Picture the following scenario:  you are a parent.  You have gone through the parent training, researched numerous empirical sources, successfully implemented the procedures that were taught to you, and finally feel as though you are fully prepared to be an integral part of your child’s behavioral treatment plan.  However, there is one problem; your child’s problem behavior is not occurring when you are around, but as soon as another family member enters the room, it’s as though a switch has been flipped.  Your child’s problem behavior occurs again, and you feel like you are back at square one.  You have no idea how you have worked so hard, but are only seeing the target behavior change part of the time.  Why is this happening?

In fact, there is a reason why your child’s behavior alters so much in the presence of another family member; no, you are not a “bad” parent and there is no magic trick that your child is performing as soon as another person walks into the room.  In reality, your presence has turned into a signal to your child that reinforcement of a particular behavior is not available.  In other words, you have become an “S-delta,” a stimulus that represents an occasion in which a particular behavior will not be reinforced. Oppositely, the other family member has become an “S-d,” or discriminative stimulus, which represents an occasion in which reinforcement will be delivered for a particular behavior.

Let’s look back at the scenario from earlier, but this time, use a specific behavior example.  The behavior that we want to decrease is screaming, which occurs following each time Johnny is given a demand.  After weeks of implementing a least-to-most prompting hierarchy for each occurrence of screaming that follows a demand, you see that he no longer screams when you tell him to do something.  However, as soon Bob tells Johnny to do something, Johnny screams, and instead of implement the prompting hierarchy, he allows Johnny to escape the demand.  Johnny has learned that when you give him a demand, you are not giving him access to his reinforcer (in this case, his reinforcer is getting to escape from the demand); however, when Bob gives him a demand, he doesn’t follow through, so Johnny gets to escape from doing whatever Bob asked him to do.  You have become an S-delta for reinforcement (escape from the demand), so Johnny has learned that he cannot scream at you to escape demands.  However, Bob has become an S-d for reinforcement, so Johnny has learned that with Bob, reinforcement (escape) is available.

So, how can Bob come to serve as a stimulus that signals no reinforcement for screaming is available, as well?  Johnny has to learn that Bob will not let him escape demands when he screams. In order for him to learn this, Bob should follow through with each demand, which will not allow Johnny to escape.  By signaling that escape is not available when Johnny screams, Bob will be helping Johnny learn that screaming is not the appropriate way for him to get what he wants.

PECS

Picture Exchange Communication System (PECS) is a specific protocol for teaching expressive language to children and adults. PECS is not just pictures or a visual schedule/display, it is a training protocol used to expand and teach a child language.  PECS was developed by Andy Bondy, Ph.D. and Lori Frost, M.S., CCC-SLP, in 1985. The training protocol can be found in the Picture Exchange Communication System Training Manual – 2nd Edition (Frost & Bondy, 2002).  There are many benefits to using PECS. Empirical evidence has shown that effective use of PECS can lead to the following; a decrease in maladaptive behaviors (Carpenter, Charlop-Christy, LeBlanc & Kellet, 1998), improved social behaviors (Le and Charlop-Christy, 1999; Le, Charlop-Christy, Carpenter, & Kellet, 1999), and improvements in speech development following the acquisition of PECS (Carpenter, Charlop-Christy, LeBlanc & Le, 1998; Carpenter & Charlop-Christy, 2000).

The following is a list of the phases for teaching PECS

When to use PECS vs Sign

There is no clear way of knowing when PECS is more appropriate, it is a case by case decision. However there are a few things to keep in mind when deciding which modality to use. PECS is typically used if the child has limited fine motor or imitation skills. Sign language is a great way for a child to communicate however it can be limiting if the child has a lot of modified signs that people not in their everyday environment would know, in which case PECS might be a better option. Consultation with a Speech and Language Pathologist and/or Behavior Analyst is recommended before implementing PECS with your child.

Misconceptions of PECS

It has been thought by some that PECS and other communication systems hinder a child’s ability to develop verbal language however; research conducted over the past 30 years (Silverman, 1995, Glennen, 1997) has demonstrated that augmentative and alternative communication strategies do not inhibit the development of speech. There is a strong positive correlation between use of PECS and speech development in children with autism (Bondy & Frost, 1994).

