Parent Training for Disruptive Behavior: The RUBI Autism Network, Clinician Manual (Programs That Work) 0190627816, 9780190627812

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Parent Training for Disruptive Behavior

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PR O G R A M S T H A T W O R K

Editors-​In-​Chief Anne Marie Albano, PhD David H. Barlow, PhD

Scientific Advisory Board Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

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PR O G R A M S T H AT W O R K

Parent Training for Disruptive Behavior The RUBI Autism Network

CLINICIAN MANUAL

K AREN BEARSS CYNTHIA R . JOHNSON BENJAMIN L . HANDEN ERIC BUTTER L U C L E C AVA L I E R TRISTRAM SMITH L AW R E N C E S CA H I LL

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1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2018 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. CIP data is on file at the Library of Congress ISBN 978–​0 –​19–​062781–​2 9 8 7 6 5 4 3 2 1 Printed by WebCom, Inc., Canada

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About

PROGRAMS

T H AT W O R K

Stunning developments in healthcare have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit, but perhaps, inducing harm (Barlow, 2010). Other strategies have been proven effective using the best current standards of evidence, resulting in broad-​based recommendations to make these practices more available to the public (McHugh & Barlow, 2012). Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and healthcare systems and policymakers have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001, 2015; Weisz & Kazdin, 2017). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-​ based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral healthcare practices and their applicability to individual patients. This series, ProgramsThatWork, is devoted to communicating these exciting new interventions for children and adolescents to clinicians on the frontlines of practice. The manuals and workbooks in this series contain step-​by-​step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing

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ancillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice. In our emerging healthcare system, the growing consensus is that evidence-​based practice offers the most responsible course of action for the mental health professional. All behavioral healthcare clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This clinician guide and the companion workbook employ a parent training (PT) approach to reduce disruptive behaviors such as aggression, tantrums, noncompliance, and self-​injury in children with autism spectrum disorder (ASD). As many as half of children with ASD display such behaviors, which can have a significant impact on a child’s well-​being and family functioning. PT has been used extensively to reduce problematic behaviors in non-​ASD children from preschool age through adolescence, and recent research supports the implementation of PT with children with ASD. This manual will be most useful for clinicians familiar with applied behavior analysis and/​or those with experience working with children with ASD. Anne Marie Albano, Editor-​in-​Chief David H. Barlow, Editor-​in-​Chief ProgramsThatWork

References Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–​878. Barlow, D. H. (2010). Negative effects from psychological treatments: A perspective. American Psychologist, 65(2), 13–​20. Institute of Medicine. (2001). Crossing the quality chasm:  A new health system for the 21st century. Washington, DC: National Academy Press. Institute of Medicine. (2015). Psychosocial interventions for mental and substance use disorders:  a framework for establishing evidence-​ based standards. Washington, DC: National Academy Press.

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McHugh, R. K., & Barlow, D. H. (2012). Dissemination and implementation of evidence-​based psychological interventions. Oxford, UK: Oxford University Press. Weisz, J. R., & Kazdin, A. E. (2017). Evidence-​based psychotherapies for children and adolescents (3rd ed.). New York, NY: Guilford.

Accessing Treatments ThatWork Forms and Worksheets Online All forms and worksheets from books in the PTW series are made available digitally shortly following print publication. You may download, print, save, and digitally complete them as PDFs. To access the forms and worksheets, please visit http://www.oup.com/us/ttw

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We dedicate this book to the memory of Tristram Smith, who was a pioneer in moving the practice and research of applied behavior analysis into the mainstream. He offered a quiet yet persuasive voice on the need for rigorous testing of behavioral interventions for children with autism spectrum disorder.

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Contents

Acknowledgments   xi Introduction to the Manual   xiii Introduction to the Behavior Support Plan   xxv Core Sessions

Session 1

Behavioral Principles   3

Session 2

Prevention Strategies   17

Session 3

Daily Schedules   31

Session 4

Reinforcement 1   47

Session 5

Reinforcement 2   63

Session 6

Planned Ignoring   79

Session 7

Compliance Training   95

Session 8

Functional Communication Training   109

Session 9

Teaching Skills 1   123

Session 10 Teaching Skills 2   137 Session 11 Generalization and Maintenance   149 Appendix A:  Telephone Booster   163 Appendix B:  Home Visit   173

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Appendix C:  Parent Training Case Example With Sample Behavior Support Plan   191 Appendix D: Problem-​Solving Common Challenges in Implementing the Program   211 Appendix E:  RUBI Progress Note   215 References   217 About the Authors   220

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Acknowledgments

Many thanks to our colleagues, Michael Aman, L. Eugene Arnold, Christopher McDougle, Jim Mulick, Denis Sukhodolsky, Noha Minshawi, Naomi Swiezy, and Susan White, for their contributions to the development of this manual.

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Introduction to the Manual

Autism spectrum disorder (ASD) is a developmental condition of early childhood onset characterized by qualitative impairments in social interaction and social communication, as well as restricted interests and repetitive behavior (American Psychiatric Association, 2013). The term spectrum implies that children with ASD may show a range from mild to severe impairment. Children with severe forms of ASD may be intellectually disabled and minimally verbal. Children with milder forms may have average or above-​average intelligence, have interest in others—​but show marked social disability. This concept of an autism spectrum has evolved over the past several decades and stands in contrast to the more narrowly defined and more severe condition called autism. Recent worldwide estimates place ASD as affecting an estimated 6 per 1,000 children (Elsabbagh et al., 2012). In addition to the core features of ASD, up to 50% of children with ASD have disruptive behaviors. Parents describe frequent “meltdowns,” “sit-​down strikes,” “defiance of routine directions,” “aggressive outbursts,” “head banging,” and other serious behavioral problems in the context of everyday life (Hartley, Sikora, & McCoy, 2008; Mazurek, Kanne, & Wodka, 2013). Over the past decade, our research group has developed and tested a 24-​week structured parent training (PT) program for children with ASD and disruptive behaviors. This manual is the product of that effort. The broadening of the diagnostic criteria and the resulting increase in the number of children identified with ASD pose challenges about how to serve this vulnerable population and their families. Among the most pressing challenge is dissemination of research findings to the clinic. As noted by Brookman-​Frazee and colleagues (2012), there is a lack of specialists trained in the delivery of empirically supported behavioral interventions for children with ASD. The purpose of this manual is to disseminate our PT methods to meet this public health challenge.

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PT has a solid track record for reducing disruptive behavior in children without ASD from preschool to adolescence (Dretzke et al., 2009). In addition, PT has several advantages as a treatment model. First, it is practical and time limited. PT is usually conducted in 10–​16 sessions over a period of 4–​6 months. Second, the intervention can be delivered across a variety of settings, including outpatient clinics, homes, and schools. Moreover, it can be delivered in one-​to-​one sessions or in groups. Third, the skills taught in PT enable the parent to be the change agent. Given that parents spend the most time with their children, PT promotes generalization of skills across multiple settings (e.g., home, church, stores, and homes of friends and other family members). The potential relevance of PT for children with ASD is compelling. Disruptive behaviors such as aggression, tantrums, noncompliance, self-​injury, and property destruction can erode the family’s quality of life (Hayes & Watson, 2013). Disruptive behavior in children with ASD poses an additional barrier to the acquisition and regular performance of everyday living skills (Scahill et al., 2012). As one mother put it, when reflecting on getting her 5-​year-​old son dressed in the morning: “He can do it, but he won’t do it.” PT has the potential to reduce disruptive behavior and to set the stage for improved adaptive functioning. Teaching parents the essentials of behavior modification is the centerpiece of PT for children without ASD (Kaminski et  al., 2008). This is also true for PT in children with ASD and disruptive behavior. The application of the term “parent training” to children with ASD requires a clarification of terminology. In ASD, the term has also been applied to interventions focused on improving one or more core features of ASD (Carter et  al., 2011; Dawson et  al., 2010; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010). In these programs, parents may be trained to promote eye contact, functional communication, interactive play skills, and joint attention. For example, Kasari et al. used a PT model (involving 24 sessions over 8 weeks) in toddlers with ASD to enhance parent–​child joint engagement. PT has also been included as an adjunct to child-​focused treatment programs. In the randomized trial of the Early Start Denver Model (ESDM), the 2-​year, 20-​hour per week intervention focused primarily on the child’s communication and social development. Parents were also given instruction in these

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methods and encouraged to use ESDM strategies during daily activities with the child (Dawson et al. 2010). Disruptive behavior was not the focus of PT in these studies. By contrast, PT has also been used to describe interventions focused on disruptive behavior in children with ASD. Although these efforts vary in emphasis, most are based on the principles of applied behavior analysis. A  key element of applied behavioral analysis is a functional analysis, which involves identifying what is driving the child’s disruptive behavior (Hanley, Iwata, & McCord, 2003). Parents are often perplexed by the child’s “meltdowns.” Although parents can be eloquent about the actual behavior (i.e., the frequency, duration, and intensity), they often describe the meltdowns as unpredictable or coming “out of nowhere.” In a functional analysis, the clinician pinpoints what immediately precedes the behavior (the antecedent) and what follows (the consequence). This sequence is often called the ABC model. The child may be focused on a tangible item such as food or a particular toy. Alternatively, the child may have learned over time that tantrums result in escape from a demand—​such as getting dressed. Parents can then be instructed to modify the child’s behavior through environmental manipulation. The consequence is the response from the environment (i.e., the parent) to the behavior. Parents are trained to recognize that behaviors are predictable and to identify how their response to the behavior may inadvertently promote their reoccurrence. For example, the parent who gives the toy to the child in response to the meltdown may actually reinforce the behavior. To monitor progress, parents are taught to record the child’s response to intervention. Other key elements of PT include positive reinforcement of appropriate behaviors, use of daily schedules, specific techniques known to enhance compliance, and systematic introduction of new skills. Specific PT techniques built on the principles of applied behavior analysis have empirical support for reducing disruptive behavior in children with ASD. Much of this empirical support, however, is based on single-​ subject design studies (Johnson et al., 2007). Single-​subject studies are valuable for demonstrating the effectiveness of specific techniques, but the application of these techniques tends to be highly individualized. The challenge we now face is how to move from this individualized approach to structured PT programs that can foster wider application. To

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this end, there is a small but growing body of literature on PT for disruptive behavior in children with ASD. In a 9-​week trial, the Stepping Stone Triple program was evaluated in 59 children (age 2 to 9 years) with ASD (29 subjects in active treatment; 30 on waitlist). Compared to waitlist, the active treatment showed a significant decrease on parent measures of child behavior problems that was maintained at 6-​month follow-​up (Whittingham et al., 2009). In a 20-​week, three-​group study of 105 children between the ages of 2 and 6, Tonge et al. (2014) compared a structured PT program to parent education and to treatment as usual (35 families per group). Treatment effects were measured at 6 months post treatment. All three groups showed improvements on measures of adaptive functioning and reductions in behavioral problems. The PT group showed the greatest gains with statistically significant differences on some measures of adaptive functioning compared to the other two groups. There were no group differences on measures of disruptive behavior problems. The key elements of a PT program for children with ASD commonly include background information about behavior modification (e.g., the ABC model and functional analysis), didactic instruction on specific techniques, role playing in session to practice each technique, homework so that parents can apply techniques in real life, home visits for consultation, and follow-​up sessions to review and refine the behavioral techniques. Organization of these elements in a treatment manual is a necessary prerequisite for testing PT for children with ASD and disruptive behavior (Smith et al., 2007). Initial pilot studies are needed to show feasibility (that the treatment manual is acceptable to families and that it can be reliably delivered by clinicians) (Johnson et al., 2007). Showing feasibility sets the stage for a large-​scale randomized clinical trial (RCT) to test the efficacy of the intervention. Rigorous testing and demonstration of efficacy may be followed by wider dissemination (Bearss et al., 2013b; Smith et al., 2007).

Manual Development This manual was initially developed in 2002 as a collaborative effort by the Research Units on Pediatric Psychopharmacology (RUPP) Autism Network in preparation for a multicenter RCT of risperidone alone xvi

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versus risperidone plus PT (Johnson et al., 2007; Scahill et al., 2009). The content and structure of the manual were designed to promote reliable delivery across study sites and serve as an adjunct to medication for treating school-​aged children with ASD accompanied by serious behavioral problems. The manual drew from PT programs designed for children without ASD and the behavioral literature in ASD and intellectual disability. The goal was to build a structured PT manual to impart effective behavioral techniques for reducing disruptive behavior in children with ASD and to promote acquisition of daily living skills. The manual is built on a set of basic assumptions: 1. Children with ASD primarily engage in unwanted behaviors to gain access to a tangible item of interest (a reinforcer), for attention, and/​ or to escape a situation. 2. Children with ASD are likely to have deficits in functional communication skills. 3. Given items 1 and 2, children with ASD are likely to exhibit maladaptive disruptive and noncompliant behaviors. 4. Children with ASD are likely to have deficits in adaptive behaviors due to developmental delays, and these will be amplified by noncompliant behavior. 5. Children with ASD are likely to benefit from stimulus control strategies (preventive and antecedent approaches). 6. PT can reduce disruptive behavior and improve adaptive behavior. 7. PT may obviate the need for medication for serious behavioral problems, but it can also be used as an adjunct to medication in children with ASD accompanied by serious behavioral problems (e.g., aggression, tantrums, self-​injury, property destruction). The areas covered in the manual incorporated essential elements of behavior modification and comprehensive behavior support (Horner, Carr, Strain, Todd, & Reed, 2002). The elements of behavior modification include functional assessment of target behaviors, antecedent and prevention strategies, reinforcement strategies, functional communication training, and instruction in teaching skills of everyday living. The sequence and selected techniques were based on available evidence (e.g., from single-​subject design trials), commonly reported parental concerns (e.g., noncompliance, disruptive behaviors), and the well-​ documented adaptive skill deficits in children with ASD. Finally, we xvii

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focused on generalization and maintenance to promote stable change in the child and to enhance the parents’ ability to apply skills learned in future situations and settings. The PT manual itself consists of 11 core sessions; 7 optional sessions, to meet the needs of specific children, are available online at www.oup. com/us/ttw. The core and optional PT sessions are 60–​90 minutes in duration. Although both parents (or caretakers) are encouraged to attend PT sessions, one parent or caregiver is expected to be the mainstay and to attend every session. The core and optional sessions should be delivered weekly. After their completion, it is advisable to move into a “telephone booster phase” of treatment, where visits are spread to every other week in order to give opportunities for the parent to apply lessons covered in prior sessions.

Research on the Manual The initial pilot study of the newly developed PT manual with 17 children with ASD between 4 and 13  years of age showed that the manual was acceptable to parents as evidenced by low attrition and the high percentage of session attendance. Parental acceptance was also demonstrated by the parents’ active engagement in homework assignments. Finally, session-​by-​session evaluation showed that clinicians were reliable in the delivery of the manual (RUPP Autism Network, 2007). The manual was then tested in a large-​scale, multisite trial of 124 children with ASD and serious behavioral problems. The subjects (aged 4 to 14 years) were randomly assigned to risperidone alone or risperidone plus PT for 6 months. Both treatment groups showed improvement. Children in the combined treatment group showed greater reduction in irritability and noncompliance (Aman et al., 2009), as well as greater gains in some areas of adaptive function (Scahill et al., 2012). The current manual is modified from the version used in the RUPP Autism Network trial for use as a stand-​a lone treatment for preschoolers with ASD and disruptive behavior. A pilot study in 16 children (aged

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3 to 6 years) with ASD showed solid acceptance by parents and reliable treatment delivery (Bearss et  al., 2013a). This modified manual was then tested in a large-scale multisite trial of 180 children with ASD between the ages of 3 and 7 years. Subjects were randomly assigned to PT or a structured parent education program for 6 months. Outcomes were assessed by parent report and by independent evaluators who were blind to treatment assignment. In addition to a diagnosis of ASD, children had to be on no medication or stable medication and have at least moderate levels of disruptive and noncompliant behavior. On the parent ratings of disruptive and noncompliant behavior, children in PT showed significant improvement compared to the control group. Independent evaluators classified 69% of children in PT as positive responders compared to 40% in the parent education group (Bearss et al., 2015).

Use of This Manual In our studies, clinicians had masters-level or doctoral-level training in psychology or a related field. The clinicians had prior knowledge of behavioral principles, experience in working with children with ASD, or both. Thus, we expect that this manual will be most useful for clinicians who are familiar with the principles of applied behavior analysis or those with prior experience working with young children with ASD. The manual provides a structure for teaching parents specific skills needed to decrease disruptive behaviors and to teach alternative behaviors. For the experienced clinician, the manual can serve as a general outline for the course of PT. For the newer clinician, the manual can be used as a step-by-step guide to implement sections directly from the manual. The manual contains a recommended order, but as the clinician, you may introduce certain concepts earlier (e.g., time out) based on family need. This flexibility is consistent with our application of the manual in our studies. Each session includes a clinician script (which can be followed closely or used as an outline), video vignettes (available online at www.oup.com/us/ttw) www.oup.com/RUBI, plus parent activity sheets and homework forms, which are available in the accompanying parent

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workbook. The activity sheets and video vignettes are intended to promote informal, but focused, problem-​solving discussions with the parent. The activity sheets guide the parent through the component steps of the technique presented in that session. For example, Activity Sheet #3 in the first session has the parent read brief vignettes in order to identify the antecedents of the situation described. A video vignette in Session Six shows a parent, portrayed by an actor, incorrectly applying a behavioral technique (e.g., talking to a child while implementing planned ignoring). In session, the parent can be asked to identify what the parent in the video is doing wrong and what might be done differently. Some parents may have difficulty relating to the videos if their child does not exhibit the problem behavior shown in the vignette. It may still be worthwhile to review the principle as it may be relevant to other behaviors displayed by the child or may become relevant to that child in the future. Based on the child’s age, level of functioning, and target behaviors, the clinician script and activity sheets can be adjusted. The manual includes numerous examples from our experience in delivering PT. Practicing clinicians are encouraged to build up their own examples over time. In addition to the didactic information, activity sheets, and video examples, the clinician also role-​plays with the parent to review and try out the given skill. In this manual, PT can be delivered without the child present. In some cases you can encourage the parent to bring the child to a session to review and demonstrate specific techniques. In every session, however, parents are given homework assignments to apply the techniques reviewed and invited to discuss the results of their effort in the next session. Sessions presented in the manual offer different homework options, depending upon the age of the child, parent-​ nominated target problems, and parent skill level. Thus, you can tailor the homework assignment to the child and family. Homework (e.g., implementing a timer to help warn the child of impending transitions; using the four steps of guided compliance to have the child put his dish in the sink) enables the parent to achieve small but noticeable changes in the parent–​child interaction. Review of the homework experience also provides an opportunity to evaluate whether the parent is making progress in the application of PT. Because homework is a key component of PT, it is reviewed in the first 5–​10 minutes of each

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session. Inability to complete the previous session’s assignment calls for a discussion about why (e.g., lack of understanding, hectic week, or skepticism about a particular technique) to address the problem. If the parent completes the homework, you can celebrate the success. In summary, the description of behavior modification techniques, completion of activity sheets, reviewing the video vignettes, role-​playing in session, and completion of homework assignments reflects the simple notion that talk is not enough. What really matters is whether the parent actually learns how to use the techniques in real-​life settings. This PT manual also includes home visit(s). Although time-​consuming (and perhaps not billable in some locations), having the opportunity to see the family’s home can give you a new perspective on the structure of family life. Suggestions on how to arrange the child’s bedroom, improve home safety, or revise kitchen seating, for example, are more easily made following a home visit. The use of video technology may be an alternative way to learn more about the home environment.

Age Range and Target Problems Although this manual is designed for parents of preschool-​age children with ASD, prior versions of the manual have been used successfully in children with ASD up to 14 years of age (Aman et al., 2009; Scahill et  al., 2012)  and in an RCT of PT and atomoxetine for the treatment of attention-​deficit/​hyperactivity disorder in children with ASD between 5 and 14 years of age (Silverman et al., 2014). In all of these applications, the target problems such as tantrums, aggression, noncompliance, and impulsive behavior were similar. Thus, PT can be applied to children from preschool through school age. In order to apply the manual for school age children, you will need a stock of age-​appropriate examples to illustrate the principles and practice of PT. For example, issues facing parents of school-​aged children often involve the completion of homework or increased independ­ ence with activities of daily living, such as bathing and completing household chores. You will also have to consider more age-​appropriate reinforcers and how strategies, such as functional communication, may

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need to be modified for clearly verbal, higher functioning school-​aged children. In addition, homework assignments and interventions should be tailored to the child and the abilities of the parent. The manual offers specific suggestions for how some techniques may be presented to parents of school-​aged children.

Adherence and Treatment Fidelity Most evidence-​ based psychosocial interventions for children have manuals intended to guide treatment delivery (Perepletchikova & Kazdin, 2005). The success of these structured interventions suggests that fidelity to the treatment is related to achieving positive clinical outcomes (Henggeler et  al., 1997). To promote manual adherence, we have included a series of Treatment Fidelity Checklists that enumerate the central topics to be covered in each session. These forms are similar to those used in our research to monitor whether clinicians are delivering the intervention as intended. Thus, we recommend you complete the fidelity checklist for each session to ensure that relevant sections have been addressed.

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Outline of Parent Training Program

SESSIONS 1

Behavioral Principles

SKILLS/​ACTIVITIES Introduce overall treatment goals Introduce concepts of functions of behavior, antecedents, and consequences of behavior

2

Prevention Strategies

Discuss antecedents to behavior problems and develop preventive strategies

3

Daily Schedules

Develop a daily schedule and identify points of intervention (including use of visual schedules) to decrease behavior problems

4

Reinforcement 1

Introduce concept of reinforcers—​to promote compliance, strengthen desired behaviors, and teach new behaviors

5

Reinforcement 2

Introduce “catching your child being good” Teach play and social skills through child-​led play

6

Planned Ignoring

Explore systematic use of extinction (via planned ignoring) to reduce behavioral problems

7

Compliance Training

Introduce effective parental requests and the use of guided compliance to enhance compliance and manage noncompliant behaviors

8

Functional Communication Training

Through systematic reinforcement, teach alternative communicative skills to replace problematic behaviors

9

Teaching Skills 1

Using task analysis and chaining, provide tools to replace problem behaviors with appropriate behaviors and how to promote new adaptive, coping, and leisure skills

10

Teaching Skills 2

Teach various prompting procedures to use while teaching skills

11

Generalization and Maintenance

Generate strategies to consolidate positive behavior changes and generalize newly learned skills

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SESSIONS Home Visit1

SKILLS/​ACTIVITIES Observe the child in the natural environment Learn about the layout of the child’s home Plan implementation of strategies

Telephone Booster

Review implementation of intervention strategies Develop interventions for any newly emerging behavior concerns

SUPPLEMENTAL SESSIONS

1

SKILLS/​ACTIVITIES

1

Token Economy Systems

This session provides parents with information on the proper use of token economies, star charts, and point systems to promote positive behaviors in the home and community.

2

Feeding Problems

This session helps the parents address a range of feeding problems that are commonly seen in children with ASD, such as food selectivity, mealtime behavior problems, and overeating.

3

Imitation Skills

This session teaches parents fundamental skills for helping their child learn to imitate others.

4

Sleep Problems

This session provides information on how to address bedtime and sleep problems often observed in children with ASD, such as difficulties with bedtime routines, delayed sleep onset, night awakening, sleep association problems, and the child entering the parents’ bed.

5

Time Out

This session provides information on the proper use of time out, how to problem-​solve if issues arise, and how to develop and implement a time out plan at home.

6

Toilet Training

This session helps the parents address a range of possible toileting issues such as diaper rituals, refusal to use the toilet, and nighttime toileting problems.

7

Crisis Management

This session provides an opportunity to problem-​ solve the management of dangerous child behaviors, family crises, and pressing educational issues.

The home visit can be delivered early on or later in treatment, at the clinician’s discretion.

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Introduction to the Behavior Support Plan

The Behavior Support Plan (BSP) is an organizing document and a living document. It is the place to track progress in the parent training (PT) program. The BSP is reviewed and revised by the clinician and the parent in real time during each PT session. The aim of the BSP is to capture what the parent and clinician want to accomplish and how this will be done. Because the BSP builds over time, the final document provides a rich description of child-​specific aims and interventions. The BSP begins with a description of the target behavior problems nominated by the parent at intake. Over time, it highlights the various intervention strategies that were devised and implemented for each child. The BSP includes the following: Target Behaviors and Functional Assessment: The behavior problems that are the focus of treatment, the preceding situations or events that are associated with the problem behaviors, and the hypothesized function of the behaviors are the first entries on the BSP. Procedures for collecting data on the target behaviors are also documented. The elements of this initial BSP are based on any available information, including parent interviews, observed parent–​child interactions, standardized parent ratings, and discussion during the first PT session. The BSP is then updated as needed in subsequent PT sessions. ■ Reinforcers: The items and activities that are preferred by the child can be included in the BSP. The child-​ specific reinforcement strategies identified and revised during the PT program are also listed. ■ Prevention Strategies: The use of visual schedules and other successful antecedent management strategies are documented on the BSP. ■ Teaching Strategies:  The BSP also documents child-​ specific teaching strategies. These personalized strategies might include the approaches used to promote functional communication and daily living skills. The task analyses, the specific prompts implemented by ■

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■



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■

the parent, as well as any other child-​specific teaching procedures, are noted and revised as necessary. Consequences:  Planned ignoring targets and the type of planned ignoring for each target also belong in the BSP. Supplemental Topics:  Some parents participate in supplemental sessions (available at www.oup.com/us/ttw) such as sleep problems, feeding problems, toileting, and time out. These strategies should also be summarized on the BSP. Generalization and Maintenance: Strategies designed to promote enduring change across settings (i.e., reduction in disruptive behavior and improved adaptive behavior) are highlighted in the last portion of the BSP. Future Considerations: Viable strategies that are generated through the course of the program but are not being actively implemented can be documented in this section. It can be considered a “placeholder” for promising strategies that the parent has not yet had the opportunity to implement.

In summary, the BSP provides direction for parents in an iterative fashion. It permits adaptation of PT to the child-​specific problems and parental responses over the course of the PT program. Each session opens with review of the homework from the previous session as well as a review and update of the BSP. The review of the BSP at each session provides an opportunity for the parent to discuss successes and challenges of previous behavioral interventions. The review can be used to identify problems, refine ongoing interventions, and develop new strategies. These adjustments in approach are then added to the BSP. As a living document, the revised BSP should go home with the parents after each session as a way of reminding them of tested interventions that should continue as well as the new techniques identified in the most recent session. The BSP is an essential component of this program. First, it is a blueprint for what the parent wants to achieve with the PT program. Second, it is a diary of the interventions developed, sustained, and revised during the course of the program. The completed BSP helps parents see the expansion in their ability to manage challenging behaviors over the course of treatment. Third, it promotes consolidation. By collating

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child-​specific successful behavioral strategies, the BSP promotes parental competence in the face of the challenging disruptive behaviors that brought the child into treatment. Fourth, the BSP provides a vocabulary for parents to describe antecedents, behaviors, and corrective strategies that can be used in discussions with other providers and educators. Thus, an organized BSP can foster consistency across settings as well as communication between parents and teachers. Finally, the BSP honors the considerable effort by the parent to reduce disruptive behavior and promote skill acquisition in the child with ASD. This cumulative and comprehensive record of the parent’s investment may help parents see beyond momentary setbacks and recognize the positive effects of their efforts. See page 182 of this clinician’s manual for an example of a completed BSP. A blank BSP can be found on page 3 of the parent workbook.

Clinician Tip Sheet Behavior Support Plan There may be a session where you generate several possible intervention strategies with the parent—​only a subset of which the parent will implement as part of the weekly homework. For example, with eight categories reviewed during the Prevention Strategies session, several potential homework options are usually generated, yet the parent will focus on only one or two strategies for that week. All viable ideas generated during that session should be written in the BSP. Strategies being actively implemented should be written in their respective sections (e.g., Prevention Strategies, Reinforcement). Potential future strategies should be added to the “Future Considerations” section. The review of the BSP at the beginning of each session then provides an opportunity to revisit strategies that were generated but not implemented (i.e., those housed in the Future Considerations section) and to discuss whether it would be a good time to incorporate the strategies into the family’s plan of action. There may be time later in the program, or even after treatment, when it makes sense for the parent to implement a strategy that was generated earlier.

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The last contact with the family (e.g., the last telephone booster session) is your opportunity to complete a final review and editing of the BSP. This review should include removing strategies from the BSP that the parents chose not to implement as well as those strategies that were implemented but did not work. The parent should exit the program with an updated and finalized document.

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Core Sessions

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SESSION 1

Behavioral Principles

Session One Overview This session provides an overview of the basic principles of the behavioral approach, the ABC model, and the importance of assessment in deciding upon strategies to address challenging behavior.

Goals 1. Introduce overall goals of parent training, session formats, and requirements. 2. Discuss how behaviors are learned. 3. Introduce the ABC model and the concept of antecedents. 4. Introduce how to clearly define a behavior. 5. Introduce consequences. 6. Review the functions of behavior. 7. Discuss the importance of data keeping and introduce the ABC Data Sheet. 8. View video vignette. 9. Discuss primary behaviors of concern and initiate home data collection. 10. Introduce the Behavior Support Plan.

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Parent Objectives 1. Parent will identify antecedents on Activity Sheet #3. 2. Parent will provide behavioral definitions for the two terms (aggression and disruptive). 3. Parent will identify antecedents, behavior, consequences, and function of behavior on Activity Sheet #6. 4. Parent will demonstrate ability to use an ABC Data Sheet to identify antecedents and consequences from a video vignette of a behavior. 5. Parent will identify a behavior(s) to track using an ABC Data Sheet.

Materials 1. Clinician Script 2. Video 1.1 3. Session 1 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan1

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A blank copy of the Behavioral Support Plan is located in the Parent Workbook. The clinician and parents should use this form and add to it each session.

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Clinician Script Goal 1: Introduce Overall Goals of Parent Training, Session Formats, and Requirements The goal of this program is to teach you strategies that will be helpful in improving your child’s behavior as well as promoting new skills. The strategies we will be discussing over the next several weeks have been used successfully for years with parents of children with autism spectrum disorder (ASD) who were hoping to improve their child’s adaptive (or daily living) skills and decrease challenging behaviors, such as aggression, tantrums, and noncompliance. This program will involve your learning to implement a number of strategies that will help to prevent behaviors, teach new skills that could replace a problem behavior, and promote positive behaviors instead of the challenging ones. Activity Sheet #1 lists the topics we will be covering. [Review Activity Sheet #1 of Session Topics, located in the Parent Workbook for Session One.] Each session ends with a Session Review that summarizes the key points from that session. We expect that your participation in session discussions, practices, and take-​home assignments will have a positive impact on your child’s behavior.

Goal 2: Discuss How Behaviors Are Learned Today, we will review the ABC model. A central idea behind the ABC model is that the majority of behaviors we display are learned. That means that behaviors that have been a problem for your child at home or school are also learned. The good news is that if your child has learned to hit others, whine, or have tantrums, he2 can also learn new, more appropriate ways to behave. This is not to suggest that someone set out purposefully to teach a child to hit others, but rather the hitting is the result of certain conditions in the environment. For a classic example, consider a child who is yelling in the checkout aisle of the grocery store because he wants some of the candy on display. His mother

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The pronoun “he” will be used predominantly throughout the clinician script as a means to reflect the higher prevalence of ASD found in boys.

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may initially say no, but when the child continues to scream, the parent may finally give him the candy. This makes sense in the moment, because the child is now happy and the mother is no longer embarrassed by the public tantrum and no longer has to listen to her child scream. That said, how may this mother’s response cause problems in the future? [Allow parent to respond: child “learned” that screaming gets candy.]

Goal 3: Review the ABC Model and the Concept of Antecedents The idea of “learned behavior” is better understood when we consider the ABC model. [Turn to Activity Sheet #2.] The A  in the ABC model stands for antecedents, the B stands for the behavior, and the C stands for consequences. The ABC model suggests that when conditions allow certain antecedents and consequences to occur around a behavior, the result may be an increase or decrease in that behavior.

Antecedents The antecedent is the situation or event that comes before a behavior. It is sometimes described as the “trigger” for the behavior that follows. If the “trigger” doesn’t happen, the child will not engage in the behavior. An antecedent can be an event (e.g., telephone ringing, a different route to school), a person (e.g., the music teacher but not the art teacher), or an object (e.g., stop sign, plate of cookies) in the environment that cues a person to do something. For example, the antecedent to a child getting up for school in the morning might be his alarm clock going off. The antecedent for us to stop while driving is a stop sign. The antecedent to a child throwing a tantrum might be his father telling him to pick up his toys. Antecedents play a very important role in determining behaviors. Let’s look at a few examples and see if you can identify the antecedents. [Review Activity Sheet #3 with the parent.]

