On August 13th, New Jersey became the fifteenth state in the nation to enact autism insurance reform.  This is exciting news for the autism community nationwide. The bill will require NJ insurance companies to provide coverage of evidence-based medically necessary autism therapies up to $36,000 annually for a child with autism that is 21 years of age or younger. Coverage includes Applied Behavior Analysis (ABA) therapy. The NJ bill was signed into law only a few short weeks after Wisconsin enacted its own legislation. Other states that have enacted insurance reform bills are Arizona, Colorado, Connecticut, Florida, Illinois, Indiana, Louisiana, Montana, Nevada, New Mexico, Pennsylvania, South Carolina and Texas. While this is substantial progress, there is still much work that needs to be done in order to have insurance reform enacted in every state across America. The majority of states, including California, still do not require insurance companies to cover treatment of autism.  What can be done? Autism Votes, an Autism Speaks initiative, has an entire website dedicated to getting lawmakers to listen. If you are interested in getting involved, the site (autismvotes.org) provides information on how to get in touch with the Speaker of the House Nancy Pelosi and the Senate Majority leader Harry Reid to urge them to pass insurance reform. In addition, you can reach State elected officials to bring this issue to their attention. Lawmakers need to understand that autism is a condition that deserves appropriate treatment, therapy and care. California is one of the states with pending reform but still faces an uphill battle to get it passed. In the meantime, follow the insurance company’s own guidelines to cover autism treatment. For a detailed roadmap on how to begin the process, click here: http://www.wellspring.com/docs/insurance-company-road-map.pdf

Is it back-to-school time already? Retailers would like us to think so. Though it may seem like they are trying to rob us of a few precious weeks of summer, marketers actually have the right idea in cueing parents to begin back-to-school preparations now. Individuals with autism spectrum disorders generally have a more difficult time with transitions. It stems from the fact that they have trouble shifting attention from one activity to the next and tend to have a greater need for predictability. As any parent of a child with autism knows, preparation strategies are crucial. These next few weeks are the perfect time to begin preparing your child for the back-to-school routine. By using this time to slowly transition into the routine, it will help avoid the meltdowns and behavior issues that can occur when a child is not adequately prepared for a new situation. If your child has trouble waking up in the morning, start putting him to bed earlier, using 15-minute increments to get the time earlier each night. Once he is used to waking up at the expected hour, waking up on the big day will be much easier. Next, you need to establish a consistent morning routine. Using a visual schedule is a great way to demonstrate to a child the sequence of events that make up this routine. You can prepare the schedule together with your child using pictures or drawings of familiar activities such as going to the potty, brushing teeth, getting dressed, and eating breakfast. The visual schedule will give your child a sense of control and allow him to understand which activity follows which. To help avoid power struggles, it is helpful to have a desired activity follow an undesired activity. For example, if TV is part of your morning routine, make sure the more difficult tasks such as getting dressed come first and TV time can serve as a reward.
Give your child a 5 or 10-minute warning (or both) before he is expected to move onto the next activity. Never whisk him away from a preferred activity and demand that he get into the car when it is time to leave. When giving warnings, try to make the instructions as clear as possible by breaking them down into simple steps. Sometimes a seemingly simple statement such as “we’re leaving in 5 minutes” can be too difficult for a child to understand. Instead you can say “in 5 minutes we have to walk out the door and get into the car”.  If power struggles over food or clothing are an issue, be sure to offer choices, as in “you can have cereal or oatmeal”. This will give the child a sense of control and reduce the power struggles. Once you have established your routine, stick to it and be consistent. Having a predictable and consistent daily schedule builds confidence in a child, decreases anxiety, and encourages cooperation. Preparation and consistency are the keys to success when it comes to back-to-school readiness.

