Within Stepping Stones’ treatment program, emphasis is placed on acquiring new and appropriate behaviors. When children have a repertoire of constructive behaviors, problem behaviors often occur less frequently. Therapists are trained to ignore undesired or disruptive behavior but to promote compliance and other positive behaviors through the use of reinforcers. Reinforcers are chosen to be whatever the child desires most that is appropriate for use in such contexts as modified DTT. Many young children initially respond to tangible or concrete reinforcers such as candy, or perhaps the chance to play with a favorite toy. Such tangibles are extrinsic in the sense that they do not occur in natural settings (e.g. teachers do not normally allow a child to go play or have a piece of candy for giving correct answers). Concrete rewards are faded as quickly as possible and replaced with social rewards such as praise, tickles, hugs, or smiles.
The purpose of our program is to teach these children how to learn through acquiring academic, language, social, and appropriate behavioral skills. Behavioral methods enhance learning not only by teaching the child but also by replacing challenging behaviors with more appropriate ones. The child’s success is closely monitored by detailed data collection. Skills that have been mastered (successfully performed with some stated frequency, e.g. 80% or better across two or more therapists) are placed on maintenance so that the child does not regress in those skills as new skills are introduced. A maintenance schedule is created to allow for periodic revisiting of learned skills to keep them fresh while the day-to-day progression of new skills continues.
Stepping Stones’ treatment program involves a range of different skills that are taught to each child, using a range of locations in which to conduct the treatment sessions, which allows for generalization, and particular strategies to cope with challenging behaviors where necessary. As the child masters these skills, it becomes important to deliberately increase variability in order to facilitate generalization to all persons and settings in the child’s natural environment. Changes in instruction are made if the collected performance data indicates that modification is needed for the child to achieve successful mastery of the skills.
Intensity of Intervention: Teaching is a process that will change over time. Initially, the duration of time spent in formal and even modified DTT steadily increases as the child becomes comfortable with the intervention. In determining the intensity or number of treatment hours, the child’s daily schedule should be considered in order to determine an appropriate balance between periods of intensive teaching and less intensive, though still structured, activities, as well as allowing for the child’s need to have periods of free time. Besides the number of hours of 1:1 teaching, the quality of teaching and the degree of structure provided outside the formal treatment hours should be considered. Research shows that many children will do best with 30 or more hours per week of direct instruction. The duration of the treatment sessions are adjusted to provide maximum benefit. Generally, it is recommended that treatment sessions last 2-3 hours. Once the child is spending part of the day in school, it may be advisable to reduce the treatment hours at home. Although not confirmed by research, it is believed that the most appropriate age to begin intensive ABA treatment is between 24-36 months (before 3 ½ years of age).
Most children are between the ages of 2 and 3 when they enter our program. Every child’s program is individualized in order to meet his or her particular needs. The following is an example of how time is allocated in a typical 3-hour therapy session:
• 20 minutes Structured Play (inside)
• 80 minutes Language (e.g. short breaks throughout: up to 20 minutes language followed by 5-10 minutes play; up to 20 minutes language; 5-10 minutes play; etc.)
• 30 minutes Self-Help Skills
• 30 minutes Structured Play (outside)
• 20 minutes Record Completion and Debriefing
Within this distribution, behavior continues to be monitored and modified, as needed, through various behavior management strategies. Any part of this distribution may be increased or decreased dependent upon the child’s age, stage of treatment and school requirements.
A positive and systematic approach to teaching functional skills and reducing problem behaviors as well as creativity and flexibility, capitalizing on the resources available for each individual child, is strongly emphasized in each child’s individualized program. In the initial treatment phases, all members of our treatment team adhere consistently to the smallest details of the teaching plan. There are a wide variety of teaching strategies that are used within our ABA as well as other interventions. Each child’s program is developed to include skills such as imitation and play (see following table). However, the emphasis of the program shifts during the course of treatment, dependent on treatment progress and behaviors, though the treatment’s general structure remains the same.
Goals For A Developmentally-Based Program
|Children Under 5||Children Over 5 With Language||Children Over 5 Without Language|
Intervention consists of a combination of interventions designed to increase communication, play, social and self-help skills. Skills that are prerequisites to language are heavily emphasized. Such skills are attention, cooperation, and imitation. This is a good example of how the steps must build from one another. If a therapist is not able to achieve the attention and cooperation of the child, it will be extremely difficult to teach language. Therefore, a strong emphasis is placed on the development of appropriate attending behavior, speech and language, conceptual and academic skills, as well as promoting play and social skills.
For young children (under the age of 5) diagnosed within the autism spectrum, the program emphasizes development in the following areas:
1) attending to elements in the environment, especially to other people; 2) imitating others including both verbal and motor imitation; 3) comprehending the use of language receptively (e.g. building on functional communication skills); 4) playing with toys appropriately to promote functional use of toys and symbolic play; 5) social interaction with others, especially peers; 6) making choices; and 7) following daily schedules and routines.
As the child becomes older, the emphasis shifts to practical knowledge and adaptive skills along with alternative means of communication, if speech has not developed. The curriculum is developmentally sequenced so that more basic concepts and skills are taught first and complex skills are not introduced until the child has learned the prerequisite skills. However, the process of program design and implementation cannot rigidly be expected to follow a fixed order. Although it is not the usual pattern, some children learn to read before they can talk. For example, with non-verbal children who enter our program, receptive language is often addressed through matching words to pictures and pictures to words. Therefore, these children begin sight-reading by utilizing receptive language as part of their program.
