Article 9

Master Article 9 Instructor Chris Garcia gives some practical tips and reminders that Arizona based Direct Support Professionals must always keep in mind.

This Presentation is made available for those individuals that have already been certified in Article 9. This presentation is for informational purposed only and may not be used for initial or re-certification purposes.

To attend an in-person training and become certified in Article 9  Click Here. We offer classes multiple times per week in both Phoenix and Chandler.
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A Paradigm Shift for Adult Day Services

Placing rings on sticks bead on strings and pegs in boards describes the day of many participants in the classic Adult day or Adult Habilitation programs. Their historical focus on skills acquisition , leisure, academics, activities of daily living and community outings is in need of transformation. Best practice recognizes that people grow and develop and become more independent as a result of participating in meaningful life activities.

The question becomes this: how do we shift the fundamental paradigm of adult day programs so that they help people towards meaningful lives? First and foremost, through are training programs we must reassure staff that what they have been doing all this time was not wrong. This approach was grounded in a philosophy that, in its time, provided people opportunities to have a level of engagement that allowed them to have some improvement in the quality of their lives.

If we begin with the widely held and reasonable assumption that what people with developmental disabilities want out of life is a real life, we must then ask ourselves, “What does real life look like for adults? What do adults do during the hours that adults with developmental disabilities are in day programs?” The answer is obvious and leads us to this conclusion: what we must offer in place of the day programs is work.

A growing number of organizations across the country are embarking on a journey of changing how adults are supported in day programs. Agencies are concluding that the only viable option out there is in fact work. In addition to being what most adults do, work has value that extends far and wide. Work is the great equalizer. Work builds self-esteem and confidence; work changes perceptions of the community at large about people with disabilities; work open the doors to real relationships; work helps people gain valuable skills that they can use many places; work helps adults we support fully enter the adult world as participants, not just observers; it allows people to become producers, not only consumers. Work is a critical piece of having a life.

Having said that, we must discuss and assess what work is. Work is not necessarily paid employment. In an ideal world with all resources, regulatory flexibility and creativity available to us, any person regardless of disability should be able to get paid to work. But in the real world of limited resources we must be willing to take what we can get closest to what we want.

Work is the expenditure of meaningful effort. Our problem now becomes operationally defining what Meaningful effort is. Those in our field who have been uncomfortable with the kinds os activities offered to people with disabilities have pressed for “meaningful activities.” defining what comprises a “meaningful activity” sometimes alludes us. The following are eight criteria that serves as the foundation for defining “meaningful activity” and for training staff in this momentous transition. These criteria can be used as a guide and measure of what is done during the work day.

  1. Meaningful – If the person doing the task stopped doing it, we’d have to pay someone else to do it.

In a typical site-based program we will often see these kinds of activities: block stacking, bead stringing, coloring, sitting in a “sensory stimulation” room, making pretend purchases, flash card work – so forth. Think of these things in terms of placing an add for employment:

                                    Wanted: Two professional block stackers

The idea is ludicrous. If we can’t imagine applying for such a job ourselves, why do we think this is an acceptable was for people with developmental disabilities to spend their time? In contrast, consider these options: removing buttons from unsalvageable clothing, sorting them selling the buttons to the local craft store; free formed water color painting that’s framed and donated to a nursing home to decorate their walls; holiday centerpieces made to sell at an art fair: growing vegetables in a community garden and giving the local homeless shelter. The possibilities are endless. Training provided must help Direct Support Professionals (DSP’s) tap into their creativity and resourcefulness and apply those qualities in their work.

  1. Functional – A person acquires a useful skill or ability as an outcome of doing the task.

Eight people participating in the same activity may have eight different functional outcomes. For one it’s attention to task, for the next it’s improving his pincer grasp, for the third it’s arm extension, the forth it’s participating in a cooperative effort – and so on. As agencies transition forward, DPSs will need the assistance of clinical consultants to assess and determine what these functional outcomes should be for each person. Most training, in fact, will need to be guided by thses clinical resources serving as trainers.

