Thursday, November 9, 2017

ABA…it may not be what you think it is

If you’ve ever broached the subject of applied behavior analysis, better known as ABA, with me, you know I’m pretty passionate about the form of therapy. I joke that I sell it as if I’m going to make a commission off of it--that’s because I believe so strongly in it. There are folks who feel completely opposite from me about ABA. Others simply don’t understand it and therefore have misconceptions about what ABA is and isn’t. About 18 months ago, I was fairly clueless about ABA myself. With that in mind, I thought I’d devote a blog post to ABA and put my sales pitch in writing. I’ll also share how ABA has tremendously improved Emelyn’s communication and independence skills over the past year, something that no other form of therapy or educational setting has been able to do.

I’ve heard the following statements more times than I can count, “But isn’t ABA for kids with bad behaviors?” or “My child doesn’t really have bad behaviors.” or “Isn’t ABA just for kids with autism?” If you’ve said one of these things, don’t feel bad, you’re not alone in your thinking. I’m sure I, too, had some of these same thoughts. ABA does sometimes get a bad rap, likely because not everyone does ABA properly. I also think the name, with the use of the word “behavior” is part of the issue. Most people see the word behavior as something that’s bad. If you’re one of those people, substitute the word “action” or “activity” anytime I say behavior. A behavior can absolutely be something positive or beneficial, such as using the potty, feeding yourself, or signing or verbally requesting a want or need. When you think about behaviors in that way, they seem much less negative. Therefore, if your child doesn’t have “bad” behaviors to decrease (though I find that hard to believe because we all have behaviors we should probably examine) then ABA will simply allow you to increase positive or beneficial behaviors.

Emelyn sporting her Halloween shirt
from her ABA clinic.

One of the first things our ABA team taught us was that all behaviors are caused by one of four reasons:

  1. To gain attention.
  2. To access a desired object/activity.
  3. To avoid an undesired object/activity.
  4. To fulfill a sensory need. 

I’ll go in reverse order to address these reasons for behaviors and give a quick Emelyn example:

#4, to fulfill a sensory need, that’s something like chewing on a finger for oral sensory input or flapping arms when excited. These are behaviors that fulfill a specific need for the individual displaying the behaviors and for that reason, they need to be addressed carefully with a Board Certified Behavior Analysis (BCBA). Emelyn, like many girls with DDX3X, is a finger chewer. By redirecting her finger chewing with a chewy tube or providing something to occupy her hands, we are working to decrease the behavior.

Emelyn and Hattie getting a little sensory input with cooking spoons.

#3, to avoid an undesired object/activity, is sometimes referred to as escape behavior. Emelyn, for example, used to kick, cry, and thrash when it was time for us to brush her teeth. By not allowing her to get out of the activity, we quickly established that we were going to brush her teeth whether she liked it or not. We started with just a few seconds and built up from there. We can now brush her teeth for 40 seconds with very little issue, but probably more impressive is that she’s quite cooperative at the dentist. Sometimes Emelyn’s escape behaviors are far less obvious. For example, she sometimes uses her cuteness to get out of work. It’s tricky to spot if you’re not a trained ABA professional (we frequently missed these), but her ABA team sees right through her cute work avoidance behaviors.

#2, to access a desired object/activity, is one of those behaviors that is easy to show the difference between a “bad behavior” and a “good behavior.” Let’s go with “bad” first. When Emelyn is in her chair awaiting her oatmeal in the morning, she’s been known to throw a pretty ridiculous fit. By crying, banging her tray, etc. she’s trying to gain access to the food without being patient. We ignore the behavior, as if it’s not happening, and get her food to her as soon as she calms down. On the flip side, when she waits patiently for her food we acknowledge her patience with, “Good job waiting patiently for your food Emelyn.” Basically, we don’t give attention to the undesired behavior and we do give attention to the desired behavior. Going a step further, if she was using her sign language to sign “eat” then we would acknowledge her with, “Emelyn, I see that you’re hungry. Thank you for waiting patiently. We’re getting your oatmeal ready as quickly as we can.” While I’m not sure she fully understands all of that, she does understand positive language/attention and that’s the important part because that’s how we increase desired and beneficial behaviors. Because of the recent success with sign language, we’ve been working to increase her use of signing. We’ve started with highly motivating signs, such as “read.” She quickly caught on that signing “read” was how she could get a book read to her. It’s cause and effect, the positive behavior gets her the desired object/activity.

