to overcome them.

Most parents and therapists miss the first step- recognizing that there is a problem. After doing a few tests it is very easy to be deluded into believing that the child ‘knows’ what is being taught though he sometimes makes incorrect responses. Some of the error patterns and how they creep in are discussed below:

I bet on a position ( Dominant position bias):

When you place pictures or dolls of cat, dog, and cow in an array and ask for one, say ‘cow’,  the student could adopt several strategies to complete the task which does not require him/her to listen carefully and make a correct selection – One is a position bias. As a student, I go for one particular position more often,  for example, the right most. Soon the therapist/mom inadvertently starts placing the target item there more often in that position, for, after all, the therapist or mom is also rewarded by students correct responses. The mistakes that happen when the target item is in other positions are overlooked and attributed to the student being ‘inconsistent’. In such a strategy, the student can completely avoid paying attention to what the instructor/ therapist/parent is asking to be selected( Technically called the Auditory stimulus presented by an adult which should serve as a discriminative stimulus for the student response).

I bet on a particular target item ( Dominant Response Bias):

Using the same example, possibly because I was taught ‘cow’ first and reinforced several times, even when the new targets of dog and cow are introduced I keep selecting cow more often regardless of what I am asked to select. On the occasions when I am correct, I get rewarded. Sometimes, this too could result in the teacher/ therapist asking for ‘cow’ more often creating an illusion of successful discrimination!

I bet on a familiar looking item :

There was a student who could identify spoon, cup, pen, socks, fork, lunch box, toy, and nearly a dozen such items from an array of 5 different objects. He never made a mistake until his teacher started presenting the array with 2 or more from his ‘known’ list. Then he started making mistakes. In the earlier procedure, the student merely had a rule that is something like ” If I see that familiar one, I will go for it”.

I respond based on body language or other inadvertent cues from the teacher:

While teaching receptive language the teacher may be inadvertently supplying additional cues which indicate where the correct responses lie. The student can be sometimes seen intently looking at the teachers face before selecting the item asked for. Some inadvertent prompts could be

  • the therapist’s eyes  dart at the target item before she asks for it (called eye-prompts or eye-gaze prompts)
  • the target item could be placed closer to the child than the other items, as the student’s hand hovers over an incorrect response the therapist’s features are taut and they relax as he switches to the correct response midway
  • the teacher uses exaggerated intonation correlated to a specific target ( Biiiiiig vs small, nineteen versus nine) but does not fade such intonation prompts.

Switching bias :

The student, after being asked to select big, switches the next response to small ( even if ‘big’ is asked for again) because historically his therapist has always switched the target from the previous teaching trial.

Random responding:

Here the student randomly selects any item without regard to what was asked. Afterall,  in an array of 3, he could be successful 33% of the times and that is fine!

Stimulus Overselectivity:

Stimulus over-selectivity or attending to one part of an item to the exclusion of all other parts of the whole could result in errors. For example, a child who looks only at wheels may find discrimination between a car, a truck and a van difficult.

Generalization Problems:

While discrimination is acquired with specific items taught it has not generalized to novel items 0r contexts.

Laura and Grow in their 2013 article talk about several evidence based strategies to avoid errors and teach receptive identification to children with autism.   These include counterbalanced assessments and presentations, requiring an observing response, avoidance of instructor errors, use of simultaneous targeting versus introducing targets one by one and use of appropriate array sizes.  In addition, Fisher, Pawich, Dickes, Paden and Toussaint (2014) conducted a very important study that explains how and why it is important to manage the consequences of correct responses in relation to errors ( they call it managing the behavior-consequence salience for children with autism who present persistent errors).

We will discuss these strategies to over come error patterns in part II of this blog series.

 

Selected References

Grow, L., & LeBlanc, L. (2013). Teaching Receptive Language Skills: Recommendations for Instructors. Behavior Analysis in Practice6(1), 56–75.

Fisher, W. W., Pawich, T. L., Dickes, N., Paden, A. R. and Toussaint, K. (2014), Increasing the saliency of behavior-consequence relations for children with autism who exhibit persistent errors. Journal of Applied Behavior Analysis, 47: 738–748. doi:10.1002/jaba.172

The Errors we See- Discrimination challenges in children with autism and Learning Disabilities – Part I

The author is a Board-Certified Behavior Analyst and works with Behavior Momentum India as a Research Associate, Faculty in teaching Applied Behavior Analysis course sequence and trains therapists who work with children with autism. He attempts to avoid jargon to make topics in Applied Behavior Analysis intelligible to parents of children with autism and learning disabilities, students, and therapists. The views in this blog are his own. This is the first blog and is expected to run into 3 parts because of the vast amount challenges in teaching receptive language to children with autism and recent advances.