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Goal 4: Introduce How to Clearly Define a Behavior In the ABC model, we are very specific about how we use the term “behavior.” A behavior is any action that can be observed, counted, or timed. Just about everything we do can be described as a behavior. Turning the alarm clock off in the morning, brushing your teeth, and hugging your child are all examples of behaviors. Children engage in behaviors throughout the day, such as playing on the computer, getting dressed, eating breakfast, or talking with friends. In addition, they may exhibit problem behaviors, such as slapping a brother, hitting the dog, or biting their own hand. In the ABC model, it is important that everyone (parents, teachers, clinicians) use specific, detailed descriptions of the child’s behav­ior so that everyone is clear about what behaviors are happening. To further illustrate, let’s go over this exchange between a mother and her child’s clinician. [Review Exchange #1 on Activity Sheet #4.] How much do you know about how Tom is behaving at home and in therapy? [Allow parent to respond.] The mother and teacher were using words that only give us a vague idea about his behavior, not a clear picture about what is actually happening. Now, let’s look at an exchange between a mother and clinician where behavioral terms are used. [Review Exchange #2 on Activity Sheet #4.] Using specific behavioral terms can be extremely helpful when talking with your child’s teacher, clinician, or doctor. It is also important as we make decisions to help change his behavior. Even the word aggressive is not specific enough. Can you think of some behaviors that would be more specific than “aggressive”? [Direct parent to bottom section of Activity Sheet #4. Have parent respond and praise correct answers. You can add other examples such as hits, bites, kicks, throws.] What about disruptive? [Have parent provide examples and note on Activity Sheet #4. Examples include screams, throws toys, runs around the classroom.]

Goal 5: Introduce Consequences While antecedents describe what triggers a behavior, consequences describe what happens immediately after, and in response to, a behavior.

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Some consequences are natural, like burning your hand when you touch a hot stove or getting a Coke after putting money in a vending machine. For behaviors that persist, it is the consequence that helps maintain the behavior or makes it more likely that it will continue over time. For example, a child learns to raise her hand in school because the consequence is that the teacher calls on her. Another child learns to swear because his peers laugh and giggle. A child may learn not to hit if the consequence is losing time on the computer.

Goal 6: Review the Functions of Behavior Because it can be difficult to figure out why a behavior is happening, it is useful to take a more systematic approach to determine the function or purpose of your child’s behaviors so that we can then decide on the best strategies for changing them. Specifically, by keeping information about the specific antecedents and consequences surrounding a behavior, we can better understand why a child continues to engage in problem behaviors. We will be asking you to collect information about your observations of your child’s behaviors at home to help with this. Once we carefully observe and analyze the antecedents and consequences of a behavior, we can better understand the possible function, or purpose, of a particular behavior. This is referred to as a “functional behavioral assessment.” This ultimately helps us make informed decisions about how to change the behavior. One of the biggest challenges parents face is trying to figure out why their child engages in certain, often problematic, behaviors. Some parents say they have no idea what set a behavior off or even describe behaviors as happening for no reason. Children with ASD usually have difficulty with communication—​they may find it hard to tell you what is bothering them or may not have a good way to ask for something they want. Even children who are typically quite verbal can have difficulty “using their words” when they become frustrated or angry. So behaviors very often serve as a form of communication. Children with ASD whose communication skills are weak may learn that their behaviors communicate their wishes very effectively. So, when your child is engaging in a problem behavior, an important question to ask yourself is, “What is my child trying to communicate through this 8

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behavior?” A tantrum could be saying, “This is too hard.” Screaming could mean, “Leave me alone.” Hitting could be communicating, “That’s mine. Give it back.” There are a few main reasons why a child may be disruptive. The first reason is the child may be acting out in order to escape or avoid a situation. For example, a child may learn to hit his neighbor in the classroom in order to be removed from the lesson. This may be his way of “escaping” the assignment just given by the teacher. Children often have tantrums when asked to do something they are not thrilled about. We think that the function or motivation of these behaviors is to escape or avoid a task or direction. Another reason a child may engage in a problematic behavior is to get others’ attention. For example, a child might bang his head because he has learned that this will quickly get his father’s attention when he is talking on the telephone. A third reason is a child may have learned his behavior serves the function of getting what he wants. For example, a child may scream loudly when his mother turns the TV off because he has learned that she will turn it back on to stop his screaming during his baby sister’s naptime. Finally, some children with ASD engage in certain behaviors because they are pleasing to the child or “automatically” rewarding. The child, for example, may engage in making loud noises because he likes the sound, or he may hand flap because he also finds this pleasant to do when he is excited. We often consider behaviors such as these as being motivated by several factors such as sensory input, reduction of internal anxiety, or perhaps just being pleasing to the child. Let’s look at some examples and, using the information about the antecedents and consequences, see if you can figure out the function of the child’s behavior. [Review Activity Sheet #5 with parent. Note that some of the examples may have more than one function (e.g., the second example could be to “get what he wants” (the radio on) or “automatically rewarding” (hand flapping). In these examples, you can discuss how taking additional ABC data could help to clarify the function of the child’s behavior.] [Refer to Activity Sheet #6.] To tie this all together, see if you can first pick out the antecedents, behavior, and consequence in each of these examples. Sometimes it is helpful to first identify the child’s behavior and then pick out the other components of the ABC model. Remembering that our choices are escape, attention-​seeking, getting what he wants, or automatically rewarding to the child in some way, 9

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what do you think is the function of Michael’s hitting in item #1? [To get what he wants: the channel changed back.] What about Susie’s screaming and kicking in item #2? [To escape from doing homework.] To illustrate the importance of knowing the function of a child’s behavior and how it relates to intervention choices, let’s discuss one more example. You have a child who is disruptive while doing classwork—​ making paper airplanes, talking loudly to classmates, making goofy noises—​and the teacher sends the child to the principal because he is so disruptive. This child may be disruptive because he is trying to escape from doing classwork. While the teacher’s consequence is logical, it is also ineffective. In this case, the child succeeded with escaping from classwork and so the disruptive behavior is likely to occur again. Take the same exact behaviors and teacher response, but this time the function of the child’s behaviors is to get attention from classmates. In this case, the teacher’s consequence of removing him from the classroom should help to decrease the disruptive behavior because she is targeting the correct function of the behavior: seeking attention. This is why it is so important not to just focus on the behavior when determining intervention strategies. It is more useful to target the function of the behavior, and you can use ABC data to figure out what that is.

Goal 7: Discuss the Importance of Data Keeping and Introduce the ABC Data Sheet It’s not always clear what the antecedents to and consequences of a behavior might be, and this is why a functional assessment is important. It is our version of detective work. Keeping data for a few days to try to determine the ABC relationship will be important. Aside from what is occurring right before the behavior, other antecedent information that is typically important to gather includes the date, time, setting, activity, and who was involved when the behavior problem occurred. [Turn to Activity Sheet #7.] Here is an “ABC” data collection sheet that has columns labeled for the necessary information. There is a column for the date, time, setting, activity, and people involved. There is also a column to describe the behavior, a column for the antecedents, and a column to describe consequences, including comments regarding how

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well the consequence worked. In other words, if you decided to send your child to his bedroom when throwing a tantrum, this would be the section in which to note whether this consequence helped (the tantrum stopped quickly) or made matters even worse. Finally, you can use all of this information to note in the “function” column what you believe is the function of the behavior.

Goal 8: View Video Vignette Let’s practice using your ABC Data Sheet by looking at a video of a situation between a child and a parent. On your ABC Data Sheet, note the behavior the child displays, any antecedents that you observe, and how the behavior is managed by the parent (the consequence). [Have the parent write down the behavior(s), antecedents, and consequences on the ABC Data Sheet.] (The videos accompanying this program are available online at www. oup.com/RUBI) Video #1: ABC and Brownies Antecedent: Child asks for a brownie. Mom says “No.” Behaviors: The child then stomps his feet, pushes the brownie box into his mom, repeatedly yells at mom. Consequences: Mom gives him a brownie.

Goal 9: Discuss Primary Behaviors of Concern and Initiate Home Data Collection Let’s wrap up by reviewing your child’s behaviors that are of most concern. [Briefly discuss these behaviors with the parents. Make sure they are using clear behavioral terms (e.g., hits, doesn’t follow directions) to describe target areas of concern.] Let’s choose one or two of these behaviors to track over the next week using our ABC Data Sheet. [Have parent choose one or two target behaviors to track.] Let’s use Activity Sheet #7: ABC Data Sheet to fill out the most recent episode of the target behavior that you recall. To continue to learn more about

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your child’s behavior and possible influences, we will be asking you to keep ABC data for the coming week on your child’s target behaviors. [Review the ABC Data Sheets and discuss logistics, such as where to keep the sheets, when to complete it, etc.]

Goal 10: Introduce the Behavior Support Plan Before we end today, I want to show you a document we will be using throughout the program. This Behavior Support Plan is a document similar to what schools and agencies use. This document starts by outlining the behaviors of concern as well as what are believed to be their “function.” Next session we will have more information about the function of your child’s behavior from the ABC sheets you will be keeping. The remaining pages of the Behavior Support Plan will be used to document how we are using the strategies with your child. We will be reviewing this document weekly and making additions along the way. I also want to show you a summary of what we talked about today. Please look this over during the week. We can address any questions you might have during our next session. [Then turn to the Session One Review and ask the parent to read over this material during the week. Close by scheduling the next session.] For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

Homework Case Examples ABC Data Assignment Example 1 Mr. Johnson completed ABC data on Robbie’s tantrums over the last week. For 10 of the 12 tantrums, the antecedent was identified as times when Robbie was asked to do something by Mr. Johnson, such as to go get in the bath or put on his coat. After carefully analyzing the ABC data, it appeared that the consequence was that Robbie was

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able to postpone doing what was asked. For example, he was allowed to use the IPad for another 30 minutes when he had a tantrum when asked to take a bath. As a result, we hypothesized that most of Robbie’s tantrums were to “escape” or “avoid” a demand/​request. The other two incidents occurred when he was very tired.

Example 2 Anton’s preschool teacher took ABC data on his self-​injurious head hitting for 2 weeks. By far, the most frequent antecedent was when another child took a toy from Anton. The consequence was an assistant would come and tell the other child to give the toy back to Anton. It was assumed that Anton’s head hitting functioned to get what he wanted, which was to get the toy back.

Example 3 Ms. Miller wrote down on her ABC Data Sheet what occurred before and after Wyatt hit, kicked, or pinched another person, as these were his “aggressive” behaviors. After several days, she observed a pattern of Wyatt’s aggression in places where there were a lot of people. The consequence was that he was removed from the crowded situation. It was therefore hypothesized that Wyatt’s aggression served to allow him to escape the situation where he felt uncomfortable (he may have been nervous or anxious or did not understand what to do).

Example 4 Mrs. Chen reported on her ABC Data Sheets that her daughter Sara screams a lot right before her speech therapy and occupational therapy sessions begin. Mrs. Chen identified the antecedent as “being told to go to the therapy room,” the behavior “screaming and running over to mom,” and the consequence “the clinician guides her back to the therapy room.” Mrs. Chen was unsure, however, of the function of the behavior—​was Sara screaming because she was trying to get more time

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with the train set in the waiting room, because she was trying to get out of doing her therapy, or because she did not want to separate from her mom? After some discussion about monitoring additional possible antecedents (i.e., what is going on in the waiting room, the time of day, and access to the train set), Mrs. Chen was asked to complete an additional week of ABC data in order to test the hypothesis that Sara was screaming because she did not want to separate from her mother.

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Behavioral Principles Treatment Fidelity Checklist Checklist 1.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Introduce overall goals of parent training, session formats, and requirements

0  1  2  N/​ A

2

Discuss how behaviors are learned

0  1  2  N/​ A

3

Review the ABC model and the concept of antecedents

0  1  2  N/​ A

4

Introduce how to clearly define a behavior

0  1  2  N/​ A

5

Introduce consequences

0  1  2  N/​ A

6

Review the functions of behavior

0  1  2  N/​ A

7

Discuss the importance of data keeping and introduce the ABC Data Sheet

0  1  2  N/​ A

8

View video vignette

0  1  2  N/​ A

9

Discuss primary behaviors of concern and initiate home data collection

0  1  2  N/​ A

Introduce the Behavior Support Plan

0  1  2  N/​ A

10

Total _​_​_​_​_​_​/​ 20

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Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session Parent Objectives

Rating

1

Parent identified antecedents in Activity Sheet #3

0  1  2  N/​A

2

Parent provided behavioral definition for the two terms (aggression and disruptive)

0  1  2  N/​A

3

Parent identified antecedents, behavior, consequences, and function of behavior on Activity Sheet #6

0  1  2  N/​A

4

Parent demonstrated ability to use an ABC Data Sheet to identify antecedents and consequences from a video vignette of a behavior

0  1  2  N/​A

5

Parent identified a behavior(s) to track using an ABC Data Sheet

0  1  2  N/​A

Total _​_​_​_​_​​​_​__​_​/​ 10

Note: We recommend that you make a copy of all session Fidelity Checklists to use with each family seen in treatment. FIDELITY NOTES:

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SESSION 2

Prevention Strategies

Session Two Overview This session provides information on antecedent management of behav­ ior. The ABC data collected during the previous week and the ideas we generate in our review of prevention strategies will be used to develop approaches to preventing behavior problems.

Goals 1. Review homework assignment from prior session. 2. Introduce prevention of behavior problems. 3. Review eight categories of prevention and identify ways that the parent might already be preventing inappropriate behaviors. 4. Assess the parent’s ability to identify ways to prevent behavior problems via video vignettes. 5. Identify 1–​2 prevention strategies for homework. 6. Update Behavior Support Plan.

Parent Objectives 1. Parent will identify ways in which he or she currently prevents behav­ior problems. 2. Parent will watch the video vignettes and provide advice for how to prevent behavior problems in the future. 3. Parent will identify 1–​2 new ways to prevent behavior problems. 17

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Materials 1. Clinician Script 2. Videos 2.1–​2.5 3. Session 2 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan

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Clinician Tip Sheet Session two can be a long session, and there are many families who would benefit from implementing multiple prevention strategies. If you sense that this is the case for your family, you can break the session into two separate sessions. Spend the first session reviewing the first four prevention techniques and assign homework. Have the second session cover the next four prevention strategies and assign a separate homework assignment.

Reviewing the ABC Homework Data Walk through each example the parent has written down. This is your best opportunity to understand specific environmental events associated with the child’s behaviors, including what antecedent events may set off the behaviors and what consequences the child may receive (e.g., how the parent is currently responding). As you are going through each example on the ABC Data Sheet, you can write in the margins ideas or strategies that might fit with that particular problem—​even if it’s something several sessions down the road (e.g., parent describes the child as engaging in repetitive statements—​flag that behavior for planned ignoring). This is also your opportunity to underscore the importance of the homework assignments:

HW Challenge 1: The Parent Did Not Complete or Only Partially Completed the ABC Sheets Refer to Appendix D:  “Problem-​Solving Common Challenges in Implementing the Program” for general recommendations around issues with homework completion. It is vital to underscore to the parent the importance of doing the homework thoroughly and accurately. When a parent has difficulty completing the ABC Data Sheets (e.g., didn’t complete the sheet, had errors in the data, only wrote down a few examples, child didn’t exhibit the target behaviors for that week), send the parent home to do ABC data for another week. 19

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HW Challenge 2: The Parent Puts Items in the Wrong Category (e.g., behaviors in the antecedent category) First, you need to be comfortable with your own ability to identify what the ABC is in any particular situation. If you cannot do that, you cannot correct the parent! If you notice that the parent has improperly identified any part of the ABCs or the function of the behavior, talk through and correct any miscategorized data or any misunderstandings about it. Help parents to understand how the data should have been recorded. An example of an error may be where the parent does not write specific behavioral descriptions and instead uses “nonbehavioral” descriptions such as “Child had a tantrum.” Another error is when a parent inappropriately identifies environmental events. For example, you may see antecedents such as “Child was having a bad day.” These types of errors should be talked through and corrected with the goal of increased accuracy on the parent’s part. Send the parent home to complete another week’s worth of ABC data as an opportunity to fill the sheets out correctly.

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Last session we talked about the ABCs of behavior and gave an assignment to keep ABC data on your child’s behaviors. Let’s take a look at that data sheet together to see what it might tell us about your child’s behavior. [Review results of ABC Data Sheet. Praise the parent for completing the chart and bringing it to the session. If the parent did not complete the chart or forgot it, complete an ABC Data Sheet in session, discussing 1–​2 target behaviors that occurred over the previous week. Also, explore why the assignment was difficult. Did the parent not understand the assignment? Did organizational difficulties or family stressors prevent the parent from completing the assignment? You may need to provide additional support to the family, such as telephone calls between sessions, to reinforce data keeping during the coming sessions.] Were there any patterns that you noted about your child’s problem behavior? For example, did the behavior tend to occur around the same time each day or during the same activity? Were different people involved, or did the behavior tend to happen when the same person was with your child? [Decide whether parent should continue gathering ABC data until the next session.]

Goal 2: Introduce Prevention of Behavior Problems Today, we will review the first of two sessions on preventing behavior problems. Parents naturally do many things to prevent problems from occurring in everyday life. For example, what do parents of toddlers do to prevent their children from falling down stairs or drinking poisonous cleansers? [Give parents a chance to respond.] Yes, parents use baby gates at the top of stairs and place safety locks on cabinets where household cleaners are stored. Parents of children with autism spectrum disorder (ASD) may prevent problems in the community by not taking the child to settings that predictably have been difficult, such as restaurants, movies, or place of worship. Other parents limit how long

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they stay at certain places. For example, parents may limit trips to the grocery store to a short list of items. These forms of prevention are also called antecedent management strategies. Often we can devise prevention strategies by looking at the antecedents to a problem behavior, just as you did with your ABC data collection. For example, if the ABC data show that a common antecedent to head banging is the vacuum being turned on, one antecedent prevention strategy might be to move the child to his bedroom while the parent vacuums the living room.

Goal 3: Review Eight Categories of Prevention and Identify Ways That the Parent Might Already Be Preventing Inappropriate Behaviors It’s likely that you already do things to prevent behavior problems in your child. So let’s talk about some of the things that you’re doing right now. To help us organize prevention ideas for your child, I’m going to give you some categories to think about. [Turn to Prevention Activity Sheets #1a and #1b: Categories of Prevention Strategies, located in the Parent Workbook for Session 2. Explain that Activity Sheet 1a is an example of how the blank one might be completed.] Let’s go over each category. We’ll see if you’re already doing some things that would fall into one of these categories. We’ll also think about things that you might do in the future. [Go through the eight categories listed below. Help the parent list strategies that are currently being done at home or in the community under each category.] 1. Avoid situations or people: I mentioned earlier how parents prevent problems by not taking their child to restaurants, shopping, or to their place of worship. Some families avoid places where their child might have to wait in line. Are there situations that your family actively avoids, and why? Can you think of some things that you do to prevent problems that fall under this category? [Have parents write these down on Activity Sheet #1b.] Sometimes certain people are also antecedents for behavior problems. For example, a child might mind his father but give his mother a hard time whenever she asks him to do something. Some children have difficulty playing appropriately with one particular child. Does any of this fit with your child? [Add any items to Activity Sheet #1b.] 22

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2. Control the environment: This may include putting locks on cabinets or keeping the doors of your house locked on the inside. Some teachers control their classroom environment by seating children away from others who tend to “set them off” or by using partitions that limit distractions. Can you think of any ways that you control the environment to prevent behavior problems? [Have parents write these down on Activity Sheet #1b.] 3. Do things in small doses or steps: As we talked about earlier, some parents find that their child can handle situations for short periods of time. So rather than avoid these situations altogether, the family limits the time in certain settings. Some families avoid long car trips. Others don’t stay at birthday parties or family gatherings for the entire time. Can you think of situations where you limit the amount of time your child is there? [Add to Activity Sheet #1b.] 4. Change the order of events: This can be especially helpful for a child who has difficulty stopping an enjoyable activity when asked to comply with a demand. For example, a child might become aggressive when her mother asks her to turn off the iPad® to get dressed and ready for school. This may be managed by having the child get dressed before being allowed to play on the iPad. Have you ever changed the order of activities to avoid similar problems? [If so, add any new items to Activity Sheet #1b.] This is an area that we will take additional time to address during next session. 5. Respond to early signs of the problem: Most parents are experts on their child’s behavior and can tell when the child’s behavior is winding up. Some parents may notice a look in the child’s eyes or sense that the child is becoming more irritated (such as crying or talking loudly). When these signs occur, some parents find ways to assist the child in order to manage the behavior. For example, if a child is showing early signs of agitation when asked to get dressed, the parent may provide extra assistance with dressing so that the child can complete the task more easily. Other parents may have the child leave an area to calm down before the behavior worsens. For example, if a child starts escalating while at a birthday party, the parent may take the child into another room in order to calm down and get away from the stimulation. Have you found that you can sense early signs of a meltdown? What are the signs? Have you been able to “nip things in the bud” at early signs of a problem? [If so, add this information to Activity Sheet #1b.]

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6. Change how you ask or respond: Some children overreact when demands are said in a certain way, especially when a transition is involved or if a child is told that he can’t have something. Some children become agitated anytime they are told “No.” Just changing how the child is asked to do something can prevent the explosive response. For example, providing choices when making requests or giving a child notice that he will need to stop what he’s doing in 5 minutes are commonly used strategies. Have you ever found ideas like this to be useful with your child? [If so, add this to Activity Sheet #1b.] 7. Address setting events: Setting events are special types of antecedents that can affect how a child responds in certain situations. Common examples include being tired or hungry or feeling ill. As every parent knows, a tired, hungry, or sick child is a cranky child! Any of these is likely to affect how a child behaves at home, school, or day care. A child who usually reacts well to teacher requests may become uncharacteristically agitated or aggressive because he is tired or sick. Missing a daily dose of a medication may set the stage for problems that day. Other possible setting events include loud and chaotic lunch rooms, the sudden departure of a parent for a family emergency, or a death of a grandparent. Setting events can be addressed in a number of ways. To take a simple example, the child is irritable and uncooperative on the drive home from day care due to hunger. The parent could address the setting event of hunger by bringing a healthy snack for the ride home. Can you think of any setting events that might affect your child’s behavior? [If so, add this information to Activity Sheet #1b.] 8. Use visual or auditory cues: Visual or auditory cues include pictures, written lists, or timers that can serve as a reminder of a pending transition or a certain activity in the daily routine. The use of these cues can prevent behavior problems and promote the child’s independence and acquisition of daily living skills. For example, visual and auditory cues can help enhance the child’s ability to process information about the sequence of events, which can provide a sense of predictability and promote the child’s flexibility. Visual and auditory cues can be used to set up choices (e.g., choice boards), time passage and sequencing (e.g., timers; first-​then boards), and

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step-​by-​step presentation of daily routines (e.g., visual schedules, social stories). For example, developing a set of pictures showing the steps of the morning routine can remind your child what needs to be done before going to school, avoiding confusion and promoting compliance. Setting a timer that signals the end of 20 minutes of computer time may be more effective than abruptly telling the child to turn off the computer. The use of visual schedules is a tried and true approach that we will discuss in more detail during our next session. Do you currently use any visual or auditory cues to help your child? [If so, add this information to Activity Sheet #1b.] Here are a few additional examples of visual cues. [Show examples of visual strategies, such as Figure 2.1: “First-​Then” Board in the Parent Workbook, and discuss potential daily applications. How the strategies are applied will be specific to the child.] One last recommendation is about how to reduce or eliminate demands on challenging days. Along with the setting events described earlier, some children become more irritable or defiant when there is a significant change in the environment (e.g., during holidays when they are out of their normal school routine). There may also be times when parents are too exhausted to wait out a tantrum. Although it is probably not the best solution in the long run, there are times when it is better to minimize the number of demands on your child to prevent setting him off in the first place. Examples include if your child is having an unusually difficult day; or if you don’t think you will be able follow through with the usual set of demands because you’re tired, not feeling well, or you have to leave the house quickly. It is better not to give a demand at all than to give a demand and then give in!

Goal 4: Assess the Parent’s Ability to Identify Ways to Prevent Behavior Problems via Video Vignettes We are going to watch a few video clips of challenging situations often faced by parents. Your job is to advise the parent in the video about how she might prevent the problem in the future. [Turn to Activity Sheet #2 as a starting point. Some suggestions are offered, but encourage

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the parent to come up with additional ideas. Start the discussion by having the parent identify the behavior problem in the vignette and then move to possible prevention strategies.] (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Dressing Struggle Parent is struggling to get her child’s coat on. CHANGE HOW YOU ASK: Give 5-minute warning CHANGE ORDER: First coat, then iPad® Video #2: Time to Clean Up Parent abruptly and hastily tells her child to pick up his toys. The child refuses to comply. Parent pushes issue and child’s behavior escalates. CHANGE HOW YOU ASK: Use a different tone of voice; use contingency (“Pick up the toys and we can go outside.”) VISUAL CUE: Use timer for 5-minute warning before having to pick up the toys. Video #3: I Want Honey Combs Parent selects cereal type for child and child protests. CHANGE HOW YOU ASK: Offer choices. CONTROL ENVIRONMENT:  Limit choices by putting some cereal boxes out of sight. Video #4: Computer Sneak Parent removes child from computer room only to have child sneak back in. CONTROL ENVIRONMENT:  Put a lock on the door to computer room. Video #5: Dressing Difficulties Mother struggles to get her child’s coat on. Dad comes in the room and child immediately complies. AVOID PEOPLE: Have dad be responsible for putting child’s coat on.

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Many parents ask if they will have to use prevention strategies forever. The answer is, no. Our goal is to prevent major behavior problems and cultivate opportunities to teach the child other, more useful behaviors. Once these new behaviors are learned, you may not need to rely on the prevention techniques.

Goal 5: Identify 1–​2 Prevention Strategies for Homework From our discussion, we know you’re already using some prevention strategies at home or in the community [Review list from Activity Sheet #1b.] Let’s try to identify 1–​2 additional strategies that you can start to use between now and our next session. [Go through the eight categories and the ABC data to develop ideas. The goal is to have the ideas generated by the parent rather than the clinician.] Try using these strategies between now and our next session—​then we can discuss how things worked out. To help keep track of things, I  suggest you keep this simple log [Turn to Prevention Activity Sheets #3a and #3b: Antecedent Management Data Sheet. Activity Sheet #3a provides examples on how to complete the activity sheet.] The log reminds you to note the date, time, target behavior, the prevention strategy used, and how it worked. [If you asked the parent to continue keeping ABC data for another week, remind the parent of this assignment as well.]

Goal 6: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under consideration, not just those targeted for homework. Then turn to the Session Two Review and ask the parent to read over this material during the week. Close by scheduling the next session.]

For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

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Homework Case Example Leah typically watches cartoons first thing in the morning. However, when her mother, Mrs. Page, tells her that it’s time to get dressed for school, she often screams and has tantrums. Mrs. Page decides that she will have Leah get dressed before being allowed to watch cartoons. That way watching cartoons will serve to motivate Leah to get dressed and will avoid the battle over turning off the cartoons in order to get dressed. Mrs. Page also will give Leah a 5-​minute warning before she has to turn off the television and leave for school. On the data sheet, Mrs. Page will write the date and time, the behavior she is targeting (tantrums when told to get dressed), the prevention strategy (change the order of events; change how you ask/​respond), and how well it worked (by noting if Leah cooperated with dressing in order to watch cartoons).

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Prevention Strategies Treatment Fidelity Checklist Checklist 2.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​A

2

Introduce prevention of behavior problems

0  1  2  N/​A

3

Review eight categories of prevention and identify ways that the parent might already be preventing inappropriate behaviors

0  1  2  N/​A

4

Assess the parent’s ability to identify ways to prevent behavior problems via video vignettes

0  1  2  N/​A

5

Identify 1–​2 prevention strategies for homework

0  1  2  N/​A

6

Update Behavior Support Plan

0  1  2  N/​A Total _​_​_​​_​_​_​_​_​_​/​ 12

Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session

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Parent Objectives

Rating

1

Parent identified ways in which he or she currently prevents behavior problems

0  1  2  N/​A

2

Parent watched the video vignettes and provided advice for how to prevent behavior problems in the future

0  1  2  N/​A

3

Parent identified 1–​2 new ways to prevent behavior problems

0  1  2  N/​A

Total _​_​_​_​_​_​​​_​_​​_​_​/​ 6

FIDELITY NOTES:

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SESSION 3

Daily Schedules

Session Three Overview This session focuses on obtaining a daily schedule for the child and helping the parent identify ways to adapt the schedule to prevent behav­ ior problems from occurring. This session also introduces the use of visual schedules. As the clinician, you can focus on schedule changes, visual schedules, or both (doing both is recommended).

Goals 1. Review homework assignment from prior session. 2. Review Behavior Support Plan. 3. Create a typical daily schedule for the child. 4. Review prevention strategies for addressing problems with the child’s daily routine. 5. Use video vignettes to illustrate how to use prevention strategies in daily schedules. 6. (Option 1) Revise the child’s daily schedule. (Option 2a) Introduce the concept of visual schedules. (Option 2b) Develop a visual schedule for the child. 7. Assign and explain homework. 8. Update Behavior Support Plan.

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Parent Objectives 1. Parent will describe child’s daily schedule, including areas where problems arise. 2. Parent will suggest an appropriate prevention strategy for each of the vignettes. 3. (Option 1) Parent will suggest appropriate prevention strategies for his or her child’s daily schedule. (Option 2) Parent will assist in developing a visual schedule.

Materials 1. Clinician Script 2. Videos 3.1–​3.5 3. Session 3 Workbook Materials 4. Materials for Making a Visual Schedule 5. Treatment Fidelity Checklist 6. Behavior Support Plan

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Clinician Tip Sheet As the amount of material presented in Session 3 may require additional time to cover, you may present the visual schedule information as a separate session from the daily schedule review.

Reviewing the Prevention Strategies Homework HW Challenge 1: Parent Implemented the Prevention Strategy in Response to Negative Behavior Examples: “John was playing with his toys and started whining when I told him to go to the dinner table, so I set the timer for 5 minutes.” “Alex started screaming that he didn’t like the cereal I set out for him, so I  offered him a choice of waffles or pancakes.” Emphasize to the parent that the strategies (e.g., a timer, 5-​minute warning, first-​then visual cue) should be implemented before the child exhibits the behav­ ior. This requires the parent to predict times that are often challenging and then set up the strategy to be implemented during those times, in advance of the potential behavior problem.

HW Challenge 2: Parent “Gives Up or Gives In” Because Child Has a Tantrum When the Parent Introduces a Prevention Technique A parent proactively set up a timer to provide a 5-​minute warning for the child to transition to bath time. When the timer went off, even with the warning, the child started screaming that he didn’t want to go take a bath. Since the timer was set as a tool designed to prevent behaviors, the parent may be confused why the child has a tantrum or screamed anyway. This requires a conversation about the role of prevention strategies in “greasing the wheel” to minimize behavior problems. There may be times when the child still protests. In fact, it is very natural for a child to test limits where there previously were none (or inconsistent limits). During these times it is important that the parent follow through in spite of the tantrum. If the parent consistently follows through with

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the strategy (e.g., having the child make the transition), the child ultimately will learn that (1) having a tantrum no longer works and (2) the timer is a predictable way of knowing when that transition needs to happen. Sometimes it just takes time for the child to learn the new rules or limits, but if the parent is consistent, and follows through every time, the resistance, protests, and tantrums should subside.

Setting Up a Visual Schedule There are several options to choose from when creating icons or pictures for a visual schedule. One common option is to use icons from the Boardmaker program. Children are often familiar with Boardmaker icons as they are used with the Picture Exchange Communication Systems (PECS). They also are commonly used in the school and in therapeutic environments. Google images can be used instead if you do not have access to Boardmaker. Finally, you can use photographs taken by the parent that are specific to the child (e.g., a picture of the child’s own bed, bathtub, favorite toys). Creating the schedule typically involves printing out the pictures, laminating the pictures and a board to place the pictures on, and then adding Velcro to the pictures so they can be placed on the board. There should be flexibility in how the visual schedule is set up. This can range from having the schedule centrally located and presented either horizontally or vertically to having a schedule that the parent carries around while the child completes his (morning/​evening) routine. Some children have schedules where the pictures stay put and the child just references the schedule. Others use Velcro and have the child peel the pictures off as they go, like a pictorial checklist. Some parents put the peeled-​off pictures in an envelope, while others move them to a completed task board. The goal is to set up the visual schedule in a way that will work for the family and work for the child.

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Last week we came up with ways to prevent behavior problems at home. We discussed the use of a log to track how these strategies work for your child. Let’s take a look at your log and see how things went. [If the parent brought back a data sheet describing the use of such strategies, congratulate the parent for completing the assignment and bringing in the data sheet. If the homework was not completed or if the log sheet was not filled in, take some time to discuss difficulties with completing the assignment. If the parent was asked to continue collecting ABC data, go over this as well and decide if ABC data collection should continue for another week.]

Goal 2: Review Behavior Support Plan Now let’s go through the Behavior Support Plan and see if you are ready to start using any additional strategies that have not yet been implemented. [Review specific strategies on the Behavior Support Plan that have not yet been put into action.]