We often encounter social situations that we take for granted, but that are difficult for children with autism or developmental disabilities. Social stories are a great tool to teach and prepare children with special needs for social situations. Social stories help to make the ambiguity of social situations more concrete. The goal of a social story is to help the individual to better understand socials situations and/or to help prepare the individual for a situation that is new to him or her. Some examples of situations when one might use a social story are: flying on a plane, walking in line at school, picking your nose, wearing a uniform, emotions, hygiene, raising your hand, quiet mouth, etc.

A social story should be written in first person. It should contain descriptive sentences, perspective sentences, directive sentences, and control sentences. A descriptive sentence addresses the where, what, who and why of the situation. Perspective sentences offer insight to the emotions and thoughts of others. Directive sentences prompt the preferred response, which is personalized to the individual. Control sentences are typically used by high functioning individuals and are not always necessary; they are written by the individual for whom the social story is intended.

Parents, teachers, therapists, and caregivers can all write socials stories to help children with special needs better understand socials situations. One can use symbols, pictures, video, story boxes, or just words when writing a social story-get creative and tailor it to the individual! Once you have written the social story, typically it is reviewed daily, and if possible right before the target situation. If you can’t review it right before the target situation when you are first introducing the social story, such as flying on a plane, then reviewing, ensuring understanding and then role playing can be beneficial to the child. It is beneficial to continue with reading and role playing until it is time for the child to go on the airplane. When the day of the plane ride arrives, read or highlight the points of the story before going to the airport and before boarding. After reading the story numerous times with you and practicing and role playing prior, the likelihood that the child will feel more comfortable with the process of flying on an airplane has increased. He or she will have a better understanding of what to expect before the day arrives and will be able to ask questions or receive clarification about any fears or confusion before it is time to ride the airplane.

When the child becomes more successful with the target behavior, the story can be faded out. Stories should be kept for each individual child and reviewed as needed. Again, you don’t have to be a therapist to write a social story-teachers and parents can do it too! Check out the great resources below for some that are already written to use or to help you write your own!

Here is an example of a social story about getting a haircut.

Getting a Hair Cut

I will go to the Hair Dresser to get a haircut.

The person who cuts my hair is called a Stylist.
When I get a haircut I sit in a special chair that turns and moves up and down.

There are sinks for washing hair. I will get my hair washed in the sink. I will try to sit still when my hair is being washed.

The Hair Stylist wraps a sheet around my shoulders so hair does not fall on my clothes.

The Hair Stylist uses scissors and a comb to cut my hair. I need to sit still when the stylist cuts my hair.

After the haircut the stylist brushes the loose hair from my neck. This may tickle a little.

I will look good after my haircut!

Some great resources for social stories:

http://www.thegraycenter.org/social-stories

http://www.polyxo.com/socialstories/

http://region2library.org/socialstories.htm

http://kidscandream.webs.com/page12.htm

http://www.thewatsoninstitute.org/teacher-resources2.jsp?pageId=2161392240601226415747290

http://www.slatersoftware.com/autism.html

http://www.autism-help.org/communication-social-stories-autism.htm

http://attainmentcompany.com/pdfs/bookSamples/LSR_Sample.pdf

Using Assistive Technologies to Foster Effective Communication Skills

A mere twenty-one months ago an event occurred that was about to catapult the field of Augmentative / Alternative Communication (AAC) into the future: The release of the iPad1. Not long after this occasion, iPads began evolving from high-tech recreational toys to bona fide learning and communication tools. Since its release date in April of 2010, a compilation of research has emerged which substantiates the utility of iPads for educational, therapeutic, and communicative functions. This is particularly true for students with special needs. The following links provide more information as well as evidenced-based research denoting the gains children with special needs have experienced while using the iPad:

Research on teaching with iPad
http://researchguides.dartmouth.edu/teachingwithipads
http://newsinfo.nd.edu/news/18178-study-results-students-benefit-from-ipads-in-the-classroom

