Unity Day 43: First In-Home Session

From Facebook:

"It was an interesting first home day. I was kind of lost without the usual schedule to follow, but got lots of great information about how to work with Ryan at home. Gram (Linda Gagnon) also did a great job learning about reinforcement today. :)"

So, today was our first in-home session. We'll be having one each Thursday for our last four weeks of Unity.  One of the senior therapists comes to our home to see how programming will work in our home, make suggestions how to use other toys we have, and basically get us ready for when Unity is finished, and we continue the work on our own.

I have to say, this first home visit felt really awkward. H. was our visiting therapist today, and she seemed to be looking to me to lead the proceedings.  I was lost. (?)  I am so used to our Unity schedule; I know what to do and where to go and which programs to work on at any given time.  But this was our first home visit, so I really didn't know what H. was expecting.  Eventually I brought out some of the goals we'd been working on for homework, showed her how I run those home programs, and asked some troubleshooting questions.  That format seemed to work well, once we got into it.

I'll list some of the things we did/talked about, and add some notes I took about what we discussed.

1. Push-Button Toys/Pushing Down with Force: It seems like I have to HOH for anything that needs Ryan to press down or put hand pressure on it to get the desired result (letter and music buttons on Thomas alphabet toy; pressing buttons on mini-computer toy; squashing down Play-Doh, etc.). I had thought it was a matter of hand strength, but H. disagrees.  She says Ryan can push down the pop-up toys and pull back the lever on his car racer toy, so it's not a strength issue. H. believes it is a motivation issue. Ryan has learned that it's just easier to let Mommy do everything.  So, we got out another toy with a push-down portion (animal barn--push down hay to hear sheep baa).  She had me HOH it a few times, and then back off (fade the prompt). Ryan was able to make it "baa" a couple of times.  H.'s suggestion is to rotate between his various push-button toys during a given session (some might be more motivating than others), while trying to fade back that HOH prompt.
2. Magnetic Stacking Blocks: I told H. about how hard it is to keep Ryan from mouthing the blocks.  Then she got to witness it. I showed her how each time I hand him a block, he immediately puts it in his mouth first (even when I try to stop him), and then he will let me forearm prompt him to stack it, but he sometimes gets upset.  The blocks themselves have a texture he really likes, so he'd rather mouth them than stack them.  H. thought about it a bit, then suggested that we try a different kind of blocks (bristle blocks) that can stick together.  Then, we can use the magnetic blocks as reinforcers, instead, because Ryan is so attracted to them. She's going to check back at S.C. to see if they have some bristle blocks we can try.
3. Matching: I mentioned, in previous entries, how we've decided to move from matching concrete objects to matching with pictures because that seems to work better with Ryan.  The trial run we did yesterday with the coloured squares went well, but L. had wanted clearer pictures of real objects.  Well, she got them ready and sent them over to us to try out with H. today.  They worked really well. Ryan was having a high sensory-needs day (lots of mouthing), but that was the only hurdle we had to overcome with the pictures (blocking him from putting them in his mouth).  Otherwise, the trials went well.  We did the same thing as yesterday, but with pictures of different things, like a car and a ball.  We did some practicing just matching one-to-one (no distractor); then we threw in the distractor; then we changed the position of the distractor and the matching picture; finally, we had him match the distractor with its match.  Overall, he did really well. He was kind of flinging the pictures at each other, but for now, we're happy as long as we can tell he's making an intentional match. We will be bringing these new matching pictures to S.C. to work on them there, too.
4. Car Racers Toy: We had worked with this one as a homework item in Month 1 in Unity, and Ryan learned to use the gearshift to make the cars go.  However, when I tried to teach him Step 2 of the toy, putting the police car on the roof and dumping it in to start a car chase, Ryan got confused and kept going for the gear shift.  So, we stopped that program.  I showed it to H. to see if she had any suggestions for re-introducing Step 2 of the toy.  H. suggested positioning the toy so that the police station roof is right in front of him, and the gear shift is further away (turn it sideways). We can start by HOH putting the car on the roof, and gesturing for him to dump it in (he already knows how to tip it in). After he goes through this procedure correctly, we can turn it so he has access to the gear shift as his reinforcement.
5. Imitations and Correcting Errors: I talked about and showed H. our on-going struggle to reduce Ryan's prompt dependency, especially when it comes to him doing imitations (pat head, waving, clapping, etc.)  Basically, she agreed with what the other therapists have already suggested:  the mixed trials, doing full prompt for two and then no prompt for three, and positioning his hands before giving the instruction. However, she brought up an interesting point about something I hadn't realized. Let's say I was doing "clapping" Ryan, and he patted his head.  I always say, "Oh, that's pat head," then HOH the correct answer, saying, "THIS is clapping!"  She thinks my wording might be confusing him, since I'm verbally drawing attention to the action he wasn't supposed to do, as well as the one he's supposed to do.  She said when I'm correcting, I should only use the words for the action I want him to do. So, using the previous example, I would simply say, "Nice try, but THIS is clapping!" (while HOH'ing the appropriate action). I think that's a good point because even with Kevin, I notice when I often say "Don't do this," he misses the "don't" part. With autistic kids, it's clearer for them if you say what you want them to do.