Goal 3: Create a Typical Daily Schedule for the Child Today we’re going to look at your child’s daily schedule to see if there are some changes we can make that will help the day go more smoothly. If your family is like most, there are certain times or activities each day where the child has difficulty. Walk me through a “typical day” for your child so I  can get a picture of where the trouble spots are. [It’s best to use a typical weekday. Go through the daily schedule with the parent (Activity Sheet #1, located in the Parent Workbook for Session 3). Start with when the child wakes up and finish with when he falls asleep. For each activity, make note of problems. This information can guide suggestions on schedule changes. Also, listen

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for activities that might be used as reinforcers for completion of less preferred tasks. For example, you may want to make iPad time in the morning contingent on getting dressed and eating breakfast. Finally, look for ways to prevent problems. For example, have the child pick up toys in the evening if doing so in the morning is a problem. Have an extra toothbrush in the first-​floor bathroom if asking the child to go back upstairs to brush his teeth is a battle.]

Goal 4: Review Prevention Strategies for Addressing Problems With the Child’s Daily Routine The daily schedule offers an excellent opportunity to use prevention strategies. Let’s review how we might use them to make your child’s day go more smoothly. 1. Change the time of a demand: Changing when an activity happens can be a helpful strategy. For example, it may be easier to have the child bathe in the evening (vs. morning), when there is less pressure to be ready in time for school. 2. Use fun activities to reward completion of less desired activities: This strategy is similar to changing the order of events, which was introduced in the last session. It’s often hard for children to stop enjoyable activities, especially if they are being asked to do something they don’t like. For example, asking a child to stop playing outside so that she can come inside and clean up her toys is likely to be a challenge. Simply changing the order of your child’s schedule so that the enjoyable activity (playing outside) comes after the successful completion of cleaning up toys may promote better compliance. 3. Establish a routine: Sometimes families don’t have established routines for getting the child ready for school in the morning or for getting to bed at night. A schedule for these daily events can help the child know what to expect—​which can all by itself improve compliance with these activities. When setting up a routine, be sure to place enjoyable activities after demanding ones (for example, selecting the bedtime story after the child is ready for bed).

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Goal 5: Use Video Vignettes to Illustrate How to Use Prevention Strategies in Daily Schedules Let’s look at a few videos and see if you can come up with some suggestions for the parent on how she might rearrange the child’s schedule or do things differently to prevent behavior problems. Included on Activity Sheet #2 are all the prevention strategies we’ve discussed so far. [Turn to Activity Sheet #2. If the parent has difficulty identifying schedule changes, offer some hints and try to come up with at least one suggestion for each vignette.] (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Dressing Distractions Parent brings her son his coat and leaves. Child ignores the demand and continues to watch TV. CONTROL ENVIRONMENT:  Keep the TV off until the child puts on the coat. CHANGE TIME: Have the child put on the coat earlier in the morning (and before TV gets turned on). FUN ACTIVITY/REWARD: Coat on, then TV. Video #2: Clean Up Later Child is asked to clean up toys before school. Time passes and child does not clean up. Child now has to go to school. CHANGE TIME: Child cleans up at the end of the day. CONTROL ENVIRONMENT: Parent stays in the room and monitors cleanup. Video #3: Nintendo Tantrum Mom asks child to turn off video game to brush teeth. Child refuses, so mom takes game away. FUN ACTIVITY/REWARD:  First brush teeth, then video game. CHANGE HOW YOU ASK:  Offer choice, change tone of voice. ESTABLISH ROUTINE: Game comes after brushing.

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Video #4: Five More Minutes Mother tries to leave play with her child so she can do laundry. Child whines, so mother continues to play with child. CHANGE HOW YOU ASK: Give child a 5-​minute warning before stopping. CHANGE ORDER OF EVENTS: Finish laundry, then play with child.

Goal 6: [Option 1] Revise the Child’s Daily Schedule It looks like there are times during the day when your child’s behavior is particularly challenging. Let’s go back to the daily schedule we completed and see how we can make changes in the schedule that may address these problem times. [Turn back to Activity Sheet #1 and encourage the parent to identify the trouble spots in the daily routine. You may have to point out some of the specific concerns to start the discussion; for example, “It looks like bath time in the evening is often difficult because John has to stop watching TV in order to take a bath.” Have the parent refer to the categories on Activity Sheet #2, if necessary, to help generate ideas. Put potential prevention ideas next to the appropriate time in the third column on Activity Sheet #1.]

Goal 6: [Option 2a] Introduce the Concept of Visual Schedules Many children with autism spectrum disorder (ASD) have difficulty with transitions and unexpected changes in their routines. As a result, parents try to keep the daily schedule as consistent as possible to avoid meltdowns. When changes in routine happen, some parents wait until the last minute to tell the child because they worry about the child’s reaction. One way to help a child with ASD manage his daily schedule or cope with unexpected changes in the routine is to use a visual schedule. The visual schedule helps establish the usual routine, but it also allows you to inform the child of an upcoming change in the routine. Let me show you an example of what a visual schedule can look like. [Figure 3.1 in the Parent

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Workbook shows an example of a schedule with 12 pictures of the day’s activities.] You can see on this schedule that the child has 12 activities for the day. For the morning routine, he gets dressed, brushes his teeth, and then has breakfast. In the afternoon, he gets off the bus, puts his backpack away, and has a snack. Later in the day, he plays outside, has dinner, and then puts his dish in the sink. For his evening routine, he plays with his toys, takes a bath, and then goes to bed. The picture schedule not only tells the child what comes next but also helps direct the child to the given activity. It promotes a sense of stability and predictability, which, in turn, increases comfort, flexibility, and independence. It works like this: Therapist Note These steps are just one way of teaching the parent how to use a visual schedule. These steps can be modified to fit the parent’s or child’s needs. 1. 2. 3. 4. 5. 6. 7. 8. 9.

Place the schedule in a central place. Encourage your child to check the schedule. Review the schedule with the child and select the first picture. Encourage the child to state the activity out loud. For younger or nonverbal children, say it out loud for the child. Have your child take the picture off the schedule and take it with him to the designated area. Complete the activity on the picture. Return to the visual schedule. Have a small box or envelope near the schedule where your child can place the picture of the completed task. Move on to the next picture on the visual schedule.

Let’s watch a video vignette of these nine steps in action: (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #5: Visual Schedule Vignette of Picture Schedule

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The video shows one schedule format; it is easy to develop variations on a theme for your child. [Refer to Activity Sheet #3 and discuss different options for the format of the visual schedule (e.g., using actual objects, icons, photographs, or words; pulling the picture off, checking off a list; keeping the schedule stationary on a wall versus carrying it around with you).] If this first visual schedule is successful, it can be expanded as the child’s activities broaden to include school and community activities.

Goal 6: [Option 2b] Develop a Visual Schedule for the Child Now that you have a feel for how visual schedules work, let’s talk about setting up a schedule for your child. [Turn to Activity Sheet #4.] Let’s start by deciding what format makes the most sense for your child. A visual schedule may start with a piece of stiff cardboard or art board. You can make the introduction of the visual schedule a fun activity for your child by decorating it or coloring it together. The board is used to place pictures or icons representing the tasks of the day. The pictures or icons can be attached to the board with Velcro. [Refer to Activity Sheet #3 to choose the most appropriate format.] Next, we need to decide whether we want to target a specific time of day that is difficult for your child, such as the morning routine, or create a visual schedule for the entire day. We can make use of the daily schedule we completed earlier to decide on the target of the visual schedule. [Circle the type of schedule on Activity Sheet #4 and write the specific time frame if the parent selects Routine.] If your child has never used visual schedules before, it may be confusing to have a long list of tasks presented at one time. In that case, we may want to start with just a few pictures and then gradually increase the number of tasks over time. For example, we could focus on the morning routine, where you might have just three key tasks on the visual schedule. What are the key elements of the morning routine? How many tasks do you think make sense for your child’s visual

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schedule? [Decide how many items to start with and add that number to Activity Sheet #4.] We also need to decide where you’re going to keep the schedule. It can be located in a central location so it’s easy for your child get to when needed. If it isn’t too bulky, it can be carried from task to task as the child goes through his routine. [Decide where the schedule should be kept and write that on Activity Sheet #4.] [For schedules where the pictures will be removed:] As each task on the visual schedule is completed, you will have the child place the picture or icon in an envelope or small container. It might be useful to have the envel­ope in a central location near the visual schedule. Alternatively, you could attach the envelope to the back of the visual schedule. [Circle parent choice on Activity Sheet #4.] Some children require what we call “hand-​over-​h and” assistance. As shown in the Video #5, this involves close parental guidance to ensure that the child takes the right picture off the schedule and places it in the envelope. Do you think hand-​over-​h and assistance is necessary for your child? [Discuss need for hand-​over-​h and assistance with the parent.] Now that we have the structure of the visual schedule, let’s write out the list of activities that we want to include. [Using Activity Sheet #4, create the list of activities to be included on the visual schedule.]

Goal 7: Assign and Explain Homework Option #1: Revising the Child’s Daily Schedule Your homework assignment will be to make the change(s) in your child’s daily routine that we just discussed (on Activity Sheet #2). So that we can assess how well these changes are working, I want you to keep a short log similar to the one you did last week. [Turn to Activity Sheet #5.] Note the date, time, target behavior, the prevention strategy used, and how it worked.

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Option #2: Using a Visual Schedule Your homework assignment will be to try out the visual schedule we designed. Try using it on a daily basis. On the “Comments” section of Activity Sheet #4, write down how well the visual schedule is working. We can review your notes next week and make changes to improve the visual schedule. [You may also want to remind the parent to continue using the prevention strategies agreed upon from the prior session.]

Goal 8: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under consideration, not just those targeted for homework. Then turn to the Session Three Review and ask the parent to read over this material during the week. Close by scheduling the next session.]

For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

Homework Case Examples Example of Change in Routine Assignment When Alice comes home from school at 3:45 pm, she likes to have a snack and then play outside. Mrs. Holcomb then struggles to get Alice back inside the house by 5 pm to start her required kindergarten homework. Once she is able to get the child inside, Alice then whines and protests the entire time while doing her homework. Between the difficulty getting her inside and the challenge of homework, Mrs. Holcomb usually cannot get dinner ready until 7 pm—​much later than she would like. To address these multiple challenges in the late afternoon routine, we rearranged the order of the schedule. We decided to give Alice her snack as soon as she came home from school and then required her to

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first do her homework before she could go out to play. We also let Alice know that she needed to finish her homework by 5 pm in order to have the opportunity to go out to play. Mrs. Holcomb could then prepare dinner from 5 to 6 pm while Alice was outside so that she could have dinner ready for the family by 6 pm.

Example of Visual Schedule Homework Assignment Riley’s current morning routine consists of being woken up at 6:45 am and put in front of the TV while eating her breakfast. Her mom is usually getting herself ready while Riley is watching cartoons. Mrs. Davis gets Riley dressed at 7:30 am, and then brushes the child’s teeth in order to be out of the door for school by 7:45. Mrs. Davis describes those last 15 minutes of the morning as a significant challenge, as Riley screams and then runs away and hides when Mrs. Davis turns off the TV to get her dressed. To address the difficulties with the morning routine, we developed a visual schedule, using picture icons from the Boardmaker program that followed this routine: Wake up; Go potty; Get dressed; Eat breakfast; Watch TV; Brush teeth; Get in car; Play on IPhone. Riley will be woken up at 6:45 am, and after going potty, she will get dressed. Mrs. Davis will then serve her breakfast while Riley watches cartoons. Mrs. Davis then can get ready for work. Mrs. Davis sets a timer so that 10 minutes before Riley has to leave for school, the timer will go off and she will be prompted to brush her teeth. Mrs. Davis will show Riley the visual schedule and point out that first she has to brush her teeth, but then she can get in the car and play with her mom’s IPhone (a highly prized activity for Riley).

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Daily Schedules Treatment Fidelity Checklist Checklist 3.1 Child’s Name:_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​A

2

Review Behavior Support Plan

0  1  2  N/​A

3

Create a typical daily schedule for the child

0  1  2  N/​A

4

Review prevention strategies for addressing problems with the child’s daily routine

0  1  2  N/​A

5

Use video vignettes to illustrate how to use prevention strategies in daily schedules

0  1  2  N/​A

6

(OPTION 1) Revise the child’s daily schedule

0  1  2  N/​A

(OPTION 2a) Introduce the concept of visual schedules

0  1  2  N/​A

(OPTION 2b) Develop a visual schedule for the child

0  1  2  N/​A

7

Assign and explain homework

0  1  2  N/​A

8

Update Behavior Support Plan

0  1  2  N/​A Total _​_​_​_​_​_​/​ _​_​_​_​_​

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Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session Parent Objectives

Rating

1

Parent described child’s daily schedule, including areas where problems arise

0  1  2  N/​A

2

Parent suggested an appropriate prevention strategy for each of the vignettes

0  1  2  N/​A

3

(OPTION 1) Parent suggested appropriate prevention strategies for his or her child’s daily schedule

0  1  2  N/​A

(OPTION 2) Parent assisted in developing a visual schedule

0  1  2  N/​A

Total _​_​_​_​_​/​ _​_​_​_​_

FIDELITY NOTES:

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SESSION 4

Reinforcement 1

Session Four Overview This session has parents focus on the child’s appropriate behaviors, rather than behaviors they want to decrease or eliminate. Emphasis should be placed on daily living skills that are within the child’s capabilities but are not consistently performed independently. Parents will identify reinforcers for their child and learn to use them to increase target behaviors.

Goals 1. Review homework assignment from prior session. 2. Review Behavior Support Plan. 3. Present the concept of positive reinforcement. 4. Review types of reinforcers. 5. Discuss how to identify reinforcers. 6. Discuss how to select a reinforcer for a child. 7. Teach parent how to use reinforcement to change behavior. 8. Assess parent’s ability to identify incorrect use of “reinforcement rules” via videos. 9. Discuss difference between bribery and reinforcement. 10. Design homework assignment. 11. Update Behavior Support Plan.

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Parent Objectives 1. Parent will provide examples of reinforcers currently used for the child or possible items/​activities that might serve as reinforcers. 2. Parent will correctly identify broken “reinforcement rules” on the video vignettes and offer appropriate suggestions. 3. Parent will assist in developing a homework plan using reinforcement strategies.

Materials 1. Clinician Script 2. Videos 4.1–​4.5 3. Session 4 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan

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Clinician Tip Sheet Reviewing the Visual Schedules Homework HW Challenge: Parent Says the Child Showed Little Interest in (or Actively Protested) Use of the Visual Schedule The child may be protesting because he understands the schedule represents the need to comply with nonpreferred tasks. Encourage the parent to “stick with it,” using physical prompting, if necessary. Additionally, problem-​solve how the schedule is arranged (e.g., does the child have embedded in the schedule enough reinforcing activities so that he has something to look forward to after completing nonpreferred tasks?). It may also be worth reconsidering the format of the schedule. For example, if the schedule is set to be in a stationary location (e.g., on the kitchen wall) but the parent struggles to get the child to the kitchen to check the schedule, it may make more sense to have the schedule “go with the child” while completing the various tasks of the schedule. This would eliminate the struggle of checking the schedule.

Challenges With Reinforcement Some parents will say that “nothing” is an effective reinforcer for the child. Others may say they’ve tried reinforcement in the past and it “didn’t work.” ■ This requires you to do some creative problem solving. A starting place is to consider whether the child has any special interests that can be turned into a reinforcer. While most parents wouldn’t consider repetitive play with a toy with flashing lights or waving a string in front of the child’s face as a reinforcer, it most certainly can be used as one if it is a highly preferred activity of the child’s. Sometimes just reframing what a reinforcer can be (which is anything a child would be motivated to earn access to) helps get around the challenge of the parent saying there isn’t anything reinforcing to the child. ■ Another discussion can involve whether there is restricted access to certain activities/​items. A parent may not view the magnadoodle® or ■

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Thomas the Tank Engine® set the child always plays with (and has free access to) as a reinforcer. Those activities/​objects can be turned into reinforcers simply by limiting the child’s access to them and then tying access to completion of a targeted behavior. ■ Finally, having the parent work on increasing the frequency of delivery and consistency in reinforcement can improve the effectiveness of reinforcement as a strategy to modify the child’s behavior.

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Let’s review the homework from last session. Were you able to make changes in your child’s daily schedule/​implement the visual schedule? [Ask for examples where the intervention worked, as well as any problems encountered. Suggest changes in the approach—​additional antecedent strategies, new or additional pictures, and so on. Emphasize the importance of continued and consistent use of these strategies.]

Goal 2: Review Behavior Support Plan Now let’s go through the Behavior Support Plan and see how things are going with your use of other strategies we have implemented so far. Are there strategies that you have difficulty using consistently? What strategies seem to be effective in addressing the target behaviors? Are you ready to start using any additional strategies listed on the Behavior Support Plan? [Review specific strategies on the BSP that have not yet been put into action.]

Goal 3: Present the Concept of Positive Reinforcement Today, we’re going to talk about reinforcers, which are rewards that the child will work to earn. Reinforcers are anything following a child’s behavior that increases the behavior. Reinforcers can be used to strengthen desired behaviors and to promote new behaviors and skills. We all respond to reinforcers. For example, if your family praises the meal you cooked, it is more likely that you will cook that meal again. Parents often use reinforcers with their children—​perhaps without thinking about it: “You can play your computer game after you clean up your toys”; “We can read the bedtime story after you get ready for bed.” Reinforcers like your attention (reading a story) or a preferred activity (playing a computer game) can be used to increase the likelihood that a behavior will continue in

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the future. Can you think of how you currently use reinforcers with your child? [Allow parent time to mention 2–​3 examples.] One challenge we often hear about is that things that are reinforcing for typically developing children don’t seem to work for children with autism spectrum disorder (ASD). This may be especially true for “social” reinforcers, such as praise or hugs. In fact, some children may act as if these gestures are unpleasant! We want to think carefully about what is reinforcing for your child. This may require you to think creatively about what can be a reinforcer.

Goal 4: Review Types of Reinforcers We’re going to discuss different types of reinforcers, how to identify a reinforcer, and how to use them to promote specific behaviors. Keeping in mind that reinforcers are preferred items, can you think of six things that could be reinforcers for your child? This can include foods, objects, toys, or activities. [Record these six reinforcers on Activity Sheet #1, located in the Parent Workbook for Session 4.] Let’s review five types of reinforcers: 1. Primary reinforcers typically involve food or drink. For example, giving a child a snack before bed after she puts on her pajamas; or buying a cookie for a child who follows instruction during a shopping trip. [Review examples from the list of reinforcers generated earlier and ask the parent for other examples of primary reinforcers. Record under “Primary Reinforcers” on Activity Sheet #1.] 2. Social reinforcers include hugs, high-​fives, praise, or any kind of social attention. Telling your child that you’re proud of how he behaved at the store is a form of social reinforcement. [Review the list of reinforcers generated earlier and ask the parent for other examples of primary reinforcers. Record under “Social Reinforcers” on Activity Sheet #1.] 3. Tangible reinforcers include enjoyable items such as a favorite toy. A parent might buy a new Matchbox car after a week without any incidents of aggression. [Review the list of reinforcers generated

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earlier and ask the parent for other examples of tangible reinforcers. Record under “Tangible Reinforcers” on Activity Sheet #1.] 4. Activities/​privileges: Reinforcing activities/​privileges include going to the park, riding bikes, one-​on-​one time with mom, watching TV, and swimming. A parent might use a trip to a favorite restaurant as a reinforcer for a child keeping his toys picked up all week. [Review the list of reinforcers generated earlier and ask the parent for other examples of activity/​privilege reinforcers. Record under “Activities/​Privileges” on Activity Sheet #1.] 5. Tokens have no actual value. They gain value by providing a system for the child to “purchase” primary, social, tangible, or activity reinforcers. Tokens can be points, stars, or even money. The child saves the tokens until he can exchange them for a reinforcer. Weekly allowance given for completing a list of chores is a common form of token economy. School programs often include point systems for children who follow certain rules, with the idea that they can trade points for special privileges. Tokens are useful for children who can understand the connection between the behavior, the token, and what the token can achieve. [If the parent indicates that a token system fits his or her child, consider the Supplemental Session: Token Economy Systems. Review the list of reinforcers generated earlier and ask the parent for other examples of token systems. Record under “Token Reinforcers” on Activity Sheet #1.]

Goal 5: Discuss How to Identify Reinforcers Let’s consider several ways to identify reinforcers for your child: ■ ■ ■ ■

Ask your child what he or she likes. Talk with others who know your child well, including teachers. Present reinforcement options and see what the child chooses. Watch the child to see what he or she does during free time. If the child spends free time watching Thomas the Tank Engine®, this activity may be a good reinforcer. Similarly, for a child who spends time lining up Matchbox® cars, this activity may be a strong reinforcer.

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Let’s watch this brief video. What emerges as a reinforcer for this child? (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Favorite Toy Child is playing with various toys, but favors his Magnadoodle®.

Goal 6: Discuss How to Select a Reinforcer for a Child Other considerations for finding reinforcers for your child include [turn to Activity Sheet #2]:

“Different Strokes for Different Folks” Every child has different likes and dislikes. Some children may love chocolate ice cream while others like strawberry. Some children may have unusual reinforcers, such as reading train schedules or shaking string. The trick is to take note of what the child gravitates to naturally! Are there unusual activities or preferences that could be used as a reinforcer with your child? [Write ideas on Activity Sheet #2.]

Use Natural Reinforcers Whenever Possible Natural reinforcers are materials or activities that already occur in a child’s home or school. Often they are given “noncontingently,” which means they are provided regardless of the child’s behavior. A bedtime story (a routine you may already do in your household) can become a natural reinforcer for getting ready for bed on time. The natural reinforcer for using a spoon is getting to eat yogurt. Behaviors that have “built-in” reinforcement can also be natural reinforcers. For example, some children enjoy water play. Hand washing involving water play could then be used as a natural reinforcer to accomplish hand washing.

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Natural reinforcers have a number of advantages. First, they are easier to provide than “special reinforcers” because they are readily available. Second, they can be the same reinforcers that are used for siblings, sidestepping concern that one child is receiving something special. Finally, natural reinforcers are more likely to remain in use after a more formal reinforcement program has ended. Can you think of natural reinforcers that might be used for your child? [Note these on Activity Sheet #2.]

Make Privileges Contingent on Appropriate Behavior Many children have free access to privileges (e.g., TV, computer, iPad®, time with friends, favorite toys). Privileges can be used to reinforce desired behavior. For example, rather than nagging a child to stay at the table during dinner, a parent can make dessert contingent on staying in his seat during dinner. This requires the child to start earning access to privileges. Can you think of everyday privileges that could be used as contingent rewards? [Note these on Activity Sheet #2.]

Reinforcers May Change With Age A child may enjoy nursery rhymes as a preschooler but prefer rock-​ and-​roll as an adolescent. The child’s developmental level and changing interests bear on the selection of reinforcers. We have come up with several potential reinforcers for your child. Let’s try to identify the top 5. [Write these on Activity Sheet #2.]

Goal 7: Teach Parent How to Use Reinforcement to Change Behavior Now that we’ve identified items and activities as possible reinforcers for your child, let’s design a reinforcement program to change your child’s behavior. [Turn to Activity Sheet #3.]

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Step 1:  Select the target problem behavior to reinforce. Let’s choose behaviors in need of change. This could range from a child keeping his hands to himself when playing with siblings, to listening to directions the first time asked, to getting dressed in the morning by himself. [Target behaviors that are the opposite of the child’s maladaptive behavior. For example, use of a spoon for the child who grabs food with bare hands.] Step 2:  Keep the behavioral requirement reasonable. The behavior needed for the reinforcer has to be within the child’s ability. If the task is hard or complicated, break it down into smaller bits and give small rewards immediately. For example, providing praise and a sticker right after the child pulls up his pants would be more successful than expecting a child to get dressed by himself all week before earning a favorite activity.

CASE EXAMPLE Jimmy is only able to sit for 3 minutes at a time. His parents want to teach him to sit at the dinner table for 15 minutes. Initially, Jimmy is given dessert for sitting for 3 minutes. Once he is consistent with sitting for 3 minutes, his parents can gradually increase the amount of time needed to sit for Jimmy to earn his dessert until he reaches the goal of 15 minutes. This stepwise approach matches expectation with Jimmy’s capabilities and sets him up for success. Step 3: Decide how often to reinforce behavior. For new behaviors, it is best to provide reinforcement every time the child is successful. Once behaviors are learned, reinforcers can be gradually faded or eliminated.

CASE EXAMPLE For 2  months, Jimmy has been sitting at meals for 15 minutes. His parents fade the reinforcer by telling Jimmy that he must sit for two meals to earn his dessert. This fading of the reinforcer continues so that eventually, Jimmy sits for all family meals for 15 minutes and is reinforced with a trip to his favorite ice cream shop at the end of the week.

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Another way to maintain a new behavior or skill is to use “intermittent reinforcement”—​providing reinforcement every once and a while.

CASE EXAMPLE Susan needed daily help from her mother to pull up her pants. Her mother would place her hands over Susan’s to pull up her pants and then give her a big hug and praise. As Susan became more skilled with putting on her pants, her mother began to back off providing praise. Over time, she praised Susan occasionally for completing this task by herself. Step 4:  Apply reinforcers closely after the behavior. If there is too much time between the behavior and the reinforcer (e.g., even several seconds), some children may not understand the connection between the reinforcer and the behavior. If that connection is lost, reinforcement is less effective. Step 5:  Use reinforcers contingently. In other words, the reinforcer must follow the desired behavior. This is called a behavior contingency and it is like a mini-​contract. When the child does the desired behav­ior, he will get the reinforcer. Can you think of some examples of contingencies you currently use with your child? Step 6: Maintain reinforcer value. Some reinforcers lose their value because they are given too freely (noncontingently) in another setting.

CASE EXAMPLE Sophia loves to play with her Magnadoodle. Her parents consider using it to reinforce the goal of getting her to sit at dinner time. However, little progress was made using this contingency. Sophia’s parents learned that she had access to a Magnadoodle at school that she could use during free time. Once Sophia’s teachers restricted her access to the Magnadoodle at school, she started responding to its use as a reinforcer for sitting at dinner. Step 7: Pair social and activity/​material reinforcement. Use praise and other forms of social reinforcement when giving primary, activity, and

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material reinforcers. Pairing the reinforcers will strengthen the overall reinforcement. It is important to be specific—let the child know exactly what you are praising. For example, if your child picks up his room, instead of just saying, “Nice job!” you could say, “Wow! You did a fabulous job of putting your dirty clothes in the hamper!” Step 8:  Consider using visual reminders of the desired behavior and reinforcer. Children with ASD often benefit from visual cues of the desired behavior and/or expectations for the reinforcer. The visual cue highlights the expected behavior, the reinforcer, and the steps needed to earn the reinforcer. Visual cues can be a simple picture (e.g., a picture of a child sitting at the kitchen table) or a photograph of the reinforcer.

Goal 8: Assess Parent’s Ability to Identify Incorrect Use of “Reinforcement Rules” via Videos Let’s take a look at some video vignettes. See if you can identify what the parent is doing wrong based on our discussion about how to use reinforcers effectively. Be ready to provide suggestions on what the parent might do differently. (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #2: Sorting Shapes Child complies with a command (sorting task), but the parent does not praise. Video #3: Toy Fight Two siblings clean up toys without prompting. Parent goes to get a treat to reward them and while she is gone, they start fighting. Mom returns and gives both children a treat. Because of the delay, she ends up providing reinforcement for the fighting. Video #4: Shape Game Reward Child complies with a request; the parent gives the child a “favorite” toy (Pokémon card) as a reinforcer. However, the child refuses the toy. The toy no longer holds value as a reinforcer. 58

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Video #5: Sorting Legos Parent correctly reinforces child with praise and goldfish crackers after child complies with each command.

Goal 9: Discuss Difference Between Bribery and Reinforcement Some parents express concern that using reinforcers to get compliant behav­ior is bribery. Reinforcement and bribery are different concepts! The difference has to do with when the reinforcer is offered to the child. CASE EXAMPLE Billy’s mother is interested in having him pick up his toys. In one example, she tells him in advance, “If you pick up your Legos, then you can have 10 minutes on your Wii.®” In another example, Billy’s mother asks him to clean up his toys. Billy starts protesting and whining. In response, his mother says: “If you clean up your toys, you can earn 10 minutes on your Wii®”—​then Billy starts cleaning up. In both scenarios, Billy’s mother offers a reinforcer for cleaning up the Legos®. How are they different? [In the first example, mom is correctly offering the reinforcer contingent on the child picking up his toys; in the second example, mom is reinforcing Billy’s protests by offering the reinforcer after Billy started engaging in problem behavior. In this example, Billy may start to connect that reinforcers are only offered when he acts out.] Reinforcers are more effective when the reinforcer is offered upfront instead of negotiated after the fact.

Goal 10: Design Homework Assignment Let’s think about how to use the reinforcers identified in today’s session to target a problematic behavior by reinforcing a “positive opposite” behavior or increasing the frequency of a positive behavior. Let’s plan one to two behavior-​reinforcement contingencies we can set up for you to use with your child at home. [Use Activity Sheet #4 to plan homework.]

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Goal 11: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under consideration, not just those targeted for homework. Then turn to the Session Four Review and ask the parent to read over this material during the week. Close by scheduling the next session.]

For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

Homework Case Examples Drew continued to have problems hitting, especially during play time with his younger sister. Mrs. Anderson chose to target the “positive opposite” behavior of “keeping his hands to himself” during play time. She created a plan where, initially, she set a timer for 5 minutes. If Drew kept his hands to himself the entire 5 minutes of play time, he could pick a toy from a prize box, which was a collection of items she had purchased at the local dollar store. In addition, Mrs. Anderson would provide praise (e.g., “You are doing a great job playing nicely with your sister!”) every minute of the play time. The plan was to slowly increase time intervals until Drew was able to successfully keep his hands to himself for a 30-​minute play period with his sister. Carter often struggled with brushing his teeth in the morning. He would run away and hide when his mother told him to go into the bathroom. Carter loved to watch Disney Jr. every morning before leaving for school, and he was typically allowed to do so regardless of his behavior. Ms. Jacobs decided to create a behavioral contingency requiring Carter to brush his teeth the first time asked in order to be able to watch Disney Jr. She used a “First-​Then” visual cue, placed next to the TV, to help prompt Carter to follow the contingency. If Carter did not listen right away, he would not be allowed to watch Disney Jr. that morning.

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Reinforcement 1 Treatment Fidelity Checklist Checklist 4.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​A

2

Review Behavior Support Plan

0  1  2  N/​A

3

Present the concept of positive reinforcement

0  1  2  N/​A

4

Review types of reinforcers

0  1  2  N/​A

5

Discuss how to identify reinforcers

0  1  2  N/​A

6

Discuss how to select a reinforcer for a child

0  1  2  N/​A

7

Teach parent how to use reinforcement to change behavior

0  1  2  N/​A

8

Assess parent’s ability to identify incorrect use of “reinforcement rules” via videos

0  1  2  N/​A

9

Discuss difference between bribery and reinforcement

0  1  2  N/​A

10

Design homework assignment

0  1  2  N/​A

11

Update Behavior Support Plan

0  1  2  N/​A Total _​_​_​_​_​_​​_​_​_​/​ 22

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Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session

Parent Objectives

Rating

1

Parent provided examples of reinforcers currently used for the child or possible items/​activities that might serve as reinforcers

0  1  2  N/​A

2

Parent correctly identified broken “reinforcement rules” on the video vignettes and offer appropriate suggestions

0  1  2  N/​A

3

Parent assisted in developing a homework plan using reinforcement strategies

0  1  2  N/​A

Total _​_​_​_​__​_​_​_​_​/​ 6

FIDELITY NOTES:

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SESSION 5

Reinforcement 2

Session Five Overview In this session, the parent will learn to increase the use of social reinforcement for appropriate behaviors during interactions with the child. This can involve “catching the child being good” throughout the day or during a more formal play time.

Goals 1. Review homework assignment from prior session. 2. Review Behavior Support Plan. 3. Teach parent to “catch the child being good.” 4. Review current ways that the parent and child interact in a play format. 5. Discuss the variety of skills that can be promoted using a structured play time. 6. Discuss strategies to encourage reciprocal play. 7. Discuss what to do if the child misbehaves during the play. 8. Discuss how to set up a play time. 9. Discuss appropriate toy selection. 10. Discuss and address parental concerns. 11. Model the play skills with the parent(s). 12. Assign homework to “catch the child being good” and/​or set up a formal play time. 13. Update Behavior Support Plan.

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Parent Objectives 1. Parent will discuss current experience engaging the child in play. 2. Parent(s) will engage in role play with the clinician. 3. Parent will develop a specific plan to “catch the child being good” and/​or a structured play time with the child.

Materials 1. Clinician Script 2. Video 5.1 3. Session 5 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan

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Clinician Tip Sheet Reviewing the Reinforcement Homework HW Challenge 1: Parent Says the Child Chose a Reinforcer but Changed His Mind by the Time the Task Was Done OR the Parent Describes the Child as Having a Quickly Changing Repertoire of Reinforcers Children who are more “fickle” with their reinforcers may work better with a choice board. Specifically, instead of having a simple first–​then contingency tying one task to one specific reinforcer, the parent can set up the demand in relation to choosing a prize from a choice board. A choice board is simply a board (e.g., piece of laminated paper) with several types of reinforcers stuck on (e.g., extra TV time, favorite dessert, favorite toy). Then, for example, the parent can say, “If you pick up your toys, then you can pick a treat from your choice board.” Once the child finishes the task, he can go and select his “in-​the-​moment” preferred reinforcer.