  1. Consequated – The task must either have internal value to the person and/or have an external positive consequence.

People do things for two reasons; either they enjoy it and / or there is an external consequence for doing it such as a paycheck. As part of the transformation process, we must look diligently for meaningful, functional activities that also have a positive consequence for each person.

The training that will be required in this area must be two-fold. Because people who require pervasive supports may only give us subtle hints of what pleases them, DSPs will need to learn how to observe these signals in an attempt to discern what activities are being met with a positive response. Secondly, it must be understood that external positive consequences may not always be perceived as such by the person being supported. For example, when a person is engaged in an activity which contributes to the larger community, that person may not realize that this creates for them a positive consequence of being perceived more favorably by others. Even if they do not recognize that a positive perception may alter their quality of life for the better, DPSs must understand and support such outcomes as they provide activity selections.

  1. Beginning to End – The person participates at some level in every step of the process.

When professionals in this field see themselves as support people stop seeing themselves as caregivers, this will not be difficult. People must be supported to engage in whole tasks; with encouragements to participate to the extent that are willing and able to do so. No longer do others do it for them. Someone wants a cup of coffee? Support them in choosing the beans, grinding the coffee, measuring the water and grounds, pouring it into a French press, pouring it out, enjoying it, then clean up. It will take longer, it won’t be efficient and it will be a lot messier; facts that may be a source of consternation to DSP’s. They will need the encouragement and training of their supervisors who must continually reinforce the idea that participation, not efficiency is the goal.

  1. Age Appropriate – The things other people of the same age use.

Adults should not use the things children use unless they are using it with a child for the child’s sake. Focused training may be necessary to help staff understand why it is imperative that we not provide adults with the things of childhood in the context of adult day services.

  1. Right time (normalized rhythms) – Activities occur at the time of day when those activities typically take place.

Hands are washed before eating, after using the restroom not as part of a “hand washing program.” Meals are eaten at mealtime. Socializing occurs on work breaks. Day services will not be used to do things that should occur in the morning, evening or weekends. bowling, movies, trips to the beach and shopping are great activities but not during the week day. These are the purview of other types os services and supports.

  1. Right Place (appropriate environment) – Activities occur in the place where those activities typically take place.

Grooming occurs privately in a bathroom. Real purchases are made at the stores. Meals are eaten at a table. Activities will be done only in appropriate and typical settings. Thus, for example, paying for one’s meal at a fast food restaurant are not taught using fake money in a classroom. Both concepts of right time and right place only require that those providing the supports look to their own lives and those of most people around them to determine what is considered right times and places for activities. Thus, training must focus on identifying typical scenarios for task to occur, not to create such scenarios artificially.

  1. Equal participation – The distinction between people supported and those providing the support must be minimized.

As much as possible, people should not see the difference between these two groups. The way they look and act and their participation in activities should look more alike than different. One of the implications of this approach is a significant need to address the sometimes poor dress and hygiene of many of the people we support. We also must tackle the issue of inappropriate behavior people may engage in and that may be seen by others as either cute or obnoxious. (This is aside from behaviors that is directly related to one’s disability, such as the involuntary tics associated with Tourette Syndrome). At all costs the people we support must look good in the eyes of others. The flip side is that DSPs must not wear hospital scrubs, smocks or other marks of being in a different or care giving role. Agencies pursuing this transformation of adult day services will hold high standards for how people present themselves, both the people supported and those doing the supporting. This is not a particularly a training focus but requires those doing the support to pay attention to their self-presentation and that of the people they support.

Work must become the driver of any significant transformation of adult day services. As stated earlier, work provides the opportunity to “open doors” to real relationships. This important secondary function for day services (typically a primary focus of other supports such as residential services) is to support people in having valued relationships. Any one of us, whether we have one or two valued relationships or a whole host of them, would agree that they are distinctly important to our quality of life. We would be hard pressed to say that our families alone or people we pay for services are enough for us, and yet that is often all that the people we support have. Valued relationships cannot be mandated or guaranteed, but everything must be done to foster the potential for acquaintances and perhaps even friendship to grow. Through the use of neighborhood connections, common volunteer interest groups, going to the same places frequently, making introductions and supporting people to be the ones interacting with others on a regular basis, we can help people find opportunities for relationships to develop.