We believe that it is important to build on a child’s successes and expand the utilization of existing skills as well as encourage the development of new ones. Some children may never learn to talk and will need an alternative means of communication (e.g. using pictures and/or sight words). Therefore, utilizing the child’s areas of strength and building upon them as rapidly as possible, while simultaneously attempting to offset the areas of weakness, is of great importance in our program. These teaching methods are based upon the application of a learning theory where the approach is very pragmatic.
Instruction Plan: The following table highlights the essential elements of the treatment plan utilized within our program. The first step in developing a plan is to specify an objective for each of the skills to be taught. This degree of specificity allows the therapist to objectively determine when a skill has been achieved. Behaviorally stated objectives include three major parts: 1) a statement of the condition in which the behavior will occur (e.g. “when instructed” and “randomly presented”); 2) a statement of the expected behavior (e.g. “imitate 10 motor movements”); and 3) a statement of the criteria for attainment (e.g. “with 80% accuracy across three consecutive sessions with at least two therapists”).
A lesson plan provides a definition of the target behavior. Normally, this is needed most when the skill is very complex (e.g. positive social interactions) or when targeting the reduction of problem behaviors (e.g. screaming). A clear description of the behavior helps to ensure consistency in the implementation of this treatment program and identifies what responses should result in positive reinforcement. Consistent administration of consequences helps the child learn correct vs. incorrect responses and acceptable vs. unacceptable behavior as determined on an individual case-by-case basis. In addition, another aspect of the lesson plan involves specifying, in writing, where the training will occur and under what conditions so that the instructional context fosters consistency across multiple therapists.
Essential Instruction Plan Elements
|Instructional Location||Instructional Conditions||Skills to be Taught|
|home and/or school||
||Behavior objectives for each skill (expected behavior):
When describing the instructional context, we visualize three points along a continuum. These three points include: 1) direct teaching; 2) activity-based instruction; and 3) incidental teaching. In direct teaching, the therapist maintains unusually tight control over the instructional activities. The therapist and the child sit face-to-face, and trials are presented in rapid succession. In activity-based instruction, the instructional trials are embedded within a specific activity. For example, language promotion trials might be embedded within an art activity. The therapist may intentionally fail to provide all the materials and teach the child to ask for them. Both direct teaching and activity-based instruction are typically led by the therapist (i.e., the therapist controls the materials, asks questions, etc.). In contrast, incidental teaching typically involves child-directed activities.
The therapist observes and interacts with the child and uses any naturally occurring opportunities to provide relevant instruction (e.g. the child indicates that he wants a drink by pointing to the refrigerator, and the therapist models the correct language).
Direct teaching sessions (e.g. DTT) are more highly structured and allow for more repetition of trials than either activity-based instruction or incidental teaching. On the other hand, activity-based instruction and incidental teaching often result in greater generalization of skills taught. All three strategies are important and are utilized at different times depending upon what specific skill is being taught and the child’s ability to respond. For example, it may be necessary to teach vocabulary to a highly distractible child using direct teaching methods. Then, once vocabulary has been acquired, activity-based instruction and incidental teaching methods are utilized to make the skill functional. Therefore, thoughtful planning results in greater consistency across team members and leads to more successful outcomes for the child.
Our program stresses direct measurement of the child’s performance. Direct evaluation is crucial because it allows the treatment team to determine the child’s progress as it guides objective and clinical decision-making. The assessment and documentation of a child’s pre-intervention or baseline behavioral performance is essential for treatment planning, decision-making, and evaluating the effectiveness of the intervention. Data collection begins prior to the first day of intervention. A baseline level of functioning provides information on the child’s current level of functioning. In turn, this information assists in the development of realistic objectives, establishing performance criteria, and developing task and step analyses. In addition, baseline data provides the “before” picture with which to compare treatment results (the “after” picture).
Baseline data is typically collected for a minimum of three data sessions and continues until a stable baseline is achieved. We record where a target behavior occurs, which often takes place in the home, school, or a center-based facility. Then a target behavior is narratively defined (e.g. “Aggressive behavior is defined as biting, scratching, and/or hitting self or others.”). Finally, each occurrence of the behavior is recorded. This includes the Antecedent (what happened before the behavior occurred), the Behavior, which is defined and described in detail, and the Consequence (what happened after the behavior occurred). In addition, the time the behavior begins and the time in which it ends is recorded in order to achieve a baseline of how long each behavior typically occurs. The result of such data helps determine whether or not there are less opportunities given for the behavior to recur (e.g. antecedent is modified), after having observed such behavior to occur, as well as whether the consequences in preventing such behavior from recurring are effective. This information helps confirm that our program produces those skill developments as claimed by experts in the field. Therefore, an ongoing assessment of progress towards outcomes, as measured by individualized data collection systems, continues to be a major part of the program in order to guide the intervention process.
Data collected per treatment session reflects information that is specific to both teaching target skills and observations of behaviors.
In addition, regular clinic team meetings take place for each individual child. These clinic meetings often take place every two weeks. They serve as forums for discussions concerning the child’s treatment program and provide continued training for the treatment team. These meetings focus on demonstration of teaching sessions with the child so that the team can observe the various interventions that take place (which allows for more consistency with therapists’ performance), reviewing the effectiveness of the treatment program and making program modifications, as needed. The meeting consists of behavior therapists, the behavior consultant/case supervisor, parents, and most importantly, the child. We welcome any other individuals working directly with the child (e.g. teachers, speech therapist, etc.) to attend and participate in these meetings, as these individuals are also an integral part of both the child’s treatment team and treatment program. Therefore, collaboration between the family members and service providers as well as flexibility in adjusting strategies in a timely manner is key in this evaluation process. All of these aspects of communication and planning are facilitated by clear and consistent treatment documentation.