HW Challenge 2: Parent Says the Reinforcer Does Not Work When a reinforcer does not work to change a behavior, it is by definition not a reinforcer! Discuss with the parent whether there were any factors impacting the power of the item/​activity as a reinforcer. For example, is access to the chosen reinforcer truly limited to when the child engages in the target behavior? Is the chosen reinforcer something the parent thought would be good, but in reality the child is not interested in earning? Sometimes the best way to identify a reinforcer is to just ask the child what he or she wants to earn!

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Let’s review how things went with using specific reinforcers as behavioral contingencies to modify target behaviors. [Ask where the intervention worked well and where problems were encountered. Suggest any needed changes in the program. Emphasize the importance of continued and consistent use of these interventions.]

Goal 2: Review Behavior Support Plan Now let’s go through the Behavior Support Plan and see how things are going with your use of other strategies we have put in place so far. Are there strategies you have difficulty using consistently? What strategies seem to be effective in addressing the target behaviors? Are you ready to start using any additional strategies listed on the Behavior Support Plan? [Review specific strategies on the Behavior Support Plan that have not yet been put into action.]

Goal 3: Teach the Parent to “Catch the Child Being Good” Today we are going to continue talking about the role of reinforcers in changing your child’s behavior and the role of reinforcers in teaching new skills. We will focus on the use of social reinforcement, paired with a tangible or material reinforcement if needed, during informal as well as formal interactions with your child. Let’s start by discussing how you can use social reinforcers to target naturally occurring positive behaviors during the day with your child. If you’re like most parents, you will intervene when problem behaviors arise. However, when your child is playing quietly or behaving appropriately, it seems to go without notice. As we will discuss, this is a missed opportunity! Some parents worry that by saying something to their child during these times, the child might start to act up again. Let’s look at an example of this. [Turn to Activity Sheet #1, located in 66

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the Parent Workbook in Session 5, and read along with the parent.] Do you think that Ginny’s mother did the right thing? [Discuss why this might not be the right way to teach Ginny to play quietly with her sister.] Times like this are wonderful opportunities to “catch your child being good.” The goal is to use your attention, whether it’s praise, a hug, or a high-five, to encourage behaviors that you want to see again and again. Some examples of behaviors that you may want to “catch” include using manners, playing nicely with siblings, completing a selfhelp skill independently, and cleaning up toys without being asked. Can you think of other behaviors that could fit with “catching the child being good?” [Discuss with parents and write down any ideas on Activity Sheet #2.] Video #1 illustrates how a mom is making a point to praise her children when they are playing nicely. (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Playing Nice Mom catches her boys playing nicely and praises them often. Social reinforcement is the primary strategy for “catching the child being good.” But you can include other types of reinforcers (e.g., stickers, time with preferred activity) as well. Do you think your child would respond well to just social reinforcement? If not, what kinds of reinforcers could you have on hand that would be easy to access and apply quickly to reinforce the behavior? [Discuss this with parent and write down comments on Activity Sheet #2.]

Goal 4: Review Current Ways That the Parent and Child Interact in a Play Format A more formal way of providing social reinforcement for appropriate behaviors is to have a structured play time with your child where you practice positive reinforcement skills. This can be a challenge for many parents. With busy schedules, some parents find it difficult to set aside a consistent time to play with their child. Other parents are unsure of how to play with their child, especially if the child’s play is repetitive,

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unusual, or difficult to follow. Many children with autism spectrum disorder (ASD) have not yet developed play skills that can be imitated or that promote reciprocal play. Before we talk in more detail about how to use social reinforcement during a structured play time, let’s review what you and your child’s play looks like now. [Go through Activity Sheet #3.]

Goal 5: Discuss the Variety of Skills That Can Be Promoted Using a Structured Play Time Aside from providing opportunities to reinforce positive behaviors you see in your child, there are many reasons for promoting a structured joint play time with your child. Play sessions can be used to encourage development of imitation and play skills, including creative or imaginative play. Play time is also a great way to promote the social skills you want to see in your child when he is with other children, such as sharing, taking turns, and cooperative play. Finally, through the use of verbal reflection on the content of the play, you can foster language development. As with “catching the child being good,” we encourage you to use social reinforcement during the structured play time to promote these skills. Although it is not always the case, the reinforcing value of parental attention may be lower for children with ASD than typically developing children. However, there are specific strategies that can enhance the value of social attention for your child. At minimum, play time is a regular opportunity for a positive interaction between you and your child. The long-​term goal is to have you and your child start enjoying the play time together.

Goal 6: Discuss Strategies to Encourage Reciprocal Play [Turn to Activity Sheet #4.] The skills we discuss here can be applied to any play time between you and your child. Some of these skills are good parenting practices. But play time is a time where you focus on

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using these recommended skills. In fact, it may be difficult to apply some of these skills throughout the day when you have to manage regular routines and direct your child’s activity. Let your child lead the play. This is the central theme of the play time. You spend time with your child while keeping the directing and controlling of the child’s behavior to a minimum. Rather than directing the play, you tune in to the child and provide regular social attention and reinforcement. Let’s talk about how to do this:

1. Observe Start by spending a couple of moments just watching your child’s play.

2. Imitate Then, start following and mimicking his play. This just means doing the same thing that your child is doing. If he is scribbling on a Magnadoodle®, you scribble as well. If he is stacking blocks, you stack blocks. Your immediate goal is to keep your attention focused on what your child is doing and let him lead the play. This approach shows your child that you are interested in being a part of his play.

3. Describe As you get into the play, start saying out loud exactly what your child is doing. For example, if he is pushing a car, you could say, “You are pushing a car.” If he is building tracks with Thomas the Tank Engine®, you could say, “You are putting all the tracks together.” Just say what you see! This is also how skill building can come into play. By labeling what the child is doing, you are putting words to actions. You can even expand on your descriptions to promote learning skills. For example, instead of just saying, “You are pushing the car,” you could say, “You are pushing the red car.”

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As you describe your child’s play, try to match the narrative with his language skills. For a child who is just learning to talk, keep your descriptions simple (“Red car.”) For children with better verbal skills, the narrative can be more complex: (“You are pushing the red race car.”)

4. Reflect This involves repeating or paraphrasing what your child says. Reflection provides immediate attention to any verbal expression and shows your child that you are listening to him. It can be a way to promote language development. For example, if your child says, “This is a red car,” you could respond, “A red car.” This can also be a way to correct speech in a nondirective manner. For example, if your child says, “boo car” (meaning blue car), you could reflect back with, “Yes, that is a BLUE car,” with emphasis on the correct pronunciation. For nonverbal children: You can repeat any intelligible and appropriate vocalization by the child. For example, word approximations like “bu” for “ball” can be reflected. You do not have to reflect inappropriate vocalizations like screeching or whining. [Talk with the parent about the child’s language skills and how reflection may be applied in a child-​specific  way.]

5. Promote Skills In the play with your child, keep an eye out for instances of emerging social or play skills. Emerging social skills can include requesting, sharing, or taking turns. When you notice the child engaging in any of these skills spontaneously, highlight it with statements such as “I really like the way you shared your crayons with me!” Alternatively, you can model the skill and label what you are doing. For example, if the child is coloring, you can give the child the crayon you are using and say something like “Here, I want to share my crayon with you” and place the crayon by the child. You’ll notice that this is teaching the skill to the child without being directive or taking away the lead in the play. 70

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Emerging play skills can include imaginative play with a doll or coming out with story elements that move beyond scripts from a TV show or video. If your child engages in spontaneous imaginative play, reinforce it with praise, such as “What a great idea to feed the doll some spaghetti.” Alternatively, you can model the skill and label what you are doing. For example, if the child is pushing cars around, you can say, “Your cars are driving around going to the store. I’m going to take my car to the garage for a car wash.”

6. Praise Take advantage of any opportunity to praise your child’s positive behav­ior using simple descriptive statements. You can praise the child’s current activity, for example, “I like the picture you are drawing,” or make note of positive behaviors such as “You are doing such a nice job sitting still.” You also want to catch positive behaviors in place of negative behaviors—​t hey deserve praise every chance you get. For example, if screaming is a common problem, then you want to praise the child for using an “inside voice.”

Finally, during the play time, try to minimize the number of commands that you give. Even if well intended, commands can interfere with the child leading the play. In some cases, issuing commands can elicit defiance in the child and turn what is supposed to be a pleasant time together into a struggle! Along these same lines, this is not the time to teach new skills. For example, this is not the time to practice school work or teach drawing skills. While teaching skills is very important during other times of the day, during this play, it would take over the lead of the play. This may cause a negative reaction in the child, especially if it is a skill that he is currently finding difficult.

Goal 7: Discuss What to Do If the Child Misbehaves During the Play Children often enjoy play time, and generally it should go smoothly, especially because you have minimized demands (e.g., commands and teaching tasks) from the play. But if your child does become 71

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agitated during the play, it is OK to play quietly for a moment without attending to any negative behaviors. If your child does not calm down, then quietly leave the play. Let the child know that the play time is all done, but that you can play together again later in the day. You can try again later when your child is calmer and seems more open to spending time together. What you want to avoid is providing social attention to your child when he is agitated. Goal 8: Discuss How to Set Up a Play Time Now let’s discuss how to set up the play time. The goal is to engage in a play time with your child as part of the daily routine. Some parents take advantage of times that the child is already playing with a toy or engaged in an activity that he enjoys. During these times, you can initiate a play period of 10 minutes using the play skills we have discussed. You can also formalize the play time into a scheduled “play time” (e.g., after school or before dinner). Let the child know that you will save this time to play with him every day. You can ask the child what activity he would like to do for that play time. Allowing the child to choose the activity increases the likelihood that it will sustain his interest. If you think your child will select toys that may be problematic (e.g., promote repetitive play), you can select a couple of activities that you think the child would enjoy playing together with you. Pick a time when you know you can be relaxed (i.e., not while dinner is cooking or 10 minutes before you have to take the kids to school). Ideally, the play time should be when you can be alone with the child so you can really focus your attention on him.

How to Handle Highly Repetitive Play Some parents are concerned about creating an interactive play situation because their child engages in highly repetitive or stereotyped play. Here’s how you might handle this situation: Select toys that are likely to sustain the child’s interest. If there is something that the child enjoys playing with that doesn’t encourage stereotyped or repetitive play, try those toys for the play session. Have toys that promote repetitive/​stereotyped play out of sight.

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If the child is only likely to maintain interest in play if it involves a toy that promotes stereotypic responses or repetitive play, then have that toy out, along with one or two other toys that the child may also have some interest in. Continue to follow the recommended play skills: imitate the child’s play, describe what you are seeing. Keep an eye out for opportunities to expand on the play theme or incorporate new elements. If the child ignores these attempts, set them aside and re-​engage with his play and try again in a few minutes. ■ If your child enjoys a specific type of toy (e.g., a musical toy), you may want to try to introduce other similar toys into the play. You may be able to move away from repetitive play with a specific toy and expand to other similar toys. For example, if a child enjoys a particular toy that makes music, you could have that toy available along with a Fisher Price® farm set that has musical components built in. ■ Initially, the play time may need to be brief and then increased as your child becomes accustomed to the new interaction. ■ Your child may switch toys or move to another part of the room in the same play session. As we have discussed, be flexible, let the child lead, and use the techniques: Observe, Describe, Imitate, Reflect, Promote Skills, and Praise the Child’s Behavior. ■

Goal 9: Discuss Appropriate Toy Selection When you choose toys or activities for the play time, avoid those that have a high degree of structure or rules such as board or card games. You want to be able to step back and let the child lead the play. Also avoid roughhousing or messy play (e.g., paint). These increase the chance of you needing to set limits, and you want the play time to be as problem-​free as possible. Finally, avoid computer or video games, as you may end up more focused on the computer screen than on each other.

For Higher Functioning Children Examples of toys that promote play opportunities include construction toys (Legos, blocks, Tinker Toys), play sets (farms, dollhouses, towns), and creative toys (coloring books, crayons, and paper). 73

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For Lower Functioning Children or Children With Impaired Creative Play Select toys or activities that are within your child’s area of interest. This could include active games such as jumping on a trampoline. Keep in mind that the toys or activities your child chooses to play with may not always be age appropriate. This may be OK in the short run. In the long run, however, we want to expand the repertoire of toys to those that are appropriate to the child’s current developmental level and interests.

Goal 10: Discuss and Address Parental Concerns When there are siblings, you can let each sibling have his or her own special time; set the siblings up with their own activities (movie, games) so they will not interrupt your play time; or have a spouse, neighbor, or friend occupy the siblings.

Goal 11: Model the Play Skills With the Parent(s) If the child is available to practice the play, you should bring out a set of toys (e.g., farm set, mega blocks) and model the play skills with the child while avoiding commands. You can make occasional comments to the parent as a way of underscoring the play skills. Then, have the parent practice the play with the child. You coach while the parent plays with the child, focusing on the targeted play skills. Repeat role play if the other parent is present. If the child is not available or receptive to practice the play, you should bring out a set of toys (e.g., farm set, mega blocks) and first model the skills while the parent pretends to be the child. Then, have the parents practice the play skills while you pretend to be the child. Make clinically sensitive corrections for commands and teaching skills. Repeat role play if the other parent is present.

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Discuss with the parents how it feels to use the skills. Offer reassurance that many parents feel awkward in the beginning, and that the skills will become natural with practice.

Goal 12: Assign Homework to “Catch the Child Being Good” and/​or Set Up a Formal Play Time Now that we have discussed how to “catch your child being good” as well as how to set up a play time with your child, let’s make a specific plan. What reinforcement approach do you feel is the best fit for your child? STRUCTURED PLAY: [Review Activity Sheet #5 and #6 with the parents to set up the play.] ■ CATCHING CHILD BEING GOOD: Let’s list 2–​ 4 situations each day where you might be able to “catch your child being good.” [Record responses on Activity Sheet #7. Discuss with the parents what reinforcers they would like to use.] There is a spot for each situation and a section for each day of the week. I’d like you to check off any day that you “catch your child being good.” ■

Goal 13: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under consideration, not just those targeted for homework. Then turn to the Session Five Review and ask the parent to read over this material during the week. Close by scheduling the next session.]

For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

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Homework Case Example Mrs. Hill wanted to target imaginative play with her son, Charles. While Charles enjoys his car set, he typically will spend most of free play repeatedly pushing a car up and down the elevator of the toy garage. After observing Charles for a moment, Mrs. Hill plans to imitate his play with another toy car while describing Charles’s play (e.g., “You are pushing the car around. You put the car in the garage elevator.”) Mrs. Hill then will model turning the elevator into a car wash, cleaning her car, and then driving it away from the garage, as a way to demonstrate to Charles a new way of playing with the garage elevator.

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Reinforcement 2 Treatment Fidelity Checklist Checklist 5.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​ A

2

Review Behavior Support Plan

0  1  2  N/​ A

3

Teach the parent to “catch the child being good”

0  1  2  N/​ A

4

Review current ways that the parent and child interact in a play format

0  1  2  N/​ A

2

Discuss the variety of skills that can be promoted using a structured play time

0  1  2  N/​ A

6

Discuss strategies to encourage reciprocal play

0  1  2  N/​ A

7

Discuss what to do if the child misbehaves during the play

0  1  2  N/​ A

8

Discuss how to set up a play time

0  1  2  N/​ A

9

Discuss appropriate toy selection

0  1  2  N/​ A

10

Discuss and address parental concerns

0  1  2  N/​ A

11

Model the play skills with the parent(s)

0  1  2  N/​ A

12 Assign homework to “catch the child being good” and/​or set up a formal play time

0  1  2  N/​ A

13

0  1  2  N/​ A

Update Behavior Support Plan

Total _​_​_​_​__​_​_​/​ 26 77

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Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session

Parent Objectives

Rating

1

Parent discussed current experience engaging the child in play

0  1  2  N/​A

2

Parent engaged in role play with the therapist

0  1  2  N/​A

3

Parent developed a specific plan to “catch the child being good” and/​or a structured play time with the child

0  1  2  N/​A

Total _​_​_​_​_​_​_​_​_​_​/​ 6

FIDELITY NOTES:

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SESSION 6

Planned Ignoring

Session Six Overview This session is about a particular type of consequence—​ planned ignoring—​and includes the proper use of planned ignoring, possible challenges to its use, and the development of a planned ignoring program at home.

Goals 1. Review homework assignment from prior session. 2. Review Behavior Support Plan. 3. Introduce parent to the concept of planned ignoring. 4. Watch videos and identify consequences that reinforce inappropriate behaviors. 5. Introduce basic rules of planned ignoring. 6. Assess parent’s ability to identify improper use of planned ignoring via video vignettes. 7. Review potential problems with planned ignoring. 8. Teach the three different ways to use planned ignoring. 9. Assess the parent’s knowledge of ignoring via video and written vignettes. 10. Create a home plan for using planned ignoring. 11. Assess the parent’s ability to use planned ignoring via role play. 12. Update Behavior Support Plan.

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Parent Objectives 1. Parent will identify consequences in videos that reinforce inappropriate behavior. 2. Parent will identify rules for using planned ignoring via use of video vignettes. 3. Parent will identify when to use the three types of planned ignoring via video and written vignettes. 4. Parent will assist in designing a planned ignoring program for home. 5. Parent will demonstrate ability to use planned ignoring via role playing.

Materials 1. Clinician Script 2. Videos 6.1– ​6.7 3. Session 6 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan

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Clinician Tip Sheet Reviewing the Reinforcement Homework HW Challenge: Parent Says the Child Had Little Interest in the Parent’s Use of the Skills and Continued to Engage in Repetitive/​Stereotypic Play Most strategies practiced to date will take effect within a week. Thus, parents are used to quick feedback on the effectiveness of their interventions. This likely will not be the case when using the play skills strategies with children with significant impairments in their play. You should encourage the parent to continue with the play time. Point out that developing play skills for many children with autism spectrum disorder (ASD) requires practice and that parents should expect change or progress to occur more slowly than they may have experienced to date. Discuss whether the play period also could be shortened while the child’s skills are developing (e.g., cutting down from 10 minutes to 5 minutes).

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Let’s review your homework assignment for [“Catching Your Child Being Good”] [having play time with your child]. [How did the child respond? Remind the parent to continue praising the child throughout the day.]

Goal 2: Review Behavior Support Plan Now let’s go through the Behavior Support Plan and see how things are going with the strategies we have implemented so far. Are there strategies that you have difficulty using consistently? What strategies seem to be effective in addressing the target behaviors? Are you ready to start using any additional strategies that we listed on the Behavior Support Plan? [Review specific strategies on the Behavior Support Plan that have not yet been put into action.]

Goal 3: Introduce Parent to the Concept of Planned Ignoring Today we’re going to talk about consequences, which are the events that follow behaviors. A consequence that is enjoyable or reinforcing, such as praise or obtaining access to a preferred activity (e.g., computer time), will increase the target behavior. A consequence that is unpleasant, such as the child being sent to his room or losing computer time, will decrease the behavior. Behaviors that are ignored (e.g., parent ignores the child’s whining) also will decrease the behavior because the child fails to get a reaction.

Goal 4: Watch Videos and Identify Consequences That Reinforce Inappropriate Behaviors Sometimes parents choose a consequence that stops their child’s problematic behavior in the moment but makes it worse in the long run.

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This is because the consequence inadvertently reinforces the child’s inappropriate behavior. For example, a child may start yelling when his mother tells him it’s time to take a bath. The mother may attempt to have the child follow through on this plan, but the child continues to protest and so the mother backs off and says the child can take a bath tomorrow. The child is now quiet (the yelling has stopped!) and the mother is no longer fighting with her child. This makes sense in the moment, but the child has just learned that if he struggles hard and long enough, he will get out of having to take a bath (i.e., escape the demand). Let’s look at some video clips and see if you can identify each of the consequences and how they might be inadvertently reinforcing the child’s behavior. In other words, what is the child actually learning in each of these videos? [Play each video vignette, ask the parent to identify the behavior problem, the consequence, and what is likely to happen the next time the child is in the same situation.] (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Chicken Nuggets Child pesters his mom for chicken nuggets. BEHAVIOR: Nagging; Consequence: Mom gives in. NEXT TIME: Child will demand chicken nuggets. Video #2: Swearing Child swears. BEHAVIOR: Swearing; Consequence: Mom repeatedly tells him to stop. NEXT TIME: Child will curse to get a reaction from his mom. Video #3: Go to the Park Child begs mom to go to the park. BEHAVIOR: Repeating demand; Consequence: Mom says no to the park but gives him a brownie. NEXT TIME: Child will repeat demand in order to get some kind of treat. In each of these cases, the consequence stopped the behavior, but it inadvertently reinforced the child’s inappropriate behavior. Children

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with ASD, like typically developing children, will behave in ways that work for them. If lying gets a child out of being punished, she may learn to lie. If throwing a tantrum gets a child out of a classroom task demand, she may learn that tantrums work. We will develop specific, appropriate, and effective consequences for your child. Today we will focus on planned ignoring. If needed, in a later session we can discuss time out.

Goal 5: Introduce Basic Rules of Planned Ignoring Planned ignoring is often used to address behaviors that are attention seeking. It is a powerful but difficult consequence to apply. When you identify a behavior to be ignored, do the following: ■ ■ ■ ■

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Avoid eye contact; don’t look at the child. Do not touch the child; walk away if necessary. Use a “neutral” facial expression; don’t react. Do not talk to the child or respond to his request/demand in any way. Make sure that your ignoring is obvious, abrupt, and exaggerated.

Goal 6: Assess Parent’s Ability to Identify Improper Use of Planned Ignoring via Video Vignettes Let’s look at a couple of video clips and see if you can give the parent some advice on how to better use planned ignoring with her child. Activity Sheet 1, located in the Parent Workbook in Session 6, lists the “five rules” of planned ignoring. Use the list and mark down which rules the parent is following correctly and which rules are being broken. [Turn to the Planned Ignoring Activity Sheet #1 and have the parent score each vignette using the five rules. Provide corrective feedback as necessary.] (The videos accompanying this PT are available online at www.oup. com/RUBI)

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Video #4: Phone Call Child tries to interrupt his mother while she is on the telephone. The mother pushes the child away and it becomes a game, with child laughing. Parent does not follow any of the rules of planned ignoring. Video #5: Refrigerator Talk Parent follows all the rules of planned ignoring.

Goal 7: Review Potential Problems With Planned Ignoring Now let’s discuss some of the challenges of planned ignoring in real life:

Challenge #1: Ignored Behavior Sometimes Gets Worse Behaviors that are ignored will often get worse before they get better. For example, the child who uses tantrums to get his way will initially be surprised the first time his father ignores the behavior. He may increase the volume and duration of the tantrum to make sure his father hears him and to try to get his father to give in. This escalation of behavior provides proof that the tantrum is attention seeking. It also requires resolve on the part of the parent to stick with ignoring!

Challenge #2: Some Behaviors Cannot Always Be Ignored Some behaviors are too disruptive to be ignored. It might make sense to ignore a child who cries in the middle of the night to get his mother to sleep with him. However, we know from Challenge #1 that behaviors are likely to get worse before they get better. Consequently, allowing the child to cry loudly for an extended period of time might wake up other children in the family. Other behaviors, such as head banging, might be too dangerous to ignore completely (unless a child can be

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provided with protective equipment, or unless the child can be effectively blocked from hurting himself or herself). These situations may require a modified form of ignoring that we will talk about shortly.

Challenge #3: Children Can Learn to Be Persistent If you find yourself in a situation where you don’t think that you can use planned ignoring, “give in” as soon as possible. This is preferable to trying to use planned ignoring for a while and then breaking down and giving the child your attention or letting him have his way. Using planned ignoring and then giving in teaches the child to persist until the adult wears down. Unfortunately, this cycle may make it more difficult to eliminate the behavior at a later time. Life is not always predictable and there are going to be situations where ignoring the behavior is just not possible (e.g., in church, on a crowded bus). It is better to do whatever it takes to manage the behavior right away than to teach the child that persistence will eventually work.

Challenge #4: Planned Ignoring Can Take a While to Work Parents often ask how long they will have to ignore the child’s attention-​ seeking behavior. The simple answer is . . . as long as it takes! A child’s behavior will likely get worse when it is first ignored. Consequently, a child whose tantrum is being ignored is likely to scream louder and may continue to do so until it becomes clear that screaming (and other attention-​seeking behaviors) will not work. If you don’t think that it will be possible to use planned ignoring in a certain situation, manage the behavior as quickly and as best you can, rather than teach your child that his or her persistence will win in the end.

Goal 8: Teach the Three Different Ways to Use Planned Ignoring The type of ignoring that we have been discussing so far involves what we call “ignoring the child and the behavior.” This means that 86

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we pay no attention to the child or to the child’s behavior. A child throwing a temper tantrum is where this type of planned ignoring can be most effective. Sometimes we can’t follow all of the rules for planned ignoring, either because a behavior is too dangerous or because a behavior occurs so often that we’d end up ignoring the child for most of the day. In these cases, we can adjust how planned ignoring is applied.

Ignore the Child but Not the Behavior We often need to break some of the basic rules of planned ignoring in situations involving dangerous behavior. For example, some children run away to get adult attention. A child obviously cannot be ignored if he runs into the street or out of the classroom. In those situations, the teacher or parent will need to intervene. This should be done in a “neutral” manner: no words, no emotions. Although physical contact is required, the principles of no eye contact and no talking to the child can be maintained. Another example is a child who chooses to have a tantrum in the middle of the school hallway. He may need to be moved to the side of the hall in order to use planned ignoring. We call this “ignoring the child” (no talking, no eye contact with the child) but “attending to the behavior” (addressing the behavior in a neutral way).

Ignore the Behavior but Not the Child Sometimes we may have to break the rules of planned ignoring when a behavior won’t stop or happens many times during the day. For example, let’s say a child frequently asks the same question over and over again (even if it’s been answered). Following the rules of planned ignoring could mean ignoring the child for significant portions of the day. Instead, you can continue interacting with the child by engaging in “small talk” or making other demands (e.g., “Ok, Jimmy, let’s set the table for dinner.”). Meanwhile, you don’t respond to the “repeated questioning.” In other words, you “ignore the behavior” (pretending as if the repetitive questions weren’t even occurring) but “attend to 87

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the child” (by otherwise interacting with and providing attention to the child).

Goal 9: Assess the Parent’s Knowledge of Ignoring via Video and Written Vignettes To review, there are three different ways to use ignoring: 1. Ignore both the child and the behavior (e.g., for a child who is having a tantrum). 2. Ignore the child but not the behavior (e.g., for dangerous behaviors). 3. Ignore the behavior but not the child (e.g., for repetitive question asking). Let’s watch a video. See if you can identify which kind of ignoring the mom could use. (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #6: Dine and Dash Mom tries to coax child to sit at the dinner table while he “dines and dashes.” SOLUTION: Ignore Child, Not Behavior. Now let’s see what it would look like if our mom applied the ignoring skills properly. Video #7: Dinner Time Mom correctly uses ignoring skills to redirect child to the table. Now let’s see how well you can match behavior problems to the best type of ignoring: 1. David often waves his hands and fi ngers in front of his eyes. His family would like to decrease this behavior and will often tell him to stop. The family believes that the function of this behavior is sensory pleasure for David. He will wave his hands and fi ngers throughout the day, whether left alone in his bedroom

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or when with family members. However, the family is worried that David is beginning to enjoy the attention he receives from family members whenever they tell him to stop waving. How can David’s family address this behavior? [IGNORE THE BEHAVIOR BUT NOT THE CHILD. The family should stop telling David to stop waving his hands and fingers, as David may be learning to wave his hands and fingers to get attention from his family. Instead, family members can direct David to more appropriate activities without drawing attention to his waving. The parents could also praise David for other more appropriate behaviors that he may do with his hands (“Catch him being good”).] 2. Susan has been sent to her bedroom because she used foul language toward her mother. While in her bedroom, Susan begins to run around and yell loudly in hopes of getting a reaction from her brother and sister. What should Susan’s mother do? [IGNORE THE BEHAVIOR AND THE CHILD. All family members should continue with their activities as usual and should not give Susan any attention while she is in her room. Susan is trying to get a reaction from others, but she isn’t doing anything that’s terribly dangerous. Susan’s mother may need to help her other children ignore Susan as well. This is a good opportunity to talk about enlisting family members when using planned ignoring.] 3. Sarah just hit her younger brother because she wanted the toy he was playing with. Sarah’s mother sends Sarah to her room. After about a minute, a loud commotion is heard from Sarah’s room. Upon entering the bedroom, Sarah’s mother discovers that Sarah has thrown all her books on the floor and has begun to throw clothing from her closet out the window. What should Sarah’s mother do? [IGNORE THE CHILD BUT NOT THE BEHAVIOR. The parent must intervene due to the dangerous/​destructive nature of the behavior. Sarah’s mother could stand in front of the window to prevent her from throwing any more clothing out the window, or she could move Sarah to another room, without looking at her or talking to her. This is not the time to make Sarah pick up her room. She should complete her time out and then she can correct whatever damage was done.]

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Goal 10: Create a Home Plan for Using Planned Ignoring Let’s create a plan for using planned ignoring at home this week. [Turn to the Planned Ignoring Activity Sheet #2 and walk through the sheet with the parent.] Here’s a data sheet for you to use this coming week. [Look at the Planned Ignoring Activity Sheet #3 or design your own data sheet. Go over how to complete the data sheet with the parent.]

Goal 11: Assess the Parent’s Ability to Use Planned Ignoring via Role Play Finally, it might be helpful for us to practice doing planned ignoring. Let’s start by having me pretend to be you. Show me what it looks like when [your child] starts to [target behavior]. [Role-​play the chosen type of planned ignoring. Role playing may lead to some changes in the previously devised plan. Then have the parents take on their own roles while you pretend to be the child.]

Goal 12: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under consideration, not just those targeted for homework. Then turn to the Session Six Review and ask the parent to read over this material during the week. Close by scheduling the next session.]

For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

Homework Case Example Robbie enjoys looking out the window to see all the cars that pass by his house. He enjoys identifying each car and expects Mr. Rivera to answer his question: “What color is it?” Because this occurs several times 90

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throughout the day, Mr. Rivera has chosen to “Ignore the Behavior but Not the Child.” We planned to use this strategy in combination with a visual cue with three boxes. Robbie gets three chances each day to ask his dad, “What color is it?” After Robbie asks the question, Mr. Rivera will put an X in one box. When all three boxes are marked, Mr. Rivera will show Robbie that all his chances are done and that he will no longer answer the question, “What color is it?” Mr. Rivera will then utilize “Ignore the Behavior but Not the Child” for the remainder of the day. That is, he will continue to chat with Robbie but will not answer his questions about the cars passing by. Mr. Rivera thinks there is a chance that Robbie may escalate (ask the question louder, repeat the question at a higher frequency). Mr. Rivera plans to ignore all these behaviors unless Robbie becomes aggressive. If Robbie hits his dad, Mr. Rivera will move into “Ignore the Child but Not the Behavior” and calmly guide Robbie into his room for a time out.

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Planned Ignoring Treatment Fidelity Checklist Checklist 6.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​A

2

Review Behavior Support Plan

0  1  2  N/​A

3

Introduce parent to the concept of planned ignoring

0  1  2  N/​A

4

Watch videos and identify consequences that reinforce inappropriate behaviors

0  1  2  N/​A

5

Introduce basic rules of planned ignoring

0  1  2  N/​A

6

Assess parent’s ability to identify improper use of planned ignoring via video vignettes

0  1  2  N/​A

7

Review potential problems with planned ignoring

0  1  2  N/​A

8

Teach the three different ways to use planned ignoring

0  1  2  N/​A

9

Assess the parent’s knowledge of ignoring via video and written vignettes

0  1  2  N/​A

10

Create a home plan for using planned ignoring

0  1  2  N/​A

11

Assess the parent’s ability to use planned ignoring via role play

0  1  2  N/​A

12

Update Behavior Support Plan Total _​_​_​_​_​__​_​/​ 24

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Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session Parent Objectives

Rating

1

Parent identified consequences in videos that reinforce inappropriate behavior

0  1  2  N/​A

2

Parent identified rules for using planned ignoring via use of video vignettes

0  1  2  N/​A

3

Parent identified when to use the three types of planned ignoring via video and written vignettes

0  1  2  N/​A

4

Parent assisted in designing a planned ignoring program for home

0  1  2  N/​A

5

Parent demonstrated the ability to use planned ignoring via role playing

0  1  2  N/​A

Total _​_​_​_​_​_​_​_​_​/​ 10

FIDELITY NOTES:

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SESSION 7

Compliance Training

Session Seven Overview This session provides instruction on the Four-​ Step Compliance Procedure, including how to reinforce compliance and how to manage episodes of noncompliance.

Goals 1. Review homework assignment from prior session. 2. Review Behavior Support Plan. 3. Introduce parents to the concept of compliance. 4. Generate a list of compliance commands. 5. Generate a list of noncompliance commands. 6. Go over the steps for teaching compliance. 7. Identify correct and incorrect use of compliance training via video vignettes. 8. Role-​play correct use of compliance training. 9. Go over how to use compliance training to teach a child to “stop.” 10. Problem-​solve if things go wrong. 11. Design a compliance training plan for the home. 12. Bring it all together (pull together lessons learned from Sessions 1 through 7). 13. Update Behavior Support Plan.

