Clinic Notes: The Science Behind ABA

Applied Behavior Analysis (ABA) is the most popular and effective therapy for autism. However, ABA also has it critics who say it is too rigid and creates kids who are robotic. (I have been working in ABA for nearly 40 years and have yet to see ABA produce a robotic child.) A second criticism states that the research behind ABA is modest. Well, I think these critics do not know the history of learning theory and the countless experiments with experimental animals and humans that can be traced back to Thorndike's trial and error experiments with cats in 1898. B.F. Skinner's Functional Analysis of Behavior, which is the backbone of ABA, examined human behavior using behavior principles tested on years of animal experiments. Even today, countless scientific journals publish peer-reviewed studies examining ABA with various clinical populations. Based on decades of research, ABA is recommended as the treatment of choice in treating autism by CDC and other health agencies. How much science do the critics want?

Clinic Notes: ABA and Time Out

Time out means time out from positive reinforcement. If there is no positive reinforcement in the child's environment then time out will not work. Recently, a child with autism in Iowa school was left in time out for 3 hours. Of course, the parents were outraged and called a lawyer. But before the case came to trial the family moved and the school system continues to use its time out rooms in the same way. http://www.kcci.com/education/13826532/detail.html.
There has always been controversy about time out and the Iowa school is not the first to get into trouble over improper use of time out. Parents are always telling me that they have tried time out with their child but it does not work. Time out is a very good procedure when done right and ineffective when done wrong. The standard time out procedure below is the procedure I have been using for 30 + years and it works. It will not work for a child with autism that is removed from an environment that has no reinforcers. For example, an environment where there is too much stimulation or too many demands being placed on the child. Being placed in time out would be reinforcing. And time out should never be used by itself, but always combined with a reinforcement procedure for the appropriate behavior.
Time out 101:
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.
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.
In the beginning of this procedure it's 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. (Record the frequency and length of time outs and you will see the child's progress.)
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. Tell your child that he/she will have to go again if your directions are not followed immediately. Do not be timid with your voice or body language. (Go to www.AbA4Autism.com for ABA programs using time out and reinforcement that eliminate inappropriate behavior and establish appropriate behavior.)

Clinic Notes: Public Awareness of Autism and ABA

According to a recent Schafer Report the mayor of Albuquerque has called for a Town Hall meeting on Developmental Disabilities. One of the panels at the meeting will be devoted to autism. I think this is a great idea. And If I were the mayor I would require all city employees to attend. Policemen, firemen, teachers, anyone who might come in contact with a child or adult with autism should be there. And perhaps a special workshop should be offered as a follow up. I am in the process of trying to organize a day camp for children with autism. Games and other activities would be available, all run by qualified staff. While the children with autism were involved in recreation I would talk to teachers, parents, and other interested adults about ABA and autism and Speech-Language Pathologists, Occupational Therapists, and others ould do their part. And hopefully the community to come together to help fight the epidemic.

Clinic Notes: Diagnosis and Denial--Denial and Diagnosis the Chicken and Egg of Autism

Everyone will agree that early diagnosis of autism and intense ABA, along with other therapies, is effective. Sometimes it is possible to diagnosis autism as early as 18 month and start intervention. But only half of all autism cases are diagnosed before kindergarten most of these the second and third year when language delays and other symptoms of autism become apparent. Parents can be in denial before and after a diagnosis. Last week a mother brought her three-year old child in to my clinic. She had thought something was wrong since the child was two but dad kept saying the child was just hard headed. Mom took a trip with her friends and left the three year old with dad. When she returned home dad told her to make an appointment because something was wrong. In this case the child was able to get a diagnosis and treatment at an early but often we do not see children for the first time until they are six or seven. The parents knew something was wrong but were in denial. And the parents did not seek services until the school system insisted. And it is not always denial in the parents that prevents a child diagnosed with autism from getting services. More often costs, both in time and money are to blame.