David is a 4-year-old boy with developmental disabilities. One day his mom was excited. She was working at training identification of everyday objects from a small array of 3 different objects and he seemed to get it right with 7-8 objects such as a spoon, cup, top and fork wherever they are placed in an array. At the ABA center he went to during the day, his case manager was surprised by mom’s report. At the center, David would only get his identifications right only 25- 30% of the time, around a chance level of success, as if he were selecting randomly. He requisitioned videos of sessions from home and played them a few times over and found that a simplified array of stimuli was being used. There would be the target object, selecting which produced rewards and two other objects such as scissors and crayon that the parent never asked. David had figured that he needs to go for the spoon or the cup whenever they appeared in the array- he did not have to listen to what was asked for and make a discriminated selection. When probed with spoon, cup, and fork in the same array, hi correct selections dropped to chance levels as now the correct response depended on his selection also tallying with what the adult asked for.


Girls who buy nail polish need to know the difference between two shades that are close to each other in appearance- one could be “just her type” and another one not so! Children with autism and learning disabilities often have serious problems mastering discrimination tasks. One of the reasons is making a selection based on one element or feature of an object instead of attending to all the parts. This is called stimulus over selectivity. For instance, a child whose attention is only on wheels may not be able to identify a car if a truck and a van are also present in the array of vehicle pictures. Examples of making a response based on attending to an incorrect part abound. Discrimination training procedures involve the use of rewarding correct responses, prompting and prompt fading procedures and may inadvertently result in responses with errors or prompt dependence.

Let’s look at some more examples of errors. At a simple level, let us say a student is taught to respond to the instruction “touch head” by touching his or her own head. When “touch elbow” is introduced as a next target, the student could proceed to touch his head as soon as he hears the word “touch”. Similar problems exist with training to answer questions such as “what is your name” and  “What is your mother’s name”. The response “David” could be blurted out as soon as “what is” is heard. A child who is taught to answer “air” when asked what does fan give could reply with “air” when asked what does cow give”. It is quite possible that the “what” or “give” part of the question controls the students answer of “air” and not the “fan” or “cow”.

At a certain stage of learning, generalization must stop and discrimination must set in. There could also be a problem of over generalization without discrimination setting in (or being taught). A child taught to request for “hug” from parent’s could request hug from complete strangers. A child who is taught to say “daddy” with her dad’s picture (let’s say dad sports a beard in the picture) starts labeling other pictures of persons with a beard also as “daddy”. Many children on the spectrum who perform discriminative tasks with nouns well, fail when it comes to discriminating even between the basic colors of red, blue, green and yellow. I have come across students who do a perfect job of matching red card to card, blue card to blue card and so on. However, when they are asked to point at the red card or the yellow card or the blue, in an array that has all these cards things start going wrong. There is some other discrimination issue at work here. Discrimination challenges are part of everyday life with all humans. Husbands could buy the wrong gift on the anniversary day, a writer, could place too many, commas in his sentences, or cops could overlook important evidence at the crime site and obsess with non-essentials while the criminal is thriving and on the run. However, with children with autism and other learning disabilities, these problems acquire serious proportions across several areas of their learning and the error patterns could become stronger confounding parents and therapists.
Behavior Analysts use research based methods to identify error patterns, understand why they could occur in discrimination training and use specific strategies to overcome these.I will look forward to examining additional error patterns and the current state of research on how they can be overcome in the next parts of this series on discrimination training.

Your queries will help me reflect further. Do send them to smbehavioranalysis@gmail.com

Errorless learning is the way- time to think outside trial and error

Trial and error learning is often counterproductive and too often we cannot afford the cost of errors especially when teaching children with learning disabilities. The proponents of trial and error learning will show you the example of throwing a baby into water without any training and behold! it swims!!!!. This is not an entirely  accurate proposition as babies may have certain reflex actions in their repertoire that may look like they are born with an ability to swim but it  is not true. such an attempt would be downright dangerous and irresponsible. Check out http://www.babycenter.com/404_is-it-true-that-babies-are-born-with-the-ability-to-swim_10313062.bc

We see examples of the danger and disasters that trial and error learning cause all around us. Recall the girl who, while learning to reverse crashed her car into a pillar in the basement and could never learn to drive after that. Do you not come across hundreds of children who ” hate math” ? Well they tried to learn by trial and error  and came across failures that stunt learning. If this is the case with typically developing chidren ( and adults) the problem with errors is much higher in children with learning disabilities trying to learn a new skill. If you have tried to teach them or have observed them being taught and you find that they engage in escape behaviors, fright reactions , aggression or behaviors suggestive of anxiety it is very probable that error rates are high. The necessary pre-requisites for successful performance may be missing or some irrelevant aspects of teaching procedures could be dictating the child’s response.These are also true about typical population where students fail in exams or people fail in their jobs without adequate training.