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Parent Objectives 1. Parent will generate a list of compliance commands. 2. Parent will generate a list of noncompliance commands. 3. Parent will identify correct and incorrect use of compliance training from videos. 4. Parent will correctly use compliance steps via role play. 5. Parent will help generate a plan for using compliance training in the home. 6. Parent will identify various intervention strategies in “Bringing it all together” video.

Materials 1. Clinician Script 2. Videos 7.1–​7.6 3. Session 7 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan

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Clinician Tip Sheet Reviewing the Planned Ignoring Homework HW Challenge: The Parent Describes Attempting to Use Planned Ignoring, but Says It Is Very Difficult to Implement or States That the Ignored Behavior Did Not Get Any Better Like the play skills session, planned ignoring is a strategy that often takes time to work. Additionally, planned ignoring can be challenging because the behavior sometimes gets a lot worse before it gets better! This is known as an “extinction burst”—​a temporary increase in the behavior being ignored since it is no longer being reinforced by the parent’s attention. If the parent is struggling with its application, review the “challenges with planned ignoring” listed in Session 6, which discusses the many obstacles to implementing planned ignoring effectively. A consolation can be that if the behaviors actually escalated over the week, it’s a signal that the planned ignoring is working and that the parent is implementing the strategy correctly (à la “the behavior will get worse before it gets better”). Also remind the parent that if she is finding the strategy too difficult to implement, it is better to avoid using the strategy altogether, rather than attempt the planned ignoring only to give in. This is one strategy where, if the parent is really struggling with its implementation, you can “cross it off” as a go-​to strategy in the parent’s toolbox.

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Let’s start by reviewing how things went with planned ignoring for [target behavior(s)]. What did you find difficult about using this strategy? How effective do you think this approach can be with [child’s name]? Are there any questions I can answer about the use of planned ignoring?

Goal 2: Review Behavior Support Plan Now let’s go through the Behavior Support Plan and see how things are going with your use of other strategies we have implemented so far. Are there strategies that you have difficulty using consistently? What strategies seem to be effective in addressing the target behaviors? Are you ready to start using any additional strategies listed on the Behavior Support Plan? [Review specific strategies on the Behavior Support Plan that have not yet been put into action.]

Goal 3: Introduce Parents to the Concept of Compliance Today we are going to talk about how to teach your child to comply with your directions. Children don’t comply for a variety of reasons. Some have difficulty paying attention and don’t even hear their parents when they are told to do something. For example, you tell your child to clean up his toys. But when you return to the room a few minutes later, your child hasn’t even started cleaning up. When you ask why, your child honestly says that he didn’t hear you tell him to pick up the toys. Other children mean well, but once they start to do what they’ve been asked, they get distracted. In this case, your child may start to pick up the toys but becomes distracted by one of the toys and begins to play with it. When you return to the room, some toys have been put away—​but your child is playing with the remaining items. Still other children are more defiant. Defiance can be relatively passive—​the child hears but ignores the request. Other children are more vocal in their protests, shouting 98

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“No, no, no . . .” The child may even escalate to a tantrum in response to routine requests. In children with autism spectrum disorder (ASD), parents are often surprised by the intensity of their child’s response. No matter the reason, noncompliance is a habit that children learn when they are given commands and permitted not to comply. Increasing compliance in your child involves teaching a new habit of listening and following through on your instructions the first time he hears them. An easy way to let your child practice following commands right away is to increase the number of commands your child readily complies with. Also, when you give your child a command that he is not likely to follow, you can make sure that your child starts to follow through as soon as you give the instruction.

Goal 4: Generate a List of Compliance Commands Let’s start by listing 8 commands that your child already complies with, even when you are not standing right next to him. This list should include only things that your child will do without any objection. You may think at first that your child never does anything you ask of him or her! But, if you said to your child, “Come here and eat this piece of candy,” you would probably have little trouble with compliance. If you told your child to put her favorite DVD in the DVD player, to take a cookie off the counter, to clap her hands or touch her head, you’d also probably have little problem. As you think about these situations, also think whether your child is able to follow these commands from a distance. Here’s a worksheet for you to list the commands. [Along with the parent, turn to Activity Sheet #1 located in the Parent Workbook in Session 7 and provide assistance to obtain 8 “compliance” commands. NOTE: Help the parent to choose commands that involve daily living skills, so this can serve as an opportunity to increase compliance in this area.]

Goal 5: Generate a List of Noncompliance Commands Now I want you to make a list of 8 commands that your child typically won’t follow. These should be commands that you know your child is 99

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capable to doing, but will often refuse to do when you ask. Examples can be “Put your toys away,” “Come inside,” or “Turn off the iPad®.” [Help the parent come up with a list of at least 8 “noncompliance commands.” Add these to Activity Sheet #1. It might be easiest to focus on commands that require a minimum of effort by the child, such as putting a dish in the sink rather than picking up an entire bedroom.]

Goal 6: Go Over the Steps for Teaching Compliance Now that we have our lists, let’s review the four steps that are necessary for your child to learn to follow commands [Turn to Compliance Training Activity Sheet #2.] Step 1: Walk over to your child and stand by him. Be sure that you have his attention by calling his name, tapping him on the shoulder, or helping him look at you. Step 2: Tell your child what to do. Be careful not to ask your child, since you are giving a command, not a choice. State the command clearly so that your child knows exactly what he is supposed to do (e.g., “Put the red crayon on the table” as opposed to “Put that over there” or “Would you like to put the crayon on the table?”). It is also important to state the command only once. We often find that parents repeat the same command over and over in hopes that the child will comply. Many parents don’t even realize they’re doing this! Step 3: At the same time you are telling your child what to do, physically guide him to complete the command. This can be done by putting your hands over your child’s hands or touching your child’s arms to help him comply with the command. Always use the minimum amount of physical contact necessary for the command to be completed. Once your child starts to comply, you can lessen physical guidance. Step 4:  As your child complies, provide immediate praise. State exactly what he did that you liked (i.e. “I liked the way you picked up the crayon when I asked you”). You should do this even if the child is successful with compliance only because of the physical guidance you are providing. Your goal is to teach the child that immediate compliance results in immediate reinforcement. 100

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Each time you give a command, try to reduce the amount of physical guidance you provide your child. Also, once your child requires no physical guidance, try to give commands from an increasingly greater distance. Eventually, you will be able to give commands effectively even when you are some distance from your child— say across the room. CASE EXAMPLE Jimmy never listens to his mother when she says, “Put your toy car away.” So, first she makes sure that she is close enough to give the command. She taps his shoulder to get his attention and says, “Jimmy, put your toy car away.” As soon as she begins to state the command, she physically guides Jimmy to put his toy car in the toy box. Jimmy’s mother provides enough physical guidance so that he puts the toy away quickly and without resistance. Just as Jimmy finishes putting the toy car away, even with help from his mother, Jimmy’s mother says, “Good job! Thanks for cleaning up!” The next time Jimmy’s mother gives the command, “Put your toy car away,” she will remember to provide less physical guidance, but enough that Jimmy complies. Eventually, Jimmy’s mother will try to give this command from greater distances, such as at the doorway to Jimmy’s bedroom or even from another room.

Goal 7: Identify Correct and Incorrect Use of Compliance Training via Video Vignettes Let’s look at our videos showing a parent working on compliance training with her child. Your job is to figure out what’s being done correctly, and also what’s being done incorrectly and provide “advice” to the parent for how to be more effective. Activity Sheet #3 lists the compliance steps so that you can rate each of the videos. [Turn to Activity Sheet #3.] (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Come Upstairs Parent yells “Come here” from upstairs while kids are downstairs. She does not follow any of the four steps.

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Video #2: A Huge Mess, Part One Parent attempts, unsuccessfully, to get her child’s attention and then repeats the command when the child doesn’t respond. She does not follow any of the four steps. Video #3: A Huge Mess, Part Two Parent does not clearly get his attention. She then gives a good command and attempts physical prompting but gives in when her child has a tantrum. She does not follow through with Steps 3 and 4. Video #4: Dinner Cleanup Parent successfully completes Steps 1–​3 but forgets to praise her child. Video #5: Pepperoni Toss Parent completes all four steps correctly.

Goal 8: Role-​Play Correct Use of Compliance Training Now let’s practice compliance training together. Let’s start by having me pretend to be your child and you give me a couple of commands from the Compliance List. [Have the parent give two different commands. Comply with both. The parent should accurately do Steps 1–​4. Then have the parent give a third command; you should initially be noncompliant but then comply as the parent physically guides you through the task. Continue with role play until the parent demonstrates his or her ability to consistently do Steps 1–​4.]

Goal 9: Go Over How to Use Compliance Training to Teach a Child to “Stop” So far, we’ve reviewed how to tell your child to do something. Parents often tell their children what not to do, such as to stop behaving in ways that are annoying, disruptive, or dangerous. For example, parents tell their children to stop fighting with each other, stop jumping on the couch, or stop making so much noise. Children with ASD may not catch on to these requests because they don’t always know what the parent wants

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them to do instead. So an instruction to stop running in the house may be less effective than a direction to sit down and start playing with toys. The next time you find yourself telling your child to stop a behavior, use this as an opportunity to practice compliance training instead. Walk over to your child, get her attention, give an instruction that tells her what she should do—​start a more appropriate activity, provide the necessary amount of guidance, and praise her for complying.

Goal 10: Problem-​Solve If Things Go Wrong Before we plan this week’s homework, let’s think about any challenges you may encounter when trying to implement the compliance training procedures. [If the parents think that Noncompliance Commands will be too challenging, they can start with commands that can easily and quickly be accomplished. For example, asking the child to clean up his room might require an extended period of time and actually involve many commands. Instead, have the parent target short commands, such as “Put your cup in the sink” or “Hang up your coat in the closet.” These can be accomplished quickly so that there is less chance that the child will become resistant.] ■ [If the parents think that praise will not be motivating enough for compliance, you can discuss making tangible reinforcers available. For example, let the child know that he can have access to a favorite book after he puts his coat away. Refer to the list of reinforcers in the Behavior Support Plan as possible options.] ■ [Let parents know that they may have to focus on the “Compliance Commands” list for a while before working on the “Noncompliance Commands” list.] ■

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Goal 11: Design a Compliance Training Plan for the Home Option 1, for Parents Who Need More Practice With This Concept This week, focus on giving your child commands each day from the “Compliance Commands” list. Let’s target 2–​4 commands from that list to apply the compliance training steps. [Review the Compliance Commands list and have the parents select 2–​4 specific commands that they will focus on over the next week. Write those commands on Activity Sheet #4 under the “Compliance Commands List” heading.] Remember to provide lots of praise, “high fives,” and so on when your child follows your commands. You can experiment by giving your selected Compliance Commands from any distance away from your child. Once you feel comfortable with the Compliance Commands, we’ll move to the “Noncompliance Commands” list. On Activity Sheet #4, circle Yes or No (did the child comply right away to your commands?) and comment if you have any problems. [If the parents decide to use a tangible reinforcer in addition to praise, write the selected reinforcer on the Activity Sheet.]

Option 2, for Parents Who Seem to Have a Good Understanding of This Concept This week I’d like you to give your child 1–​2 commands each day from the Compliance Commands list while using the compliance training steps. [Review the Compliance Commands list and have the parents select 1–​2 specific commands that they will focus on over the next week. Write those commands on Activity Sheet #4 under the “Compliance Commands List” heading.] You can experiment by giving your selected Compliance Commands from any distance away from your child. I’d also like you to try to give your child 1–​2 commands each day from the Noncompliance Commands list. Let’s choose those commands from

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that list and have you apply the compliance training steps. [Review the Noncompliance Commands List and have the parents select 1–2 specific commands that they will focus on over the next week. Write those commands under the “Noncompliance Commands List” heading.] Remember to provide lots of praise, “high fives,” and so on when your child follows your commands. [If the parents decide to use a tangible reinforcer in addition to praise, write the selected reinforcer on the Activity Sheet.] On your Activity Sheet #4, circle Yes or No (did the child comply right away?) and comment if there are any problems.

Goal 12: Bring It All Together (Pull Together Lessons Learned From Sessions 1–7) Let’s close by reviewing the skills covered over the past seven sessions, as the next set of sessions will focus on teaching strategies. We’ve talked about prevention strategies, schedules, reinforcement, planned ignoring, and compliance training. The video clip we will now watch shows a parent appropriately using many of these techniques while assisting her child to get ready in the morning. [Have the parent identify the various techniques being used.] (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #6: Integrate Behavioral Principles Bringing It All Together. Parent should identify use of visual schedule, physical prompting, planned ignoring, guided compliance, and praise.

Goal 13: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under

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consideration, not just those targeted for homework. Then turn to the Session Seven Review and ask the parent to read over this material during the week. Close by scheduling the next session.]

For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

Homework Case Examples Mr. Lee wanted to target “Clean up your toys” with Matthew. Because of concerns about the amount of physical prompting that would be required to have Matthew clean up all of his toys, Mr. Lee targeted the specific task: “Put your red truck in the box.” To help aid compliance, Mr. Lee was coached to place the clean-​up box next to the red truck so that he wouldn’t have to guide Matthew very far when using hand-​over-​ hand physical prompting. Along with praise, Mr. Lee wanted to use his assistance with cleaning up the remainder of the toys as the reinforcer for compliance. As a result, the final command was “Put your red truck in the box. Then daddy will pick up the rest of the trucks for you.” Ms. Edwards wanted to target “Wash your hands” with Andrew. We first discussed what command to use for this task. Specifically, we discussed whether Andrew would understand and comply with the more general command of “Go to the bathroom to wash your hands” or whether he needed the commands (and use of the Four Steps) to be broken down into smaller steps (i.e., “Go to the bathroom”; “Turn on the water”; “Put soap on your hands”). Ms. Edwards decided that the most difficult part was getting Andrew to go into the bathroom. Once there, he generally followed through with the hand washing. Ms. Edwards was coached on using the command “Go to the bathroom to wash your hands” with the physical prompt of a hand on Andrew’s back to move him toward the bathroom. Ms. Edwards felt Andrew would respond to praise and would not require a tangible reinforcer to aid compliance.

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Compliance Training Treatment Fidelity Checklist Checklist 7.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​A

2

Review Behavior Support Plan

0  1  2  N/​A

3

Introduce parents to the concept of compliance

0  1  2  N/​A

4

Generate a list of Compliance Commands

0  1  2  N/​A

5

Generate a list of Noncompliance Commands

0  1  2  N/​A

6

Go over the steps for teaching compliance

0  1  2  N/​A

7

Identify correct and incorrect use of compliance training via video vignettes

0  1  2  N/​A

8

Role-​play correct use of compliance training

0  1  2  N/​A

9

Go over how to use compliance training to teach a child to “stop”

0  1  2  N/​A

10

Problem-​solve if things go wrong

0  1  2  N/​A

11

Design a compliance training plan for the home

0  1  2  N/​A

12

Bring it all together (pull together lessons learned from Sessions 1 through 7)

0  1  2  N/​A

13

Update Behavior Support Plan

0  1  2  N/​A Total _​_​_​_​_​​_​_​_​_​/​ 26

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Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session Parent Objectives

Rating

1

Parent generated a list of Compliance Commands

0  1  2  N/​A

2

Parent generated a list of Noncompliance Commands

0  1  2  N/​A

3

Parent identified correct and incorrect use of compliance training from videos

0  1  2  N/​A

4

Parent correctly used compliance steps via role play

0  1  2  N/​A

5

Parent helped generate a plan for using compliance training in the home

0  1  2  N/​A

6

Parent identified various intervention strategies in “Bringing it all together” video

0  1  2  N/​A

Total _​_​_​_​_​_​​_​_​_​/​ 12

FIDELITY NOTES:

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SESSION 8

Functional Communication Training

Session Eight Overview As challenging behaviors typically serve a function for the child, this session introduces the idea of teaching an alternative and more appropriate functional communication behavior to replace the inappropriate or undesirable behavior.

Goals 1. Review homework assignment from prior session. 2. Review Behavior Support Plan. 3. Introduce concept of functional communication training. 4. Introduce procedural steps of functional communication training. 5. Review video vignettes illustrating the use of functional communication training. 6. Discuss written vignette examples of functional communication training. 7. Set up a functional communication training homework assignment. 8. Update Behavior Support Plan.

Parent Objectives 1. Parent will identify target behaviors, their function, and the implemented functional communication strategy on the video vignettes. 109

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2. Parent will provide ways to implement functional communication training for behaviors on the written vignettes. 3. Parent will generate a plan to implement functional communication training at home to target the child’s problematic behavior.

Materials 1. Clinician Script 2. Videos 8.1– ​8.3 3. Session 8 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan

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Clinician Tip Sheet Note for Treating Verbal Children It is not difficult to imagine how functional communication training can be helpful for a child who is nonverbal and often reliant on his behaviors to communicate his wants and needs. Implementing this session can be more challenging for children who have the language to express themselves because these children are viewed as already “using their words” in place of challenging behaviors. Even verbal children, when upset or frustrated, often resort to nonfunctional forms of communication, whether it be whining, yelling, or hitting, to communicate. When teaching this session to parents with a verbal child, the focus should be on additional opportunities for the parent to teach the child to “use his words.” Examples of targets for intervention include replacing yelled requests with “asking in a nice tone of voice,” changing whispered requests to “a big boy voice,” or saying “Can I have a break?” instead of whining when sitting at the table while doing homework. This session also provides an opportunity to replace less socially appropriate requests or exchanges with more appropriate skills. For example, a child who interrupts could be taught, instead, to say “Excuse me.” A child who has difficulty introducing himself could be taught to say, “Hi, my name is . . . ” A child who grabs toys from her sibling can learn to say, “Can I have a turn?”

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Let’s start by reviewing how the past week went. How did things go when using compliance training? Let’s look at the data you collected. What did you find difficult about using this strategy? Are there any questions I can answer at this time about the process of using guided compliance? [Review Activity Sheet #4 from the previous session. Suggest modifications and needed changes in the use of compliance training.]

Goal 2: Review Behavior Support Plan Now let’s go through the Behavior Support Plan and see how things are going with your use of other strategies we have implemented so far. Are there strategies that you have difficulty using consistently? What strategies seem to be effective in addressing the target behaviors? Are you ready to start using any additional strategies listed on the Behavior Support Plan? [Review specific strategies on the Behavior Support Plan that have not yet been put into action.]

Goal 3: Introduce Concept of Functional Communication Training Today we will discuss how to teach your child a new communication behavior as a replacement of a problematic behavior. This new behavior will serve the same purpose as the problem behavior but will be much more appropriate and “functional.” This is often referred to as functional communication training. We have already discussed how a child’s behavior serves a function or purpose, such as to get out of something, to get attention, or to try and get or keep a preferred item. For example, a child may hit others because he wishes to get out of situations, such as leaving the dinner table or his therapy sessions. This behavior is very communicative (i.e., you 112

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know what he is trying to say when he hits: “This is too much! I need a break!”), but it is also inappropriate. Instead, we might consider teaching the child a more functional or appropriate way of making a request for a break. For a child not yet talking, this might be teaching him to manually sign “all done” or to have him point to a picture icon of “break” when he needs to leave the table or therapy session. For children who have strong verbal skills, it might be teaching the child to “use his words” and tell an adult when he needs a break (though picture communication is sometimes useful as well for children with words). Communication strategies that can be used include gestures, signs, or words, as well as low-​tech strategies such as a picture exchange or high-​ tech strategies such as augmentative devices. It is important to teach children more functional means of communicating as an alternative to negative behaviors. Before you begin teaching your child a new, alternative behavior to replace a problematic behavior, however, it is very important to first figure out why the child might be engaging in that inappropriate behavior—​ that is, what is its purpose or function. In fact, the success of this approach depends on knowing this! CASE EXAMPLE Anna screams at her mother in a fast food restaurant after finishing her French fries. In order to teach her a more appropriate behavior to replace the screaming, we would first have to figure out what this behavior is attempting to communicate. Is it her wish for more French fries, to leave the restaurant, to get her mother’s attention as she is attempting to finish her meal, or to get sensory feedback from the scream itself? We need to know the specific function or purpose of the screaming to know what we should be teaching Anna to replace it with. If we know Anna’s screaming serves to communicate her wish for more food, we might teach her to hand her mom a picture of French fries. If she can do this, she no longer needs to scream to meet this need. If we know Anna is screaming because she wishes to leave the restaurant, we might teach her to say, “Go to car.” If Anna wishes to get her mom’s attention, the replacement behavior might be to say, “Excuse me.” If the goal is sensory, the replacement behavior might be to teach Anna to request her headphones that will provide auditory feedback.

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So, in order to know what specific replacement behavior you should be teaching your child, you first need to know the function of the problematic behavior. If the function is unclear, one of the best ways to figure it out is to use the ABC tracking procedures that we completed in our very first session. Remember, this method allows us to help think about the antecedents and consequences to a particular behavior, and that can, in turn, be used to help figure out the function of the behavior. Say we completed an ABC assessment and it appears that a child whines and pulls on his mother’s arm in order to get her attention when she is busy or occupied. For this child, we might consider teaching a communication skill such as holding up a picture to indicate his wish for attention. Other options include teaching a child to raise his hand to get his mother’s attention or gently tap his mom on the arm to signal her to pay attention to him. There are several advantages of taking this approach in addressing difficult behaviors. As with teaching new skills in general, this is a proactive approach that builds independence. This approach is also more likely to result in changed behavior that lasts and that the child will use in various settings and situations.

Goal 4: Introduce Procedural Steps of Functional Communication Training Here are a few things to keep in mind when replacing a challenging behav­ior with a more functional behavior. 1. The replacement behavior should work quickly for the child. Sometimes a child has to keep going on and on with a problematic behavior—​for example, whining for parent attention—​before the parent responds. If the child instead learns to use a more functional way of asking for attention, such as a tug on the shoulder, and the parent responds quickly, the child will then learn that tugging on the shoulder is a much quicker way of getting his parent’s attention. That will increase the likelihood that he will use that strategy again over whining in the future. 2. The replacement behavior should work every time for the child. Especially in the beginning, the new replacement behavior should

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be responded to every time the child uses it: in all situations, and with all adults working with the child. 3. The chosen behavior should require less effort than the challenging behav ior. Throwing a tantrum requires a lot of time and energy on a child’s part! If he can get the same needs met by simply handing a parent a picture, or using a certain phrase to communicate, this requires much less effort and is a much easier way to get his needs met. While any replacement behavior may take a good amount of practice before it is learned and used in appropriate settings, we want to set your child up for success. Th is can best be accomplished by keeping in mind your child’s current skill sets and thinking about how the new replacement behavior fits within that. If a child has very limited verbal skills, we would not want to teach him the skill of saying “I need a break” to replace hitting. For this child, this would likely be more effortful than just hitting. It is most helpful if the replacement behavior includes skills already mastered. For a child who already uses several manual signs in some situations, we might choose to teach the child to sign “all done” as a replacement for hitting others when it has been determined the hitting serves to avoid a task or request. For a child well-versed in picture exchange communication system (PECS), it would make sense to use a picture format for communication. Verbal children can be taught to “use their words.”

Goal 5: Review Video Vignettes Illustrating the Use of Functional Communication Training Let’s watch a few examples of functional communication training in action. (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Help Card Parent teaches her child to say “help” using a picture.

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Emphasize that there is sometimes a need to teach the child the communication skill in multiple one-​on-​one sessions before it can be used in daily, real-​life situations. This is true for signing, picture exchange, or using words. Video #2: Sign for Drink Child signs “thirsty” after pushing food away. Ask the parent what could have happened if the child had not been taught to sign for a drink? The child would become more agitated and possibly throw the food off the table. Video #3: Help Please Child uses the word “help,” first prompted, then unprompted when having difficulty zipping up his coat. Emphasize that teaching is important and that the child eventually can learn to use the skill to communicate independently.

Goal 6: Discuss Written Vignette Examples of Functional Communication Training As we saw in one of the video vignettes, teaching the child in a one-​on-​ one setting might first be needed. Here are some written examples to help think through how functional communication training could be applied to challenging child behaviors. [Walk through Activity Sheet #1, located in Session 8 of the Parent Workbook.] CASE EXAMPLE #1 Tommy is a 5-​year-​old boy with a vocabulary of approximately 10 words. When his sister takes away one of his toys, he quickly becomes agitated and hits her until she gives back the toy. Tommy may be communicating “I want that back,” “That’s mine,” and so on. Since he is essentially nonverbal, his mother should focus on teaching a strategy that does not rely on language (e.g., sign, picture). Tommy could be taught to seek out his mother for assistance and sign or show a picture of “mine.” His mother could practice with Tommy by taking away a preferred toy and then prompting him to use the sign or picture to request it back; she could also supervise play with the sister and prompt for sign/​picture. Tommy’s father could prompt Tommy to seek out his mother. 116

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Let’s go through the next example on the activity sheet. CASE EXAMPLE #2 Theresa is a 4-​year-​old girl who is extremely talkative. She chats about her interests and lets her parents know what she wants in general. However, at school she becomes very upset when a teacher asks her to leave the play area. Theresa will have a tantrum and refuse to leave the area. She may be communicating “I want more time to play.” Since she is verbal, Theresa could be taught to use her words and ask the teacher if she can stay in the play area. Teaching could begin by asking Theresa to leave a less-​desired activity (making it easier for her to use her words in a less frustrating situation for her). When she succeeds, the teacher could respond with praise and allow her to continue her activity for five more minutes. Theresa could be rewarded for using her words in lieu of throwing a tantrum. Theresa might benefit from a visual reminder to use her words. Many parents worry that their child will repeatedly ask for breaks whenever requests are made of him. Initially, we need to let the child have the breaks every time he asks in order to teach him that his new, more appropriate, communication strategy works! Once the child is using the strategy consistently, the parent can start to gradually limit the number of times a child can request breaks (e.g., “You can ask for a break three times while we work on your worksheets.”) The parent could also teach a child to gradually delay his break (“You need to do two more problems on your worksheet, and then you can have a break”). This also applies to many other functional communication responses such as asking for help, food, or attention, among others.

Goal 7: Set Up a Functional Communication Training Homework Assignment Now let’s figure out a problematic behavior that your child currently exhibits that we can address by teaching a new, more functional replacement behavior. [Along with the parents, turn to Activity Sheet #2 and walk through it with them.] Can you think of a behavior that

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we could target using this strategy? [Offer suggestions if the parents cannot readily come up with any examples.] What do you think the function of that behavior is? What alternative behaviors do you think we might teach to replace this problematic behavior? What would be the most appropriate type of communicative strategy for the replacement behavior? [You can give some examples relevant to the child’s skills and function of problem behavior, such as teaching a manual sign, a one-​word statement, use of a gesture such as clapping, or use of a picture or other augmentative communication behavior.] While it may be helpful to start teaching a functional communication behavior in a more structured setting, you also want to make sure the child is given opportunities throughout the day to practice or try out the new replacement behavior. For example, if we are teaching the child to sign “help,” we might want to purposefully put preferred items out of reach so he needs to ask for help to gain access to them. We could also give him a toy or activity that we know is not working (not on, needs batteries) to promote the use of the new replacement behavior. To monitor your progress with the teaching of this new replacement skill, we would like you to complete a data sheet between now and the next session. There are separate areas to record the times that you purposefully set up opportunities to practice the new skill as well as times that the new skill may be observed and/​or taught in naturalistic settings. [Turn to Activity Sheet #3.]

Goal 8: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under consideration, not just those targeted for homework. Then turn to the Session Eight Review and ask the parent to read over this material during the week. Close by scheduling the next session.]

For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

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Homework Case Example Ms. Connors wants James to practice his handwriting at home. However, not 2 minutes into the practice, James starts whining and complaining that writing is too hard. Ms. Connors decides to apply the techniques of functional communication training to address this behav­ior. She hypothesizes that the function of James’s whining is to get out of (or escape from) the handwriting practice. She wants to teach James to “use his words” and ask for a break instead of whining. The next time she has James practice his handwriting, as soon as he starts whining, Ms. Connors prompts him to use his words and ask for a break. James stops whining and says, “Break, please.” Ms. Connors then immediately sets a 5-​minute timer and allows him to take a break from the handwriting exercise. Only once James is consistently using his words instead of whining does she increase the demand of writing (and delay escape) by requiring him to write one more word (then two, then three, and so on) before he is allowed to escape by using his words of “Break, please.”

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Functional Communication Training Treatment Fidelity Checklist Checklist 8.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​A

2

Review Behavior Support Plan

0  1  2  N/​A

3

Introduce concept of functional communication training

0  1  2  N/​A

4

Introduce procedural steps of functional communication training

0  1  2  N/​A

5

Review video vignettes illustrating the use of functional communication training

0  1  2  N/​A

6

Discuss written vignette examples of functional communication training

0  1  2  N/​A

7

Set up a functional communication training homework assignment

0  1  2  N/​A

8

Update Behavior Support Plan

0  1  2  N/​A Total _​_​_​_​_​_​_​_​_​/​ 16

Rate the degree to which the parent participated, responded correctly, and completed activities.

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0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session Parent Objectives

Rating

1

Parent identified the target behaviors, their function, and the implemented functional communication strategy on the video vignettes

0  1  2  N/​A

2

Parent provided ways to implement functional communication training for behaviors on the written vignettes

0  1  2  N/​A

3

Parent generated a plan to implement functional communication training at home to target the child’s problematic behavior

0  1  2  N/​A

Total _​_​_​_​_​​_​_​_​_​_​/​ 6

FIDELITY NOTES:

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SESSION 9

Teaching Skills 1

Session Nine Overview This session provides parents with step-​by-​step procedures for teaching skills that increase a child’s independence and promote positive behavioral change.

Goals 1. Review homework assignment from prior session. 2. Review Behavior Support Plan. 3. Introduce importance of explicitly teaching adaptive skills. 4. Discuss how to choose which skills to teach. 5. Teach task analysis and practice with brushing teeth example. 6. Introduce parents to chaining as a teaching technique. 7. Review video vignette of chaining. 8. Provide homework assignment. 9. Update Behavior Support Plan.

Parent Objectives 1. Parent will come up with a list of new skills she or he would like to teach the child. 2. Parent will task analyze the example of brushing teeth.

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3. Parent will pick a behavior to teach and complete a task analysis on that behavior. 4. Parent will assist in creating the homework assignment.

Materials 1. Clinician Script 2. Video 9.1 3. Session 9 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan

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Clinician Tip Sheet Reviewing the Functional Communication Homework HW Challenge: Parent Says the Child Showed Little Progress in Using the Chosen Functional Communication Training Strategy This skill generally takes more than a week (and more persistence on the parent’s part) to take effect. Following the principle that this skill requires multiple practice opportunities for the child to learn the new skill, problem-​solve ways that the parent can set up additional opportunities for the child to practice the new, more functional communication strategy, both in real situations and in orchestrated practice situations. The story behind this skill is “practice makes perfect.” Practicing once a day likely will not produce change in the short run.

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Let’s review the data on your use of functional communication training. How effective do you think this approach was with your child? What did you find difficult about this approach?

Goal 2: Review Behavior Support Plan Now let’s go through the Behavior Support Plan and see how things are going with your use of other strategies we have implemented so far. Are there strategies that you have difficulty using consistently? What strategies seem to be effective in addressing the target behaviors? Are you ready to start using any additional strategies listed on the Behavior Support Plan? [Review specific strategies on the Behavior Support Plan that have not yet been put into action.]

Goal 3: Introduce Importance of Explicitly Teaching Adaptive Skills So far, we have learned about setting up antecedents such as making changes in the environment and developing a schedule. We have also discussed the use of reinforcers to encourage appropriate behaviors while decreasing disruptive behaviors. We can also have a big impact on a child’s behavior by teaching him skills he might not have. So we are going to shift our focus to encourage positive, prosocial behaviors by teaching new skills. Teaching skills is an important part of a comprehensive treatment package targeting problem behaviors in children with autism spectrum disorder (ASD). A reduction in your child’s disruptive behaviors opens the door to teaching new skills that in the past would have been too difficult because of the amount of resistance you might have encountered with your child. The types of new skills and behaviors that could be taught to your child include play or leisure skills, social skills, self-​help skills, organizational

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skills, academic skills, and coping skills. As discussed during the previous session on functional communication training, it can be very helpful to teach a child a new communication strategy as an alternative to a disruptive behav­ior. For example, if a child is typically aggressive when he finds certain fine motor tasks difficult, it would be useful to teach him instead to communicate his need for a break using a sign, verbal request, or picture. Teaching the child a more appropriate way of saying “I need a break” eliminates the need for him to become aggressive to communicate. It can also be helpful to teach a child a specific new skill to replace a disruptive behavior. For example, teaching a child to use a DVD player might prevent her from becoming upset when you are not available to do this for her. There may also be skills that your child is able to do but finds difficult or frustrating. For example, a child may seem to have the skills to brush his or her teeth but does not like to do this task. The strategies we are going to discuss will be helpful for teaching these skills. As parents, you have already taught your child many skills needed in everyday life at home and in the community because parents are a child’s first teachers. Some children with ASD, however, need extra help in learning new skills. This requires us to carefully design a plan to teach a specific skill. We will review how to systematically teach a new skill using behavioral techniques that have been shown to be effective for children with ASD. We also will be relying on a number of strategies that we have already discussed, such as reinforcement, giving commands, and the use of planned ignoring.