Clinic Notes: An ABA Army to Combat Autism

A friend of mine has just returned from Iraq. I was asking him about how the war was going and he told me that the press is not giving enough credit to our military forces. They are well-trained professionals, doing an excellent job, under extremely difficult conditions. This got me thinking about my "war" with autism. Everyday I am asked to travel here and there--sometimes to foreign countries--to set up ABA programs for children with autism. If I can't go then I'm asked to recommend someone. Professional, well-qualified ABA therapists are in short supply. Parents around the country, and the world, cannot find ABA services, and if they do fined someone they are either not qualified or too expensive. I'm retiring from my university appointment, staying on to teach an ABA course and direct ABA students in internships, but most of my time now will be devoted to my practice. What we need is some kind of national program to train ABA therapists--an army of ABA therapist to go out and fight the autism war. Of course we will also need OT's, SLP's, and pediatric neurologists in the army too. If we don't do this we will loose the autism war and there will be a large fraction of a generation incapacitated by autism. Autism research needs to be better supported too, but until we find some answers the ABA army will have to fight the battle.

Clinic Notes: The "Autos" in Autism

In 1943, American psychiatrist Leo Kanner published the first paper on autism. The word “autism” comes from the Greek word “autos” or “self” and was first used by Eugen Bleuler, a Swiss psychiatrist, in 1912. Bleuler described “autistic thinking” as not involving outside reality, but only the individual's inner thoughts or feelings. He thought schizophrenics were locked into this way of thinking. Kanner used the term autism to describe the extreme social disinterest he observed in eleven young children, and thought the disorder was congenital. The stereotype of the child with autism being aloof locked in his or her own little world is still with us. However, I think that I have seen a change in this stereotype during my 37 years of clinical experience. Many of the kids who come to my clinic now with an autism diagnosis are very social or at least interested in being very social. Unfortunately, their verbal communication holds them back so they do not do well socially. Social stories and modeling social interactions can help, but unfortunately many kids do not solve their communication problems earlier enough to develop socially.

Clinic Notes: Jobs for People with Autism

Parents who bring their children diagnosed with autism to my clinic want to to know what the future holds. Of course, they ask about the immediate future, but they also ask about vocations and employment for adults with autism, even if their children are only two-years old at the time. I cannot predict the future, but I was glad to read about a new job placement service for people on the autism spectrum. Natural Learning Concepts which offers books and other materials has a job placement resource at http://www.nlconcepts.com
/autism-jobs.htm. Pro autism employers can post jobs and employees looking for jobs can "network." No word yet on the number of successful job placements.

Clinic Notes: The "Brat Syndrome" and Autism

When I was first starting out in ABA 30 + years ago I recall reading an article titled "The Brat Syndrome." The thesis of the article was that noncompliant behavior and tantrums or "brat behavior" in a child does not by itself constitute any psychiatric disorder or neuropsychological disorder. At the time ADHD was being over diagnosed and often children would receive an ADHD diagnosis just because they were noncompliant and had frequent tantrums (brat like). Now I see the same thing happening with autism. Noncompliant children are coming to my clinic with an autism diagnosis, usually conferred by a Special Ed teacher rather than a psychologist, pediatric neurologist, or psychiatrist. Many of my colleagues and associates do not like me to tell a parent that their child has the "Brat Syndrome." And I certainly do not tell a lot of parents that even when it is true. But a lot of parents are relieved when they hear that their child has the "Brat Syndrome" rather than autism.

Clinic Notes: It's the Season for the IEP's

If you are a parent of a child with behavior problems you have probably had to battle the school system in an IEP to get needed services. Often parents do not know what to ask for in an IEP meeting nor do they know their rights. (Unfortunately, school systems are equally in doubt about the law or play like they are.) For help go to a great website http://www.wrightslaw.com/nltr/07/nl.0516.htm
for help.

Clinic Notes: ABA Workshops: The Good, Bad, and the Ugly

At least several times a week I am invited someplace to give an ABA workshop. The workshop audience that I am invited to speak to may be parents or other caregivers and that's good, but often the workshop is for professionals--therapists, teachers, classroom aides, etc. Nowadays my clinic is so over run with children with autism and my waiting list is so long that I politely decline, but even if I weren't busy I would decline most invitations. The problem is that with the popularity of ABA as a treatment for autism everybody wants to get into the ABA business. Most of the invitations come from organizations that want me to train their staff in ABA. In one day. Then the newly trained staff can go out and do their own ABA. And bill. Families and school systems do not know that the "ABA therapists" they are contracting with only have one day training and know just enough to be dangerous.

