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Steven C Altabet, Ph.D
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The Dialogue of Autism #12

3/29/2014

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                                                    The Use of Routines in Skill Building 

One of the hallmark features of people with Autism Spectrum Disorders is a strong preference for routine behavior.  The routines can appear nonsensical and interfering for outside viewers, but may hold significant importance for the person with ASD.   Routines frequently allow the person with ASD to engage in established behavior patterns without having to integrate much new information, which can be potentially overwhelming.  From what I've observed over the years, I believe that the need for routine is so strong for people with ASD that it cannot and should not be extinguished.  Instead, the need for routine can be used as a strength in skill building, independent behavior, and eventually employment.    

One of the easiest ways to incorporate routines in a positive way is with the establishment of morning and bed-time routines.  Building on the last post about task analysis, set up a stepwise procedure for getting ready in the morning for school or work and for getting ready in the evening for bed.  The steps should be consistent with the person's abilities and preferences so the individual will be able to complete the procedure with little to no resistance.  Help can be provided when needed until the person feels more comfortable completing the steps independently.  A routine is established when these procedures are repeated daily.  The repetition over time will allow the person to have comfort and familiarity with what is expected, typically resulting in less resistance and more independence.  Routines can be used for a multitude of behaviors including self-care, homework, and work related tasks.  

Some care must be used in establishing routines, however, as once a routine is established it is very difficult to break or modify.   Make sure that the routine is set up in a way that it can be carried out consistently.  For example, if the morning routine takes a specific amount of time then it is imperative that the necessary amount of time is available in the person's schedule for completion of the routine.  Consistency of routines needs to be across settings and people as well as time.  A new job coach or supervisor needs to allow the employee with Autism to work within their regular routine.  The same with a new teacher or caregiver.  

That does not mean that routines are unchangeable.  Sometimes routines need to be altered for legitimate reasons.  For altering the timing of a routine, show the person with ASD the proposed time change on their calendar and explain and reasons and logistics of the change.  For example, if a morning routine needs to start earlier in the day, the person may need some assistance in resetting their alarm or be shown on a clock the new time for the routine.  If the steps of the routine need to be altered, review the new task analysis (list of steps) and show the person with ASD how it is different.  Some practice sessions may be needed with the new routine before it is formally adopted.    

There are many jobs and activities in society that require repetition and routine for success.    Since people with Autism have a natural tendency for this type of behavior,  using routines for developing skills and independence can not only be helpful for the person with Autism individually, but can help the people with Autism get more opportunities to make greater contributions to society in general.    

Steven C. Altabet, Ph.D.
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The Dialogue of Autism #11

3/23/2014

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                                                Task Analysis - Breaking it Down

Many people with Autism have deficits in Executive Function (EF).  EF refers tot he brain's ability to organize information and regulate your thoughts and actions.  Some people refer to EF as the 'brain's secretary.'  Without a well developed EF, people are unable to organize all of the information they receive and thus have difficulty planning out and completing even the most activities without becoming overwhelmed.  This can lead to individuals resisting activities even when there is positive incentive for completion.  for people with a poorly developed EF, the effort and emotional stress associated with doing activities requiring organization and planning exceeds and positive consequence they may receive for completion.  This avoidance is often more powerful and negative consequences for incompletion as well.

Fortunately, there is a method helping people with poorly developed EF to complete activities and develop skills.  Applied Behavior Analysis (ABA) therapist call this a Task Analysis.  A task analysis refers to breaking an activity down into a series of short discreet steps.  These steps are then put on a picture or word list for the person to use as a reference.  This allows the person with an EF deficit to only have to think about one small step at a time.  Organizing thoughts or keeping track of multiple steps is not required saving the individual from being overwhelmed and making them more likely to attempt and complete the activity.  For example if one wanted to make a task analysis for washing your hands, it look like this:

1. Turn on cold water 1/2 turn 
2. Turn on hot water 1/2 turn
3. Place both hands under faucet.
4. Squirt soap on hands.
5. Rub hands with soap.
6. Place hands under faucet again.
7.  When soap is off, dry hands with towel.
8. Turn off water.

This can be modified to meet the person's needs.  Some may need pictures or less words, but this type of approach can be used for not only simple tasks like this, but for more complicated tasks as well (.e.g. school assignments, chores, work activities, finances, etc.).  In general if a person with EF deficits is resisting a task it is likely because they perceive the task as either too larger or too difficult.  Often times a task analysis can make the activity seem less daunting.