The training that will be required to accomplish this must focus on teaching DSPs how forge and make the most of community connections as well asutilizing that most basic of skills – making introductions. It will not do for DSPs to be the only ones interacting with broader community. They must learn to see themselves as stage hands to the actors in the play of life, providing Individuals with the tools needed to strike up their own acquaintances.

It may be asked if this focus on having people work and supporting them to develop relationships will be effective. Can we actually help people get a life? Absolutely we can and it is our obligation, the reason we have our jobs. Perhaps the thorniest challenge that lies before any of us seeking to redefine adult day services is helping people break old habits, particularly those connected with care giving, and forge new ones. Training alone will not accomplish this. A radical culture shift, one that is defined by Good Enough for Me will help to move us forward.

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Preparing for the Holidays with Autism

The holidays can be a stressful time for children with autism and their families.  Sensory overload occurs quite easily, what with the extra stimulation the holidays bring.  Here are some ways you can help your child and family prepare for the upcoming holiday season and minimize the amount of stress he/she deals with.

Use Social Stories

Social stories are a great way to teach children on the spectrum about the upcoming holiday season.  Autismsocialstories.com/christmas offers a variety of social stories for the holidays, or you could even create your own.  These social stories help you create a plan for your child, and they can also help you assess your child’s level of tolerance for certain holiday activities.  For example, if your child struggles tremendously with the “Santa Claus” social story, visiting Santa this year might not be a great idea.

Keep It Simple

Many of us like to go big for the holidays, but that is likely to change when a child on the spectrum is involved.  Children on the autism spectrum do not necessarily do well with all the sensory stimulation of the holiday season, such as lights and music.  If your child has sensory issues, you might scale down your decorating, at least indoors.  Put up a tree (again, social stories and planned explanations can assist your child in understanding why there is a tree in the house).  Place a few decorations around that you don’t mind your child touching or playing with (because he/she will probably be curious) or keep decorations out of reach.  Avoid any type of plant that might be poisonous, such as poinsettias or mistletoe, or older painted decorations that might have lead paint.

Allow For Down Time…

The holidays are a busy time for many families, with parties and other holiday comings and goings.  Schedule in “down” time for your child (and even for yourself) to prevent an overload of holiday cheer.  Learn to say “no” – you don’t have to attend every holiday party or event – know what your child will tolerate and what he/she won’t.  And if possible (and you want to), have the holiday feast at home, where your child is most comfortable.  This allows your child to go to his/her “safe” place when things get overwhelming without having to completely stop the holiday festivities.

…But Do Try New Things

Allowing for down time is important, but exposure to new things is important too.  At least try some of the holiday traditions (using social stories or other methods to plan/prepare), such as visiting Santa or taking a winter train ride.  If your child won’t sit on Santa’s lap, that’s okay – even standing next to a strange man in a red suit is a huge accomplishment for many children on the spectrum.

Don’t Get Discouraged

This is especially hard for parents who love the holidays.  Many children on the autism spectrum are disinterested in the holidays, and they don’t have much care for presents or holiday traditions.  Some children won’t open up presents or pose for Christmas pictures, while others may actually have meltdowns due to the changes in routine.  Work within your child’s repertoire; if he will tolerate a picture, take one, if not, why not settle for a candid shot?  If your child is interested in opening presents, revel in it; if not, let siblings or family members “help” open up the gifts with him/her.  Understanding the holiday from your child’s point of view will help you make more sense of the day(s) and keep your stress level from rising.

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How does ABA stack up?

Positive Behavior Supports (PBS) is a widely known concept and is accepted and practiced by schools district-wide as well as state agencies. As where Applied Behavior Analysis (ABA) is a newer science and is increasing its recognition as well. With the evolution of science and the progression of times, it is important the similarities and differences be discussed.

PBS is non-aversive and was designed to replace the belittling interventions that took away the rights of individuals with special needs. Environmental conditions are altered in attempts to alter behaviors while no specific technique to define it. PBS focuses on the rights and values of the individuals it serves. Its main purpose is to support the individual throughout their life.

