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Meeting Point: Latest From Lovaas

September 07

Meeting Point: Latest From Lovaas

The First Hour of Trent's Intervention Program

In March 2007, four days after his second birthday, Trent, who had been diagnosed at a very early age with Pervasive Developmental Disability, Not Otherwise Specified, PDD(NOS), began receiving Family-directed services supervised by Jennifer, a consultant at the Lovaas Institute.

While it is not uncommon to mistakenly think of initial hours of behavioral treatment, as described in Catherine Maurice's well known book Let Me Hear Your Voice, an ordeal for both parents and children, the first hours are and should be reassuring to the parents, the child, and the new instructors. These are trying hours for everyone involved. The parents are anxious; it is their child's future they are discussing. The new instructors are anxious; they are unfamiliar with the skills needed to teach a young child with autism. The consultant is anxious; will she succeed at building the child's, the parents' and the instructors' trust these first hours, knowing that it is so important for the long and winding road ahead?

"To the untrained eye, the initial consultation may look more like play therapy than behavior therapy, especially for very young children like Trent" says Jennifer. "But the principles and procedures are very much in the tradition of applied behavior analysis."

The first hour of Trent's initial consultation was devoted to identifying reinforcers, that is, items and activities that would help motivate him to learn when the structured part of treatment began and that would give him courage enough to leave his parents for brief moments during the first hour.

Trent was sitting in his father's lap as Jennifer approached him. He turned away from her and hugged his father tightly. Jennifer held up a Mickey Mouse toy that lit up and spun around. Trent turned toward the sound and looked briefly at the toy. A good sign? Yes! Trent did not turn to look the second time Mickey Mouse was spun and Jennifer proceeded to demonstrate a variety of other toys to find out whether any of them would interest Trent enough to look again. Finally, a wind-up car caught Trent's interest. Jennifer placed the car on the table and as it moved across the table, Trent jumped off his father's lap, ran over to the table and grabbed the car. When the wheels stopped spinning Jennifer held out her hand and Trent allowed her to rewind it and hand it back to him. A good sign? Yes! Jennifer kept rewinding the car until Trent seemed quite comfortable in this give-and-take situation, then she asked one of the new instructors to join them and do the same. Trent hesitated a second, but accepted the change in the situation. Once the instructor had rewound the car a few times with Jennifer at her side, Jennifer withdrew to her chair. After a few minutes, Jennifer faded in a second instructor who also successfully played with Trent. Then Jennifer asked for a break to explain what this situation meant. Trent's aunt who was there to help out and who knew Trent well, took Trent with her out of the room.

Jennifer explained that what they had just witnessed was the beginning of trust. Trent discovered that Jennifer and the instructors had something he wanted and they gave it to him. In technical terms, they were beginning to acquire reinforcing properties in their relationship to Trent.

"Intervention is often less structured in the beginning than it used to be in the past," says Jennifer. "How relaxed or how structured we start does, of course, depend on the child's age, the amount of stress or anxiety the child indicates, and the skill level of each child, but for very young children, like Trent, a lot of time is devoted to establishing a trusting relationship. For example, learning to attend to an adult doesn't necessarily have to take place at a table. Beginning therapy should occur where the child feels most comfortable whether it is at the table or next to his mother on the floor or on his father's lap. The objective for us is first to identify toys, activities and foods that are strong enough motivators for the child to want to be around us, and second, to use these items and activities systematically as rewards when we gradually add contingencies for receiving them. Take for instance the wind-up car. When Trent comes back I will place the car on the chair next to the table and Trent will have to walk over and fetch it before I wind it up for him, just a tiny contingency for my help."

Luckily, the wind-up car did not lose it's magic during the next half hour and when Trent returned Jennifer gradually placed other contingencies on Trent's access to it. For example, she built a small tower of blocks on the floor next to his father's chair and with hand-over-hand support, helped Trent knock them down; for this she immediately rewarded him with the wind-up car. The immediacy of the reinforcement would, over trials, teach Trent that he gets the wind-up car for knocking over the tower.

Once Jennifer had successfully demonstrated an activity with Trent, she faded in the instructors one at the time, and guided them through the same process. At the end of the hour, Trent put metal circles in a slotted metal container, played with a ball popper toy, and threw a block in a bucket, all for playing with the wind-up car.

Jennifer also demonstrated how the wind-up car could be used to identify novel reinforcers that Trent had not experienced before. For example, he was willing to be guided by Jennifer to sit on a blanket, and with wind-up car in hand, he "went on a ride" on it, and loved it. Eventually, he also let Jennifer pick him up for a quick spin, which he also liked. These activities were noted on the list of activities and items that was marked Trent's Reinforcers. These events also triggered Trent's parents' memories of other toys and activities he liked and at the end of the first hour, the list extended to at least 15 items that would help Trent in his learning process.

During this first hour Trent would stay with the instructors for up to a few minutes but would sometimes run back to his parents after a brief period of less than a minute. When Trent ran to his parents, Jennifer readily let him go. His parents were obviously his greatest reinforcement at this time, they already had reinforcing properties in abundance. Jennifer would use this knowledge and place a tiny contingency on being allowed to run. The contingency was that he would knock down a tower before he ran, with quick hand-over-hand help from Jennifer.

"To escape from a situation that may suddenly feel too demanding to something that feels good and safe, like being held in mom and dad' arms, is also reinforcement. In technical terms this is called negative reinforcement. We can gradually require that Trent do a little bit more, and a little bit more, before we let him run to mom or dad. He will soon discover that the reinforcement is his, if he just works a little bit for it. This certainty increases the likelihood that he will work more the next time, and before we know it, we are building a new behavior, in this case using escape to mom and dad as reinforcement. Again, this is called negative reinforcement, maybe not the smartest term but it has, as you saw, nothing to do with punishment; that is a misunderstanding of the term."

"Now, this is just the first demonstration. We have lots of time to gradually teach skills," said Jennifer. "The key now is reinforcement."

The names of all children in this newsletter have been changed in respect for family confidentiality.

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