Dr. Murray Sidman, a pioneering behavioral scientist in  a 2010 publication argues that the typical learning curves which show an acceleration towards a peak performance (during which period learning is progressively happening by trial and error) followed by a plateau appears like pat explanation only because  such curves are developed by aggregating data of the learning process of hundreds of individuals. If an individual’s learning is tracked there will be seen a lot discontinuities and irregularities. He then presents an alternative learning path which is that when all pre-requisite skills are taught there is an instantaneous vertical climb (no acceleration or curve) to performance with all learning and no error. He quotes two simple and elegant examples from the non-human kingdom.

B. F. Skinner, taught rats to press a lever in a chamber in a errorless fashion by teaching 5 pre-requisites. He first let them explore a chamber and experience that the environment was safe. By mixing food pellets with the rats regular food, he taught them that pellets were food too. He then dropped the pellets in a food tray occasionally and the clanking noise from the dispenser was a indication of when pellets would be available. soon the rats started going to the dispenser whenever the dispenser made a sound and they picked up their food pellets.  Next a  lever was introduced in the chamber. When the rat pressed the lever the first time, the dispenser operated making a sound, the rat went to the food tray and ate the pellet. There after it continued pressing the lever at a high rate pausing only to eat the food pellets dispensed. The rat acquired the ‘lever pressing skill’ in a immediate fashion ( see figure 2 below). Imagine another rat which was not trained in the pre-requisites being let inside a similar chamber. How long could it be before it starts pressing the lever and accessing food is anybody’s guess. The latter rat may even give up after the fist lever press and stay hungry and anxious because it does not have the pre-requisite training to look into the food tray or even identify the food pellet as a reward.

Terrace in his Doctoral dissertation in 1963 built on the foundation and demonstrated error-less learning with pigeons. The first goal was to teach them to peck a key only when red light was on and not when green light was on in a chamber. He achieved this with a set of pigeons errorlessly by having the red light on in normal intensity and rewarding lever presses. He introduced the green light ( to which the pigeons should not respond) in a gradual fashion from low intensity to eventually an intensity equaling the red light. These pigeons made no error responses – never pecked the key when green light was on and always pecked when red light was on. Compare this with another group of pigeons which were introduced to both the lights at equal intensity from the start and they made a large number of error responses before acquiring the discrimination that it is worth pecking only when red light is on. There were many other brilliant facets to the great experiments done by Terrace. Suffice to note that the pigeons that learnt errorlessly also performed better later much after the training was withdrawn. Their learning endured. Another important note is that errors do not produce rewards and hence can produce fright reactions or aggressive behaviors.

Figure from sidman (2010)

The dad who successfully manages to teach his young son to cycle was not only patient but also manipulating the learning in such a way as to avoid nasty falls or unsuccessful turns. Every successful coach works hard on pre-requisites training and minimizing errors though he may seen to be commandeering. You would have doubtless come across the story of someone who succeeded in the eighteenth attempt. If you are able to examine closely you will find that the previous 17 attempts involved gaining some new ground everytime , identifying missing pre-requisites and working on them diligently and the 18th is a success. Otherwise if the previous attempts were a utter failure with no rewards contacted or no new pre-requisites identified it would have stopped at 2 or 3?

Behavior Analysts work towards promoting error less learning by a variety  of research based procedures such as shaping, prompts combined with effective and timely prompt fading procedures, evaluating the use of time delay before providing prompts, adding cues that can be faded to stimulus materials before fading and arranging rewards in proportion to task difficulty. There is now a large body of research that confirms the efficacy of these procedures not only in effectively facilitating skill acquisition but also in minimizing  escape responses and aggression during the teaching process. Pairing of the instructor with positive experiences and rewards also plays a key role. If  errors still occur then a Behavior Analyst would go deeper into component skills and focus training on those.

Play, A., Activities, G., & Team, T. (2017). Is it true that babies are born with the ability to swim? | BabyCenter.            BabyCenter. Retrieved 3 February 2017, from http://www.babycenter.com/404_is-it-true-that-babies-are-born-with-the-ability-to-swim_10313062.bc

Sidman, M. (2010). Errorless learning and programmed instruction: The myth of the learning curve. European Journal of Behavior Analysis, 11(2), 167-180.

Terrace, H. S. (1963). Errorless transfer of a discrimination across two continua. Journal of the experimental analysis of behavior, 6(2), 223-232.