Research on iPads and autism
http://www.iautism.info/en/2011/04/09/links-to-academic-papers

Research on iPads and disability
http://www.disabilityscoop.com/2011/05/20/study-backs-ipad/13142

Finding App resource for specific functional limitations
http://www.inov8-ed.com/2011/02/theres-a-special-app-for-that-part-5-5-mind-mapping-apps-for-students-with-learning-disabilities

Research is beginning to substantiate what has already been widely known by parents and educators: Children gravitate toward electronics becoming engaged, and even motivated, in some of the most arduous of tasks. With all its accolades and its explosion in popularity, we are understandably seduced by the iPad trend. However, it is a mistake to regard the iPad and its multitude of apps as a cure-all solution to the communicative and educational challenges faced by children with special needs.

 Cautionary Considerations for Communication

AAC systems existed long before the iPad came into being. It is true that some of the older, high-tech devices were awkwardly shaped, too heavy, and not particularly functional for every day communicative interactions. Fortunately, this is no longer the case; the DynaVox now looks like a streamlined laptop and there are text-to-speech devices small enough to fit in a pocket. Low tech options such as visual schedules, choice boards, or picture exchange systems (PECS) are have long since proven their efficacy in the therapy and educational settings. Lower – tech AAC devices are user friendly and easy to adapt to individual student needs. While it is an excellent learning tool, it is not always the answer for every communicator. It is vital to match an AAC device with the child’s communication abilities. The following websites are helpful in evaluating and selecting appropriate applications.

http://www.snapps4kids.com/
http://www.iautism.info/en/
http://a4cwsn.com/
http://www.squidalicious.com/2011/01/ipad-apps-for-autism-spreadsheet-of.html
http://slpsharing.com/
http://appsineducation.blogspot.com/
http://www.appannie.com/top/iphone/united-states/education/
http://techinspecialed.com/category/appfriday-by-momswithapps/
http://www.aactechconnect.com/ – coming soon aac apps evaluation
http://langwitches.org/blog/2011/08/21/blooms-taxonomy-and-ipad-apps/ – Using Blooms Revised Taxonomy for Evaluating

Apps
http://teachwithyouripad.wikispaces.com/Blooms+Taxonomy+with+Apps
http://ilearntechnology.com/?p=4025
http://otswithapps.wordpress.com/
http://www.inov8-ed.com/category/special-app-for-that/

Apps For The Blind And Visually Impaired: iPad/iPhone Apps AppList http://appadvice.com/applist_ipad_client_view/apps-for-the-visually-impaired

Hearing Apps http://journals.lww.com/thehearingjournal/Fulltext/2011/11000/There_s_a_hearing_app_for_that.3.aspx

The URL’s above as well as additional information about useful iPad accessories can be found at:

 http://www.iod.unh.edu/PriorityAreas/assistivetechnology/resources/iPadApplicationsAccessoriesandModifications.aspx 

Please seek the assistance of a qualified Speech Language Pathologist for assistance in choosing the most appropriate communication device and/or application for your child.

In the past, children in our public schools have required a minimum of a diagnosis and/or psychological testing in order to receive special services to meet their needs. Today, the story is different. Thanks to Response to Intervention (RtI), children can receive help at the first sign that they show a need for extra instruction.
RtI is defined as “a systematic and data-based method for identifying, defining, and resolving students’ academic and/or behavioral difficulties” (Brown-Chidsey & Steege, 2005). In a nut-shell, it is a data-driven process used to help meet students’ needs with an appropriate intensity of resources.

Data? Intensity of resources? What does that look like? It looks somewhat different at each tier of the process:

Tier I: Each fall, winter, and spring, Florida public schools conduct a school-wide screening of students’ skills in reading and math. (This is the data.) The screenings help identify which students are falling behind on basic reading and math skills. When students are identified as falling below a particular level of achievement, these students receive extra services in addition to their regular curriculum.