Emelyn and Hattie can often be found pulling
books out of Emelyn's book bin.

#1, to gain attention, is probably the biggest as you’ve seen it woven into some of the above examples. It kind of intertwines. Every kid wants attention and I fully believe all children deserve attention. The key is to be sure you’re giving attention to desired/beneficial behaviors in an effort to increase those behaviors and not giving attention to an undesirable/negative behavior in an effort to decrease those behaviors. Most of us know the rule about tantrums, ignore them and they go away, give them attention and you’ll send the message that they work at generating attention. It’s the old adage, “what you permit you promote.” There are other negative behaviors that are a bit more subtle and those are the ones that BCBA’s really do a nice job helping you decrease.

Let’s talk about attention as it relates to desired behaviors. About six months ago Emelyn’s ABA clinic informed us they wanted to start potty training Emelyn. Patrick and were both 100% skeptical. They implemented a reward system for successful voids and we followed suit. First, we decided to try M&M’s. As it turns out, Emelyn seemed confused by the M&M. What got her excited was the enthusiastic, “good job, Emelyn!” that she got after she had a successful void. We’ve now implemented a special potty song in addition to the positive praise. Attention is a powerful motivator, at least for Emelyn. When she does something like use the potty, feed herself, follow instructions, i.e. desired behaviors that are tied to her future independence, she’s really proud of herself and we want to encourage her excitement by showing our excitement.

We teach extended family ABA principles to
help them better understand how to react
(or not react) to Emelyn's behaviors.
Another misconception about ABA is its delivery method. I’ve heard of ABA being implemented in public school settings, but I’m not very knowledgeable about that, so I’m going to touch on the two I am knowledgeable about:

  • Clinic-based: This is how Emelyn receives ABA. She goes five days a week for six hours a day. The word clinic may sound harsh, but visit a clinic-based ABA program and you’ll likely find a facility that looks far more like a pre-school than a clinic—there are toys, learning centers, music circles, and peer engagement areas. In order for children to receive clinic-based ABA, an autism spectrum disorder is required by insurance. 
  • Home-based: Emelyn also receives home-based ABA twice a month. This is to be sure we’re implementing the clinic-based plan in our home, and more importantly, that we’re collaborating on the best ways to increase communication and skills of daily living. In Virginia, in-home ABA is covered without an autism diagnosis for children on Medicaid with a developmentally delayed diagnosis. Many families, especially those with older children in the school system during the day, find home-based to be the best option for their family.

How do I know ABA isn't just for kids
with autism? Because we apply these same
principles to our typically developing

To me, ABA is about finding the right motivators to increase desired behaviors that will help Emelyn develop the skills she’ll need to live as independently as possible. A trained ABA professional would probably say, “Jamie, there’s more to it than that. You’ve left out the whole piece where we measure and chart all of this progress.” (Which is totally true! And I’m sure there is even more I’ve left out.) But, for me as a parent, I know my daughter understands cause and effect and ABA taps into that. Knowing that ABA is more involved than what I’ve explained here, I hope I’ve given you enough information to at least get you thinking about its possibilities. As with all things, do your research and be sure you’re picking an ABA program that’s reputable and working towards the right goals. Visit multiple providers and ask lots of questions. When we picked Emelyn’s clinic we picked it because my momma-gut said it was the right place for her. I’m glad I listened because Emelyn has made tremendous progress and that’s critical at her young age. Her ABA team cares deeply about her future and they are constantly working toward the goals we established together.

People are a great motivator for Emelyn and
that includes her baby sister, Hattie.

I have to give credit to Lauren Abel from Next Steps Academy in Houston, TX. Last April, when we went to Chicago for our very first DDX3X family day, she came and sat down with Patrick, Emelyn, and me. She told us that she was compelled to come talk to us and I’m so glad she did. She saw Emelyn’s potential at a time when we were struggling with Emelyn’s current educational setting. They were seeing her deficits, but Lauren saw her potential. She inspired us to find a team of people who see nothing but potential in our little Emmy.

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