Step 1: When implementing a therapy with a child (or adult), first identify the biggest needs. In the case of our autistic son, Greg, he stopped brushing his own teeth, dressing himself and engaging in any sort of task independently when puberty hit. He lost his ability to make a choice, even between a red and a blue M & M! We were flabbergasted. Why was color important? To the ordinary child, a handful of M & Ms entered the mouth without a thought about color! To Greg, there was a right and wrong, and he got stuck. It’s just one of those peculiarities of autism that many parents of children on the spectrum deal with from one moment to the next.
With the goal of promoting greater independence in adulthood, ensuring Greg’s ability to function in a group home someday without us and providing him with some tools to fall back on should this stage of “helplessness” ever hit again, we wanted an intervention that had measured success, behavior modification therapy.
Step 2: Identifying what type of reward works with your child is an essential part of this therapy. Greg’s aide and I identified several: lots of verbal praise, one minute of putty time, a short trip outside to play with water balloons, a favorite candy, time out with the aide to relax, a short car ride up the mountain and back, a walk in the neighborhood and others, all quick rewards that could be done in a few seconds or minutes. On the long term after a larger success? Watching a video, going to the mall, going to an IMAX, going to the arcade, going bowling, and others, all available with the spin of a dial on a spinner board, adapted especially for Greg when he met a goal.
Step 3: Our next step was to break each large task into as many small tasks as possible. For example, brushing one’s teeth involves: picking up glass, turning on faucet, filling glass, setting glass down, grabbing toothbrush and toothpaste, opening toothpaste, putting toothpaste on brush, putting brush on sink counter, closing toothpaste, putting toothpaste on counter, brushing teeth to the count of twenty, spitting, rinsing mouth, rinsing toothbrush, placing toothbrush in empty glass. Believe me, if we missed a step, Greg let us know every time he got stuck at something we had not reinforced during practice sessions. We even had to work with “handedness”, spending time helping him determine which hand he preferred to hold the toothbrush! We spent months re-teaching him each and every step. Re-teaching? He’d brushed his teeth independently as a young child, but lost the skill. Gone, kaput, disappeared! We will never know why, but what we did know was that we had to instill in him some kind of independence in moving through tasks or he would never be able to be productive at a workplace someday. It was all about fluency training, working at a task with as much fluidity as possible until its completion by organizing the steps into one smooth action.
Greg practiced daily for months. Our government aide and I kept data, rewarding each new milestone with a reward. If Greg hesitated at a task, we practiced it some more, stop watch in hand to see how many times he could drop his toothbrush into a cup during time trials, hoping for greater speed and less prompt dependency. That is not to say that we dropped all of our prompting. Greg continued to need our verbal, “Come on, Greg! You can do it!” comments for months, but gradually the need for prompting lessened until today, at age 28, an aide at Greg’s group home just has to say “Greg, go brush your teeth” and he gets the job done. Short duration? For sure. But, done!
Step 4: Once Greg mastered each smaller task, we moved to putting two, then three, then four tasks together, practicing each repeatedly. The work of recording data helped us monitor Greg’s progress, and we were able to push him harder and harder after checking the previous time trial by making each session fun and rewarding despite its tedious repetition.
When, after months and months of practice, we deemed Greg ready for the final test, we sent him upstairs to the bathroom with this instruction, “Greg, go brush your teeth.” We waited and listened. Heard the water faucet. Heard the brushing. Would he manage the elusive final task of putting the toothbrush into the glass? He generally stood there for minutes deciding what to do, reluctant to end without a prompt. We waited.
It was a bit short of miraculous when that toothbrush hit the bottom of the glass. Greg came downstairs and we praised him, cheering him on, showing him that he could do it. With each new mastery of skills, we pushed him toward greater challenges. Some worked; some didn’t. Nevertheless, he basked in the attention, latched onto our craziness every time he succeeded and prospered. Today, Greg works. He feels the productivity of completing a task. He is happy.
Next blog? See how we turned a Monopoly board into a tool for use with task completion and reward.