Goal 4: Discuss How to Choose Which Skills to Teach Let’s first think about which skills would be the most useful to teach. [Refer parents to Activity Sheet #1 located in Session 9 of the Parent Workbook. Note that if the parent has completed a rating of the child’s adaptive behavior (e.g., Vineland Adaptive Behavior Scale), you can use that data to help generate ideas for specific adaptive skills to target that the child has not yet mastered.]

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1. What skills could you teach your child that might help with his disruptive behaviors? Are there any skills, such as learning to work the TV or turning on the computer, that might eliminate a disruptive behavior? 2. What skills would make your child more independent and not as reliant on you? It is helpful to think about daily living skills that your child currently does not do, but should be capable of completing (e.g., getting dressed, putting dishes in the sink, putting on coat, fastening zippers/​buttons). 3. What skills does your child seem to be able to do most of the steps for, but refuses to do, or finds frustrating? This may be because he finds it challenging or not terribly pleasant to do. Through systematic teaching strategies, you can teach the child to do the skill with less frustration. 4. What would your child be motivated to learn? If your child is trying to put a DVD in the DVD player, this might be a good time to teach him how to operate it. If your child loves to swing on the swing set, you could teach him to get on and off the swing by himself. When choosing what you would like your child to learn, start with a small number of skills. Once you are comfortable with one skill, you can then work on others.

Goal 5: Teach Task Analysis and Practice With Brushing Teeth Example Let’s review how to systematically teach a skill. Start by thinking how we all learn new skills. Suppose I want to learn how to brush my teeth. What directions would you give me? [Give the parent an opportunity to respond.] While we think of brushing our teeth as one task or skill, you can see that it actually involves learning a sequence of several smaller steps. Most important skills we learn are tasks that can be broken down this way. This is called a task analysis of a skill. It is important first to task analyze the steps of a skill before you can prepare to teach it. Let’s choose one skill in particular that you think would be important for your child to learn. [Reference Activity Sheet #1. Write this skill

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on Activity Sheet #2.] How could this skill be broken down into easy steps to learn? [Write out each step on Activity Sheet #3a.]

Goal 6: Introduce Parents to Chaining as a Teaching Technique Now we can think about how we are going to teach your child each step. First, think about what steps your child does not know how to do and will need to be taught. This will give us a sense of what steps we are going to focus our teaching on as well as where we will start our teaching. [Ask the parent to star the steps the child needs to be taught on Activity Sheet #3a.] Your goal will be to teach your child one step at a time. Only once your child has mastered a particular step in the task analysis should you move on to the next step. In the meantime, you will complete for him all other steps that he has not yet mastered. For example, if you are teaching him to tie his shoelace and your first step is to have him cross over the laces, you would then pick up from there and complete the remainder of the steps until the shoelaces are tied. This really allows your child to focus on learning just that one step. This is different from how parents usually teach their child to do something—​by requiring the child to learn every step of the task all at once. It can be challenging for kids with ASD to have to remember and perform multiple steps at once. Parents also often find that one specific part of the task might be particularly frustrating for their child. It is that step or two that children with ASD often get hung up on, subsequently refusing to do the task altogether. By instead breaking a task down into small chunks using a task analysis, and focusing on teaching only one step at a time, you will end up teaching your child a new skill in a much more acceptable way. While this method may seem like it will take longer to teach a new skill to a child, in the long term you may end up with more success because you are avoiding a teaching approach that otherwise might trigger noncompliance, defiance, and protests! The next thing to consider is in what order you would like to teach the steps. That is, you can start by teaching the very first step in the task

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analysis and build off that or you can start with the very last step in the task analysis and then work backward. Teaching a skill step by step in this manner is called chaining. You will continue to add steps one by one in this way until your child is able to complete all of the steps in the task analysis. One way to figure out what place to start teaching is to begin with the easiest step to teach your child. This will help both you and your child feel like you’ve accomplished something quickly. When your child is doing that step well, you can then add the next step. With our earlier example of teeth brushing, you might first teach your child to pick up the toothbrush as the first step. Once he is able to do this, then the next step would be added. This is called forward chaining because you are starting with the first step and then moving forward. When you begin to teach this way, the steps will naturally build on each other. At other times, you may want to start with the last step. In this case, you will do all of the steps for your child, then let him finish up by doing the last step for himself. Finishing this way will give your child a sense of accomplishment. When he is doing the last step well (for example, putting the toothbrush away), you can then begin to have him do the last two steps by himself, then the last three steps, and so on. This is called backward chaining. To illustrate, think about teaching your child to zip his coat. You may do the first few steps, such as connecting the zipper at the bottom and zipping the coat up a few inches, but then let your child finish pulling the zipper up over his chest. Another example would be cleaning up toys at home. If you ask your child to clean up a room that is scattered with many toys, your child may feel overwhelmed and refuse to complete the task. However, if you cleaned up most of the items before you ask him to clean up, you may find he is much more successful. Finally, it is important to use reinforcers as you are teaching each step. This can be as simple as providing social reinforcement (i.e., praise, high fives) or can involve providing a tangible reinforcer (e.g., goldfish, access to a preferred toy) every time the step being taught is attempted. As you increase the number of steps that your child needs to complete, you can praise your child as he completes each step, but hold off on providing the tangible reinforcer until all steps are completed. So once your child has learned one step in the task analysis, you will then require your child to

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do two steps before getting a reinforcer. With this information in mind, let’s finish creating your plan for teaching your child a new skill. [Finish Activity Sheet #2 with the parent.]

Goal 7: Review Video Vignette of Chaining Let’s review this brief video vignette of teaching using backward chaining. (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Backward Chaining This video provides a demonstration of backward chaining when putting on a sock. The parent demonstrates a four-step process of scrunching the sock, fitting the sock over the toes, pulling the sock over the heel, and pulling up the lower leg. The parent starts with teaching the last step and moves the child through mastery of each step before moving on. The parent completes all steps that have not yet been mastered by the child. Keep in mind good teaching involves using the behavioral strategies we have already discussed. For example, visual cues can be particularly helpful when your child is learning a new skill, such as posting next to the DVD player a picture of how to put a DVD in the machine. Even the steps for turning on the DVD player might be in pictures. Providing reinforcement for attempts to complete a step of a new skill is important. You may even have to ignore some whining or complaining as the child attempts a particular step.

Goal 8: Provide Homework Assignment This week, practice the skill you chose on Activity Sheet #2. [Turn to Activity Sheet #3b.] Here is an example of a completed homework sheet You’ll see the example homework lists each step of the task of brushing teeth. Each date includes the steps that have been mastered (as

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noted by the plus mark), which ONE step is currently being addressed (as noted by the abbreviation INP), and what remaining steps have not yet been introduced and so are being completed by the parent.

Goal 9: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under consideration, not just those targeted for homework. Then turn to the Session Nine Review and ask the parent to read over this material during the week. Close by scheduling the next session.]

For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

Homework Case Examples Mr. Roberts wants to teach Allie how to wash her hands. He breaks the task into six discrete steps. Allie can turn the faucet on, but she has difficulty getting the soap out of the dispenser and properly cleaning her hands. Mr. Roberts decides to use backward chaining by focusing first on having Allie turn the water off, then, once mastered, adding the second to last step of having her properly rinse her hands. He plans to do all prior steps for her. Mr. Roberts thinks having a visual schedule outlining the steps of hand washing will be helpful. He plans to post it on the bathroom mirror. Finally, he wants to reward Allie with a gummy bear, her favorite treat. Ms. Clifton would love it if Alex could buckle his own seat belt. After completing the task analysis (five steps), Ms. Clifton states Alex is unable to complete any of the steps independently. She chooses to start by teaching Alex the first step of the task:  grabbing the belt buckle. Ms. Clifton will then pick up the remainder of the task—​pulling the

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belt, by the buckle, across his lap with one hand; holding the extended belt with the other hand; lining the buckle up; and pushing the buckle in. We decide to include a visual prompt to help Alex learn how far he needs to pull out the seat belt and where he can put his hand on the extended belt. Specifically, Ms. Clifton put a mark on the seat belt that shows Alex that he has extended the belt far enough and where he should put his hand. Ms. Clifton wants to reward Alex’s completion of his step by playing his favorite CD on the car radio.

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Teaching Skills 1 Treatment Fidelity Checklist Checklist 9.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​A

2

Review Behavior Support Plan

0  1  2  N/​A

3

Introduce importance of explicitly teaching adaptive skills

0  1  2  N/​A

4

Discuss how to choose which skills to teach

0  1  2  N/​A

5

Teach task analysis and practice with brushing teeth example

0  1  2  N/​A

6

Introduce parents to chaining as a teaching technique

0  1  2  N/​A

7

Review video vignette of chaining

0  1  2  N/​A

8

Provide homework assignment

0  1  2  N/​A

9

Update Behavior Support Plan

0  1  2  N/​A Total _​_​_​_​_​_​_​_​_​/​ 18

Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s)

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1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session Parent Objectives

Rating

1

Parent came up with a list of new skills she or he would like to teach the child

0  1  2  N/​A

2

Parent task analyzed the example of brushing teeth

0  1  2  N/​A

3

Parent picked a behavior to teach for homework and completed a task analysis on that behavior

0  1  2  N/​A

4

Parent assisted in creating the homework assignment

0  1  2  N/​A Total _​_​_​_​_​_​_​_​_​_​_​/​8

FIDELITY NOTES:

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SESSION 10

Teaching Skills 2

Session Ten Overview This session continues with teaching skills by reviewing a variety of prompts that can be used to enhance a child’s skill acquisition.

Goals 1. Review homework assignment from prior session. 2. Review Behavior Support Plan. 3. Introduce parents to modeling as a teaching procedure. 4. Introduce verbal, visual, and physical prompting as teaching procedures. 5. Discuss how to use prompts. 6. Review video vignette using a variety of prompts. 7. Discuss use of stimulus prompts, stimulus fading, and time delay prompting. 8. Review tips that will increase success in teaching skills. 9. Choose skill(s) with the parents to teach at home and discuss methods to teach the skill. 10. Update Behavior Support Plan.

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Parent Objectives 1. Parent will describe how she or he has used a variety of prompts in the past to teach the child new skills. 2. Parent will identify prompts being used in the video vignette. 3. Parent will generate how she or he might teach the child a new skill using a variety of teaching methods.

Materials 1. Clinician Script 2. Video 10.1 3. Session 10 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Last session, we talked about how to decide what to teach your child and how to break complex skills down into simple, smaller steps. We also discussed using chaining in teaching new skills. Let’s look at the data you kept on using chaining as an approach for teaching your child [specific skill]. How did that go? [Review with the parent the data form from the previous session.]

Goal 2: Review Behavior Support Plan Now let’s go through the Behavior Support Plan and see how things are going with your use of other strategies we have implemented so far. Are there strategies that you have difficulty using consistently? What strategies seem to be effective in addressing the target behaviors? Are you ready to start using any additional strategies listed on the Behavior Support Plan? [Review specific strategies on the Behavior Support Plan that have not yet been put into action.]

Goal 3: Introduce Parents to Modeling as a Teaching Procedure Today we will cover additional strategies that can be used to teach your child new skills. When teaching a new skill, there are many ways we give children help. When help is given to your child at the same time you are giving him a direction, we refer to this as prompting. You probably already use prompts every day with your child. Helping your child guide his arm through a long-​sleeve shirt to help him put it on is a kind of prompt. Giving your child a hint like “Pick up the big block . . . it’s red” is another type of prompt. Giving your child prompts helps him to learn a new skill without giving up or being upset and frustrated. It will also prevent your child from learning the wrong way to do a skill or task.

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There are several types of prompts you can use to teach your child a new skill. This first type of prompt is called modeling, which means that you show your child what you want him to do. The idea is that he will learn the skill by observing and then imitating you. Many skills can be taught to children by modeling the skill and having them watch. Children often learn to wave “bye bye,” jump on one foot, or use sign language by watching someone else. Children also often learn a great deal by watching other children model how to do something. Can you think of ways that you have taught your child through modeling? [Encourage parents to give a couple of examples when they might have used modeling.] While most children learn a variety of skills by observing a model and then imitating him or her, this can actually be quite difficult for a child with autism spectrum disorder (ASD). This can cause problems for the child because it means that she is not taking advantage of many naturally occurring opportunities to observe and imitate others in order to learn new skills. Part of the difficulty may be that the child is not inclined to observe what the model is doing. Additionally, even if she sees what a parent, teacher, or another child is doing, she may not connect that she should be doing the same thing, and instead she may continue with her own activity. For example, a teacher may show a child how to stack blocks. The child may see what the teacher is doing but then insist on arranging the blocks in the pattern that she wants to create. Because of these difficulties, some children might need to be explicitly taught how to imitate what is modeled for them. Have you noticed your child having any difficulties with imitation? Can you give me some examples of your child imitating something you have modeled? [If the child does not imitate, you should incorporate Supplemental Session 3: Imitation Skills (available at www.oup.com/us/ttw) into the program.]

Goal 4: Introduce Verbal, Visual, and Physical Prompting as Teaching Procedures There are many other types of prompts for children that will give them the added help they need when learning a new skill. The best way to remember the types of prompts is that they are things that you SAY, 140

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SEE, and DO, that will help your child to learn a new skill. Let’s look at definitions of the kind of prompts we often use. One type of prompt you might use to teach your child a new skill is a verbal prompt. This is anything that you SAY that tells your child what you want him to do. One kind of verbal prompt is a hint that may give your child help with the new skill. For example, in teaching the name of animals, you might point to a stuffed cow and say, “What animal is this? It says moo.” Another example of a verbal prompt is when you stress a particular word of an instruction, such as “touch NOSE.” You can also give your child the answer as part of the question. For example, “This is a blue cup. What color is this?” Another example would be to say, “If I were thirsty, I would ask for a drink of water,” to prompt a child to make a request. Can you think of ways you have used verbal prompts to teach your child a skill? [Discuss examples.] Another type of prompt is a visual prompt. This is anything that your child can SEE that shows him what you want him to do. We follow visual prompts every time we follow traffic signs (e.g., stop at a red light.) Children follow visual prompts in the classroom when they are quiet when the teacher turns off the lights. Gestures are the most common kind of visual prompt we use. When an adult walks into a house talking loudly when there is a sleeping baby, a gesture which is a visual prompt would be putting your finger to your lips to say “shush.” You might point to the trash can and say “throw away.” Types of visual prompts that we have already reviewed include visual schedules or any other type of pictorial prompt as well as timers, which provide a visual prompt for when an activity may end or a transition needs to occur. Sometimes teachers use pictures to teach children the different areas of the classroom. Can you think of examples of how you have used a visual prompt such as gestures or pictures to teach your child a new skill? [Discuss examples.] Finally, another type of prompting is a physical prompt, which refers to providing some physical guidance to help your child DO a task. We already talked about physical guidance during our Compliance Training session, so we will just review some key points about its use. You can vary the level of physical guidance depending on how much assistance is needed. A full physical prompt is used when your child is not familiar with doing the skill you are teaching and needs help practicing the movement required to do a skill. An example would 141

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be using hand-​over-​hand guidance to help your child draw shapes or learn a new sign. A partial physical prompt is used when your child has some familiarity with the skill. Can you think of ways you have used a full or partial physical prompts to help your child learn a new skill and how you may have reduced your use of prompting? [Discuss examples.]

Goal 5: Discuss How to Use Prompts Deciding on which prompts to use will be based on what you are teaching, how much of the skill your child can already do, and what type of prompting you and your child are comfortable using. Here are a few guidelines to remember: 1. Use only the prompting that is needed. It should be enough for your child to be successful, but not so much that your child is not learning. 2. Use several different prompts to teach a skill. For example, to show your child how to write a letter A, provide him with a visual prompt of the letter and provide hand-​over-​hand physical guidance to ensure that he is holding the pencil correctly as he attempts this skill. 3. Add prompts as needed. You may have to use more prompting if your child initially does not respond to you or attempts the skill but is unable to do so correctly. 4. Lessen your prompts over time as your child masters a new skill. This is done gradually to ensure your child continues to do the skill correctly, and it encourages independence. For example, when teaching your child to brush his teeth, you might first provide physical assistance for all teeth but then gradually only a partial prompt for “harder to reach” places in the mouth. 5. Prompting can be used for each step of your task analysis or for just the first step. For example, when teaching your child to put her clothes away, you might model putting one item away while saying “Put your clothes in your drawer.” Then, you may be able to just give the verbal direction or the visual prompt of pointing to the stack of clothing items.

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Goal 6: Review Video Vignette Using a Variety of Prompts Here is a video clip of a parent using a variety of prompts when having her child hang up his coat. See if you can identify the prompts being used. (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Using a Variety of Prompts Parent demonstrates modeling (unzipping her coat, taking her coat off, putting it on the couch), verbal prompts (e.g., commands “Hat off ”; “Unzip your coat”; “Scarf off ”), visual prompts (hat off and scarf off gestures; patting/pointing to the couch to show where clothes should go), and physical prompts (hand-over-hand guidance to help the child with unzipping his coat).

Goal 7: Discuss Use of Stimulus Prompts, Stimulus Fading, and Time Delay Prompting The prompts we have reviewed so far are called response prompts because the prompt is provided by another person (e.g., a physical prompt from the parent) in order to get a certain response from the child. Sometimes we might also wish to use stimulus prompts, in which the material or object provides the cue as to how the child should respond. Stimulus prompts can be very helpful when teaching certain skills, such as academic skills like sorting, matching, or learning to write. For example, when a child is learning to write letters of the alphabet, he first may trace over the letters A, B, C. Those letter patterns serve to prompt the child to complete the task of writing his letters. Once the child is able to do this consistently, the teacher may then have the child trace over the letters very faintly drawn or in dotted lines. Eventually, the teacher will require the child to write the letters without any prompts. We refer to this process as stimulus fading, as the guidance provided by the stimuli (in this case letter forms) is slowly reduced over time. In this example, the stimuli are faded out because their guidance is reduced over time.

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Stimulus prompts can also be faded in. For example, a student may learn to sort colors by first having just red and green blocks. After those two colors have been mastered, a teacher may then add a yellow block to be sorted. The teacher could then gradually add more yellow blocks (and eventually even more colors) as the child continues to be successful. So the teaching stimuli (colored blocks) are gradually increased, or faded in. The goal is to use stimulus fading (in or out) so gradually that you increase the likelihood of success on the child’s part. While these strategies are most often used with academic skills, they can also be used when teaching daily living skills, such as sorting laundry (e.g., varying the colors that need to be sorted), cleaning up toys (e.g., gradually increasing the number and type of toys the child needs to clean up), or setting the table (e.g., increasing the number and types of tableware that are placed on the table). In thinking about what you wish to teach your child, can you think about how these strategies might be used? [Discuss examples.] A final prompting technique that may be helpful is a time delay. In this approach, the prompt is presented to the child only after a certain amount of time has passed and the child has not given the correct response. Parents sometimes use this approach when teaching skills like labeling items (e.g., body parts, colors). For example, the parent might say, “Touch your nose” and then wait. If the child does not respond after a few seconds, she might say, “Touch your nose” again and then put her child’s finger on his nose. In another example, a teacher might ask a child, “What color is this?” while holding up a red card. At first, the teacher might very quickly answer “Red” for the child or prompt the child to say “Red.” The teacher then might gradually wait longer and longer before she gives the child the answer so that the child has the opportunity to answer spontaneously. Can you think of times you have used this approach with your child? [Discuss examples.]

Goal 8: Review Tips That Will Increase Success in Teaching Skills Over the last two sessions, we have reviewed several tools for teaching new skills to your child. Here are some tips on how to ensure that you and your child will be successful with whatever tools you use.

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1. Start simple when you start teaching a new skill. It is easier for a child to be successful “finding the circle” when there are only two shapes on a table versus a pile of shapes. A child is much more likely to continue with the learning process if the initial learning tasks aren’t overly demanding and if he has been able to complete them successfully. 2. Teach in a distraction-​free zone. Sometimes it is necessary to teach a child a new skill in a more structured situation where there are no distractions. 3. Be mindful of when you are teaching your child. It is best to teach your child new skills when it is natural for them to happen. However, sometimes this is not possible. For example, teaching a child to put his coat on when the bus is waiting is not the best idea. You also don’t want to teach when you or your child are tired. 4. Use reinforcers to promote learning. Make sure you are using your child’s preferred materials or activities. For example, in teaching a child to dress independently, you may wish to use clothes with your child’s favorite characters on them. Use of reinforcers for each step of a difficult skill is often necessary.

Goal 9: Choose Skill(s) With the Parents to Teach at Home and Discuss Methods to Teach the Skill Let’s come up with a plan for you to teach your child a new skill this week. When thinking of what you will teach and how you will teach your child that skill, we can pull from all of the teaching strategies we have discussed over the past two sessions, including performing a task analysis, chaining, and using stimulus or response prompts and time delay procedures. What skill would you like to teach this week? [Depending on what skill the parent is interested in teaching the child, choose the appropriate Activity Sheets located in Session 10 of the Parent Workbook and walk through the sheets in order to design the homework. If the parent wants to teach a new skill using response prompts, review Activity Sheets #1a and #1b. If the parent wants to use a stimulus prompt approach, review Activity Sheets #2a, #2b, and #2c. If the parent wants to use a time delay approach, review Activity Sheets #3a, #3b, and #3c.] This week, practice teaching this skill to your child.

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Use your data collection sheet to track your practices. Let us know what problems arise by noting this on the bottom of the form. Goal 10: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under consideration, not just those targeted for homework. Then turn to the Session Ten Review and ask the parent to read over this material during the week. Close by scheduling the next session.] For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

Homework Case Examples Mr. Nazari wants to target zipping up his son Aaron’s coat with Aaron. Mr. Nazari breaks the task into four discrete steps: (1) hold each side of the bottom of the coat next to the zipper; (2) put the zipper in the fastener; (3) pull the zipper up from the fastener; (4) pull the zipper the rest of the way up the coat. Aaron currently doesn’t complete any of the steps independently. Mr. Nazari decides to use backward chaining by focusing first on having Aaron pull the zipper up once it has been fastened. The father decides to use a verbal prompt of “Pull up” to help Aaron with this step. Once the child has mastered this step, Mr. Nazari wants to use physical prompting to help Aaron with the more challenging second and third steps of fastening the zipper and pulling the zipper up from the fastener. Finally, Mr. Nazari will use modeling to demonstrate where Aaron should hold the coat. He plans to reward Aaron with verbal praise for each step that he is teaching. Ms. Miller wants to teach Wyatt how to write his telephone number. Using stimulus prompts, she starts by drawing the numbers herself and has Wyatt trace them. She then uses stimulus fading and makes a dotted outline of the numbers. Once Wyatt is able to do this step, his mother verbally prompts him to write the numbers in the correct order. With practice, Wyatt is able to write his telephone number in response to the question “What is your telephone number?” 146

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Teaching Skills 2 Treatment Fidelity Checklist Checklist 10.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​A

2

Review Behavior Support Plan

0  1  2  N/​A

3

Introduce parents to modeling as a teaching procedure

0  1  2  N/​A

4

Introduce verbal, visual, and physical prompting as teaching procedures

0  1  2  N/​A

5

Discuss how to use prompts

0  1  2  N/​A

6

Review video vignette using a variety of prompts

0  1  2  N/​A

7

Discuss use of stimulus prompts, stimulus fading, and time delay prompting

0  1  2  N/​A

8

Review tips that will increase success in teaching skills

0  1  2  N/​A

9

Choose skill(s) with the parents to teach at home and discuss methods to teach the skill

0  1  2  N/​A

Update Behavior Support Plan

0  1  2   N/​A

10

Total _​_​__​_​_​_​_​_​/​ 20

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Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session Parent Objectives

Rating

1

Parent described how she or he has used a variety of prompts 0  1  2  N/​A in the past to teach the child new skills

2

Parent identified prompts being used in the video vignette

0  1  2  N/​A

3

Parent generated how she or he might teach the child a new skill using a variety of teaching methods

0  1  2  N/​A

Total _​_​_​_​_​_​_​_​_​/​ 6

FIDELITY NOTES:

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SESSION 11

Generalization and Maintenance

Session Eleven Overview This session reviews the concepts of generalization and maintenance. These strategies promote continuation of behavioral changes and the extension of learned behaviors from one context to another.

Goals 1. Review homework assignment from prior session. 2. Review Behavior Support Plan. 3. Review the child’s positive behavior changes and new skills learned. 4. Introduce the concept of maintenance. 5. Introduce the concept of generalization. 6. Discuss strategies to promote maintenance of behavior change and new skills. 7. Discuss strategies to promote generalization of behavior change and new skills. 8. Watch video vignettes and have parents generate ideas about promoting generalization and maintenance. 9. Review written vignettes and have parents generate ideas about promoting generalization and maintenance. 10. Develop a plan to generalize or maintain changes in a target behavior. 11. Update Behavior Support Plan.

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Parent Objectives 1. Parent will describe improvements in the child’s disruptive behavior and/​or adaptive skills. 2. Parent will generate ideas about promoting generalization and maintenance from the video vignettes. 3. Parent will generate ideas about promoting generalization and maintenance from the written vignettes. 4. Parent will develop a specific plan to maintain positive changes in behavior and promote positive behavior in new settings.

Materials 1. Clinician Script 2. Videos 11.1 and 11.2 3. Session 10 Workbook Materials 4. Treatment Fidelity Checklist 5. Behavior Support Plan

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Clinician Tip Sheet This session should be administered after the parent reports positive changes in the child’s behavior. Changes could include reductions in challenging behaviors such as noncompliance and aggression, or improvements in daily living skills such as toileting or dressing independently. Some children may have made progress, but not to the point where you can actively plan for maintenance and generalization of skills. For these cases, you can deliver this session with a focus on helping parents think about when and how generalization and maintenance strategies should be implemented in the future.

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Clinician Script Goal 1: Review Homework Assignment From Prior Session Let’s start by reviewing the homework from the previous session. [Summarize the new skill that was targeted in the previous session and the teaching strategies that were outlined for the homework assignment.] So how did it go with teaching this new skill? What did you find effective? What changes in the strategies would make teaching this new skill more successful? [Review the data form on teaching skills from the last session. Suggest modifications such as breaking the skill into different components, increasing practice opportunities, practicing the skill in a different situation, using a different reinforcer, or using a different combination of prompts.]

Goal 2: Review Behavior Support Plan Now let’s go through the Behavior Support Plan and see how things are going with your use of other strategies we have implemented so far. Are there strategies that you have difficulty using consistently? What strategies seem to be effective in addressing the target behaviors? Are you ready to start using any additional strategies listed on the Behavior Support Plan? [Review specific strategies on the Behavior Support Plan that have not yet been put into action.]

Goal 3: Review the Child’s Positive Behavior Changes and New Skills Learned Over the last several weeks, we have covered many strategies designed to increase your child’s cooperation with daily routines. More recently, we discussed strategies that are designed to promote more functional communication and teach adaptive skills. These strategies were meant to help you manage challenging behaviors when they occur and improve your child’s positive behavior. Today we will discuss how to promote continuation of these positive behaviors and new skills over

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time and in different situations. Let’s start by reviewing the specific improvements that you have seen in your child. [Complete the first three items on the Progress Review on Activity Sheet # 1, located in Session 11 of the Parent Workbook.]

Goal 4: Introduce the Concept of Maintenance It is really exciting to hear about these positive changes in your child’s behavior. As these new positive behaviors begin to take root, we need to think about how to hold on to these improvements even after our work together ends. We call this maintenance. Before developing strategies to promote maintenance of improved behavior and new skills, we have to decide whether these improvements are good enough. For example, a child who complies with simple requests 85% of the time may have achieved an acceptable level of compliance. However, with physical aggression or dangerous behaviors, we might be looking for zero occurrence of the behavior. Other behaviors such as tantrums might be acceptable if they occur two or three times a week but only last 2 minutes. Let’s talk about the positive behaviors that you hope will continue even after the program ends. Are these behaviors acceptable, or do we need to push for greater improvement before talking about maintenance? [Complete the Time for Maintenance? section on Activity Sheet #1. Discuss acceptable levels of behavior for the child based on the parent’s expectations and your input on developmentally appropriate levels of the behavior.]

Goal 5: Introduce the Concept of Generalization We also want to increase the likelihood that positive behaviors happen in different settings and when conditions vary, such as with different types of materials and with a variety of people. For example, we want to see compliant behavior at home, but also while out shopping, at school, and at family events. This is called generalization, which is the transfer of behavior to situations other than the ones we used in this program to train the child. The truth is, we can’t really expect generalization

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to occur automatically. But we can put into place specific strategies to promote it. There are different kinds of generalization. One kind involves the child’s ability to perform a skill in different settings. For example, the child is able to brush his teeth in any setting that has a toothbrush and toothpaste (e.g., home, hotel room, grandparent’s house). Another example would be a child who can use the toilet at home and at school. Another kind of generalization involves the child’s readiness to perform a specific skill even when conditions vary, at least to a certain degree. For example, a child is capable of operating various pop-​up toys after having been taught to use just one. A  child who has been taught to pull a tee shirt over her head can also put on a turtleneck or sweater. Another example is a child who has learned to ask his mother for help and then extends this skill to other family members as well. Let’s think about your child’s new skills and see which of these your child has generalized so far. [Complete the What to Generalize section on Activity Sheet #1. Discuss the settings and conditions where the child has made progress and think about how to extend these gains across settings and conditions. For example, if a child shows decreased aggression at home, can it be extended to school? If a child has learned to take off his coat and hang it up at school, can it be extended to home? ] For many children, when a new behavior is learned and reinforced in one situation, it often naturally starts to be performed in other similar situations. For children with autism spectrum disorder (ASD), however, this effortless generalization of behavioral improvements or new skills from one setting to another may not occur. Instead, the child may need a specific plan to promote generalization. For example, a child who learned to wash his hands with bar soap at home may need to walk through the procedures and be rewarded for washing his hands at school with liquid soap from a dispenser. Can you think about behavioral improvements or new skills that are evident in specific settings, situations, or with certain types of materials that may be ready for generalization? [Review other examples as needed to get the parent to think about child-​specific examples.]

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Goal 6: Discuss Strategies to Promote Maintenance of Behavior Change and New Skills Today, we will develop a plan to maintain the gains in your child’s behav­ ior and to generalize new skills across settings and when conditions vary. Before we do that, let’s discuss some tips to keep in mind when you are trying to promote maintenance and generalization of a new behavior. Let’s start by reviewing some tips for promoting skill maintenance. [Review the Maintenance Tips on Activity Sheet #2.] 1. Continued reinforcement is important in maintaining a behav­ ior. Often times when a parent sees significant positive changes in a child’s behavior, the parent may think it is OK to back off using the skills that promoted the improvement in the first place. This often includes backing off the use of reinforcers. For some behaviors (e.g., toileting) this backing off works. There are many behaviors, however, that aren’t naturally maintained when they are no longer reinforced. For example, a child may have learned to stay at the dinner table because the parent provided a lot of social reinforcement to remain seated. The parent may even have offered a tangible reinforcer (e.g., stickers, a small treat) for that behavior. If the parent backs off on the use of reinforcers, it is possible that the child may start wandering from the dinner table again. To maintain the behavior, you need to continue to reinforce it, though perhaps not as often as in the initial effort to promote the behavior. 2. Fade reinforcement of the new skill to a more realistic reinforcement schedule. Maintaining the use of reinforcers may sound like an exhausting job. Luckily, there are ways to provide reinforcement in ways that are reasonable. One way is to move from reinforcing a behav­ior every time it occurs to reinforcing it every third or fifth time. We call this intermittent reinforcement. Even with intermittent reinforcement, we reduce the frequency slowly. If you go from rewarding a child every time he puts his shirt on to rewarding at the end of the week, the behav­ior of putting on his shirt is not likely to maintain. Once the behavior is firmly in place, you could reinforce the behavior every other morning, then move toward every third morning, and so on. Another approach is delayed reinforcement. With delayed reinforcement, you move from immediate reinforcement of a behavior to reinforcement after a certain period of time. The amount of time the 155

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reinforcement is delayed can vary widely from a few seconds to several weeks depending on the child’s developmental level. Delayed reinforcement occurs naturally for all of us. For example, we may get a paycheck on Friday for the work done in the prior week.