Tier II: Although services at this tier can vary, typically services involve small-group instruction in the specific skill area (e.g., phonics, reading fluency, addition, division) of need. These services are more intensive than at Tier I, because in addition to being exposed to the regular school curriculum (i.e., Tier I instruction), students receive small group instruction in their area of need. At this stage, data is collected on the students’ learning in the skill(s) being targeted, to ensure that students are appropriately responding to the Tier II interventions. This data collection process is called progress monitoring, and generally occurs once per week, to every other week. When progress monitoring data indicate that students still are not achieving, then students have the opportunity to receive Tier III interventions.

Tier III: Typically, these interventions involve individual instruction in the skill area(s) of need. Progress monitoring of students’ learning is still maintained, but students’ achievement is monitored more frequently than at Tier II (e.g., once per week or even daily). When the level of services required to see progress in achievement mimics special education services, then a multidisciplinary team (including parents!) makes a decision as to whether the student qualifies for special education services. At this time, psychological testing is sometimes requested to inform decisions with educational planning.

So…if you feel that your child demonstrates a need for extra services, please don’t hesitate to inquire about how RtI can help meet your child’s needs!

We are in the throng of the holiday season – busy getting gifts, hanging lights, finding that tree and wrapping presents. I can remember back when I was a kid and how excited I was for school break, opening presents, eating food and visiting with family members I used to see once a year. However, the holidays may be more stressful for our kids than we think, especially for children with special needs. We at Keystone would like your family to have the most successful holiday break possible; therefore, we are going to give you some strategies to help achieve this goal.
1. Recognize a change-up has, or is about to occur. Our kiddos love structure, consistency, and sameness. With the holiday break, all of this is lost. Be proactive! Begin by letting your child know that a change-up is about to happen in their daily routine.

2. To combat this change-up, use visuals like a daily schedule. For example, create a schedule and include three things that are going to take place in the next hour; this will help your child expect and understand what is going to take place. Visuals assist your child in understanding what is going to happen, what the expectations maybe, who may be coming over, etc. In order to keep that sameness going, and to create structure during the break, develop a daily schedule with your child with the events that will be taking place on each day. Do not make the schedule complicated. Using a piece of paper with three events that will take place is more powerful than creating an elaborate daily schedule.

3. Write a social story! You may be asking yourself “What is a social story?” A social story is a story written from your child’s perspective on what to do during a social situation or event. This may be especially helpful for a child that has holiday parties to attend, difficulty with unexpected guests, or if you are planning on having many people over during the break. If you would like more support or assistance with writing a social story for your child ask your child’s provider at Keystone. The following are guidelines to writing a good social story:

• It sounds more like a “to do” list than a source of helpful information and suggestions;
• You sense that it was written with a sole focus on eradicating a problem behavior;
• It seems as if the goal of the story is to just get a child to comply with an adult’s rules or expectations;
• It contains negated verbs (i.e. not…);
• There are first person statements – i.e. statements written in the child’s “voice”- that refer to a child’s mistake or negative behavior (the combination resulting in a self-depreciating statement);
• It contains second person statements;
• It contains the word “should”;
• You realize the stories for this child always provide new information
• There are statements that, if they were interpreted literally, would not be accurate or true, and/or
• The title identifies a desired behavior, as in, “I Sit Quietly in my Desk.”
  (this criteria was developed by Carol Gray)

4. Work with your child on techniques to help calm their body when they feel overwhelmed or stressed out. Techniques like breath and counts, taking space, squeezing a stress ball, hugging a pillow, asking for squeezes, etc. are good tools for your child to learn. These tools are helpful in calming their body during stressful situations. Practicing these techniques before a stressful situation, by role playing, can help prepare your child for how to react once it occurs. Being prepared can help minimize the anxiety and stress that would have happened without these skills and techniques. If your child is not able to role play you can practice these tools by modeling for them what to do. You will be amazed how much your child is watching you.

