Clinic Notes: When Time Out Does Not Work for Children with Autism

In my last blog I discussed how to do time out properly. As I mentioned time out is a often used and misused procedure. But even when used properly time out can have limited success with children with autism. Time out means time out from positive reinforcement. So if a child with autism is engaging in a reinforcing activity such as playing with a toy, watching a video, etc, and you send the child to time out for some inappropriate behavior such as not following directions then time out will in all probability be effective. On the other hand, if you are running discrete trial training and trying to teach a child with autism letters of the alphabet, which is hard for the child, then sending the child to time out for an inappropriate behavior such as not paying attention will not be effective. The drills are not reinforcing so time out will not work. In this situation we usually run the body parts drill. In this drill we take the child’s wrist and use the child’s hand to point to different body parts. Fade the physical prompts as the child begins to do the drill on his or her own. In other words, use less and less force to move the child’s hand as the child becomes compliant. (This is the same behavioral principal a rider would use to get a horse that balks to cross a ditch or go up a hill. The rider would pull the reins to the right or left and make the horse go around in a circle several times. If the horse did not comply then the rider would have the horse go around in circles several more time and try again.

Clinic Notes: Time out and Autism

Time out is an often used and misused procedure. If done properly, time out is a very effective, humane procedure. Find a place in your house where a time out chair, preferably a chair with arms and not a bench, can be left. The chair should face a blank wall and not be close to a window, shelves, glass, electrical outlets, or storage cabinets containing chemicals. Hallways and alcoves often work. Do not use bathrooms or closets. The time out chair should be close to the play area so the child can be placed in time out quickly. Think safety, especially for small children. (If the child is very young, then the baby bed will do, and no, the child will not develop an aversion to the baby bed and have sleep problems. An alternative time out procedure for a young toddler is to sit him/her down on the floor with his/her back to you and hold them there for thirty seconds. Do not talk to the child except to tell him or her at the beginning and end of time out why he or she is in time out.) For young toddlers you can just count to thirty in your head. For older children, use an egg timer and teach the child that he or she cannot get out of time out until the egg timer goes off. The child has to stay in time out for three minutes plus one minute of good behavior. In other words, the child has to be quiet and cannot be arguing, complaining, or tantruming for one full minute before he or she can get out of time out. Do not be surprised if the child comes up with a whole bag of new inappropriate behaviors in order to get out of time out. Kids have been known to gag, vomit, and one of my own kids even hit herself in the face several times. Do not respond and thereby reinforce these new inappropriate behaviors or they will increase in their frequency. Only good behavior gets the child out of time out. (Initially, some kids have to be held in time out. Gradually, decrease the restraint you have on the child and make sure he/she is sitting there quietly for one minute before he/she gets out. If the child is too large to safely hold in time out, then use a response cost procedure instead. In response cost something the child values is taken away temporarily. Examples include watching TV, going outside, videos, the opportunity to play games with caregivers, favorite foods or beverages, a favorite toy, etc.) In the beginning of this procedure, it is not unusual for a child to be in time out for fifteen to twenty minutes before he/she quiets down, and to go to time out as often as twenty times a day. After a few days the child learns the requirements of the time out procedure and he/she gets out in the minimum four minutes. The number of times the child goes to time out each day also drops dramatically. When the child gets out of time out, remind your child of why he or she had to go to time out in a firm tone. Do not be timid with your voice or body language. (Excerpted from my ABA eBook available at www.aba4autism) In my next blog I will discuss why time out does not always work with children with autism

Clinic Notes: Autism and Hearing

Parents and professionals expect auditory processing problems when they see a child with autism cover his or her ears with their hands. Other children with autism act as if they are deaf. Many children with autism, who have partially recovered, report sensory distortions. The sound of a vacuum cleaner or hair dryer may be so loud that it frightens the child with autism. A single voice may be so soft that it is not heard, while several voices, as in a classroom, may be deafening. Temple Grandin’s governess used to punish her when she was a child by popping a paper bag. In my clinic we often run an ABA program to desensitize a child to aversive sounds. Desensitization also works well for the child with autism or other neuropsychological disorders who are distracted by sounds when they are trying to concentrate. Go to my website aba4autism.com for a desensitization program for your child.