 

 

The art and science of generalization

November 8, 2016 Leave a comment

Note: The author is a Board Certified Behavior Analyst who works with Behavior Momentum India (www.behaviormomentum.com) . The views in the blogs are his own.I would like to thank a fellow Behavior Analyst,Dr. Geetika Agarwal, BCBA-D for her valuable comments and pointers on an earlier draft of this blog.

One of my  ‘aha’ moments came like this. I was teaching a boy on the autism spectrum to request (mand) information using ‘where’. Soon enough,he was asking “where are the crayons”, ” where is the scrabble box” and so on. One day, his mom came to observe his session, observed carefully, made notes and left after about 45 minutes. I was taking him around to play. He didn’t seemed very enthused about the play options and was looking a listless and a tad sad. A few more minutes later, he peered into my eyes and asked in a low sweet voice ” Sridhar, where is mummy? “. Aha…. generalization had happened and it was so functional and appropriate! We cannot always  assume that generalization will happen in due course. Rather, from the first instance of teaching any skill, generalization has to be planned for and programmed.

All of us generalize what we have learnt. Performing in practice tests to performing in a real exam, learning dining etiquette and using it in corporate dinner event, cracking jokes with friends to using humor in meetings , lectures or talks.. the examples are numerous. Generalization is important because the skill learnt in one setting needs to be used sometimes in vastly varying contexts.

Parents of children with autism and developmental disabilities are most concerned about this. We need generalization for sure.  If the child’s acquired skills do not generalize across people, different environments and across different contexts where they are meaningful the value of acquired skill is down to zero!  Like all good things , it needs to be planned for right from the beginning and when achieved  it needs to be balanced.  Over generalization or under generalization can be a problem  too. consider the following scenarios:

Image result for over generalization fallacyImage result for generalization

  1. Neeraj has learnt to wash hands independently but he does that only at home independently. In a restaurant or at a friends place, after a meal he may not proceed to wash his hands.
  2. Pranav sits and attends appropriately to task in the math class but not in the english class
  3. Keerthi a 3 year old girl has been taught to point at mummy and daddy when asked. However, when there were many visitors at home and someone asked her ‘where is daddy?’ she pointed to the nearest male – generalization without requisite discrimination?  Image result for multiple exemplar trainingA mom is not a girl? need for training with multiple examples

4.Rachel, a teenager  could fold her clothes and stack them up in her cupboard. One day, when mom tried to get her to help with folding towels and blankets at home and was surprised that Rachel could not fold blankets

5. Chris had learnt to answer questions about himself when his mom or his therapist asked. However, when was lost briefly in a mall and when people who wanted to help him asked for his parents name and phone numbers, he just sat down crying and was not able to answer questions about himself.

While it may not be possible to discuss this vast topic of generalization a look at some of the key principles and strategies behavior analysts use to program for generalization could help. Parents who see their children acquire skills in clinical setting  could focus on immediately generalizing those at home and in community settings. If there is a hurdle in generalization they should discuss it with the Behavior Analyst responsible for programming as they could plan and program for generalization better. Some strategies are discussed below:

a. It begins with target selection. Target only those behaviors and skills that will meet reinforcement in natural communities after the skill is acquired. For example, teaching to sing or play keyboard in a small group setting can generalize all the way to stage performances with potential to contact reinforcement from natural communities throughout life. Conversation skills, Social etiquette, play skills etc. too fall in such a category. A non example – would it be appropriate to teach penmanship to a child who does not read or recognize words yet?.

Image result for useless goals

need for meaningful targets

b. Teach Multiple examples or sufficient examples for every target : For instance if discriminating between clean versus dirty is being taught , multiple examples could be used  – a dirty cloth vs clean cloth, a dirty paper versus clean one, badly stained glass versus clean glass etc., all the time probing to see if generalization has occurred to other novel contexts. Teaching sufficient examples means teaching using as many examples as required until generalization to all possible variations occurs. For example teaching a child to pronounce 5, 6 or 10 words correctly with the “r” sound until he or she is able to pronounce all functional words with ‘r’ correctly.

Multiple examples of sharp:
Image result for sharp items  sharp-items

c. Teaching both context and response variations : To the question “how are you ?”different responses such as ” I am fine”, ” I am good” , ” great”, ” Ok”.. can be taught. Similarly the response “14 years” should be produced by the learner regardless of whether the question was ” How old are you? ” or it was ” whats your age”.

d. Teaching all possible situations – this involves teaching all examples that could covers all possible situations and varying responses – for example , teaching the use of every type of ATM machine in the neighborhood. This may not always be a feasible option, and nor may it be required in most scenarios.

