POOGI for ABA

Frequently, I’ve discussed a variety of problems that occur when we attempt to measure progress in ABA for children with autism. Even when the data are collected perfectly, a variety of factors can make it look like the child has made more progress than he or she really has. Those issues can be problematic, because they can lead to bad treatment decisions.

I believe that one way to partially overcome some of those problems is to decide this ahead of time:

What will we consider success in ABA treatment?

There is only one answer, regardless of the child:

What happens after treatment ends?

We are thrilled when the child reduces tantrum behaviors, learns new words, eats something that isn’t orange, uses the toilet, or learns a new leisure skill. But if the child only uses those skills in therapy, it probably is not very meaningful for the child’s life.

Now, many times we have to start in a place that is very far from what it might look like when therapy ends. Sometimes, it can take a long time to get to the point where the skills are useful outside of therapy. We understand that. But if you start with the idea that success is what happens when therapy is over, you are much less likely to fool yourself with great looking videos, reports, or graphs of hundreds of changes that were made. There are lots of ways to do that which won’t last over time.

Of course, we don’t want to wait until therapy ends to see if we are successful. By then, it is too late. We need to do testing to determine if the long-term success if likely.

I have frequently discussed on this blog that while ABA has been extremely successful in the treatment of problem behavior, there is a very high risk that the effects will not last over time. That’s probably because the new behavior changes did not work under real world conditions. This has been understood since the earliest days of our field. Teodoro Ayllon and Nathan Azrin called this the relevance of behavior rule.  The rule simply states that you don’t change any behaviors that won’t work in the real world after treatment ends.

This puts BCBA’s in a conflict. On the one hand, we want to focus on the long term to ensure that our treatment will work in the real world and maintain over time. On the other hand, we have pressure to handle immediate problems. The parents are upset about the behavior in church or not being able to find a babysitter. The art teacher is complaining about behavior in class, the social worker wants intervention on peer interactions, and the bus driver says he won’t stay in his seat.

The basic problem is that we only have one good long-term solution. That long-term solution is to teach the skills needed to be successful in natural situations. It requires careful programming done in a step-by-step fashion until successful. Unfortunately, for many children, that can take a significant amount of time. It is not likely to help the bus driver worried about tomorrow’s ride. If you try to put the long-term solution into effect in every natural situation, right away you will almost certainly fail to be successful.

Now, we do have a lot to offer that may help all those other situations relatively quickly. But those procedures are not long-term solutions. Those are short-term fixes to get us to the point where the long-term solution becomes possible. But those short-term fixes can actually look really good for a long time. Don’t get fooled by the data. You need to do a lot more to ensure long-term success. 

In my view, in most cases, the solution to the problem is comprehensive treatment with two behavior plans. First (and most important); a plan to teach the necessary skills to ensure success over the long-term. Second; develop procedures to immediately help parents, teachers, and others who interact with the child. Those procedures will likely look very different from the procedures we are using to build the long-term skills. Although this is different than the traditional advice, I think the logic of two behavior plans is compelling.

Many children with autism and other developmental disabilities struggle to learn communication skills. Today, I’m making a simple argument that often, teaching pointing is a simple thing that can be done relatively easily with most learners that has a huge potential to make a big difference in his or her life. Unfortunately, in my experience, teams rarely pursue this as one of the skills they choose to teach.

There are a variety of ways to teach children who need help learning to communicate how to indicate their wants and needs. Some children can make excellent progress using their voices right from the start of therapy. Others can benefit from a wide variety of effective procedures. A few examples include:

• Teaching children sign language.
• Teaching children to communicate using pictures (Picture Exchange Communication System-PECS).
• Teaching children to communicate with speech generating devices (iPad with an app like proloquo2go).

All of these systems have advantages and disadvantages, and a particular system might be more or less appropriate for a child based on his or her individual needs. Often, I think there is a reasonable argument to be made for a child to have multiple systems. There are many articles debating fine points like you can’t take the PECS book with you in the pool, the cashier won’t understand sign language, or what happens when the iPad isn’t charged.  I don’t intend to get into that here.

Today, I’m just making the simple point (ha!) that teaching pointing in addition to whichever other communication system(s) you use can make an enormous difference. Although this skill is known to be useful in the ABA world, rarely do teams pursue this. I suspect that part of the reason might be that as far as I’m aware, this skill has not been researched thoroughly. Some of the advantages to teaching pointing include:

• Many learners, even those with the most severe impairments, can learn to point for things they want in a relatively short period of time. It does require a good teacher who is skilled at shaping. But unless there are severe physical limitations, most learners can acquire this skill.
• Often, after a few days of teaching, learners will generalize this skill and be able to use it in a wide variety of contexts to ask for many items. With any of the other systems described above, it will typically take much longer to acquire a large number of items. This makes it possible to reduce frustration much faster with many children.
• Children with autism often want things that aren’t easy to communicate with sign language, PECS, or even speech generating devices. This includes things like getting a specific piece of Play-Doh, rubber band, something lined up, a piece of string, or a person to play in a particular way. All children, but especially children with autism, want idiosyncratic things that aren’t simple to communicate. Often, this becomes possible through pointing. Children can often learn to show us what they want this way, which wouldn’t be possible with any of the other systems. Again, it gives the child a way to communicate relatively quickly.
• Later, when the child has a strong pointing repertoire (often just a few days of teaching), this skill can be used to teach other skills. When the child communicates what they want through pointing, you now know what they want in that moment, which is the perfect opportunity to try to teach sign language or vocalizations.

Of course, teaching pointing does not eliminate the need for other more comprehensive communication systems. But it can be a quick win that can make a huge difference.