The other key aspect of the task analysis is the list itself.  Having the reference list with the individual steps is highly important.  It allows the person to see the steps so they do not have to think about them.  It also helps because the person realizes that if they forget a step they can refer to the list.  This further creates a sense of independence because if the person has access to the list (and understands it) they do not have to rely on others to tell them what to do.  If a person can complete a task independently that they were once not able to do, the sense of accomplishment is often greater than any reward or incentive that is given.

Steven C. Altabet, Ph.D.         
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The Dialogue of Autism #10

3/13/2014

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                                                            Positive Use of Routines

The strong need for routine by most people with Autism can often lead to distress and challenging behavior whenever a routine is interrupted, postponed or changed in some way.  However, this same need for routine can also be used to  help people with Autism learn new skills and increase their independence.  Many people use routines in their everyday lives to help get ready in the morning for work or school and in the evening to get ready for bed or the next days activities.  

When teaching people with Autism, any new skill can be made into a routine by taking the steps of that skill and repeating them THE SAME WAY each time the person performs the skill.  It may take several, if not more, repetitions before the routine is learned, but once it is the person with Autism will be able to perform the task based on rote memory rather than conscious processing.  In other words, the individual will not have to think about what to do.  They will automatically know it.  Once the knowledge/procedure becomes automatic
then a simple cue may be all that is needed to allow the routine to be completed independently.  Routines are not just for morning and evening preparation, but can be used for self care, chores, homework, paying bills, and other independent living skills.  When routines are incorporated into a schedule (see previous post) they can be more easily remembered and carried out with less prompting. 

While routines can be helpful for strengthening skills, they can also contribute to resistance to change if certain safeguards are not put into place, namely generalization and transition.
Generalization refers to the ability to transfer new skills or knowledge across different situations (e.g. people, settings, and times).  People with Autism typically have difficulty with generalization, unless the generalization is built into the training.  That involves the person perform the new skill/routine with different people, in difference places, and at different times.  More details on generalization will be described in a future post.  In addition, there are times when a routine needs to be changed for reasons that cannot be helped.  Many people with Autism also have difficulty with transition and sudden change.  Adaptation can also be incorporated into training.  Once the base routine is established, flexibility can be trained by introducing small changes into the routine (one change at a time) and giving the person advance warning about the change(s).  Transition strategies will also be discussed in more detail in future posts.  

By using routines to help teach new skills and encourage independence, a characteristic that was once seen as a weakness can now be viewed as a strength.  some people view this as compensation.  I see it as taking your natural gifts and using them to your advantage.  This theme will be emphasized in many of the upcoming posts.     

Steven C. altabet, Ph.D.
 
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The Dialogue of Autism #9

3/7/2014

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                                                       Respect the Schedule


Last week's post provided an overview of how Positive Behavior Support (PBS) strategies could help establish a calm and predictable environment that allows the person with Autism to slowly be able to explore their world and learn new skills.   Over the next several weeks specific PBS strategies will  be outlined to help put these principals into practice.  It is important to remember that each of these strategies will need to be tailored to the individuals' preferences and abilities, but hopefully this will give you a general direction in which to start.  Also keep in mind that each individual may respond better to some PBS strategies over others, so do not get discouraged if one of the strategies is working more effectively than the others.   


The first PBS strategy to be discussed is establishing a schedule.  This is typically the first strategy offered by therapists who serve individuals with Autism because it provides the foundation and reference point for all of the others strategies.  Setting up a schedule establishes a predictable routine and sets up expectations for the day, week, work routine, etc.  Schedules are most effective when they are consistent with the person's abilities (e.g. using pictures for those who communicate nonverbally) and the schedule is reviewed with the person prior to starting the activity.  Here are some examples of different types of schedules:


Daily Schedule - List the daily activities in the order that the person is expected to do during the day.  This is just as important for home as it is for school.  Include daily self care routines/activities as well as time for school work, chores, free time and play.  Inclusion of preferred activity in the schedule is very important so the person knows there is something positive to look forward to.  Sometimes placing a preferred activity directly behind a work or chore activity can serve an incentive for completing the work.  With individuals who go to school or work, it may be important to schedule some free/down time immediately upon returning from school or work so the person can wind down from the stressful day before having to exert more effort and concentration.  Transition times are typically best when they are 30 minutes or less because if the persons with Autism relaxes too much it will take too much effort for them to get started again.  Nonnegotiable/special interest activities need to have their own place in the schedule.  This schedule should be reviewed daily, with any changes in the schedule reviewed prior to the change.