5. Building familiarity in training setting – In the teaching setting it may be useful to introduce features of what will be out there in the natural setting where the skill has to be used. For instance, while teaching shopping skills in a dummy super market set up it may be useful to include shelves, ‘promotional signs, ‘pay here’ signs, trolleys etc., If you are teaching teaching dining with peers in a home setting with eventual goal of eating out in a restaurant, it will be useful to have cutlery, menu card, napkins and perhaps adult attending on the students and taking orders  like waiters would in a restaurant.

6.  Use some elements from teaching setting in generalization setting : For example a student who is used to a point system or a smiley reward system may benefit if the same is used in a generalization setting such as following etiquette rules in a restaurant or making a choice independently from a menu or being engaged appropriately in the back seat in a long journey. Yes, for some time, it may be a good idea to introduce rewards in the real life-generalized setting similar to the ones used during training.

7. Some children on the spectrum who have difficulties with responding consistently correctly to different people or in different locations will benefit from variations in teachers, positions, location of teaching, variety of tones , distractions being present etc.

8. Rule out dependence on inadvertent cues :  If a child performs well with one therapist but not with another, or with parent but not anyone else it is also important to see if the first therapist or parent is providing some subtle cues inadvertently which others do not provide. Behavior Analysts constantly strive to promote independence and will need to critically examine and completely fade out dependence on any type of prompts that may have emerged during training.

There are many other specific strategies but the above should provide an insight into some of the guiding principles for successful generalization. Much can be achieved by planning for generalization, conducting generalization probes before , during and after training on any skill ( “will he play the keyboard equally well in front of a small group of strangers? “, ” Will he whack the ball to the boundary line when playing in a larger field?”…) and planning and teaching taking into account variations in contexts and responses. Discrimination and generalization go hand in hand and training one would also require training on the other. That is a topic for another day.

Do feel free to send your questions via the comment window or by filling out the form here:

Article Review highlights – Evaluation of HBOT Therapy

Some of what I have written in this review is technical – If you are interested in highlights you could check the intro and conclusion section directly

Some excerpts  from my scientific article review
Using behavior analysis to examine the outcomes of unproven therapies: An examination of hyperbaric oxygen therapy

Lerman, D. C., Sansbury, T., Hovanetz, A., Wolever, E., Garcia, A., O’Brien, E., & Adedipe, H. (2008). Using behavior analysis to examine the outcomes of unproven therapies: An examination of hyperbaric oxygen therapy. Behavior Analysis in Practice, 1, 50–58.

Introduction

Behavior Analysts are often confronted with a situation where parents of children with autism or other learning disabilities turn to other unproven, untested interventions ( also referred to as science fads, pseudo-scientific interventions etc.) in their search for improvement in their child’s rate of skill acquisition , reduction in inappropriate or challenging behaviors etc. Chelation therapy, vitamin doses, dietary restrictions etc. are some such examples. The BACB guidelines for responsible conduct enjoin Behavior analysts to study, appraise and review the likely effects of alternative treatments including those provided by other disciplines. The authors of this study have accordingly evaluated the effectiveness of Hyperbaric Oxygen Therapy – HBOT , a treatment that, while being expensive also has been gaining attention of parents of children with disabilities. Some parents have claimed that the therapy offers improvements in socialization, language, attending and compliance along with reductions in stereotypic behavior, aggression, disruption, self-injury etc. within 20 weeks. In keeping with the requirement not to turn a blind-eye but to scientifically and objectively evaluate alternate treatments or interventions, the authors have conducted this study.
The authors aim to validate their hypothesis that hyperbaric oxygen therapy does not offer any benefit beyond those offered by ongoing behavior analytic services and also lay down the procedures and challenges in conducting a behavior analytic intervention on unproven therapies.
Methods:
Particpants:
A 7year old girl and two 6 year old boys with 8months, 3.5 years and 4.5 years history of receiving behavior interventions were chosen for the study ( as the study proposes to determine if the alternative intervention can provide more benefits than ongoing behavior interventions).
Further parents of these children had requested HBOT therapy.

The setting for ongoing behavioral services was a private clinic providing behavioral services in 1:1 format as well as in small group formats. The education covered academics, communication, peer interaction, self-care and play. The HBOT therapy sessions were provided in a chamber with 88% oxygen at 1.3 ata sold for in-house use. The chamber dimensions when fully inflated were 233 cm length x 11 cm width and 86 cm diameter.

Dependent variables – Behaviors measured:
Improvements with the therapy are claimed to be in language, task engagement, compliance, socialization, as well as decreases in inappropriate behaviors. The authors used very specific and measurable behaviors as dependent variables in the study. For example, in the area of communication, spontaneous communication, defined as signs or words emitted without prompts was measured (number of occurrences per session). Task engagement was measured as exhibiting targeted response within 5 seconds of instruction with gaze directed at task materials or therapist. Problem behaviors such as hitting, throwing materials were measured in terms of responses per minute as the authors state that each such response had a discrete beginning and ending.