Many kids are picky eaters. Picky eating is one of those parenting challenges almost every parent faces. And while picky eating is not unique to autism, it can be exacerbated by it because of the heightened sensitivity to texture and taste that many children with special needs experience. Last week we talked about some of the applications of Applied Behavior Analysis (ABA) and its use with autism. But we also tried to emphasize that the use of ABA is not synonymous with treatment for autism. In fact, ABA can be applied in any situation where a behavior change is desired. So many ABA methodologies can be applied in every day parenting. Picky eating is a great example of this.  The same systematic techniques combined with positive reinforcement used to teach any skill can be used to address picky eating. If a child has a severe aversion to a food or a more involved developmental disability, you will need to start with baby steps, breaking down each task into very small reachable goals. For example, you can start by just having the undesired food on the plate. Get the child used to having it there next to his other food. Once he accepts the food on his plate, you can move on to having him smell it, bringing it closer to his mouth. Remember that every successful step needs to be rewarded with a bite of a food that the child likes. Possible next steps can be to have the child lick the food, getting him used to the taste. After that, move on to taking a bite. He may not even chew or swallow the food, just take a bite and spit it out. Remember, we are breaking this down into tiny achievable steps. After the child agrees to take a bite, you can move on to swallowing and so on and so forth until the child agrees to eat the new food.  These baby steps may not be necessary with a typically developing child. Most of the smaller steps can be bypassed and the idea is simply to convey to the child that he at least needs to try the food before saying he doesn’t like it. If the child tries and does not like it, he can have a reward of something else to eat, then slowly move up towards eating more than one bite of the food the child refuses to eat. Eventually, you will be able to say to your child “you can’t have your dessert until you eat dinner” and the child will get the point.  Most children will usually give in to eating something over going hungry. Keep in mind that some food aversions can be related to allergies and should be checked with a doctor. Also, even adults have food preferences so if your child really does not like a certain vegetable, there is no reason to ever force a food on a child. Good parenting almost always involves offering choices.

I recently read a great blog (http://abama.webs.com/) dedicated to the ethical application of Applied Behavior Analysis (ABA). The site draws attention to some very common misconceptions about ABA. For example, that ABA is only relevant to the treatment of autism, or that it is synonymous with Discrete Trial Training (DTT). Discrete Trial Training is a procedure that is based on the fundamental principles of applied behavior analysis, but it is only one of the many aspects of ABA. ABA is a methodology and much more than any one particular teaching procedure or intervention. It is based on many years of research into behavior, its causes, and techniques for changing behavior. ABA can be applied in any situation where a behavior change is desired. Other teaching methods included in an Applied Behavior Analytic approach include Incidental Teaching, Interspersal Teaching, Personalized System of Instruction (PSI), Verbal Behavior Training (VB), and many others.

DTT (sometimes referred to as the Lovaas method) is an intensive treatment designed to assist individuals who have developmental disabilities such as autism.  It involves systematically and intensively training a variety of skills that individuals with disabilities may not pick up naturally. It is often said that because these children do not learn the way we teach, we should teach the way they learn. Programs designed for children on the autism spectrum initially teach pre-learning skills (sitting, attending, looking at the therapist), social skills, self-help skills, communication skills, safety skills and basic concepts (colors, letters, numbers).  After these basic skills are mastered, higher-level skills are taught. DTT is conducted using intensive drills of selected materials.  Complex behaviors are broken down into small, reachable components. A specific behavior is prompted or guided, and children receive reinforcement for proper responses.  Shaping procedures are used to teach children to respond to other types of reinforcement, such as praise or breaks. Adversaries sometimes suggest that DTT promotes robotic responses in children but research has demonstrated a 50% recovery rate for autistic children who participated in discrete trial training 40 hours per week, including parent education, and began treatment during the preschool years. But like any therapeutic program, DTT, as well as ABA, needs to be tailored to meet the needs of the individual client because no two cases are alike. A good behavior analyst will know how to adapt a program to fit the child because as all of us working in the field of autism know, “when you know one person with autism, you know one person with autism”.