Early Intervention for the Treatment of Autism Spectrum Disorder (Part 2): What to do When You Are Waitlisted

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Tamar Varnai, MA, BCBA

DrOmnibus

The cause of Autism Spectrum Disorder (ASD), a neurological disorder affecting millions of individuals worldwide, is not currently known.  Researchers have connected environmental and genetic factors to the disorder, but have not yet pinpointed exact causes or developed a cure.  That said, research data show that Early Intervention (EI) for children with ASD can lead to significant gains in targeted skill areas, a greater chance of inclusion in general education classrooms, and a decrease in the amount of money required to pay for services later in life.  Researchers agree EI services should start as soon as symptoms, or “red flags,” are seen, and immediately when a diagnosis is made.  It is recommended that services be provided 5 days per week to mimic school hours and that opportunities to practice targeted skills be repeated consistently and daily.  Unfortunately, the availability of qualified individuals to provide appropriate EI services for children with ASD can be meager in many areas throughout the US and worldwide, leaving many families with children on a waitlist for services.  Since it is so important to begin therapy as early as possible, families on a waitlist can and should begin activities to target key skills while they wait.

Applied Behavior Analysis (ABA) is currently the only evidence-based methodology proven to be effective for children with Autism.  Main components of ABA include using assistive communication methods, consistent consequential strategies and reinforcement, and modifying the environment to provide a calming space with consistent and predictable routines.  Parents can begin by modifying the environment in simple ways like setting up a quiet work space with minimal distractions.  This could mean setting up a small work table and chairs or organizing toys and creating a calming space for breaks.  ABA relies heavily on positive reinforcement and only uses punishment as a last resort.  Some common examples of reinforcement systems for early learners include sticker charts and token systems.  Families can start using reinforcement strategies to increase positive behaviors by praising the child for the positive behaviors they engage in and pairing praise with tangible rewards like special games, treats, or even hugs.  It is important to be consistent with consequences so the child does not get confused.  For example, if one parent provides reinforcement when the child requests a desired item using the item’s name, but the other parent only provides reinforcement when the child requests using the item’s name and eye contact, you might not see an increase in eye contact at the same rate as if both parents require the eye contact.

Children with ASD crave predictability.  Knowing the schedule of the day or when they will be able to access their favorite toy or activity will help alleviate some anxiety and rigidity that is commonly felt by individuals with autism.  Families can create a visual schedule for their children to help them understand the daily routine and what can be expected throughout the day.  Visual schedules can also highlight changes to the normal daily routine.  While EI professionals will often create these resources for their clients, families waiting for services can find good templates and examples of visual schedules and token boards at BoardMakerOnline (BMO) and TeachersPayTeachers (TpT).  Both sites require you to create a free account and have some free resources.  BMO requires a monthly subscription to access paid resources, while TpT allows you to pay as you go for paid resources.  Along with visuals schedules, parents can use timers and verbal countdowns to help ease children into transitions.  For example, when it is time to clean up, give a verbal warning, “5 minutes, then clean up”.  Set a timer so at the end of the 5 minutes, the tone will also signal it’s the end of the activity.  A visual timer is especially good for young learners because they can look and see the time running down.  Continue giving warnings: “two minutes, then clean up”. At the end of the time, help the child clean up and praise them for cooperating.