Clinic Notes: Autism in Malaysia

Last week I noticed that an order on my website for one of my ABA eBooks was from a woman in Malaysia. I receive orders from all over the world, but I think this was the first one that I have from Malaysia. I recall wondering at the time what services were available for children with autism in Malaysia. I'm still not sure what all the services are like, but a recent report indicates that there was some abuse by parents of the so-called "naughty" children. The National Autism Society of Malaysia (Nasom) has set up 13 Nasom centers nationwide to provide early behavioral management for children with autism. In addition, Nasom plans to train 2000 preschool and primary school teachers on how to teach children with autism. Perhaps things aren't so bad for children with autism in Malaysia.
http://tinyurl.com/mk

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Clinic Notes: Sex Differences and Autism

Autism is 4 to 5 times more prevalent in boys than girls and often more severe. In a recent study at the University of Washington, researchers found that different genes may be involved in autism in males and females. Furthermore, different genes may cause early onset autism and regressive autism. (http://www.emaxhealth.com/37/6827.html).

Clinic Notes: Down Syndrome and Autism

Last year I had a child come to my clinic with Down Syndrome who had recently developed autism. Recent studies find that 7 to 10 percent of children with Down Syndrome also have autism. I think that it is more appropriate to say that they exhibit some autistic behavior. In 1959 the genetic basis of Down Syndrome was found to be trisomy 21 in 95 percent of the cases and the extra chromosome is usually maternal in origin. People with Down Syndrome are depicted in ancient art; so apparently the disorder has been around for a long time. In 1866 Dr. John Langdon Down wrote about the facial similarities of many of his patients with mental retardation using a racial description (Mongol), which unfortunately stayed around for nearly a century. Once the genetic basis of the disorder was known ,the terminology changed and now the correct terminology is to refer to them as persons with trisomy 21 or a person with Down Syndrome. See http://www.nas.com/downsyn/trumble.html for a detailed discussion of Down Syndrome.
Women older than forty or mothers who already have a child with Down Syndrome are more likely to give birth to babies with Down Syndrome, and routinely undergo amniocentesis at sixteen weeks. Taking into account surgical and spontaneous abortions the incidence of Down’s is approximately one in every eight hundred births. Younger mothers who do not undergo amniocentesis deliver the majority of Down’s babies because they don’t get tested. A new test, which combines blood tests and an ultrasound, is 90 percent accurate in the first trimester and can be done four to six weeks earlier than the standard Triple Test. (We understand more about genetics now than we did in John Donne’s day. But it seems like fate still plays a role.)
Children with Down’s have a variety of physical characteristics. Most of these children do not reach adult height. The head is usually smaller (microcephaly) and the nose may be flattened. The tongue protrudes and the eyes slant upward. Many children with Down’s have a rounded fold of skin (epicanthal fold) in the inner corner of the eye. The hands and fingers are broad and have a single crease in the palm. Medical problems may include congenital heart defects, gastrointestinal problems, hypotonia, and acute lymphocytic leukemia. The average mental age is eight years.
Some newborns with Down Syndrome have visual and hearing deficits. Cataracts occur in 3 percent of the cases and glaucoma is more likely also. Hearing should be tested on a yearly basis according to some experts. Hypotonia not only affects mobility it also affects feeding. The protruding tongue means feeding will take longer and dysphagia (difficulty in swallowing) and choking episodes are common. The usual developmental milestones are globally delayed.
Ten percent of kids with Down Syndrome have seizure disorders which are usually tonic clonic. In older patients with Down Syndrome, seizures associated with Alzheimer’s often develop.
Children with Down Syndrome usually do well with ABA. When autistic behavior develops with Down Syndrome the ABA is more difficult.
Go to http://www.aba4autism.com and read case number 15 for additional information on Down Syndrome.