Archive for March, 2013

Step by Step

A boy, Andy, recently came into my office with his father. The family is having difficulty getting Andy to leave the house. We began by cartooning a basic errand (grocery store visit) to create a visual to reference and to see if Andy could share what was causing him anxiety/discomfort. When Andy could not identify anything in particular, we moved to breaking the action down into small steps (This can be seen on the right hand side of the image). Once we were able to break the larger activity (daunting in its entirety) down into smaller steps, we then role-played through the grocery store visit. I did this with Andy, including him in things like helping me “ckeck out”, choose produce, etc. Then we went through each step and rated the step on a scale of 1-10 (1 = not scary at all, 10 = overwhelmingly scary). By the end of this exercise, Andy was smiling and stated that the errand of going to the grocery store did not sound scary to him anymore.

Another parent I work with recently made a step-by-step incentive chart for her son’s daily chores. The chore of cleaning his bedroom was broken down into simple, manageable steps. The visual chart had a picture of his clean room on the front and the steps for cleaning on the back. A money incentive ($.50 for completing the 4 steps) ran across the bottom of the chart. The boy has a piggy bank where he keeps his earnings.

Both these examples take a large task and break it down into manageable steps. I love to role play these events after breaking them down, because it adds another level of practice to a new or challenging sequence of events. By creating a rating scale (1-10) for each step, we can target the scariest part of the overall task and spend more time processing and preparing for that piece.

I also love the analogy of baking bread (a very deliberate process) – something I have taken on as a hobby within the last year.

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In young children, communication barriers quickly can morph into behavioral issues. The sheer frustration of not being able to ask for what one wants (key to the bathroom, snack, etc) leads to hitting, grabbing, and other forms of acting out that jeopardize positive peer and adult relationships.
The following article was sent to me by a parent whose daughter recently began receiving speech therapy for a communication disorder. The article is from the author of the blog “Along Came The Bird“. Lana (author and mother) explains how she uses the PEC system to help her daughter communicate her needs in the home. Adding value to this post is the wonderful pictures she provides of the PEC System set up on the door. As always, think about how you could implement all/some of these ideas in your own home. I particularly like the idea of the “first –> then” visual she uses.

Here’s the link:

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In my practice, I regularly meet with parents, caregivers, teachers, and social workers to discuss “problem behaviors”. In fact, I am often unable to work with clients unless they “qualify” for services. This essentially means that their symptoms need to be significant enough that we (therapists) can justify the need for our service. What is so often lost, undervalued, and rarely discussed when creating a plan for treatment is the idea of self-worth. This may sound fluffy but give me a chance to explain.
If we only ever discuss “problem behaviors”, symptoms, and challenges, what message are we sending? What value should we put on helping a child feel good about themselves? What value do we place on a child feeling extraordinary about something/anything they feel passionate about? How do we integrate the child’s interests into our work with them, for the purpose of building a stronger sense of self?
When working with children with anxiety and depression, I often pray for something to come along that will invigorate their spirits, give them hope, or motivate them to put their energy into something outside of their presenting symptoms. However, it’s rare that we value this enough to make it part of the treatment plan with children on the spectrum. I think we need to start.
I recently began a project with a 9-year old boy in which he records 5-minute videos every week on the topic of bacteria (a topic he is infatuated with and so interested in sharing that he rarely talks about anything else). With this project, our goal is to make a collection of teaching video’s that he can have and share with others for years to come. In truth, the real goal is to highlight this child’s excellence and exceptional knowledge in a specific area. By highlighting a child’s interest/passion, we are instrumental in helping them see themeselves as a person who has something valuable to contribute to the world.
This “campaign” is simply about giving you the green light to highlight your child/client’s strengths and interests (no matter what those interests are). Furthermore, it is my hope that you will recognize that doing so is therapeutic and will serve him/her for their lifetime -as much as, if not more than, a new “coping skill” or the latest evidence based behavioral intervention.

That’s my rant for the month.

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Using a program called “Comic” on my apple computer (this program is included with Macs- atleast on mine which is a 2008), I created a simple visual map to use with kids around homework. The visual map has three simple steps that make up a very typical afternoon routine: Get home and chill out for 30 minutes (get changed, have a snack, check the computer quickly, etc), Complete Homework, and finally, Free Time.
The next sheet is a simple way for you and your child to measure the completion of this routine during the week (how many days was Ralph able to come home and go through the visual map successfully). On the bottom of the measure, there is the reward for objective met. This reward is critical for forming a new and challenging habit and it must, must, must be something the child finds enticing (30 extra minutes of Wii, a new pack of cards, etc). I never start with the expectation of 100% success (its a recipe for failure). In this example, I’ve started with 50% success. Success = Ralph will be able to follow the 3 step visual map without extreme opposition* 2 out of the 4 days of the school week. On the measure, I use a simple “YES/NO” to clearly indicate whether the homework was completed.
It often helps to come up with some simple rewards, small and large, with your child during the first review of the visual map and measure worksheet. If he really needs visual reminders to keep him motivated, print a picture of the reward he is working for and place it on the workspace.

Take a look and let me know if you have any additions that would improve this simple form.
Ralph1 001
Ralph2 001

*extreme opposition is something defined differently by each parent. If your child is struggling but giving it more of a go than is normal, he/she should earn the “yes” on the measure. We need to look for slow progress (which means improvement from stasis or existing pattern).

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The Dreaded Dentist Visit. Your child, if they’re anything like other children on and off the spectrum, dislikes (to put it mildly) going to the dentist.

Keeping to my latest video modeling kick, I recently came across this video that very simply displays a typical dental visit. This may be helpful to gradually begin the process with your child around going to the dentist (what a typical dental visit might look like). Use this video as a tool to help your child uncover specific areas that make him or her particularly uncomfortable (is it the polishing, the scaling, the suction, etc?). If you have a willing dentist (I know of several), ask him/her to review this video and follow it (step by step) as closely as possible. If your dentist needs to add any steps, ask for these additions in advance so that you can review them with your child beforehand.
Once the video has been reviewed (for several weeks, months, whatever is necessary), agreed upon by the dentist, and processed for particular areas of fear with your child, it is time to make a visual map (first this, then this, then reward for bravery…then your done) of the visit (schedule and/or social story that will provide structure to the visit). I will try to post one of these dentist social stories to reference as a template.

As always, any thoughts or comments from parents out there who have had success with dental visits is welcomed.


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