ABA is a science that uses environmental variables to influence socially significant behavior and develops a technology for behavior change. ABA focuses on the practical application of the interventions as well. It relies on using data to guide the interventions and demonstrate empirical support. The main purpose of ABA is to, not only reduce the challenge behaviors, but decrease skill deficits driving the individual to independence.

While the similarities are few, they are noteworthy. Accordingly to Johnston et al (2006), PBS should acknowledge ABA as a foundation. It is based on the improvement of the lifestyle and focuses on the values and rights of the individuals. While ABA respects those same components, along with social validation, person-centered planning, and integrity of the individual (just to name a few), ABA is regarded as a scientific practice thus providing a strong foundation for some of the interventions that PBS uses and implements. PBS and ABA, both, want to see the behavior modified, and that is done through the implementation of interventions. Some commonalities amongst the interventions are a focus on lifestyle change, modification of ecological interventions and setting events, antecedent manipulations, building environments, proactive planning, and emergency procedures all while preserving the dignity of the individual. Even though all of these components have shown to improve behavior, they have different explanations.

What distinguishes them from one another is their primary focus. PBS focuses on the cultural values and the antecedent influences while ABA is the effectiveness of the treatment and the 3-term contingency. The 3-term contingency refers to the antecedent and consequence of the behavior both as contributing factors to the cause and maintenance of the behavior, which also supports the reason for any behavior changes. Since PBS tends to use more general environmental changes there is a lack of clear justification of any behavior changes. PBS uses behavior supports to assist with changing the individuals’ behavior change. When done incorrectly can lead to increased dependency, reduced generalizability of skills, and challenges regarding transition from services. ABA has shown that through the development and reinforcement of skills individuals increase the likeliness of reaching independence which is our ultimate goal with services.

And while both disciplines evaluate the effectiveness of treatment it is important to note that ABA uses the scientific method to drive their practice including, modification of interventions and progress of the individual.

Through the expansion in practice of ABA we, as a field, can maximize the potential of the individuals we serve, and after all, isn’t that why we do what we do?

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Autism and Aggression: Intervention Strategies

Aggression in children with autism can take many forms, such as hitting, kicking, scratching, biting or destroying property. A child’s aggression can be directed at self or others, and can be scary for everyone involved. Not every child with autism displays aggression. But for parents and teachers that do have to deal with their child’s outbursts of rage, feelings of frustration, exhaustion, and embarrassment often ensue.

Aggression is most likely a side effect of communication and/or coping issues. So when a child with autism becomes aggressive, there is a reason. For instance, many children with autism have a hard time with change, so changes to their routine can cause them to get upset. It’s up to us to figure out why they are being aggressive and to teach them that 1) aggression will no longer be reinforced and 2) other things they can do instead of being aggressive.

Here are some strategies to use to get your child out of the cycle of aggression:

Teach Communication. Children with autism usually have deficits in communication. Lack of effective communication skills often leads to frustration, and frustration can lead to aggression.  Imagine if you wanted something but could not say it! So one of the first things you need to do is address any communication issues your child might have. Your child should be taught how to communicate his needs, either through spoken language, sign language, or picture communication systems designed for people with special needs. This alone should help with a lot of behavior problems.

Teach Alternative Behaviors. Once you know the reason(s) why your child becomes aggressive, the child should be taught how to get what he wants without hitting. For example, say your student throws items whenever he is asked to do independent seat work. You might try teaching him to say, “I need help” or “Break, please.” You may also need to figure out how to make certain tasks easier for the child. As time goes on, you can teach him to work independently for longer and longer periods of time.

Another strategy is to teach your child that he has options. For example, if you tell your child he cannot have a cookie, you should also tell him what he can have- such as crackers or an apple. The goal is to teach kids to make a different choice when one option is not available.

Reinforce Good Behavior. Whenever your child uses appropriate behavior to get his needs met, such as asking nicely for something, praise him for it! Initially, you should give your child what he asks for (within reason!) as often as you can in order to reinforce appropriate asking. So if instead of throwing his books, your student says, “Help me please!” It’s a good idea to help him right away so he learns that “using his words” results in reinforcement, whereas throwing items does not.