Goal 7: Discuss Strategies to Promote Generalization of Behavior Change and New Skills Now, let’s review some tips for promoting generalization. [Review the Generalization Tips on Activity Sheet #2.] 1. New skills are more likely to be generalized if they are reinforced across different settings. For example, a child who has learned to ask his mom for help with zipping up his coat is more likely to ask for help in school if the teacher tunes into the request and reinforces the request. A child is more likely to clean up her toys in various places if the behavior is reinforced at home, at school, and at her cousin’s house. Generalization of the positive behavior change is less likely if reinforcement of the behavior is not provided in various settings. Can you think of other adults working with your child (e.g., teacher, babysitter, grandparent) who should tune into target behaviors and effective reinforcers to promote generalization? 2. It is helpful to use reinforcers that naturally occur in different settings. It can get complicated to use the same reinforcer across different settings. So we try to think about naturally occurring reinforcers in the environments being used to promote generalization. This will make it much easier to provide equivalent reinforcement immediately as you try to extend the behavior in a new setting. Thus, a child might receive one reinforcer at school, another at child care, and yet another at home for the behavior that we want to promote in all these settings. For example, a child may receive iPad time every time he successfully uses the potty at home and may receive a sticker when he uses the potty at school. 3. If a situation is dramatically different from the setting where the skill is learned, sometimes the new skill will not generalize to the new situation. For example, if a child has learned to sign “more” for additional food instead of screaming and slapping himself, but this has only been practiced at his kitchen table with his mother, 156

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he might not use the sign for “more” in a noisy fast food place with his uncle. Recalling our past discussion on setting events, we can say that the setting events are so different that we should not expect to see the new behavior without additional effort. In contrast, after the child has learned to sign “more” at his kitchen table with his mother, the next step would be to extend the sequence in the same setting with other family members. To manage a change in setting event, going to a calmer restaurant first with his mother, and then other family members, is more likely to “generalize” this skill. 4. Make sure that behavior problems are not being reinforced in situations outside of the home. It can be especially frustrating if your efforts to change a behavior are undermined by being inappropriately reinforced in another setting. For example, teaching a child to stay at the table for 15 minutes during mealtimes may not work if the child is allowed to wander during meals every time he goes to his grandmother’s house. Once you start a behavioral plan, make sure that adults regularly involved in the child’s care are on board. Otherwise, even a good plan may not work.

Goal 8: Watch Video Vignettes and Have Parents Generate Ideas About Promoting Generalization and Maintenance To practice your understanding of generalization and maintenance, let’s watch a couple of video vignettes from earlier sessions and discuss what might be done to help the behavior generalize and maintain. [Use Activity Sheet #3a. Ask parents to generate suggestions to improve the chances of generalization and maintenance of behaviors in video vignettes.] (The videos accompanying this PT are available online at www.oup. com/RUBI) Video #1: Sorting Legos MAINTENANCE: Ask parents how the immediate reinforcement used in the vignette might be faded:  (1) intermittent reinforcement with the primary reinforcer (goldfish) might be provided; (2) delay 157

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reinforcement until after the child is done sorting the Legos; (3)  use something other than a primary reinforcer (e.g., star/​ token) to be cashed in for a primary reinforcer later on. GENERALIZATION: Ask parents how the sorting task could be generalized: (1) complete sorting task with different Lego sizes/​colors; (2) have another adult run through the sorting task; (3) use different items (e.g., sorting different color clothes). Video #2: Help Card MAINTENANCE: Ask parents how this skill of asking for help might be maintained over time: intermittent social reinforcement (praise) might be provided. GENERALIZATION: Ask parents how this skill of asking for help might be generalized over time: (1) another adult might respond to the child; (2) asking for help can be used for other behaviors besides opening a jar; (3) practice asking for help in other locations. Goal 9: Review Written Vignettes and Have Parents Generate Ideas About Promoting Generalization and Maintenance See if you can think of strategies in these written vignettes that would help promote skill maintenance and generalization. [Review Activity Sheet #3b. Provide suggestions and feedback on parent ideas, as needed.] 1. Vignette #1: Timothy is consistently using the toilet at home for which he is reinforced by being allowed to watch a few minutes of his favorite video. What steps might we take next to be sure he maintains this behavior and also uses the toilet in other places? [Maintenance suggestions might include delaying or intermittently rewarding him at home. Generalization suggestions include varying the reinforcement used at home to something that

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can more easily be used in the community, identifying equivalent reinforcers in other settings, practicing using the toilet in other settings, such as at school or grandma’s house.] 2. Vignette #2: Toby’s aggression toward adults has decreased from 15 times a day to several days with no aggression. Toby is rewarded with M&Ms every 5 minutes for “keeping his hands to himself.” He has also been taught to ask for help when he is frustrated by a task. What steps would you take to make sure his aggression remains minimal and he uses his verbal skills to request help across settings? [Maintenance suggestions include slowly increasing the time interval he is reinforced. Generalization suggestions include varying the reinforcers and ensuring all adults are reinforcing his requests for help.]

Goal 10: Develop a Plan to Generalize or Maintain Changes in a Target Behavior Today we have discussed how to maintain behavior changes over time and to generalize the behavior to new settings and when conditions vary. Let’s focus on 1–​2 behaviors or skills that your child has learned (or started to learn) in the course of this program and apply these concepts. We’ll use the homework sheet to help you plan this. [Review Activity Sheet #4 and develop a plan for the parent to practice skill maintenance and generalization. Use Activity Sheet #1 to help inform development of the plan.]

Goal 11: Update Behavior Support Plan [With the parent, update the Behavioral Support Plan based on discussion during this session. Be sure to include all strategies under consideration, not just those targeted for homework. Then turn to the Session Eleven Review and ask the parent to read over this material during the week. Close by scheduling the first Telephone Booster session to occur in about 2 weeks from this session. Explain to the parent that you will mail her or him a copy of the completed Behavior

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Support Plan between this appointment and the first Telephone Booster. Clarify that the first Telephone Booster will review and finalize the Behavior Support Plan.]

For additional sessions that build upon these core topics and provide different intervention approaches, go to www.oup.com/us/ttw.

Homework Case Examples Using compliance training, Jack has been cleaning up the toys in his bedroom consistently for the past 3 weeks. His mother would like this behavior to continue. As a reward, Mrs. Moody currently lets Jack watch a 30-​m inute cartoon after he finishes picking up his toys. We discussed the possibility of providing a smaller reinforcer  for Jack so that his mother does not have to wait 30 minutes before they can move on to the next daily activity. Mrs. Moody stated Jack loves watching Disney movie trailers on her iPhone. We created a plan to change the reinforcer to the shorter video snippets when Jack completes picking up the toys in his room. Nathan has been following the bedtime routine at his house for the past month. Mr. Jenkins has been using a visual schedule to aid transitions through the nighttime routine, and he reads Nathan two books of his choosing right before lights out. Nathan’s grandmother would like to have him over for a sleepover. Mr. Jenkins is concerned that this will be challenging as Nathan’s grandmother tends to be more relaxed about rules when he is visiting. We discussed how, prior to Nathan’s visit, Mr. Jenkins should talk with the grandmother about the importance of a predictable routine for Nathan and also spend some time reviewing with her the bedtime routine that is currently in place. When it is time for Nathan to visit his grandma, the plan should be for her to keep the same bedtime routine at her house. She should use Nathan’s visual schedule to help him with the bedtime routine transitions. Finally, Mr. Jenkins has Nathan pick out two books to bring to grandma’s house for her to read before he goes to sleep.

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Generalization and Maintenance Treatment Fidelity Checklist Checklist 11.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session

0  1  2  N/​A

2

Review Behavior Support Plan

0  1  2  N/​A

3

Review the child’s positive behavior changes and new skills learned

0  1  2  N/​A

4

Introduce the concept of maintenance

0  1  2  N/​A

5

Introduce the concept of generalization

0  1  2  N/​A

6

Discuss strategies to promote maintenance of behavior change and new skills

0  1  2  N/​A

7

Discuss strategies to promote generalization of behavior change and new skills

0  1  2  N/​A

8

Watch video vignettes and have parents generate ideas about promoting generalization and maintenance

0  1  2  N/​A

9

Read written vignettes and have parents generate ideas about promoting generalization and maintenance

0  1  2  N/​A

10

Develop a plan to generalize or maintain changes in a target behavior

0  1  2  N/​A

11

Update Behavior Support Plan

0  1  2  N/​A Total _​__​_​_​_​_​_​_​/​ 22

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Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session Parent Objectives

Rating

1

Parent described improvements in the child’s disruptive behavior and/​or adaptive skills

0  1  2  N/​A

2

Parent generated ideas about promoting generalization and maintenance from the video vignettes

0  1  2  N/​A

3

Parents generated ideas about promoting generalization and maintenance from the written vignettes

0  1  2  N/​A

4

Parent developed a specific plan to maintain positive changes in behavior and promote positive behavior in new settings

0  1  2  N/​A

Total _​__​_​_​_​_​_​_​_​/​ 8

FIDELITY NOTES:

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Appendix A Telephone Booster

Telephone Booster Overview The telephone booster session provides an opportunity to review progress with generalizing and maintaining the child’s behavioral gains, to review the Behavioral Support Plan, and to refine the treatment strategies. The call should also be used to problem-​solve any new or continuing behavioral concerns.

Goals 1. Review homework assignment from prior session (if applicable). 2. Review Behavior Support Plan. 3. Summarize changes made to the Behavior Support Plan. 4. Discuss current behavior concerns. 5. Problem-​solve intervention approaches that might be implemented to address behavioral issues or newly targeted skills. 6. Provide homework assignment (if applicable).

Parent Objectives 1. Parent will assist in finalizing the Behavior Support Plan. 2. Parent will describe child’s progress since last meeting and report current behavioral concerns.

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3. Parent will be able to problem-​solve the application of strategies to any behavioral issues or new skills.

Materials 1. Clinician Script 2. Behavior Support Plan 3. Activity Sheet (located in this session of the Clinician Manual) 4. Treatment Fidelity Checklist

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Clinician Script Goal 1: Review Homework Assignment From Previous Session (If Applicable) Today we will be reviewing the Behavior Support Plan that we created for your child over the course of the program. Before we do that, though, let’s review the homework you were assigned at our last session. [Ask parent for examples of how the homework was implemented. Make any revisions required.]

Goal 2: Review Behavior Support Plan Now let’s turn our attention to your child’s Behavior Support Plan. [Make sure the parents have the Behavior Support Plan in front of them to follow along.] Let’s go page by page and review where we started in terms of the behaviors we were hoping to target through this program. Then we can discuss all of the strategies we came up with to address these and other behaviors and skills. You may still be using some of these strategies, while others may no longer be in use (either because they are no longer needed—​because the behavior improved—​or because a particular strategy may not have worked or there were too many challenges in implementing it). Let’s review all of our strategies, and along the way, we can think of whether there are any additions or changes we should make to the Behavior Support Plan. [Review the Behavior Support Plan with the parents and make adaptations in the document as appropriate. Keep an eye out for strategies the parents say they no longer use. If this is because the strategy was too difficult, or the parents gave up, see if there is a way to problem-​solve the use of that strategy so that it can be implemented more effectively. Do not remove any strategies the parents report they are no longer using.]

Goal 3: Summarize Changes Made to the Behavior Support Plan So today we have discussed making the following changes to your child’s behavior support plan. [Summarize modifications.] 165

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Goal 4: Discuss Current Behavior Concerns [Complete Activity Sheet #1, located later in this session, while speaking with the parent. This sheet will document any current behavioral concerns or new skills the parents plan to target.] Now we can focus our attention on what has been happening since our last appointment. It has been a few weeks since we last met. How have things been going? [Allow parents to give an account of what has occurred since the last appointment. Document their comments on Activity Sheet #1.] Are there any new behavioral problems you are having your child? Are there any potential problems that you are worried may develop? Or are there any old behavior problems that have returned or you are worried may return? Are there any new skills you would be interested in teaching your child? [Encourage the parents to respond. Document comments on Activity Sheet #1.]

Goal 5: Problem-​Solve Intervention Approaches That Might Be Implemented to Address Behavioral Issues or Newly Targeted Skills You are reporting that you would like to work on [behavior/​skill.] Let’s now think about how we can address this [behavior/​new skill]. [For any behavior problems identified or new skills the parents endorse an interest in teaching, problem-​solve with the parents how this can be accomplished. Encourage parents to be the ones to come up with the strategies. Apply the full range of strategies covered in the program to address the behavior/​skill. Have the parents reference their Behavior Support Plan when planning an intervention approach. Document the new behavior/​skill to be targeted and its planned intervention strategy on Activity Sheet #1 and on the Behavior Support Plan.]

Goal 6: Provide Homework Assignment (If Applicable) [If appropriate, provide a homework assignment and document it on Activity Sheet #1.]

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If the family requires additional support and follow-​up: Schedule a follow-​up appointment with the parents, approximately 2–​4 weeks later. Finalize any changes made to the Behavior Support Plan and mail an updated version to the family prior to the next Telephone Booster Call. ■ If the family has successfully completed the program and does not require additional follow-​up:  Congratulate the parents on all of the progress made during the program and encourage continued use of the strategies documented in the Behavior Support Plan. Finalize any changes made to the Behavior Support Plan and mail an updated and final version to the family. ■

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Telephone Booster Activity Sheet 1 Parent report of child’s current behavior/​progress:  _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ New behavior problem(s): _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ Behavior problem(s) parent is worried may develop: _​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_

Old behavior problem(s) that have returned or parent is worried may return: _​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ New skill(s) parent would be interested in teaching child: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_

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Additional notes/​comments on child’s behavior: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ Intervention plan (target behavior; strategies to be implemented; homework assignment): _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ Note: We recommend that you make a copy of the Telephone Booster Activity Sheet to use with each family as needed.

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Telephone Booster Treatment Fidelity Checklist Checklist A.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Review homework assignment from prior session (if applicable)

0  1  2  N/​A

2

Review Behavior Support Plan

0  1  2  N/​A

3

Summarize changes made to the Behavior Support Plan

0  1  2  N/​A

4

Discuss current behavior concerns

0  1  2  N/​A

5

Problem-​solve intervention approaches that might be implemented to address behavioral issues or newly targeted skills

0  1  2  N/​A

6

Provide homework assignment (if applicable)

0  1  2  N/​A Total _​_​_​__​_ ​/​ _​_​_​_​_​

Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session

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Parent Objectives

Rating

1

Parent assisted in finalizing the Behavior Support Plan

0  1  2  N/​A

2

Parent described child’s progress since last meeting and reported current behavioral concerns

0  1  2  N/​A

3

Parent problem-​solved the application of strategies to any behavioral issues or new skills

0  1  2  N/​A

Total _​_​_​_​_​_​_​_​_​/​ 6

FIDELITY NOTES:

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Appendix B Home Visit

Home Visit Overview The home visit is designed to allow you an opportunity to become familiar with the child’s environment and conduct a naturalistic observation of the child with his family. You should plan 60–​90 minutes for the visit. Note: The home visit should be scheduled during a time when the child is home and ideally during a problematic time of the day (e.g., meal time, challenging transition).

Goals 1. Establish rapport with the family. 2. Observe where the child spends his time via a tour of the home and assess the child’s environment for safety, organization, and presence of developmentally appropriate materials. 3. Conduct a naturalistic observation of the child’s behavior in the home setting and the parent’s use of specific skills and behavioral strategies. 4. Record observations of the home environment that can be used in future parent training sessions.

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Parent Objectives 1. The parent will show and describe for the clinician where daily events occur in the home. 2. The parent will interact with the child and intervene as is typical for the time of day.

Materials 1. Clinician Script 2. Home Visit Data Form 3. Treatment Fidelity Checklist

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Clinician Tip Sheet The benefit of conducting a home visit provides you with an opportunity to observe the child’s behavior while in his natural environment, ideally during routine activities or during a problematic time of the day. The home visit also allows you to gain a better sense of the layout of the child’s home. This can be helpful when implementing strategies, such as choosing a wall or room to place a visual schedule, or figuring out the best spot for a time out chair. The home visit can be included in the program at several time points. 1. Before treatment begins, as it provides an excellent opportunity to conduct a blank slate assessment of the child’s behavior and the parents’ response to the child while in the natural environment. 2. Between the visual schedule and reinforcement sessions. In many cases, because of the personalized nature of visual schedules, you may not have a completed visual schedule ready to give the family at the end of the Visual Schedule session. Conducting the home visit between these two sessions allows you the opportunity to create the schedule after the Visual Schedule session and bring it to the family’s home in order to role-​play its use and problem-​solve placement and implementation while at the home. 3. Toward the end of treatment (during the Booster Phase session), as this provides the opportunity to provide final coaching of the parent’s skill implementation for any remaining behavioral problems. This also provides you with the opportunity to observe, first-​ hand, modifications to the child’s environment and the parent’s successful implementation of skills.

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Clinician Script Goal 1: Establish Rapport With the Family [Spend some time putting the family at ease and reinforcing the parent about the home setting, for example, setup, available toys and activities, and other positive features of the home.]

Goal 2: Observe Where the Child Spends His Time via a Tour of the Home and Assess the Child’s Environment for Safety, Organization, and Presence of Developmentally Appropriate Materials To begin with, let’s walk through the home following a typical daily schedule for your child so that you can show me where things are occurring with him throughout the day. Let’s start with where your child wakes up. [Refer to the Home Visit Data Form, located later in this session of the Clinician Manual. Follow the questions in Section I: Home Tour/​D aily Schedule on the form. Observe whether there are any obvious safety concerns; where various materials are kept and stored; how doors and cabinets are locked; and what materials are present in what areas of the rooms. Document observations and parent responses on Section 1 of the Home Visit Data Form.]

Goal 3: Conduct a Naturalistic Observation of the Child’s Behavior in the Home Setting and the Parent’s Use of Specific Skills and Behavioral Strategies For the next 30 minutes, I  would like to observe what usually goes on at this time of day. Go about what you would typically be doing. I will sit back and just observe your child and her reaction to what is going on. I will be taking some notes that we can discuss in upcoming sessions. [Observe the family and child as unobtrusively as possible while completing Section II: Naturalistic Home Observation on the

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Home Visit Data Form. You should not intervene. Denote different activities occurring in the different blocks. Note the beginning and ending of an activity by the time during which they occurred. The observation can end after you have observed the child in at least two activities. Make sure to ask the parent if your observations today are representative of the child’s typical behav­ior during this time.]

Goal 4: Record Observations of the Home Environment That Can Be Used in Future Parent Training Sessions [After leaving the home, complete Section III: Home Visit Checklist, Section IV: Behavior Strategies Used During Observation, and Section V: Clinician Notes for Future Sessions, if not completed during the observation period.]

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Home Visit Data Form Form B.1 CHILD’S NAME: _​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​​_​_​_​__​_​_​_​_​_​​_​_​_​__​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​ FAMILY MEMBERS PRESENT: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ CLINICIAN: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_​_​​_​_​_​ Was this time identified as a problematic time for the child?   YES   NO I.  HOME TOUR/​DAILY SCHEDULE Ask Parent the Following Questions

Clinician Observations and Parent Response

Where does the child start his/​her day?

Note presence of any safety concerns in the bedroom, types of toys available.

(Observe where child sleeps.)

Does your child sleep through the night here?

Note whether the child is likely to awaken and enter another room and with whom.

Does he routinely sleep here?

Where else does your child sleep?

Where does your child use the toilet?

Is he/​she able to do this independently?

Does he/​she need your assistance?

178

Note the distance to the bathroom from the bedroom, and other parts of the house where the child spends time; note presence of any safety concerns, note accommodations for the child.

7 19

Ask Parent the Following Questions Where does your child eat meals?

How long will he/​she sit and eat?

Where does your child play by himself/​ herself?

Clinician Observations and Parent Response Note whether the child eats in a regular chair at a table, whether any adaptations have been made, if the child has a routine place he/​she eats; if there are distractions such as a TV. Observe play area for any safety concerns, note types of toys available and what child chooses to use.

What might your child do while playing independently?

Will he/​she play independently while you complete a household chore?

Note whether the child is able to play independently and where the parent might be (within eyesight, down the hall, on another floor).

Where would you be while he/​she is playing?

Where does your child play outdoors?

Note area for safety concerns; is the area fenced; are the toys reasonably safe and appropriate.

Does he/​she wander off?

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Ask Parent the Following Questions Do you use time out with your child?

Where does time out take place?

Where else in the house does your child spend time?

180

Clinician Observations and Parent Response Note the area of the home; is it free from safety concerns such as outlets, electrical equipment, unstable furniture; free from distractions and access to reinforcers.

Note where the child might spend time in the home and again observe for any obvious safety concerns.

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II.  NATURALISTIC HOME OBSERVATION Place and Time [Note Start and End Times]

Clinician Observations and Parent Response

Who Is Present

Observed Antecedents [Note antecedents, including change or interruption of activity, denial of something, playing alone, demand]

Child Behaviors Observed [Record positive and problem behaviors; hypotheses of function (escape, attention, access to tangible, self-​ stimulatory, transition, unknown)]

Parent Behaviors Observed [Record appropriate and inappropriate skills (given preferred object/​ sensory input, attention/​ help, demand removed, removed from area, ignored)]

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Ask parent if the observation was representative of the child’s typical behavior during this time: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​

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III.  HOME VISIT CHECKLIST Part 1: Home Environment: General Instructions: Complete the following ratings based on the entire home visit. These ratings are intended to be global ratings of your observations. Also make note of your observations as these may be used in subsequent sessions. The following scale should be used to rate the items: 0 = Not observed or not present; 1 = Somewhat, but not consistent; 2 = Observed where or when appropriate; NA = Not applicable Environmental Arrangement and Stimulation

Rating

Is the household safety-​proofed for the child (unsafe materials out of reach)?

0 1 2 NA

Is the home organized to promote play in certain areas?

0 1 2 NA

Does the child have easy access to preferred play activities?

0 1 2 NA

Does the child have developmentally appropriate toys/​activities available?

0 1 2 NA

Does the layout of the home allow for a safe play area?

0 1 2 NA

Does the layout of the home allow parent supervision of the child while completing other household tasks?

0 1 2 NA

Are there toys and materials to teach and stimulate learning (i.e., books, computer with learning software)?

0 1 2 NA

Are there materials/​toys to promote gross motor skills (e.g., playground area, bikes, trampoline)?

0 1 2 NA

Clinician Observations

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814

Part 2: Parent Behavior: General Instructions: Complete the following ratings based on the entire home visit. These ratings are intended to be global ratings of your observations. Also make note of your observations as these may be used in subsequent sessions. The following scale should be used to rate the items: 0 = Not observed or not present; 1 = Somewhat, but not consistent; 2 = Observed where or when appropriate; NA = Not applicable Parent Behaviors

Rating

Does the parent 0 1 2 NA spontaneously communicate with the child (excluding making requests or reprimanding)? Does the parent spontaneously verbally reinforce the child for appropriate behavior?

0 1 2 NA

Does the parent attend to and reinforce the child’s communication attempts?

0 1 2 NA

Does the parent use antecedent or prevention approaches to manage the child?

0 1 2 NA

Does the parent use minimal physical guidance?

0 1 2 NA

Does the parent provide the child with appropriate activities?

0 1 2 NA

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Clinician Observations

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IV.  BEHAVIOR STRATEGIES USED DURING OBSERVATION General Instructions: Complete the following ratings based on the entire home visit. These ratings are intended to be global ratings of your observations. Also make note of your observations as these may be used in subsequent sessions. The following scale should be used to rate the items: 0 = Not observed or not present; 1 = Somewhat, but not consistent; 2 = Observed where or when appropriate; NA = Not Applicable Strategies Implemented

Rating

1. D  aily schedule followed

0 1 2 NA

2. V  isual schedule used with Child

0 1 2 NA

3. O  ther visual prompts/​cues used

0 1 2 NA

4. C  ontingent verbal reinforcement used

0 1 2 NA

5. Verbal reinforcement paired with tangible reinforcer

0 1 2 NA

6. Token economy used

0 1 2 NA

7. Parent reinforces compliance

0 1 2 NA

Clinician Observations

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816

Strategies Implemented

Rating

8. P  arent appropriately addresses noncompliance

0 1 2 NA

9. P  arent encourages and reinforces child for using functional communication behavior

0 1 2 NA

10. Parent uses appropriate teaching skills to promote new skill

0 1 2 NA

11. Parent uses planned ignoring as intended

0 1 2 NA

12. P  arent uses time out as intended

0 1 2 NA

13. Other strategy in place (specify)

0 1 2 NA

186

Clinician Observations

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V.  CLINICIAN NOTES FOR FUTURE SESSIONS Session

Possible Intervention Goal

Observations relevant for Prevention Strategies

Observations relevant for Reinforcement Strategies

Observations relevant for Compliance Training

Observations relevant for use of Planned Ignoring

Observations relevant for Teaching Skills

Observation relevant for Functional Communication Training

Observations relevant for Supplemental Sessions (Token Economy Systems, Feeding Problems, Imitation Skills, Sleep Problems, Time Out, Toilet Training, Crisis Management)

Observations relevant for Other Strategies

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Home Visit Treatment Fidelity Checklist Checklist B.1 Child’s Name: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__​_

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​

Clinician: _​_​_​_​_​_​_​_​_​_​_​_​__​_​_​_​_​_​_​_​_​​_​_​_​_​_​_​_​_ Rate the degree to which session goals were attained by the clinician. 0 = Goal was not achieved 1 = Goal was partially achieved 2 = Goal was fully achieved N/​A = Goal was not covered in the session Clinician Integrity Goals

Rating

1

Establish rapport with the family

0  1  2  N/​A

2

Observe where the child spends his time via a tour of the home and assess the child’s environment for safety, organization, and presence of developmentally appropriate materials

0  1  2  N/​A

3

Conduct a naturalistic observation of the child’s behavior in 0  1  2  N/​A the home setting and the parent’s use of specific skills and behavioral strategies

4

Record observations of the home environment that can be used in future parent training sessions

0  1  2  N/​A

Total _​_​_​_​_​​_​_​_​_​/​ 8

Rate the degree to which the parent participated, responded correctly, and completed activities. 0 = Parent did not demonstrate skill or understanding/​did not complete assignment(s) 1 = Parent understood or responded correctly to a few of the queries/​partially completed assignment 2 = Parent understood and responded correctly to nearly all queries N/​A = Objective was not covered in the session

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Parent Objectives

Rating

1

Parent showed and described for the clinician where daily events occur in the home

0  1  2  N/​A

2

Parent interacted with the child and intervened as is typical for the time of day

0  1  2  N/​A

Total _​_​_​_​_​_​_​_​_​/​ 4

FIDELITY NOTES:

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Appendix C Parent Training Case Example With Sample Behavior Support Plan

Background Information Ben Smith1 is a 5-​year-​old Caucasian male who lives with his biological parents. He is an only child. No complications were noted during Mrs. Smith’s pregnancy. Ben attended a private daycare from 6 months through 2 years of age. From ages 2 to 3, Ben attended an in-​home day care setting. Mrs. Smith recalls that Ben began babbling around 7 months of age and speaking single words (e.g., ball, dog) around 12  months. Ben began crawling at 9  months of age, but he did not start walking until 16  months. The family history is significant for attention-​deficit/​hyperactivity disorder (ADHD) and language delays on the maternal side and depression on the paternal side. Mrs. Smith reported first having concerns about Ben’s development around 15 months of age when Ben’s language did not progress. Due to these concerns, Mrs. Smith sought an evaluation by a child psychiatrist in the community, who assigned a diagnosis of pervasive developmental disorder-​not otherwise specified (PDD-​NOS). At 2 years of age, Ben was evaluated by the early intervention program in his state. He qualified for 1 hour each of speech and occupational therapy. These services continued until he aged out of the program at 3 years of age. Ben then transitioned to a special needs preschool, where he continued to receive speech and occupational therapy, each for 1 hour per week. At the time

1

The name Ben is a pseudonym.

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of the initial evaluation, Ben was enrolled in a special needs kindergarten classroom for 30 hours a week that used the SCERTS (Social Communication, Emotional Regulation, Transactional Support) model of early intervention for children with autism spectrum disorder (ASD). As part of his school programming, Ben also received 1 hour per week of speech therapy and 1 hour per week of occupational therapy. Outside of school, Ben received an hour of private occupational therapy per week. Mrs. Smith contacted our program seeking advice on how to handle Ben’s behavioral problems at home and in community settings (e.g., stores, parks, restaurants). She reported that Ben began exhibiting tantrums by 2  years of age, which Mrs. Smith attributed, in part, to the frustration of being unable to communicate his wants and needs. When asked about the two most prominent current problems for Ben, Mrs. Smith reported noncompliant behavior and tantrums. He often ignored or actively protested routine requests. His seeming low tolerance for frustration often resulted in explosive tantrums if things “didn’t go his way.” Mrs. Smith reported that his tantrums and noncompliance were causing daily disruption in family routines and strain between her and her husband on how to address these behaviors.

Assessment and Diagnostic Information Mrs. Smith brought Ben to the clinic first to confirm the diagnosis of ASD. Mrs. Smith completed extensive interviews regarding Ben’s developmental history and current diagnostic presentation (Autism Diagnostic Interview –​Revised), while Ben completed a direct observation diagnostic session (the Autism Diagnostic Observation Schedule, Module 2)  and a cognitive assessment (Stanford Binet Intelligence Scales–​ Fifth Edition). Ben’s adaptive functioning (Vineland Adaptive Behavior Scales, Second Edition, Parent Report Form) and behavioral difficulties (Aberrant Behavior Checklist [ABC]) were also evaluated.

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Assessment Procedures Cognitive: Stanford Binet Intelligence Scales–​Fifth Edition (SB-​V ) Diagnostic: The Autism Diagnostic Interview-​Revised (ADI-​R) The Autism Diagnostic Observation Schedule–​Module 2 (ADOS) Adaptive: The Vineland Adaptive Behavior Scales, Second Edition, Parent Report Form Behavioral: The Aberrant Behavior Checklist (ABC) Results of the cognitive assessment suggested that Ben had an overall IQ within the Average range compared to same-​age peers (Full Scale IQ = 108); however, he exhibited a significant split between his Verbal and Nonverbal IQ (Nonverbal IQ = 97, Verbal IQ = 119). The diagnostic assessments (ADI-​R and ADOS) confirmed an atypical pattern of development in Ben’s social interaction, communication, and the presence of repetitive behavior. Early signs of autism were evident within the first 2 years of Ben’s life and included language delays, limited use of eye contact during social interactions, poorly developed play skills, and the presence of repetitive interests by the age of 2 (i.e., Thomas the Tank Engine). Ben’s current level of social interest in other children is limited. He often ignores invitations to interact with peers. His mother reports that Ben has more successful interactions with adults. She notes that occasionally he seeks out adults to share his interests, such as Thomas the Tank Engine. Although his language was described as phrase speech and he occasionally engages in back-​and-​forth exchanges with his mother about a topic that she initiates, he does not engage in fluid reciprocal conversations. Regarding his nonverbal communication, Ben shows a reduced frequency of spontaneous gestures and eye contact. Finally, Ben currently shows an intense interest in stop lights and also was observed engaging in visual examination of objects during the diagnostic play assessment. Overall, Ben exceeded the established cutoffs for ASD on both the ADOS and ADI-​R . Regarding his adaptive functioning, Ben’s scores on the Communication and Daily Living Skills Domains fell within the Average range.

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In comparison, Ben demonstrated notable delays in his Socialization (Standard Score = 77), as well as moderate delays in his Motor Skills (Standard Score = 84). Mrs. Smith completed the Aberrant Behavior Checklist (ABC) to provide information on Ben’s current behavioral problems. The ABC has five subscales that measure a range of disruptive behavior, hyperactivity, and stereotypic behavior. The child’s scores can be compared to large samples of children with developmental disabilities. On the Irritability subscale, which reflects tantrums, aggression, and self-​ injurious behavior, Ben received a score of 23, which is a standard deviation higher than the mean. This score is also similar to the average baseline score for children who participated in the multisite trial conducted by the Research Units on Behavioral Intervention Autism Network (Bearss et al., 2015). Qualitatively, Mrs. Smith reported that Ben had 2–​3 tantrums per day lasting 10–​15 minutes in response to routine demands. She also estimated that Ben was noncompliant 75% of the time. In summary, test results utilizing “gold standard” measures (i.e., the Autism Diagnostic Observation Schedule [ADOS] and Autism Diagnostic Interview-​Revised [ADI-​R]) along with clinical impression confirmed that Ben met the diagnostic criteria for ASD. He has average cognitive abilities, but lower than expected scores on the Vineland. His scores on the ABC indicate that he has serious behavioral problems.

Treatment Mrs. Smith began the parent training protocol within a week of Ben’s assessment. She attended a total of 12 in-​person sessions, 2 home visits, and 2 telephone boosters over the course of 24 weeks (see the Sample Behavior Support Plan for a detailed account of treatment activities and generated strategies). Mrs. Smith initially collected Antecedent-​Behavior-​C onsequence (ABC) data to learn more about the function of Ben’s tantrums and noncompliance. In Ben’s case, these behaviors were primarily driven by “escape” from a routine parental demand or “to get what he wants.” Initial prevention strategies

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focused on aiding Ben with transitions (e.g., using a timer to provide warnings) as well as a change in the afternoon snack routine to reduce whining before dinner and to reduce Ben’s demands for inappropriate snacks (e.g., cookies, potato chips). Several sessions then focused on using prevention and reinforcement strategies to shape meal time behaviors, including reinforcements for “on-​task” behaviors such as staying at the table and eating his food. Mrs. Smith was taught how to use planned ignoring to tackle “negative talk” (e.g., calling his mother names) while simultaneously reinforcing “kind words.” Guided compliance techniques along with reinforcement were used to target successful completion of morning routine demands. Finally, because Ben had a long and persistent history of sleep problems, we reviewed the supplemental Sleep Problems session (available at www.oup.com/us/ttw). Mrs. Smith described sleep association problems (i.e., Ben needed to have his DVD player on in order to fall asleep). She also reported frequent night awakenings resulting in Ben sleeping in his parents’ bed. To address the sleep association problem, we replaced the DVD with a sound machine by his bed. When Ben got up at night, Mrs. Smith redirected him back to his own bed. As we moved to the Teaching Skills sessions, Mrs. Smith had already noted significant reductions in Ben’s tantrums and defiant behavior. To build compliance and daily living skills, we focused on teaching Ben how to buckle his seat belt. The parent training program, overall, emphasized the importance of Mrs. Smith implementing all strategies in a manner that promoted consistency and predictability in Ben’s daily routine. Mrs. Smith successfully implemented all aspects of these programmatic components. The Behavior Support Plan summarized the many behavioral strategies that were introduced to Mrs. Smith throughout the course of the program. At a Week 24 follow-​up visit, Mrs. Smith reported significant reductions in Ben’s tantrums and noncompliant behavior. The ABC Irritability subtest score dropped from 23 at Baseline to 10 at Week 24, which is just below the mean for children with developmental disabilities. In addition, Mrs. Smith reported that tantrums had been reduced to 1 per day lasting 1–​2 minutes. Ben was generally cooperative with performing skills of daily living. Noncompliance was estimated to occur 10%–​15% of time.