Functional communication in a common deficit in young children with ASD, so building these skills is generally targeted immediately upon beginning EI services.  Communication and speech skills are targeted by Speech and Language Pathologists (SLPs), as well as Board Certified Behavior Analysts (BCBAs), Registered Behavior Technicians (RBTs), and Licensed Behavior Analysts (LBAs).  It is important that together with the family, everyone works as a team and approaches language goals in the same way.  This may include using an alternative communication method such as a speech-output device, a picture exchange system, or sign language.  Spoken language is always paired with these methods to provide an appropriate model of verbal language.  Prior to EI commencing, families can pave the way for language training by modeling simple language in daily routines and when it is known that the child wants a particular item or activity.  Then they can provide an opportunity for the child to repeat a sound, word, or phrase.  For example, if a parent sees their child reaching for a toy car, the parent can say the word “car” and pause for the child to attempt to repeat.  If the child repeats the word, the item should be given to the child immediately.  The parent can say “car” 2-3 times, pausing for an opportunity for the child to repeat the word after each time, but if the child does not repeat after 2-3 times, the parent can give the item to the child.   Parents can intentionally place favorite items out of reach to set up opportunities to practice repeating words or phrases requesting the items.  During play and interactions, use simple and repetitive language to elicit language from the child.  Simple language that is in context like “Ready, set, go” and “beep, beep” when playing with cars or saying “up” when the child wants to be picked up, will be easier for the child to echo.  For additional examples of increasing eye contact and language through play, watch the YouTube video “Playing With Toys Real Look Autism Episode 5” (link in resources).

Reading with your child is a fantastic activity that can allow for many skills to be targeted while also building a love of books.  While reading books with your child, point to the pictures and give words for the different items or characters in the story.  You can also describe what an item is.  For example, when reading “Goodnight, Moon”, you can point to the mouse, say “mouse” and then add that a mouse says “squeak, squeak.”  You can make a game of trying to find the mouse on each page that shows the room.  You can ask simple questions about the items in the pictures.  When reading a book like LeSieg ’s “In a People House”, you can point to the different items and say things like “Look, a bed! You sleep in a bed!” You can also ask questions like “Do you see something blue?,” or “What is something you can eat?”

Using technology to begin therapy services at home can be helpful while waiting for an EI program to begin.  There are several apps available for computer or tablet use that provide instruction directly to students with ASD.  These apps are designed by professionals specifically for children with ASD and other language delays.  While many professionals in the field use these apps in therapy services, they are also variations for home and family use.  These are ideal for families to use while waiting for EI services, since they are created by qualified professionals and require very little experience from the user.

DrOmnibus is one program developer that offers a computer and tablet based app for home use which uses the main components of ABA to teach children with autism. The DrOmnibusHome app targets various receptive skills and offers numerous games, each targeting a specific skill group.  Each game begins with a pretest to gather a baseline for the skill and targets of that game.  The game uses the results of the baseline to tailor the teaching trials to target the skills the student needs to learn.  The teaching trials increase in difficulty as the student begins to answer independently.  A unique component of the program is that it incorporates positive reinforcement in the form of virtual tokens.  Using virtual tokens allows for easier generalization into EI therapy sessions, where physical tokens are very often used as reinforcement.  The program offers the ability to target several skills areas including receptive identification of objects, colors, shapes, emotions, and more.  They also have several games for teaching sound identification, which is a unique feature that most other ABA apps do not offer.  Each game targets a specific category, though targets within the category are intermixed within the game. For example, there is a game for teaching receptive identification of shapes where the .  The student will begins with a pretest for to establish a baseline;  and then the the program then will presents any shapes that were unknown during the pretest.  It might begin only with one target, presenting that target in an increasingly larger field.  Prompts are used as necessary and when the student begins to respond independently and correctly for that target, another target will be added with the original target for discrimination training.  This mimics how an EI therapist might teach the same concept during EI sessions.  The program is presented in an easy to use manner that allows parents and caregivers to open the app, choose a target program and get started.  DrOmnibusHome has a small monthly fee for use.

You can check for free how the ABA DrOmnibus Home App can support your therapy with a child.

Injini is an iPad app that has a onetime purchase cost and includes 12 activities, including tracing, puzzles, matching, and receptive tasks.  Parents or children can choose one activity at a time from the home screen. Each activity has several levels of difficulty and can be started on any level.  If the activity is started on a lower difficulty level, the tasks within the activity will increase in difficulty as the playing continues.  Tasks are presented more as games than as therapy teaching tasks.  This makes the app’s tasks fun for the child, though will not mimic EI tasks as closely.  Besides being beneficial for use while waiting for EI services to begin, Injini is a good option to have available when you want to offer use of an iPad but still have an educational component.

