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Providing Care in the Clinic for Non-verbal Patients Lora Perry, MS, BCBA Board Certified Behavior Analyst Director, ABA Services Providence of Maine Corporate University of Providence Lperry@provcorp.com (207) 841 7491

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Learning Objectives Review the role of the family as an important member of the care coordination team, and barriers to this State the difference between a developmental approach to language acquisition and one based upon the function of language List three ways non-verbal patients might communicate Explain the important role of reinforcement when interacting with patients Explain why reinforcing a challenging behavior is acceptable in the context of a response class hierarchy Identify skills patients need to acquire to participate in and cooperate with their health care

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Autism Every Day 07:34

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Family as a Member of the Care Coordination Team Families may be in stages of griefregardless of how old the child is Important information and instructions should be provided in writing as well as orally Families can work with their child using the Doctors Visit task analysis (more on that later)

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Speech/Language: Developmental vs Functional Approaches Traditional Speech/Language Therapy employs a developmental approach to the development of communication Increasing mean length of utterance Increasing vocabulary Increasing the scope of detail in communication

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A Functional Approach to Language Development The Analysis of Verbal Behavior Based on the work of BF Skinner Verbal is not the same as vocal Approaches the development of language from a functional perspective Requests (mands) Labels (tacts) Intraverbals (non point-to-point) Echoics (imitation)

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Three Ways a Non-Verbal Child Might Communicate Acting Out Vocal Speech Icons (eg Mayer Johnson symbols) Laminated in a communication book, or On a device such as an iPad

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How You Might Communicate With a Non-Verbal Patient Symbols (on iPad or other) Spoken Word Modeling/Demonstration Building a Positive Learning History/Stimulus Pairing

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Never Underestimate the Value of a Fabulous Waiting Room: Stimulus Pairing 101

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What is Reinforcement and Why Do We Care?

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Positive Reinforcement: The Big Bang Theory 04:53

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No! Bribery is given before the target behavior Reinforcement happens after the target behavior, with the intention that the behavior will be repeated as a result of the learning history Do not confuse this with allowing an individual to sample some items to determine their value to the individual, as in a preference assessment Isnt Reinforcement Really Bribery to Get Individuals to Do Something?

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A Word From the Cat 01:29

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A group of responses (behaviors) of varying topography, all of which produce the same effect on the environment (Cooper, Heron, Heward). Response Class

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Ordering of responses within a response class based upon their probabilities of occurring. Response Class Hierarchy

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Interfering Behaviors Sometimes called problem behaviors, challenging behaviors or maladaptive behaviors Maladaptive is really incorrect: these behaviors are actually almost always very effective, efficient and functional for the client

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SIB Grabbing Kicking/Hitting Stomping, Kicking Out, Growl-like NCVs Elbow Bang (hard), thumb press (hard) Crying, pinched expression Facial tension, rocking, gait changes, stomping, elbow bang (gentle), NCVs louder, hands over eyes, clenched hands, thumb press NCVs at low volume, calm facial expression, happy, smiling, compliant This is where we want to be! CHILDs Levels of Agitation Crisis phasePBSP was not followed, or failed due to variables in play Maintain safety of CHILD, staff/caregivers and peers Do not attempt to teach at this levelthis is not a teachable moment This is a Critical Incident; Complete Critical Incident Report, and convene a Collaborative Problem Solving meeting as soon as possible to analyze what went wrong. Revise PBSP accordingly. Provide break; re-direct to a preferred activity Increase schedule and value of R+ for the absence of escalating behavior Examine antecedents to behavior. CHILD is happy and calm! Provide lots of reinforcement while working together. (NCV=Non-communicative vocalizations) Be aware that crowded, noisy or hot environments are difficult for CHILD and may trigger escalation in agitation.

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Example: Jason I dont want to talk about it right now. Inserting a New, Pro-social Response into a RCH

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Simons Cat: Let Me In 01:51

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Lalli, J. S., Mace, F. C., Wohn, T., & Livezey, K. (1995). Identification and modification of a response-class hierarchy. Journal of Applied Behavior Analysis, 28, 551559. Richman, D.S., Wacker, D. P., Asmus, J. M., Casey, S. D., & Andelmand, M. (1999). Further analysis of problem behavior in response class hierarchies. Journal of Applied Behavior Analysis, 32, 269-283. Key Journal Articles

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Step on the scale and remain for data Permit height measurement Permit practitioner hands on Permit invasive equipment Blood pressure cuff Tongue depressor Reflex hammer Stethoscope Otoscope Thermometer, etc Some Skills Patients Need to Benefit from Health Care Permit blood draws Take Pills upon request Ingest liquid meds Remain still Say ahhh Take deep breaths upon request Identify body parts Identify good and bad feelings

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Task Analysis: The Doctor Program Basically, play Doctor Desensitizes the patient to routine healthcare procedures Families and community caregivers can practice Offers an opportunity for stimulus pairing Practice should be maintained throughout childhood

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The Do Statements Do include a wide variety of engaging toys in the waiting room and exam room that will appeal to a variety of developmental levels and physical abilities Consider music, iPads Do train all staff to offer reinforcement often for the absence of challenging behaviornot just at the end of the encounter Do take the patient into the exam or procedure room on time Unpredictable wait times are anxiety provoking and confusing to the patient, Stressful for the caregiver Contribute to an undesirable Learning History

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The Do Statements Do give instructions and information to caregivers in writing as well as orally. Caregivers are distracted and stressed during visits Do remember some patients with developmental disabilities can be very literal thinkers

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Rainman: Dont Walk 01:56

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Questions? Comments? Stories?

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For More Information Lora Perry, MS, BCBA Board Certified Behavior Analyst Director, ABA Services Providence of Maine Corporate University of Providence Lperry@provcorp.com (207) 841 7491