The intervention involved 40-60 minute HBOT sessions administered in the chamber described above upto a maximum of 40 dives per participant. Considerations in setting limits involved providing claimed minimum threshold exposures and minimizing exposure to the unproven therapy. Acclimatization procedures were used initially followed by 60 min sessions with the chamber activated to provide oxygen in specified concentration and with the child present with access to favorite toys, books etc. throughout. If for any reason the child did not get a full 60 minute exposure, the session was excluded from the study. A therapist recorded data for each dive in terms of start time, end time, pressurization start, time when full pressurization was reached and total time at full pressurization. These could be noted from the gauges in the equipment. While the authors describe the HBOT therapy implementation in detail, they have not done an independent evaluation of the accuracy of treatment procedure implementation (treatment integrity).

To study the effect on outcomes therapists videotaped 10 minute sessions  and recorded  data on spontaneous communication, task engagement and inappropriate behaviors. Handheld computers, or desktop pcs and instant data software were used for scoring the above from video tapes.
Further baseline (pre-treatment) sessions data has also been recorded for control purposes.

Results:
Two of the children showed increasing trends in task engagement in the baseline phases capturing the effect of ongoing behavioral interventions on the dependent variables. HBOT therapy did not change the level, trend or variability. For the third child while the levels of task engagement were variable throughout the baseline phase, the gradual increase continued during and after HBOT therapy again suggesting that HBOT therapy by itself did not contribute to any additional beneficial effects. A confound was identified as increase in prompt levels coinciding with withdrawal of HBOT therapy and this was addressed by rescoring to ascertain the level of increase in prompts and its effect on increased task engagement.
Similarly, for problem behaviors, with two of the children decrease in levels in baseline phase continued during intervention. A slight increase in problem with third child was observed.
Discussions and Conclusions
One firm conclusion that authors reach is that the additional cost of HBOT therapy does not result in concomitant increase in benefits. While discussing limitations, they refer to limited generality as the study involved only 3 participants, the need to evaluate the effects of more intense HBOT treatments with possibly higher concentrations, some non-controlled confounds such as a reduction in instruction time along with increased access to preferred activities during HBOT sessions etc.

References

Lerman, D. C., Sansbury, T., Hovanetz, A., Wolever, E., Garcia, A., O’Brien, E., & Adedipe, H. (2008). Using behavior analysis to examine the outcomes of unproven therapies: An examination of hyperbaric oxygen therapy. Behavior Analysis in Practice, 1, 50–58.

Join the cause – Applied Behavior Analysis based interventions for children with Autism

sm pic Jo Pnarasimhanmama1With ABA India Runners after finish 1

Saturday, 10 May 2014

For the third year running ( pun intended) , Jo a technology professional and Nara an entrepreneur will run 10 kms non-stop with Sridhar, President ABA India to raise funds in the TCK Premier world running event to be held in Bangalore on Sunday 18th may 2014.

Autism is a severe learning disability and a neuro-biological disorder ( not a disease   ) estimated to affect 1 in 88 children. The science of Applied Behavior Analysis and the technologies based on the science hold out great hope and have  50+  years record of successfully helping these children acquire new skills and integrate with the larger society.

ABA India is planning to conduct a 2 day intensive immersive learning experience for parents of children with autism and tutors and trainers who work with them.  The event is scheduled to be in Hyderabad with international and Indian experts in Behavior Analysis imparting knowledge on practical techniques to families in need of such evidence based technologies.

To give an idea, Rs. 2500.00 can part fund  the cost of attending  one parent  or tutor/ trainer.  We expect around 250-300 people to register and benefit. In this run, we are working towards a fund raising target of around 1.5 lakhs.

We encourage you to contribute whatever you can- no amount is too small. Do pass the message around. We hope giving gives as much joy to you as asking for the cause does to us.

Ways to give :

1.  Bank Transfer ( please send me transaction reference number)  : Bank – Oriental Bank of Commerce, Gurgaon, HAryana 122003,  A/c Name:  Association for Behavior Analysis India, A/c No. 51671131000593.  IFSC code for direct transfer is ORBC0105167. send us a screenshot afterwards.

2. Cheque-   You can make the donation by cheque favoring ” Association for Behavior Analysis India” and post it to:  Sridhar Aravamudhan, President , ABA India, A2- 201, L&T South City, Mico Arakere Layout, Bangalore – 5600076

3. By cash in person – let me know – I’ll arrange a visit to collect.

If any of us know you personally you may get a call to check how you are getting on and incidentally asking you for a donation ( or vice-versa!)