Another computer and app based program is called TeachTown.  TeachTown offers different ABA-based programs for children with autism ranging in age from 18 months through teenager years.  TeachTown Basics, for children ages 2-12, has the ability to target language, listening skills, social-emotional skills, academics, and cognitive skills.  The program will begins with an overall assessment of the child’s current skill level before beginning instructional sessions.  The facilitator (parent or educator) then has the option to allow the program to generate progressive lessons or to input specific goals to target for each session.  All skills are intermixed during the session, allowing the student to complete an entire session of varying target skills without having to move in and out of different lessons during the session.  The program incorporates reinforcement and prompting, which are two key components of ABA. The  The program will keeps track of data and graphs student progress.  TeachTown now offers a new program called Meta-Play, which is a play-based curriculum for children 18 months through 4 years, and targets imaginative thinking, pretend play, and social skills.  This program is a hands-on learning experience, as opposed to their other computer or tablet based programs.  It includes physical toys and lesson plans to guide parents and educators through play-based lessons.  EI professionals often use play-based lessons when working with really young children, so this is a good option for families waiting for services to begin.

Being on a waitlist for EI services is not ideal, but it does not have to translate to a delay in learning for your child.  Adding visual supports and reinforcement systems can be helpful for daily routines and behavior.  Creating a work space will prepare your child for working with EI professionals when they begin.  Utilizing family-friendly therapy apps and programs will help target early skills at home.  Modeling and pushing for more language will set a precedence of what is expected, even if your child is not yet repeating and using language themselves.  With these strategies, families can maximize their time on the EI waitlist.

 

Technology Summary:

 

Visual Support Examples:

Token System example:

www.dromnibus.com/en

Daily Visual Schedule Example: (Morning Routine)

www.dromnibus.com/en

Additional Resources:

http://www.AutismSpeaks.org

https://boardmakeronline.com/

http://www.dromnibus.com/en/

https://itunes.apple.com/us/app/injini-child-development-game-suite/id452962000?mt=8

https://www.teacherspayteachers.com/

http://web.teachtown.com/

https://www.youtube.com/watch?v=V-c50HNnPg0&list=PLS2PJR64ZE_EUgqfbk__XaE1uzDuDGgp3&index=5

Cohen, Howard, Amerine-Dickens, Mila, Smith, Tristram. (2006). Early Intensive Behavioral Treatment: Replication of the UCLA Model in a Community Setting. Journal of Developmental & Behavioral Pediatrics, 27 (2), 145-155.

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd Ed). Upper Saddle River, NJ: Merrill/Prentice Hall.

Jacobson, John W., Mulick, James A, Green, Gina, et al. (1998). Cost Benefit Estimates for Early Intensive Behavioral Intervention for Young Children with Autism:  General Model and Single State Case. Behavioral Interventions, 13, 201-226.

National Research Council. (2001). Educating Children with Autism. Committee on Educational Interventions for Children with Autism. Cathernie Lord and James P. McGee, eds. Division of Behavioral and Social Sciences and Education. Washington DC: National Academy Press.

Tamar Varnai, MA, BCBA, is a Board Certified Behavior Analyst originally from New York. She received her Master’s degree in Applied Behavior Analysis from Columbia University, Teacher’s College in New York and has been working with students with special needs for over 20 years.  She specializes in working with children on the Autism Spectrum, as well as shaping behavior and teaching language and social skills to students of all ages.  Tamar has worked in special education and inclusion classrooms and supervised home-based ABA programs.  She has extensive experience working with children and teenagers, ages 1 year through 16 and has worked in several countries outside of the United States and throughout Europe.

Tamar provides direct teaching services individually or in group settings, educational and behavioral assessments, program development and supervision, language and social skills instruction, as well as trainings for parents and teachers.  She is a consultant at DrOmnibus for ABA DrOmnibus Resource APP.

*Paid content by DrOmnibus.

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