5. If your family goes to a holiday party, or hosts one, make sure there is a safe place (i.e. spare bedroom or an office not being used) to take your child if they require a break from the commotion. When our kids have meltdowns in public places or at social events it can be an awkward situation for us. But what about how difficult it can be for the child? Think about it for a second; imagine you are feeling overwhelmed, stressed out and you cannot take any more of what is going on. The worst part is you don’t know how to escape it or communicate how you feel. This is how it can feel for your child during these moments. Therefore, it is highly recommended that you have safe areas where no one else is around. This will allow your child some time alone to regulate their bodies in order to deal with social pressure. You may need to use a timer to let your child know how much time s/he has in this room in order to transition smoothly. Using the schedule you created can also be helpful in preparation and transition.

Hopefully these strategies will be useful during your holiday celebrations. If you need other tools or suggestions to use during the break do not hesitate to talk to your provider. From all of us at Keystone we wish you and your family a happy, healthy and successful holiday break!

This is a question that I hear all the time, “Why use praise and rewards? My child is supposed to behave well because it’s the right thing to do. I’m not going to bribe them to do the right thing.” It’s a great question. The simple answer is you aren’t bribing them to do the right thing; you are focusing on the behaviors you want your child to do instead of the behaviors you don’t want them to do.

By praising and rewarding good behavior, the child becomes motivated to engage in the desired behavior. By rewarding the positive you get a higher pay off – the child wants to receive praise or rewards, and is more likely to do what is desired. For instance, you tell a joke to get a laugh. Just think- if people stopped laughing at your jokes, would you want to keep telling them?  The behavioral principle of reinforcement can be explained like this: behaviors that obtain what someone wants or needs will grow strong and continue being used, but behaviors that don’t pay off will stop since they are not effective or efficient.

You are trying to motivate desirable behaviors including behaviors like: asking nicely for items, sharing toys with siblings and peers, complying with directions the first time the direction is given, independently getting dressed and doing chores, and even being a good sport whether your child is winning or losing.

Motivating desirable behaviors doesn’t necessarily mean providing your child with money, items, or expensive things to do. A parent’s attention is one of the most valuable things that a parent has to offer. A kind word, a listening ear when your child has had a difficult day at school, hugs and excitement, spending time playing with the G.I. Joes/Legos/Barbies that are already in their room — all of these are forms of attention that really show your child that you care. Likewise, a child’s toys and activities also make great rewards. You don’t have to buy new games or new toys, but rather make sure that toys come out when work gets done. Let’s say that your child likes video games. If doing homework means that your child can play their video game, but refusal to do homework means no video games or other privileges, then your child will be much more likely to at least attempt to get things done. Sure, you may have to help with homework or whatever else that you ask them to do. However, your child will do these desirable behaviors as long as those behaviors pays off more than the problem behaviors, and the task isn’t too far beyond your child’s ability.

Given that behavior either pays off and continues, or doesn’t and drops off, parents have a choice. Would you rather pay off the desirable behaviors or the undesirable behaviors?

With the holidays approaching, temptation to modify your child’s schedule is going to be there. Little Johnny is supposed to be taken to the bathroom every 60 minutes but you’ve got to leave soon to get to Aunt Martha’s dinner party. You could take him now, even though it’s only been 45 minutes. Not a big deal right? Well 10 minutes into the trip Johnny has an accident. Instead of praising him for going to the bathroom on schedule and building important habits and learning history, we’re rushing into a Hungry Howies to get as many napkins as it takes to dry the back seat of the Yukon. (Don’t forget to grab a few extra to dry off the now saturated pea coat you had sitting next to Johnny).

9 times out of 10 it is not worth it to make modifications or forgo aspects of your child’s treatment for the sake of convenience. Ironically, trying to make things “easier” can actually cause more problems, just as in Johnny’s example above. There are ways to make your holiday season go relatively smooth without having to sacrifice tradition, or your child’s treatment.

Plan ahead. Make a plan in advance for everything that is likely to be a stressful decision. Then have a plan B in case things go awry. Make sure everyone in the family is aware of what their role is going to be, whether it’s diaper changer extraordinaire, or just a moral support who will praise Johnny for staying dry and Mom and Dad for staying sane.