Change Your Behavior. Many children with autism will engage in certain behaviors because of the reaction they get out of people. If you yell or get angry, or otherwise provide the child with a lot of attention after they hit, then your reaction may be reinforcing the behavior. Also, if the child is allowed to get out of a non-preferred task after they become aggressive, this can also be reinforcing the behavior. In general, aggression should be met with firm, yet calm redirection.

Prevention.  Implementing the above strategies should help reduce aggression. But you should also learn the warning signs that aggression is about to occur. When you see a “precursor” behavior, NOW is the time to act! There is no reasoning with a person during a meltdown. So do it before your child loses control. For instance, if you know your daughter begins to stomp her feet prior to lashing out, then if you see her stomping her feet, use that opportunity to remind her of the benefits of staying calm versus the consequences of losing her temper. Also, if you know a certain task usually results in a meltdown, re-think whether or not that task is truly necessary. If it is, you may need to provide more assistance and more reinforcement for task completion.

The main idea to take home is that s­ome children resort to aggression because it usually works! Therefore, it is very important to not give your child what he wants when he becomes aggressive. If you give in, you are reinforcing aggressive behavior. What you should do is teach him how to communicate his needs, and how to cope when he cannot have his way. Set boundaries and follow through. Reinforce good behavior as often as you can. If a serious meltdown occurs, take your child to a safe place to calm down, but once he’s calm, follow through with any instructions you gave prior. Other consequences such as loss of privileges may be necessary, but it’s better to focus on teaching and reinforcing good behavior.

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Selecting and Defining the Target Behavior

In ABA, a target behavior is the behavior that has been selected for change. If a parent would like their child to learn how to eat with a fork, then “eating with a fork” is the target behavior. Likewise, if a teacher would like her student to stop wandering around the classroom, then the target behavior would be, “sitting in chair.” Usually, we behavior analysts like to keep things positive. So instead of defining what the child should not do, we identify what the child should be doing. So it would not be suitable to define a target behavior as, “child will stop eating dinner with his hands.” Instead, a better definition would be, “child will eat with a fork.” Not only does this sound more positive, but it makes data collection on the target behavior easier as well, and allows us to explain to the child what they should do.

Before a behavior can be analyzed, it should first be defined in a clear, concise, and objective manner.  Because we will be taking data on the child’s progress, it is helpful to know what to record and what not to record. A definition is considered clear, concise, and objective when anyone can read it and know exactly what to look for. For example, if we ask two therapists to record the number or tantrums your child has, but we do not provide an objective definition of tantrum it is very likely that the two therapists will come up with different results. However, if we define tantrum as “crying, falling to the floor and/or refusing to do what was asked of the child,” then we can all be on the same page as to what constitutes a tantrum. In turn, this makes data collection and monitoring of progress easier, and much more accurate.

But wait- there’s more. Ethically speaking, a behavior analyst must choose to teach behaviors that are socially significant. Socially significant behaviors are behaviors that have immediate and long term benefits for the person engaging in them. For example, teaching a 5 year old child with autism algebra, especially if the child is not potty trained and engages in self injurious behavior regularly, would probably not be something that we would want to work on! However, teaching the child to use the potty would be something that would benefit the child immediately and in the long term, as well as make life more peaceful for the entire family.

A competent behavior analyst will prioritize the behaviors selected for change. It is not uncommon for parents and teachers to have a long list of behavior problems they want stopped and a long list of skills they would like the child to learn. But we must be patient and start with the things that will provide the most value to the child. This means that in general, working on communication is preferred over something like “hand-flapping.” Nevertheless, every child is different. If hand-flapping is truly preventing the child from learning and engaging with others, then an intervention plan may be put in place to help the child reduce it. And, as mentioned before, an ABA program can have one target behavior, or many target behaviors. It all depends on what is best for the child.

So let’s review with a little quiz. Is this a good target behavior?

Child will exercise good manners.

Answer: No. My definition of “good manners” might be different from yours. Furthermore, what exactly will I take data on? A better definition would be, “Child will say ‘please’ when requesting an item, and ‘thank you’ after receiving an item.” This way, I can actually record the number of times the child uses these phrases. And remember, as the child learns, we can always add more criteria, such as saying, “excuse me” before interrupting.