POOGI for ABA

A team I was working on many years ago was teaching a young child with autism who had minimal language how to talk. One of the things he had learned to spontaneously request was “Oh, no!” When the therapist heard, “Oh, no!” he or she would fall down. It was a highly motivating and fun way to get him to use language. A couple of weeks after he learned this, an evaluator was coming to assess the student. The child ran up to the evaluator, and as the person was saying, “Hello I’m doctor so-and-so,” and extending a hand, the child was enthusiastically saying, “Oh, no!” When the evaluator didn’t respond correctly, the child had a major tantrum that disrupted most of the evaluation.

I think this experience can teach us some important lessons. Some obvious, but one not so obvious. Let’s start with the obvious lessons. First, I knew the evaluator was coming to see this student. There are lots of things I could have done to prepare. In particular, warn the evaluator ahead of time so the evaluation time wasn’t ruined. Second, whenever you are teaching requests, part of the procedure must be to teach the student that the requests are not always available, otherwise problem behaviors are inevitable.

But some people who have similar experiences learn what I think is the wrong lesson. Specifically, some will argue that is absolutely essential right from the beginning to ensure that the child can be understood by novel people to avoid these types of problems. I’ve heard this used as an argument against games like my student learned. I’ve heard this used as a rationale to put an immediate and major focus on articulation. I’ve heard this used as an argument against teaching sign language. A common argument against sign language is, “How will he be able to make a purchase at a store?” “How will he be able to talk with peers in class?”

These are real problems, but I don’t think we need to worry about them too much. Our goal should always be to teach skills that will meet a natural contingency, which certainly means we have to reach the point where novel people can understand. The way to do that is to teach the child to be a sophisticated communicator. If you do that, you will overcome these types of issues easily. Sometimes, it may be possible and beneficial to start out immediately with procedures that novel people can understand (e.g., iPads, PECS, articulation training), but I doubt that means we always have to do that immediately. In my view, there isn’t sufficient research to make a definite determination for every case, and currently it requires some clinical judgment.

My student who started talking by learning to say “Oh, no” became a fairly sophisticated communicator. Whether other procedures would have achieved more, better, or faster is hard to say. But always avoiding these types of activities is a big mistake.

There is a tremendous amount of excellent advice published about effective use of Telehealth for BCBAs. I don’t intend to cover that here as there are many great resources to turn to for those looking for advice. Today, I’m interested in discussing some reasons why Telehealth might actually be an improvement over traditional in-person therapy in some cases.

Many BCBA’s I talk to are absolutely astonished by how amazingly well Telehealth services have gone in some cases. As my friend Alan teaches, when you are surprised, that means that there is something that you didn’t understand about reality. I think it is worth taking the time to think this through. Why is it that I (and many other BCBAs) did not expect Telehealth services to go well, yet in some cases things have gone better than we could have imagined?

Probably, many predicted that Telehealth services would not go well because of the obvious limitations of things you can’t do on-line. Things like the BCBA can’t model during training, the short attention span of some children, and difficulty getting a complete picture of what’s happening online. Let me emphasize that those are valid concerns in many cases, and that in-person services are essential much of the time. In some situations, modifications can be made to make Telehealth reasonably effective.

Given all the issues above, I never would have suspected that Telehealth might actually be a tremendous upgrade in the quality of the services. But it can be, particularly when the primary service being delivered is training. This might happen for a few reasons:

1. Increased Frequency and Duration of Services:
   Often, if I’m doing training for a parent or therapist, I might only see that person once per week, or even every other week. But online, it is no problem to schedule sessions several times per week, or even every day. If I’m providing training, and I have to drive to the client’s home or school, I’m going to want to stay awhile to make it worth the time. I’m not likely to drive 45 minutes to an hour to do a 45-minute session. But in a short session online, we can often accomplish a tremendous amount. In summary, if I have three hours per week to work with a client, I’ll get much more done four 45-minute sessions than in one 3-hour session.
2. A Common Training Error Can No Longer Occur:
   Trainers often do too much of the work for the trainees. Those of us who do this type of work usually love to work with the children, and don’t like to give that up. But trainers have to take care not to take up too much of the training time having people “observe.” Sure, observations can be helpful, but too much observation can waste precious training time. With telehealth, the trainer can’t take over.
3. More Responsibility for Trainees:The trainee has to be really motivated to make training successful. If I’m doing training, I’ll probably be responsible for preparing training materials, supplies, and everything we will need to successfully teach the child. But online, that situation is reversed. It is the parent or therapist that has to make sure all the supplies are ready to go. I believe this advance preparation significantly helps trainees learn more.
4. No Modeling:
   One of the major problems with working online is that unless you have great video models of exactly what you want the parent to do, modeling is generally impractical. One potential upside to this, though, is that the parent or therapist can’t just mimic exactly what you are doing. He or she has to really understand what to do and when to do it. I strongly suspect that this problem may actually make the skills more likely to generalize to similar situations.

For me, the lesson is clear. There are many situations where online Telehealth goes beyond just being practical or nearly as effective as in-person services. There are a few situations where it can actually offer a significant amount of Poogi compared to in-person services.

A common concern among parents of children with autism who have significant language deficits is that they won’t be able to express when something is wrong. For example, if they have a sore throat, ear infection, sprained ankle, or other health issue, they may not have the skills needed to communicate that something is wrong. These types of issues can make problem behaviors, social skills, or school difficulties more difficult.

This creates a major teaching challenge. It is much easier to teach children to talk about things happening inside of other people. That’s because the teacher can be sure of what’s happening in pre-planned pictures, videos, or live models. So, it is usually relatively easy to teach children to label pictures or videos as happy, sad, angry, or even hurt. But teaching them to talk about things inside themselves is much harder. The teacher doesn’t really know what is happening inside the child, so it is hard to provide the prompting and feedback needed to teach children to talk about those things.

The standard answer to what to do in this situation is to wait for opportunities when you do know what happened. This is probably how typically developing children learn to talk about these types of internal events. For example, if the child accidentally bumps his or her knee and starts crying the parent can immediately start talking about that. Oh no! You hurt your knee! Pointing to it, talking about it, etc. While I think that advice is fine, it is rather unsatisfying. First, the child is not getting hurt frequently (hopefully). Second, when a rare situation occurs when the child does gets hurt, it doesn’t mean the parent observed it and is able to take the necessary actions. Third, children with delayed language need many opportunities to learn new, difficult language skills. This procedure usually will simply not deliver enough learning opportunities.

As far as I am aware, there is not a published solution to this problem available in the research literature. But having to deal with this frequent concern from parents, I have improvised a solution that seems to work; and even if it doesn’t work, will likely lead to the child learning some useful language skills.

My suggested procedure is based on clinical experience and interpretation of the basic principles, not actual published studies. It is a relatively simple idea. Teach the child to talk about how things feel on different parts of the body so that when a critical situation occurs, they might be able to generalize to talking about an injury.

Here is how to do it:

1. Teach the child the names of body parts without looking (e.g., cheek, elbow, knee, ear, etc). This can often be made into a game that many children enjoy (e.g., cover your eyes, blindfold, etc)
2. Teach the child to label various sensory stimulation without looking (e.g., warm, cold, rough, smooth, tap, squeeze, soft, hard, etc).
3. Teach the child to combine both without looking. The teacher asks, “What do you feel?” and the child makes responses like “Warm ear,” “Rough elbow,” “Squeeze hand,” “Soft knee.”
4. Keep teaching this skill until the child starts making correct responses on novel, untaught examples, and thus demonstrating that they have generalized use of the skill.

I have used this program several times, and on at least two occasions, I have heard from parents that the child spontaneously used the skill when they actually got hurt. The program is generally well liked by children, teachers, and parents. It also has the potential to solve a huge problem for families.

Of course, it would be quite challenging to prove in a controlled research study that the two-component language skill program is why the children were able to respond accurately in the novel injury situation. But it certainly looks plausible.