 

With regards and Thanks,

 

Sridhar Aravamudhan

President

Sridhar.a@aba-india.org

+91 9538001515

 

Activity Schedules for children with autism

Efficacy of Activity Schedules as Intervention for Children with Autism

 Children with autism have difficulty with the concept of time, experience anxiety relating to what events come next and have difficulty in independently planning and engaging in appropriate activities. Activity schedules visually represent a set of tasks or activities. Pictures are used for visual learners and words are used for children who have reading abilities. Sometimes it is seen that children with autism, even while competently doing their activities keep looking at an adult for a prompt to move to next or continue to stay on task. Visual schedules can help reduce dependence on adults or other people.

Activity schedules can be for a simple three or four step activity ( Dressing – wear underpants, wear vest, wear shirt, wear trouser)  they could cover a series of activities the child need to perform ( make a toast, play with iphone, finish a worksheet), it could cover events throughout the day ( breakfast,  get dressed, go to school, return by bus from school, evening meal, TV time, play at park, homework, supper, sleep) and with children that have advanced at learning schedules  even events during a month can be visually presented (  Grandma visit, long weekend stay at beach , going to a marriage…).

In my practice I come across several children who  would start their next activity which could be fixing a puzzle or going and playing on the swing only after an adult gestures or prompts.  They could move from one activity to another in a span of 3- 4 minutes but would be dependent on parent or trainer to stop an activity or start the next activity. Even in seemingly simple functional routines where they are  fluent in all the steps they could need prompts such as open the tap, rinse mouth, take toothbrush, squeeze paste on to the brush etc.,  Further, there are children who can complete the parts of the chain but will look at adult for some kind of a prompt to move on. In the context of helping such children  become atleast partly independent,  I started looking at a combination of visual schedule which can prompt the next activity to move to and and a  timer which can tell them when to stop ( in case the activity is a open ended activity like playing with ipad as opposed a closed ended activity like completing a 25 piece jigwas puzzle). I had to start with research on work that has already happened and felt I’ll share what I learnt while studying literature-  I’ll try to lighten the technical heaviness of what I am going to write but do bear with me if I am not entirely successful as I am trying to look at technical research..

According to Schopler, Mesibov (1995),  activity schedules reduce the need for adult prompts, help children transition between activities and provide a structured teaching environment. Further, the use of visual schedules also  help given the auditory deficits  of children with autism Schopler, Mesibov, and Hearsey (1995) .

Thus activity schedules are expected to transfer  control from verbal or imitative or gestural prompts  given by adults to pictures, symbols or photographs thus reducing the child’s dependence on adult prompts. Further, if correctly designed and implemented, activity schedules visually let children know their rate of progress, estimate time remaining to complete allotted activities and thus can reduce frustration.

One of the early studies by Applied Behavior Anlaysts examined teaching children with autism to be independent in emitting complex  response chains (Macduff, Krantz, & Mcclannahan, 1993).

The authors selected four youth whose interventions involved staff giving verbal instructions and physical prompts. The instructions rate were as high as 2 per minute ( Look at the level of dependence on adults and possible aversion to voice that may arise?) . The authors further reported that most of the responses had to be prompted and there was  no spontaneous emission of previously taught chains of activities. The study, after a baseline measurement went on to use photographic activity schedule depicting 6 leisure and homework activities.  The teachers stood behind and used  graduated guidance ( a procedure where initially trainers provide prompt to the extent required and reduce or fade as the child begins to gain independence)  from behind the participants to teach them to follow a schedule and be on task ( i.e., they had to teach the use of visual schedules using prompting and prompt fading procedures so that the actual performance of chain of activities may be dependent only on the photo schedules).

In terms of results, all the participants , after the training phase ( 13- 27 sessions) were found to be independent , i.e., not reliant on any teacher prompts , were on task and on schedule. They also generalized schedule following to novel chains. Anecdotally, the authors record a reduction in aberrant behavior from the participants. The effectiveness of photographic schedule training with graduated guidance was evidenced by the fact that the participants were able to independently engage in complex leisure and daily living activity chains for one full hour ( Quite a dramatic achievement is’nt it , considering the children needed 2 adult prompts per minute at baseline ).

Referring to the above study and replicating  it  Bryan & Gast (2000) taught four children with autism in a public elementary school program to  use visual activity schedules using a Graduated Guidance procedure. They measured on-task and on-schedule behaviors of the children after teaching them the mechanics of using activity schedule. The children carried the activity schedule in a book. The students not only learnt how  to use an activity schedule (with graduated guidance support from experimenters) but also maintained high levels of independent on-task and on-schedule behaviors with just the support of picture books . This had an automatic effect on reducing non-scheduled behaviors.