Weekly/Monthly Schedule - This is typically used for scheduling special events that are not part of the daily routine.  This could include a family trip, visit to a doctor (if not a regular appointment), or a holiday.  The idea behind this is to prepare the individual for the changes associated with these special events.  This type of schedule can also be helpful with planning long range work projects or term papers by having different stages of the project scheduled intermittently.


Work Schedule - Work activities can be more easily completed when the work is broken up into a series of discreet steps and the steps are detailed on an ordered list.  Including time constraints may be important for some individuals so they become aware of how much time/effort to devote to a specific activity.  For those who are more obsessed with time, however, the inclusion of time constraints may make the person too anxious and interfere with their ability to complete the activity.  


Once these schedules are established programming for educational, social, and family activities becomes easier.  They key is for consistent review of the schedule with the schedule being visible, understandable, and accessible.  The schedule can always be used as a reference during periods of uncertainty.  Consistency in reviewing and implementing the schedule is necessary, as it may take some time for the person to get used to following it.   Once the person with Autism gets used to the schedule, however, it will be hard for the person with Autism, as well as the people supporting them, to imagine life without it.


Steven C. Altabet, Ph.D.          
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The Dialogue of Autism #8

3/1/2014

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Hi all,
Thanks again for coming back. For those of you who are new to this series, the first seven posts focused on interaction techniques aimed at better connecting to people with Autism Spectrum Disorders. The next several sessions will focus on Positive Behavior Support that I consider the behavioral foundation for working with people who have Autism.  Today's  post will review what Positive Behavior Support is, along with a general philosophy of the approaches.  The more specific/technical aspects of the approaches will come in later posts. 

Positive Behavior Support is a form of Applied Behavior Analysis (ABA) that focuses on strategies primarily aimed at preventing problem behaviors and correcting inappropriate behavior by emphasizing appropriate alternatives.  The strategies are set up to be consistent with the way a person with Autism frequently thinks and processes information. In general Positive Behavior Support are driven by the following guidelines.


Key Aspects of Positive Behavior Support

Prevention - The majority of strategies discussed will be aimed at preventing problem behaviors from occurring, either by setting up the environment for a successful interaction or by teaching alternative behaviors that may reduced the need for or take the place of a problem behavior. 

Predictability - All strategies discussed will be presented in a way the is consistent with the person with Autism's need for predictability.    People with Autism tend to respond much better when they can anticipate an action or predict an outcome.

Expectations - A major focus of the approaches will center on letting the person with Autism know what to expect.  People with Autism typically thrive on expectation when the expectation is clear and is presented in a way that attainable (see section on Teaching and Gradual).

Consistency - Consistency is very important with any type of intervention, because consistency allows for a sense of predictability, which is important for reducing anxiety and resistance. 

Positive - Nobody likes to experience negative news, feedback, or consequences.  However, people with Autism tend to be more emotionally sensitive than most (even if they have difficulty expressing it) and the negative feedback or consequence tends to result in such an intense reaction that the person with Autism is often unable to process the situation and learn from result.

Teaching - Once a calm and predictable environment with positive expectations can be gained through the teaching of skills.  The assumption in most cases is the person with Autism is behaving inappropriately because they do not know of a better that way will work for them.  It is our job to teach them that better way.   

Gradual - Because of a person with Autism's sensory and neurological sensitivities, the teaching typically has to be done gradually to be effective.  Information that is presented too quickly or is too large in scope will be overwhelming and met with resistance.  A gradual approaches ensures a positive experience and greater willingness to participate in the next lesson. 

Physical - Because Autism is a neurologically based disorder, helping the person achieve an optimal physical state is important for helping the person concentrate and control their impulses/emotional reactions.  It takes quite a bit of effort for a person with Autism to concentrate and control their behavior and fatigue can certainly impair that ability.  Factors that can positively or negative affect physical functioning are sleep, nutrition, exercise, and stress. 

Natural - All behavior has consequences, some immediate and some long term.  Either way, Positive Behavior Support emphasizes the natural consequences that go along with every behavior.  It also helps the person with Autism understand those consequences so they can act in a way that best benefits them.  

That is all for now.  Again, this was just a philosophical overview.  Next week's post will begin to explore specific Positive Behavior Support strategies.

Steven C. Altabet, Ph.D.   

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    Steven C. Altabet, Ph.D. Licensed Clinical Psychologist with a specialty in Autism Spectrum Disorders  

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