Clinic Notes: Asperger's and Bullying

Whenever I get young children in my clinic who have been diagnosed with high functioning autism or Asperger's I think about how they are going to fare in school. Of course, I know that if they are not compliant and verbal and have age appropriate skills they are not going to do well so these are the ABA programs that I run first. ABA programs to develop social skills are not run for a while and if they are then they are run with a lesser intensity. I want these kids to do well socially from the beginning but if I cannot get to the programs I know that social problems such as bullying don't usually start until middle school. I may have to rethink my ABA programming. According to a recent Schafer report Five elementary school student is Oregon are going to be charged with assault after they beat a classmate with autism with sticks.

Clinic Notes: The Two Faces of ABA

In a previous blog I discussed who was qualified to do ABA. With the increase in children with autism, and ABA being recognized as the best therapeutic approach, the number of people holding themselves out to be ABA therapists and preying on an uninformed public is geometrically increasing. Psychologists and Behavior Analysts are big on qualifications. At the same time they say paraprofessionals can do ABA. On my website I tell caregivers that anyone can learn to do ABA and I believe that. But to do ABA independently with someone else's children, without supervision of a Behavior Analyst or Psychologist can be risky.

Clinic Notes: Who is Qualified to Do ABA?

Recently a school system nearby had an ABA consultant come in to give a workshop on ABA for a day. The special education aides were asked to attend as well as the cafeteria ladies. The parents of the children with autism were then told that their children would be given several hours of ABA each week.
ABA is riding a wave of popularity with the onset of the autism epidemic. And many people are offering their services to families and schools. This brings up an important question. Who is qualified to do ABA? Under supervision anyone can do ABA. But without supervision a little bit of ABA knowledge can be harmful. I think that it is very clear that only Board Certified Behavior Analyst or Licensed Psychologists should be doing ABA unsupervised. I have seen many children in my clinic who received ABA from unqualified therapists and did not progress. It is accepted that with autism the earlier the interventions the better. Parents cannot afford to waste a year with an unqualified therapist.

Clinic Notes: Chelation

I've been in practice long enough to remember when children severed brain damage from lead poisoning. Most of the lead poisoning was caused by children eating paint that was peeling off the walls. Now paint does not contain lead and most clinicians have never seen a case of lead poisoning in children. Removing the lead (Chelation) was a popular therapy back the. This week police raided a doctor's office in Pennsylvania who was using Chelation therapy to remove mercury in a child suffering from autism. Chelation therapy for autism is not an approved therapy and is highly controversial. This week police searched a doctor's office whohad used chelation for treating autism in a 5 year old boy who had died. (This is the third death reported.) The family's attorney stated that the physician was ... "giving a treatment that's not an approved treatment for autism. He gave the wrong drug in the wrong dose and he gave it the wrong way."
http://www.pittsburghlive.com/x/pittsburghtrib/s_502280.html
Of course this statement should not imply that's there is a right drug and a right doss and a right way to do chelation.

Clinic Notes: Preventing Autism in Babies

In a previous blog I cited studies suggesting that intensive ABA can prevent autism in high- risk children. (Preventing Autism Now: A Possible Next Step For Behavior Analysis, Philip W. Drash, Autism Early Intervention Center). Now Geraldine Dawson, a University of Washington Psychologist is running intensive ABA programs for children younger than two. Much of her 25-30 hour per week program focuses on social development in order to facilitate language development. Language development by age five is an important predictor of how high functioning a child with autism will be.