A contra indicator is the study by Waters, Lerman, & Hovanetz ( 2009). Transitioning from a one task to another, often from a high preference task to a low preference task can be accompanied by emotional reactions and inappropriate behaviors. A treatment package consisting of extinction plus differential reinforcement of other Behavior (DRO) was tried with and without visual schedules. In this study the authors found that problem behaviors reduced with extinction plus DRO regardless of whether a visual scheduled was used or not.

This study calls into question the usefulness of activity schedules in facilitating transitions especially preferred to non-preferred. However, I would still like to examine the value of removing adult mediation during the transition.

Bryan & Gast (2000) also report a number of prior studies which found the use of activity schedules effective . They are tabulated below:
Betz, Higbee, & Reagon ( 2008) made a first of its kind study when they studied the effect of two children ( a social pair) following the same activity schedule to play  a series of interactive games. The three pairs of children with autism chosen for the study were between 4 and 5 years of age and they were assessed to be able to follow activity schedules independently. Activities or games were chosen for them to engage in that allowed  two people to take turns ( don’t spill the beans, crocodile dentist etc.,)  and the children were taught how to play these games fluently.  While in baseline condition no joint activity schedule was used, in the intervention phase teaching was given for each of the paired children to refer to the joint activity schedule, say brief lines from script and enagage in an activity or game collaboratively.  This study found that for every pair the engagement level ( defined as being on task and taking one’s turn appropriately) that was very low in baseline phase reached to 80% in the teaching phase and was sustained in the maintenance, re-sequencing and generalization phases.  This is a higher order training method and demonstrates the utility of activity schedules in promoting peer engagement in children with autism.Heres another big breakthrough possible with activity schedules: They can be used to teach joint activities, peer play etc., especially where turn taking is involved?

As  elaborated with several examples in this paper, activity schedules have proven to be effective in teaching children to be on task, on schedule, to be independent to a higher degree, in reducing inappropriate behaviors, in facilitating peer play without adult prompts, in teaching vocational skills, home living skills, leisure skills, play skills etc.

From the foregoing discussion it can be discerned that research on activity schedules had started in the 1980s and is continuing till date. It is important to note that though the dozen odd studies referred to in this article have demonstrated effectiveness barring the study by Walters etal., ( 2009), the volume of research and replication in the three decades does not seem to be high. This relatively low volume of research activity is surprisingly at variance with widespread use of activity schedules in one form or other across special schools catering to children with autism and other learning disabilities.

In terms of recommendations, activity schedules along with training to use them should be considered as a treatment of choice to promote independence , reduce dependence on adult prompts and to promote generalization. This is on account of the fact that the studies that have been done have reported success and the treatment will gain more favour with increasing replications and novel variations.

References

Bryan, L. C., & Gast, D. L. (2000). Teaching on-task and on-schedule behaviors to high-functioning children with autism via picture activity schedules. Journal of autism and developmental disorders, 30(6), 553–67.

Betz, A., Higbee, T. S., & Reagon, K. a. (2008). Using Joint Activity Schedules to Promote Peer Engagement in Preschoolers with Autism. (G. Hanley, Ed.)Journal of Applied Behavior Analysis, 41(2), 237–241. doi:10.1901/jaba.2008.41-237

MacDuff, G. S., Krantz, P. J., & McClannahan, L. E. (1993). Teaching children with autism to use photographic activity schedules: Maintenance and generalization of complex response chains. Journal of Applied Behavior Analysis, 26, 89–97.

Miguel, C. F., Yang, H. G., Finn, H. E., & Ahearn, W. H. (2009). Establishing derived textual control in activity schedules with children with autism. Journal of applied behavior analysis, 42(3), 703–9. doi:10.1901/jaba.2009.42-703

Neitzel, J., & Wolery, M. (2009). Steps for implementation: Graduated guidance. Chapel Hill, NC: The National Professional Development Center on Autism Spectrum Disorders, FPG Child Development Institute, The University of North Carolina.

Schopler E, Mesibov G, eds. Learning and Cognition in Autism. New York: Plenum Press, 1995:311–334.

Schopler, E., Mesibov, G., & Hearsey, K. (1995). Structured teaching in the TEACCH system. In E. Schopler & G. Mesibov (Eds.), Learning and Cognition in Autism (pp. 243-268). New York: Plenum Press.

Waters, M. B., Lerman, D. C., & Hovanetz, A. N. (2009). Separate and combined effects of visual schedules and extinction plus differential reinforcement on problem behavior occasioned by transitions. Journal of applied behavior analysis, 42(2), 309–13. doi:10.1901/jaba.2009.42-309

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