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Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN

TARGET PROBLEM BEHAVIORS: Definition of the behaviors we want to go away (Topography) Behavior 1: Tantrums

Yelling, screaming, sometimes with accompanying aggression or throwing/​k nocking over items

Behavior 2: Noncompliance

Refusal to comply with directions when asked to perform certain tasks (e.g., morning/​evening routine) or nonpreferred demands (e.g., clean up). PERCEIVED FUNCTION(S): The cause of target behaviors

Behavior 1: Tantrums

To get what he wants (e.g., access to inappropriate snack) Escape when given a demand that he does not want to comply with Escalation to get attention (during planned ignoring)

Behavior 2: Noncompliance

To get out of an unwanted activity (e.g., not sitting at the dinner table; clean up; morning/​evening routine demand)

PREDICTORS/​TRIGGERS FOR PROBLEM BEHAVIORS: Situations that may cause the behaviors to occur more frequently Transitions (from more to less preferred activities) When limits are set (e.g., when told “no”) When given a nonpreferred demand When Ben wants his mother’s attention

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Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN DATA COLLECTION: How to track progress of problem behaviors

ACRONYM

What It Stands for

Definition

A

Antecedent

Cue or trigger that occurs right before the behavior takes place

B

Behavior

The target behavior that can be observed, counted, or timed.

C

Consequence

What occurs right after the behavior; can be positive or negative

Examples   Being told what to do ■  Not getting what you want ■  Not getting attention ■

 Hitting  Yelling ■ Talking back ■ Whining ■ ■

 Time out ■  Privilege removal ■ Ignore ■ Reward ■  Hug/​praise ■

1) Use your ABC’s to determine the function of the behavior: ■ To escape or “get out of doing” demands ■ To get attention ■ To “get what Ben wants” ■ Because it's “self-​stimulatory” 2) Determine which behavioral strategy (or strategies) would make the most sense to target the function of the behavior. 3) Create/​use data tracking forms to track your implementation of the strategy and progress in terms of changes in Ben's behavior.

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Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN

PREVENTION STRATEGIES (ANTECEDENTS): What we are going to do so the behaviors do not occur in the first place STRATEGY Timers (a type of visual cue)

SPECIFIC DETAILS Visual timers (time-​timers) provide a great way to indicate to children when a transition or a reward will occur or when an activity is over. Instead of verbally telling Ben how much time until a transition will occur, use a timer to present this information.  This avoids parents having to be the “bearer of bad news” (i.e., that a transition needs to occur). ■ When the timer goes off, it is important to respond immediately. ■ A timer was recommended to use as a cue that it was time to clean up the toys. ■ During Ben’s dinner routine, a timer was introduced to help him stay at the table for his entire meal (10–​15 minutes). ■ We started with providing M&Ms every 3 minutes for appropriate sitting during dinner, then increased this to every 4 minutes ■ Eventually, we moved to using timed intervals to consume portions of the meal (e.g., dinner divided into four segments; Ben had 3 minutes to eat each segment. Completion = M&M reward). ■

Changing the order of events “First-​then”

Changing the order of activities in the daily routine can make the day run more smoothly, making sure less preferred activities come first, followed by more preferred activities. Having preferred activities come second serves to motivate completion of the less exciting activity. This was used during the morning routine: “First get dressed; If there is time left over, you can watch TV.”

DATE INITIATED

9 1

Changing the Saying “no” directly can often result in increased way that you problem behaviors. Instead, it can be helpful to find ask alternative ways to respond. Giving choices can help to increase compliance and reduce difficult behaviors.  Ben can be given choices as part of his routine (e.g., do you want to do this activity or that one?). ■ This was also applied in offering snack choices (to promote selection of healthy afternoon snacks). ■

NOTE: If Ben does not accept your choices or offer an appropriate alternative, then you can say “Make a choice or I will make the choice for you”—​then follow through! Reduce demands or give in quickly on challenging days

Ben (and sometimes mom!) has “off days.” When you have a sense that this is going to be a “bad day” for Ben, it is ok to back off the number of demands for that day. It is better to not give the demand at all than to give a demand and then have to back off. When Ben is having a “bad day,” we discussed becoming targeted in the demands you expect him to follow through on. For example, instead of demanding compliance on the entire morning routine, focus instead just on brushing teeth. In the evening, focus on showering and brushing teeth. You can also prompt Ben to “ask nicely and I’ll _​_​_​_​_​” so that you are responding to a positive/​ appropriate behavior and not the tantrum.

Address setting events

Setting events include being hungry, tired, or sick. They increase the likelihood of “setting off” difficult behaviors. For Ben, mom introduced protein bars as a way to address the setting event of hunger at mid-​ afternoon, in order to tide him over until dinner.

Set aside a time for scripted talk ("school talk")

Ben is engaging in repetitive talk about school. To help set limits on this, allow Ben a select time to engage in this “school talk” (e.g., on the drive to school). During this time, he can talk about school. If he tries to bring up the topic outside of the car ride, mom can prompt him to hold off and wait until the car ride to do “school talk.” This sets limits on this behavior, while still providing Ben the opportunity (daily) to engage in this behavior.

20

Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN

REINFORCERS: Items or activities that are motivating to the child Primary reinforcers

Chocolate (M&Ms) Chicken nuggets Cookies Macaroni and cheese Juice box

Social reinforcers

High five

Tangible reinforcers

Matchbox cars Superheroes Anything with a car Toys that light up/​noisy toys Mega blocks

Activities/​privileges

Going outside/​bike riding with mom Riding trails with mom Going to the park Chucky Cheese Kindle game

Token reinforcers

OT—​uses a ticket system Home—​point chart Marble jar

Additional Notes About Reinforcers:

Reinforcers work best if: ■ Ben’s access to the reinforcer is limited except in the context of the behavioral contingency ■ Ben really wants to work for the reinforcer ■ The reinforcer is given ONLY when Ben successfully completes the behavior Use of stereotyped interests as reinforcers: ■ The goal for repetitive behaviors/​ stereotyped interests is to make sure that they are not interfering with Ben’s social interactions or learning. ■ These highly reinforcing behaviors can be used as motivators for target behaviors. Tie access to the highly preferred toys/​activities (e.g., Matchbox cars, toys that light up) to the completion of more functional tasks/​behaviors. ■ Keep in mind it is ok to allow Ben to engage with these stereotyped interests/​ behaviors as they likely act as a stress reliever for him. There is just a right time and place for him to play with these items (i.e., you can allow time for it, but you can also put limits on it).

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Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN

REINFORCEMENT STRATEGIES: Ways to provide your child with rewards for good behaviors STRATEGY

SPECIFIC DETAILS This strategy involves requiring a specific, targeted behavior to occur in order for Ben to earn access to a reinforcer. To help encourage Ben to get dressed independently in the morning, we developed a reinforcement contingency: If Ben dresses independently, then he earns a point on his point chart. This assumes that you follow through and do not provide the point if Ben is noncompliant in any way with the target behavior of “getting dressed independently.”

Using reinforcers in a behavioral contingency

A note about behavioral contingencies: You can “up the ante” as Ben progresses with his compliance in the targeted behavior. For example, as part of the morning routine, you could first say, “Get dressed all by yourself, then you get a point on your point chart.” When Ben is consistently following this contingency, you can “up the ante” to “Get dressed all by yourself and put your PJ’s in the laundry hamper, then you get a point on your point chart.” And so on. NOTE: To PREVENT behaviors, it is important that behavioral contingencies are set up in advance (i.e., being aware of predictable challenges, such as difficulties with parts of the morning routine) before behavior problems arise. Implementing a contingency AFTER the behavior has happened (e.g., Ben has already tried to run out of the room as a way to get out of a demand) will lessen the impact of the contingency, and it may reinforce negative behavior (i.e., Ben may learn that if he runs away, he is offered a fun reward for moving forward).

DATE INITIATED

20

If-then negative consequence contingency

Timed reward for “using kind words”

This is related to the above: While we encourage “positive” or reward-based contingencies, this could instead involve a contingency such as "If you call mom by my first name, then you will lose #####." For particularly challenging times of the day, when Ben is more likely to use “negative talk,” allot time intervals that reinforcers can be provided for the absence of the targeted problematic behavior: Ben will receive a particular reward for the absence of “negative talk” (paired with praise, “good job talking kindly”). For example, if Ben uses kind words for the next 30 minutes, then he can earn access to his mom's kindle. This strategy involves using child-led play activities to engage in a positive play session with Ben. This session, lasting approximately 10 minutes, can occur at a prearranged time or during a time of the day when Ben is already playing with his toys.

Special time #1 Rule is to: FOLLOW Ben's LEAD

Mom should attempt to copy Ben's play, describe his actions and point out, via praise, any spontaneous appropriate imaginative play skills. This is a great opportunity to praise play skills and also to model these skills where appropriate. These interactions can be really helpful for language, social, and play abilities. Ignore any mildly disruptive behaviors that may occur in the play. We targeted using Legos as a means to promote social skills (sharing, taking turns). This can be used as a "Calming Activity" before the bedtime routine to help counter Ben's tendency to escalate/ramp up before bedtime (because he is overtired).

Catch Ben being good

This strategy encourages highlighting spontaneous positive behaviors using social reinforcement (praise) as well as tangible reinforcers, if needed (e.g., points on his point chart). For example, if Ben transitions well between activities or complies right away with commands, this should be praised in combination with putting a point on his chart. Mom is also using this to praise good “sleep” behavior (staying in his bed all night).

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Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN

OTHER CONSEQUENCE STRATEGIES: What to do AFTER the behaviors occur STRATEGY

SPECIFIC DETAILS For nondestructive but attention-​seeking behaviors, ignore both the child and the behavior.

Types of planned ignoring

For dangerous behaviors (e.g., bolting down the street; self-​injury), attend to the child and stop the dangerous behavior, but do not provide attention to the child while you are addressing the behavior. For high-​frequency behaviors (e.g., repetitive question asking), ignoring the child when this behavior occurs could result in ignoring the child for large portions of the day. Instead, just do targeted ignoring of the behavior while otherwise providing attention to the child. Ignore the behavior COMPLETELY (no facial expression, no talking, walk away if needed)

Rules for planned ignoring

Ignore until the targeted behavior stops. If you break down and pay attention before the behavior stops, the child learns that is your “breaking point.” The behavior typically gets worse before it gets better (kids like to “up the ante”)  Ignore Ben's “negative talk.” Ben often said inappropriate words. Planned ignoring was used to eliminate any social attention provided to these behaviors. Initial concerns about Ben escalating to destructive behavior were addressed by applying “Ignore the Child but NOT the Behavior.”

■

Planned ignoring strategy for Ben:

DATE INITIATED

204

Ignore the child and the behavior

 When on the phone: This strategy is best implemented in combination with prevention (setting Ben up with something to do while you are on the phone) and reinforcers (“If you play quietly while I’m on the phone, you can earn ####”). If an unexpected call occurs and Ben is unoccupied/​likely to be disruptive (e.g., when in the car), you can tell the person you will call her back in X minutes. Then set up the prevention/​ reinforcement contingencies, and then call the person back.

■

Teaching your child to comply with requests involves a number of important steps:   Gaining his attention and eye contact ■ Telling (not asking) him exactly what to do and at the same time providing some physical guidance to complete the command ■ Providing immediate and specific praise as your child complies ■

It is important to WAIT to give the command until you are ready to follow through—​and not from across the room. Compliance training

We discussed the use of Planned Ignoring and Reinforcement in combination with Compliance Training when cleaning up toys. This is to target some of the (ignorable) negative behaviors (laughing) that occurred when mom was using physical guidance to have Ben clean up. Reinforcement (e.g., point on point chart) can be used as an additional motivator to comply with commands. We discussed using this strategy in order to teach Ben to comply using the “Compliance Commands”—​“Clean up your toys,” “Go to the bathroom to brush your teeth,” and “Get in the bathtub.”

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Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN

TEACHING STRATEGIES: What we are going to teach the child so the behaviors do not occur STRATEGY

SPECIFIC DETAILS Start by identifying the “function” of the inappropriate behavior (i.e., is Ben acting out to communicate that he wants attention, wants to get out of a demand, or wants access to something) Teach a new, replacement skill using the following guidelines: Functional Communication Training should i) Work quickly ii) Work every time it’s used iii) B  e less effortful than the nonfunctional communicative behavior

Functional communication training

Ben is already very verbal and is able to use his words to request help and to explain his needs. So our goal is to teach Ben to “use his words” as a functional replacement for any communicative (but nonfunctional) behaviors.  When thinking about Ben's difficulties with completing homework, we discussed how this behavior may be “escape” based. Our goal is to teach Ben that, instead of whining or complaining, to ask mom for a “break” from his homework ■ Initially, you need to respond immediately when Ben uses his words and asks for a break. This will reinforce the behavior and show him that using his words works to get a break (and that he doesn't need to whine/​complain, attempt to leave the table). ■ Once he is consistently asking for a break, you can start requiring him to wait for longer periods of time before you provide the break (e.g., one more problem, then you get a break). ■

DATE INITIATED

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We discussed the main principles of teaching a new skill: 1.  Perform a “task analysis” ■ Break down the larger task into its smaller steps 2. Determine which steps Ben already knows how to do vs. which steps he still needs to learn ■  When practicing the skill, Ben should always complete the steps that he does know how to do

Teaching new skills

3. Decide what step you want to start teaching first ■ It helps to start teaching with an “easy” step 4. Focus on teaching only one step at a time, helping to minimize frustration 5. Once there is mastery of the step, move to the next step ■ You can use “forward chaining” (starting with the first step in the task and moving on down the list) or “backward chaining” (starting with the last step in the task and then working backward). 6. If needed, incorporate reinforcers to reward completion of an “attempt” at a particular step. ■  We discussed using these strategies to target putting on Ben's seat belt

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Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN

SUPPLEMENTAL SESSIONS: SLEEP:

We targeted the following sleep issues: ■ Sleep association (requiring watching DVD in bed in order to fall asleep) ■ Sleep association (requiring mom to be present if Ben doesn't fall asleep via the DVD) ■ Night wakings, involving moving to mom's bed Intervention included: ■ Changing the bedtime routine so that DVD playing occurs BEFORE Ben is in bed. ■ Introducing a sound machine (DVD with quiet sounds) that will play all night as the new “association” to falling asleep. ■ Using redirection (back to bedroom) and timed check-​ins by mom while Ben is falling asleep. ■ Using redirection (back to bedroom) if Ben moves to mom's bed in the middle of the night. ■ We discussed how sometimes mom doesn't notice he's moved to her bed and problem-​ solved use of baby monitors, or other means, to alert her to his movement. We also discussed moving Ben back to his room when mom wakes up in the morning to try to ensure Ben ends up in his bed before waking. ■ Providing a reinforcer (point on his chart) for waking up in his own bed. ■ Using a baby gate to block Ben's access into his mom's room. When he “encounters” the baby gate (and wakes mom up), she can then redirect him back to his own bed.

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TIME OUT: To address “negative talk” as well as cursing: ■ Time Out should be used for ONE BEHAVIOR AT A TIME, so that Ben knows exactly what behavior will get him sent (consistently) to time out. ■ Let Ben know in advance that there is a new “house rule.” You can remind him each morning that this rule is “in effect.” You also can put up a visual reminder about this house rule (e.g., something posted right above the time out chair). ■ EVERY TIME Ben engages in negative talk, he should be sent to time out, using as little physical prompting as necessary, and providing no attention to him. ■ If he is too disruptive on the time out chair, he should be moved to his room. ■ Ben should stay in time out for a minimum amount of time (e.g., 3 minutes). NOTE: Ben should not be able to leave time out until he is quiet. So, if 3 minutes passes and he’s still upset, you should wait until he calms down before he is allowed to leave time out. To help Time Out work, it is important that you increase the amount of positive attention you provide to Ben (i.e., catch him when he's being good). Time out is most effective when there is a “healthy balance” of positive attention to counter the negative that comes with time out. We want to use the positive attention to remind Ben what happens when he behaves (i.e., I get a lot of plus attention from mom!).

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Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN

MAINTAIN /​GENERALIZATION: How to MAINTAIN low rates of problem behavior in all environments Tips for Maintaining Behaviors: 1. Continued reinforcement is important in maintaining a behavior. 2. Fade reinforcement of the new skill to a more realistic reinforcement schedule. One way would be to move from reinforcing a behavior every time to reinforcing a behavior every third or fifth time; this would be an example of intermittent reinforcement. Another way to provide reinforcement less often is to use delayed reinforcement, which means you reinforce a behavior not immediately but after a certain period of time.

Tips for Promoting Generalization of Skills Across Settings and People 1. New skills are more likely to be generalized if they are reinforced across different settings. 2. It is helpful to use reinforcers that naturally occur in different settings. 3. If a situation is too different from the one the skill was learned in, sometimes the new skill will not generalize to the new situation. 4. Finally, make sure a problematic behavior is not being reinforced in situations outside of the home.

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Child’s Name: Ben S

ID BEHAVIOR SUPPORT PLAN

FUTURE CONSIDERATIONS: Strategies that can be implemented in the (near) future STRATEGY Reinforcement: Earning time toward access to preferred activities (see Mealtime Timer Plan)

Prevention: Visual schedule

SPECIFIC DETAILS As an alternative to giving M&M's for on target mealtime behavior, Ben could also earn “amounts of time” toward a preferred activity. For example, every 4-​minute interval that Ben finishes his meal portion earns him 5 minutes of special time with mom; or 5 minutes of time on mom's kindle. Presentation of information in a visual format (as opposed to auditory) can be extremely helpful for children with ASD. Visual schedules are pictorial representations of activities and transitions during the day.   While this was not introduced in our program, it may be a useful strategy in the future to help provide visual cues to the structure of daily routines ■

Prevention: Creating a routine

This will increase predictability for Ben. The evening routine is already nice and predictable. As the school year starts, it may be helpful to create the same kind of predictable routine for the “morning flow.” Mom may want to also consider adding a visual schedule to help lay out for Ben the morning schedule.

Teaching skills

Future targets could be as follows: pouring juice, packing backpack, getting clothes out

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Appendix D Problem-​Solving Common Challenges in Implementing the Program

Some parents, like Mrs. Smith in the Appendix A case example, are near perfect—​they show up on time, attend to materials presented during the session, and complete the homework. In the “real world,” however, this is not always the case. Families face multiple demands, some beyond their control. For some parents, the challenge of the child’s behavior erodes their motivation and confidence. Thus, internal and external elements can influence parental participation. To help maintain the integrity of the program and assist parents to make the most of their time in parent training, here are some useful strategies to handle obstacles that may be encountered during treatment. 1. The parent does not fully understand the materials. In the midst of the many activities and exercises imbedded in the early sessions, you sense that the parent is having difficulty picking up the information. First, try different ways to explain the materials. It may also be helpful to depart from the scripts in the manual and apply the principles to the specific child. For example, a parent may better connect with the ABC’s in the Behavioral Principles session if you talk about a situation that the parent just dealt with that morning. When it comes to assigning the homework, only bite off what the parent can chew. It is more important to set the parent on a course for success with small but meaningful behavioral changes than to create elaborate homework assignments that the parent may not be able to put in place. 2. The parent isn’t sold on a particular strategy or isn’t engaged in the program. One way to increase “buy in” to the program is to have the parent choose the homework assignment. In the prevention strategies session, for example, the parent and therapist may generate several

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strategies to address problem behaviors. You may have your eye on a strategy that provides “the most bang for the buck,” but the parent may be more interested in a technique that fits with a child-​specific problem. Especially when there are concerns about “buy in,” let the parent choose the strategy to address this concern in the coming week. If the parent is then able to apply the chosen strategy with success, it supports the model and promotes engagement. Building on this success, the parent may be more open to therapist-​suggested strategies in future sessions. 3. The parent “ forgets” to bring in the homework sheet. Completion and documentation of the homework are essential components of a successful program. Without documentation of the homework experience, the therapist relies on parental recall—​which may be less accurate than tracking behavior as it occurred over the previous week. Here are a few suggestions to encourage homework completion: ■ Take the time to discuss the homework, whether the parent has completed a homework sheet or not. This sends a clear message that homework is an essential part of the program and will be reviewed every session. ■ Have a blank homework sheet handy and have the parent take the time to fill it out as you are discussing the homework. Ask the parent to walk through specific strategies that were tried over the last few days. ■ Identify barriers that get in the way of completing the homework. Is the homework sheet kept in an inconvenient place? When does the parent complete the sheet—​at the end of the day when the child is in bed or soon after completion of the target skill or behav­ior, such as at bath time or mealtime? 4. The parent does not complete the homework assignment. The parent training program moves to a new topic each session. Because of this pace, it is important for parents to complete the homework. The first time an assignment is missed, you can “double up” assignments from the current and prior session. If the parent misses two assignments in a row, slow down the pace and spend a session problem-​solving challenges with implementing the strategies. The parent can then be sent home to complete the previously assigned homework. Let the parent know that you are still interested in the success or failure of

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the homework. If a parent returns and still has not completed any assignments, a pointed discussion on treatment engagement, structural barriers, and life stressors is warranted. For example, parents in the midst of divorce may not be able to focus on the expectations of the parent training program. Include in the discussion the possibility of taking a break from or terminating the program, stressing that the program will not work if the parent is not implementing the strategies. 5. The parent states a technique didn’t work because the child had a meltdown when it was introduced. Help the parent temper this expectation. Despite the parent’s best effort, tantrums may happen anyway. For example, a parent introduces a timer as a 5-​minute warning ahead of bath time. This strategy is designed to minimize difficulties as it provides a clear prompt for the child of an impending transition. As instructed, the parent sets the timer and verbally prompts the child that bath time will occur in 5 minutes. The timer goes off 5 minutes later and the child starts screaming that she does not want to take a bath! The parent, understandably, is confused why the timer didn’t “prevent” the tantrum. Let the parent know that this response is not unexpected. The parent needs to follow through with the strategy (e.g., move to the bath when the timer goes off). This teaches the child that there is meaning, and not empty threats, behind the parent’s words. If the parent is consistent and follows through with the strategy, the child’s resistance should decrease over time. The timer will eventually work to promote a smooth transition to bath time. 6. The parent brings in a crisis to the session. If all goes according to plan, you should be able to move from topic to topic each session. Things don’t, however, always go according to plan. A parent may arrive to a session with a crisis such as problems with the child’s school, or marital, family, or other interpersonal issues. First, take time to acknowledge the problem and think through possible solutions based on available resources. If a more in-​depth discussion is required, you can go to the optional Crisis Management session (available at www. oup.com/us/ttw). This session allows you to focus on a specific child behavior (e.g., increased aggression or self-​injury) or a more global problem (e.g., parent wants to change the child’s school program). If you feel that the parent requires more support, a discussion about referrals to outside resources is warranted (e.g., individual/​marital

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counseling, advocacy/​legal counsel). In some situations, the pressing nature of the problem may signal that the parent needs to take a break from the parent training program to address the issue. 7. The parent comes to a session and says the child has “exploded.” Experience will show that certain times of year can be particularly challenging for families. The beginning and end of the school year, major holidays, and even trips to fun places like Disney World may coincide with a parent reporting that the child has fallen apart and that the strategies aren’t working. These moments provide a great opportunity to discuss with the parent the importance of consistency and predictability for children with ASD. Large changes in schedules, such as school transitions, holidays, and vacations, can cause increased anxiety and dysregulation in the child. You can recast the increase in challenging behaviors as expected given the major changes in the child’s routine. Let the parent know that the increase in behavioral problems is likely to be temporary and should subside once the child gets back into a regular routine. In the meantime, review strategies successfully applied to date and think with the parent about how they may be applied to help reduce the current behavioral challenges. If the parent is feeling overwhelmed by the uptick in behaviors, remind the parent about the strategy of backing off from usual demands until the child gets back into his normal routine. The good news is, with enough time and consistency in use of the strategies, the child should bounce back to the level of behav­ ior prior to the “explosion.” 8. Additional reminders that may be needed throughout the program: Daily structure and consistent application of effective parenting strategies are essential elements for reducing the child’s behavior problems. ■ Children engage in behaviors that work for them. The parent’s challenge is to change well-​established behavioral patterns. It takes time and patience to work through the child’s resistance to bring about improvements in behavior. ■ There will be times when the parent comes to a session feeling overwhelmed—​due to an unexpected spike in the child’s behav­ ior, or because the parent is struggling with financial or personal problems. During these times, it is OK for the parent to lessen the demands on the child. ■

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Appendix E RUBI Progress Note

Child’s Name: 

Visit Date: _​_​_​ _​_​_​ /​ _​_​_​ _​_​_​ /​ _​_​_​ _​_​_ _​_​_​ _​_​_

Therapist: Session: Homework Issues:

Behavioral Concerns:

Session Issues:

Decisions (Additions, Changes)

Homework Assignment:

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References

Aman, M. G., McDougle, C. J., Scahill, L., Handen, B., Arnold, L. E., Johnson, C., . . . Wagner, A. (2009). Medication and parent training in children with pervasive developmental disorders and serious behav­ ior problems: Results from a randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 1143–​1154. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th ed. DSM-​V. Washington, DC: Author. Bearss, K., Johnson, C., Handen, B., Smith, T., & Scahill, L. (2013a). A pilot study of parent training in young children with autism spectrum disorders and disruptive behavior. Journal of Autism and Developmental Disorders, 43, 829–​840. Bearss, K., Johnson, C., Smith, T., Lecavalier, L., Swiezy, N., Aman, M., . . . Scahill, L. (2015). Effect of parent training versus parent education on behavioral problems in children with autism spectrum disorder: A randomized clinical trial. Journal of the American Medical Association, 313, 1525–​1533. doi: 10.10001/​jama.2015.3150. Bearss, K., Lecavalier, L., Minshawi, N., Johnson, C., Smith, T., Handen, B.,  .  .  .  Scahill, L. (2013b). Toward an exportable parent training program for disruptive behaviors in autism spectrum disorders. Neuropsychiatry, 3, 169–​180. Brookman-​ Frazee, L., Drahota, A., Stadnick, N., & Palinkas, L. A. (2012). Therapist perspectives on community mental health services for children with autism spectrum disorders. Administration and Policy in Mental Health and Mental Health Services Research, 39, 365–​373. Carter, A. S., Messinger, D. S., Stone, W. L., Celimli, S., Nahmias, A. S., & Yoder, P. (2011). A  randomised controlled trial of Hanen’s “MoreThan Words” in toddlers with early autism symptoms. Journal of Child Psychology and Psychiatry, 52(7), 741–​752. Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., . . . Varlet, J. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The early start Denver model. Pediatrics, 125, 17–​23. doi: 10.1542/​peds.2009-​0958.

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Dretzke, J., Davenport, C., Frew, E., Barlow, J., Stewart-​Brown, S., Bayliss, S.,  .  .  .  Hyde, C. (2009). The clinical effectiveness of different parenting programmes for children with conduct problems: A systematic review of randomized control trials. Child and Adolescent Psychiatry and Mental Health, 3(7). doi:10.1186/​1753-​2000-​3-​7. Elsabbagh, M., Divan, G., Koh, Y., Kim, Y., Kauchali, S., Marcín, C., . . . Fombonne, E. (2012). Global prevalence of autism and other pervasive developmental disorders. Autism Research, 5, 160–​179. Hanley, G. P., Iwata, B. A., & McCord, B. E. (2003). Functional analysis of problem behavior:  A review. Journal of Applied Behavior Analysis, 36, 147–​185. Hartley, S. L., Sikora, D. M., & McCoy, R. (2008). Prevalence and risk factors of maladaptive behaviour in young children with autistic disorder. Journal of Intellectual Disabilities Research, 52, 819–​829. Hayes, S. A., & Watson, S. L. (2013). The impact of parenting stress: A meta-​analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 43, 629–​642. Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G., & Hanley, J. H. (1997). Multisystemic therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology, 65, 821–​833. Horner, R. H., Carr, E. G., Strain, P. S., Todd, A. W., & Reed, H. K. (2002). Problem behavior interventions for young children with autism:  A research synthesis. Journal of Autism and Developmental Disorders, 32, 423–​446. Johnson, C. R., Handen, B. L., Butter, E., Wagner, A., Mulick, J., Sukhodolsky, D. G., . . . Smith, T. (2007). Development of a parent training program for children with pervasive developmental disorders. Behavioral Interventions, 22, 201–​221. Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-​ analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36, 567–​589. Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism. Journal of Autism and Developmental Disorders, 40, 1045–​1056. doi: 10.1007/​s10803-​010-​0955-​5. Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013). Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–​465.

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Perepletchikova, F., Hilt, L. M., Chereji, E., & Kazdin, A. E. (2009). Barriers to implementing treatment integrity procedures:  Survey of treatment outcome researchers. Journal of Consulting and Clinical Psychology, 77, 212–​218. http://​d x.doi.org/​10.1037/​a0015232 Perepletchikova, F., & Kazdin, A. E. (2005). Treatment integrity and therapeutic change: Issues and research recommendations. Clinical Psychology: Research and Practice, 12(4), 365–383. Research Units on Pediatric Psychopharmacology (RUPP) Autism Network. (2007). Parent training for children with pervasive developmental disorders: A Multi-​site feasibility trial. Behavioral Interventions, 22, 179–​199. Scahill, L., Aman, M. G., McDougle, C. J., Arnold, L. E., McCracken, J. T., Handen, B., . . .Vitiello, B. (2009). Trial design challenges when combining medication and parent training in children with pervasive developmental disorders. Journal of Autism and Developmental Disorders, 39, 720–​729. Scahill, L., McDougle, C. J., Aman, M. G., Johnson, C., Handen, B., Bearss, K.,  .  .  .  Vitiello, B. (2012). Effects of risperidone and parent training on adaptive functioning in children with pervasive developmental disorders and serious behavioral problems. Journal of the American Academy of Child and Adolescent Psychiatry, 51(2), 136–​146. doi: 10.1016/​j.jaac.2011.11.010. Silverman, L., Hollway, J. A., Smith, T., Aman, M. G., Arnold, L. E., Pan, X.,  .  .  .  Handen, B. L. (2014). A  multisite trial of atomoxetine and parent training in children with autism spectrum disorders: Rational and design challenges. Research in Autism Spectrum Disorders, 8, 899–​907. Smith, T., Scahill, L., Dawson, G., Guthrie, D., Lord, C., Odom, S.  .  .  .  Wagner, A. (2007). Designing research studies on psychosocial interventions in autism. Journal of Autism and Developmental Disorders, 37, 354–​366. Tonge, B., Brereton, A., Kiomall, M., Mackinnon, A., & Rinehart, N. J. (2014). A  randomized group comparison controlled trial of “preschoolers with autism”:  A parent education and skills training intervention for young children with autistic disorder. International Journal of Research & Practice, 18(2), 166–​177. Whittingham, K., Sofronoff, K., Sheffield, J., & Sanders, M. R. (2009). Stepping Stones Triple P:  An RCT of a parenting program with parents of a child diagnosed with an autism spectrum disorder. Journal of Abnormal Child Psychology, 37(4), 469–​480.

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About the Authors

Karen Bearss, PhD, is Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington. She directs the RUBI clinic at the Seattle Children’s Autism Center. Eric Butter, PhD, is a Pediatric Psychologist, Associate Professor of Pediatrics and Psychology at the Ohio State University, and Chief of Psychology at Nationwide Children’s Hospital in Columbus, Ohio. Benjamin L. Handen, PhD, is Professor of Psychiatry and Pediatrics at the University of Pittsburgh School of Medicine and Director of Research and Clinical Services at the Center for Autism and Developmental Disorders at Western Psychiatric Institute and Clinic. Cynthia R. Johnson, PhD, is the Director of the Cleveland Clinic Center for Autism in Cleveland, Ohio, and Faculty at the Lerner College of Medicine, Case Western Reserve University. Luc Lecavalier, PhD, is a Clinical Psychologist and Professor of Psychology and Psychiatry at The Ohio State University. Lawrence Scahill, MSN, PhD, is Professor of Pediatrics at the Emory University School of Medicine and Director of Clinical Trials at the Marcus Autism Center in Atlanta. Tristram Smith, PhD, is a Licensed Psychologist, Board-​ certified Behavior Analyst, and Haggerty-​Friedman Professor of Developmental/​ Behavioral Pediatric Research at the University of Rochester Medical Center.

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