Clinic Notes: Catch a Falling Star

A recent cover story in time magazine talked about our failing public education system and possible ways to fix it. According to a recent article (The Painful Parallel Universe of Special Ed Parenting By Bob Sipchen in the LA Times.
latimesblogs.latimes.com/schoolme/2007/01/emotions_best_d.html#more)
much the same criticism could be made of our failing special education program for children with autism and other neuropsychological disorders. Special Ed teachers have too many students with to many diagnoses and a crippling curriculum. They are often pressured into advancing special ed children even though they have not mastered the material or else they may loose funding. Aides in the special ed classroom often do the work for the child because they are not showing progress A child's rate of learning and learning style may not be considered in such an environment. No child left behind is a noble goal but special ed teachers must have the resources and the time to achieve such a goal.

Clinic Notes: ABA for Normally Developing Children

Thirty-seven years ago when I was in graduate school ADHD was in the new as much, if not more than autism is today. Parents were rushing their kids to pediatricians, many begging that they be put on Ritalin. Now it's déjà vu all over again. Parents of small children are now concerned that their child could have autism because they have not reached their developmental milestones as rapidly as some of their peers. These children do not have developmental delays because they still have not reached the end o their maturational period, but their parents are running scared. Reassuring parents that their child is developing normally is not enough. They want ABA to speed up the acquisition of skills for their child. This presents an interesting dilemma. Do I provide ABA for these children or say "sorry" and go to a child on my waiting list who has a diagnosis of autism?

Clinic Notes: Asperger's and ABA

Without question Asperger's is often misdiagnosed as ADHD or bipolar mood disorder and children are given psychotropic medications that do nothing for the conceptual problems and the social problems that are the core of Asperger's. It wasn't that long ago that in my clinic children diagnosed with Asperger's did not usually present until their preteens or teens. But now I am getting children referred with a diagnosis of Asperger's at a much earlier age, often 5-6 years of age. This makes it much easier to run Discrete Trial Training (DTT) on stimuli and concepts that will cause problems later in school. Socialization drills can also be started much earlier when children are kinder to children that are different.

Clinic Notes: Autism Questions Redux

When people find out that I have a clinic for children with autism the first question they usually ask me," Is autism increasing?" And the second question is usually, " What cause autism?" I can throw our some stats and research findings, but, unfortunately, I can't answer either question with any degree of certainty. And I can't do much better on the third question: "Does the mercury in vaccinations really cause autism?" I simply say this question is hotly debated and I am undecided myself at this point. A recent article, (Regressive Autism: Putting Together the Pieces By Michael Wagnitz
(www.americanchronicle.com/articles/viewArticle.asp?articleID=21973)
makes a strong argument for mercury. He cites data from first baby haircuts that find children with autism have seven time higher levels of mercury than normal children. Wagnitz also cites data which finds that monkey brains dosed with mercury have cellular changes which are already known to cause neurodegeneration and these cellular changes are found in autopsies of brains of children previously diagnosed with autism. In the future perhaps I can give better answers

Clinic Notes: What Causes Autism?

Everyone has a theory but know one knows what causes autism according to a recent article (No Easy Answers In Autism
Theories abound, but no known cause or cure for baffling disorder By Lisa Schencker, for the Californian
http://www.bakersfield.com/102/story/104427.html)
Well that's obvious and as the article points out there is no cure and a lot of "businesses" will prey on the ignorance of parents desperately looking for help. Genetics are one of the culprits but something in the environment is also responsible. The data on vaccines being the culprit is equivocal. I think we can rule out social and psychological causes. So that leaves the environment. Well what could be wrong with today's environment? How about the air, the ground, the food, the water, etc. And it is going to be hard to track down the causes or causes. Like everyone else I have a theory. I use to enjoy hunting quail. "Birds" as they are called in the south. Dogs would point the birds, we'd walk in and flush them, and when they flew we would shoot. Quail are delicious, all white meat. But the quail in the south are gone. There are many theories why--almost as many as there are about the causes of autism. I think it has to do with agriculture--fertilizer, pesticides etc. Larger animals survive but the smaller animals are always affected first by poisons. In parts of the south, like Texas, where there is only pasture or open land and no agriculture the quail are still around. Something is killing the quail and something is causing autism. I wouldn't be surprised to see that it was the same culprit.