• Expect the unexpected. Holidays mean a change in schedule and a change in scenery for most of our families. A lot of you have children that do not react particularly well to sudden changes. While it can be impossible to predict exactly how your child is going to react, you can expect him/her to have some difficulties. Plan some extra time so that you can respond appropriately to whatever behavior you’re seeing.
• Set aside break time. Another common ingredient thrown in the mix is added sensory stimuli in the environment. Whether it’s Christmas lights, delicious turkey smells, colder temperatures outside, more cars on the road and more cars honking at the guy from Colorado in the wrong turning lane, tis the season of more sensory input in the air. Give your children opportunities away from all this input to engage in their preferred sensory integration activities. Compression, deep pressure, headphones, counting, etc. Chances are it will help the child avoid problem behaviors by successfully processing more of that added sensory input.
• Be realistic. Something that kills me every year is the expectation that parents put on their children to have the “ideal” holiday experience. Many families try faking it – forcing smiles,  engaging in witty banter, and sipping eggnog in ugly sweaters by a fire. I much prefer the scenario where everyone gets a piece of their respective holiday pie and then supports their family. This can be dad wearing his favorite ugly sweater, mom getting the eggnog, little Suzie going to a friend’s house for the day, and infamous Johnny may simply be content watching a 30 second clip of National Lampoons Christmas Vacation several times as a reward for staying dry the whole way to Grandma’s house.

Make a concerted effort to maintain structure and treatment schedules while you also take the time to enjoy the holiday times with loved ones. Fill your stockings with patience, open a big box of consistency, and by all means, enjoy some eggnog.

Sometimes it can be difficult to get kids to listen to your directions, so it may seem like a constant battle between you and your child. The simplest directions may turn into a huge headache. Here are a few simple pointers that may make it more likely that your child will listen to your directions:

• Give one direction at a time and keep directions short and simple. Try to limit directions to 4-5 words. For some kids, 1-3 word directions may be the limit.
• Make sure your directions do not imply that following the directions is a choice the child can make. Give directions as STATEMENTS in a firm tone of voice rather than QUESTIONS.
• Specifically identify what you want the child to do.
• Make sure you have the child’s attention. Try to be within arm’s reach and at his/her eye level.
• Use do instead of don’t statements Give directions so that you are telling your child what he/she should be doing instead of what he/she shouldn’t be doing. 
• Use gestures. Gestures such as pointing may help your child understand what you are asking them to do.
• Do not begin the instructions with “Let’s…” If you are planning on helping your child with instructions, you can use let’s, but otherwise try to avoid using let’s.
• Reward following directions!  We want to make sure that compliance earns more attention and positive consequences than noncompliance! 

I know, the “Sippy-cup” is very useful; it prevents spills, is mobile and convenient.  However, mixing in the use of a “regular cup” will help your child’s oral-motor development.  To do this, start by giving your child 2-3oz of their drink in a regular cup 1 time a day for one week.  Then, choose one meal a day where only regular cup or a “big kid cup” is available.  This will help them coordinate the complex fine motor movements within the oral cavity.  If your child is over the age of 2 and uses a pacifier or a bottle, PLEASE STOP!!  The use of a pacifier or bottle beyond the infant stage maintains the infantile tongue-thrust swallow that can impede oral-motor development.  Tongue-thrust can be caused by prolonged pacifier, thumb or finger sucking. Constant thumb sucking in particular may change the shape of the child’s upper and lower jaw and teeth, requiring speech, dental, and/or orthodontic intervention. Tongue-thrust is a type of Orofacial Myofunctional Disorder (OMD).   With tongue-thrust, the tongue pushes too far into the anterior portion of the oral cavity while speaking and/or swallowing. The tongue may lie forward during rest or may protrude between the upper and lower teeth during speech and swallowing, and at rest. Typically a frontal ‘lisp’ (i.e. saying ‘thith’ for ‘sis’) is due to tongue-thrust.  Other sounds that may be impacted due to tongue-thrust include: /s/,/z/, “sh”, “zh”, “ch” and “j” . 

For further information, visit http://www.asha.org/ or contact the Speech and Language Department at Keystone Behavioral Pediatrics.