Circle Time: I ran my first in-home circle today.  I used the same one as I did at S.C. yesterday, in the hopes the familiarity of it might settle Ryan some. It was a good thing Grandma was there to support Ryan with circle because he was getting irritated, and again, did not seem to like that I was the leader, and not sitting behind him.  Grandma learned a lot about reinforcement during circle time because Ryan needed a lot of reinforcement to keep him focused.  Like I said, he was mad because I was leading; it was weird for him to do circle at home; he also had no one other child to share the circle activities/tasks. 

I had a hard time getting circle started because I wasn't sure how to set it up at home. Also, both the opening songs we've been taught have "our classroom/our school" in them, so I wasn't sure if I should sing them that way. It was a little thing, but it kind of threw me off right at the start.  Anyway, circle went okay.  As I said, Ryan needed lots of encouragement to stay on task and to sit up nicely. He did participate by pulling off the Velcro pictures and letting Grandma HOH some song actions with him.  He also did well matching out of two choices for the pages in the "Brown Bear" book.

H.'s comment when circle was over: it was "not too shabby!"  Um, okay. I'm not sure if that was a positive or a negative. Sometimes I find her a bit hard to read.

I then asked for some suggestions as to how I could do circle time when it was just me and Ryan, since we won't always have a third person to support Ryan. H. said she likes how I often put Ryan in the rocking chair, facing me, for activities; it keeps him physically supported, focused, contained, and there's even a little room on the chair to place materials in front of him. She also suggested sitting him in one of his foam chairs or on the floor with his back against the couch, so he could have that core body support and leave his hands free to participate in circle time activities.

Purposeful Communication: I also talked to H. about how I'd like to increase Ryan's functional/purposeful communication.  I mentioned how the "making choices" program is a no-brainer  if it's between food/bottle and some totally different object.  H. said we could start offering him other things he might like as the second choice, such as his bottle and something from his reinforcer basket. We give him the item he asks for, until he indicates otherwise.

Since Ryan has mastered the "more" sign, I asked about teaching Ryan new signs.  H. said we had a bit of a decision to make: Will we use signs or PECS (Picture Exchange Communication System) for Ryan?  We have to consider the big picture: not only what will work best for Ryan, but will work best for us as a family.  Although I think PECS might be the better system, I know we've already had some difficulties with it as a family.  Our speech therapist and resource consultant from Children First had given us a few PECS to try at home a month or two before we started Unity.  They didn't work well because Ryan sometimes ignored the pictures, but mostly because Kevin wanted to play with them all the time.  Kevin kept taking the pictures off the Velcro and disappearing with them, or putting them in strange positions on the Velcro strip.

On the other hand, Ryan has done really well learning the "more" sign at S.C.  As usual, the key to Ryan is motivation:  he will sign for things he really wants.  So, H. suggested that I start teaching Ryan signs for the things he has strong motivation to ask for/really likes:  "bottle/milk," "bubbles," etc. She is going to get me the addresses for some reputable websites for learning the signs. Grandma also took a sign language course a few years back, and has a book which might help us pick up some of the signs.

Sibling Involvement Issues: Finally, I got a chance to get H.'s thoughts on how to handle Andrea and Kevin's interactions with Ryan and their attempts to be involved in his therapy.  She agreed with me that we don't want to discourage their interactions with Ryan, but we can shape things to make them more appropriate.

For example, when the kids want to give Ryan his reinforcers during programs, I might hold the reinforcer item/bin until it's time for them to present it to Ryan.  Or, if they both want to do something at the same time, they could each get 3 items (thus, 3 turns) to give him for reinforcement, and then it's the other person's turn.

Circle time, at home, could also be a great opportunity to get them involved.  Andrea, being older, might be able to help with prompting Ryan, while Kevin could be another participant in circle time activities.  Or, they could take turns being the leader for some of the circle activities while I assist Ryan.  I'm sure they'd think that was fun. :)

Finally, we talked about making up new token boards for Andrea and Kevin. Token boards are a form of positive reinforcement; they get a token for doing something properly, and when their board is filled up, they can get a special prize/treat/activity.  So, they could be receiving tokens for interacting well with Ryan, or helping with programs or circle time appropriately, etc.  They have used token boards in the past, when Kevin did his ABA (Applied Behavioural Analysis) emotional regulation program through JMCC (John McGivney Children's Centre) and TVCC (Thames Valley Children's Centre) in the fall and winter. They got tokens for playing together nicely, being good sports winning/losing, handling their anger appropriately, etc.  I think this might work for a while,  but as I saw last time, the novelty wears off. Then again, I now realize it could have been an issue of having strong enough reinforcement; if filling the token board doesn't lead to something they are really motivated for, it loses its power.

Overall, despite some awkwardness due to it being the first in-home session, I was pleased with the information I got.  It was good to have an opportunity to ask some questions that had been on my mind for awhile, but I didn't have the chance to ask in centre.

On to Easter Weekend.  I have to say, H. was generous in letting us spread out one day's worth of homework over the 4-day weekend. We can handle that. :)