When it comes to language development, speech therapists and behavior analysts tend to hit a wall. Perspectives differ, orientations may not coincide, and discussions can get heated. The goal of this blog is to provide perspectives on language development in children with autism, language disorders, and developmental disabilities from the perspectives of a speech and language pathologist (SLP) and certified behavior analyst (BCBA), in order to show how these two domains can happily work together and collaborate. This is a new endeavor, so please be patient as we work together to address topics in language development. Questions, comments and concerns are welcomed and encouraged!

Thursday, December 31, 2009

ABA Therapists versus the Related Service Provider - By Angela Mouzakitis (BCBA)


I've worked with many related service providers over the past ten years, and have heard many horror stories regarding the interaction between ABA therapists and Speech and Occupational Therapy providers specifically. As an ABA provider, coordinator and professor, this is very disheartening, albeit common. However, most importantly, when there is a rift between the disciplines and perspectives, it is the child and family that suffer, or rather do not achieve appropriate collaborative programming. I wanted to address why this may happen.

To be frank, applied behavior analysis, and programs based on applied behavior analysis to work with children with autism have the MOST research to show the effectiveness. (Period.) What this means is that researchers, have contrived environments and settings to (as objectively as possible) analyze the effectiveness of these programs. While some may feel that ABA is inappropriate for their child, or they don't like the methodologies, that is a different story. ABA is not a religion, and it isn't a matter of believing in ABA. You cannot choose to believe in it or not. The data is there. You may not like it, but there are many effective programs that have been based on applied behavior analysis.

While this is great, it causes a great deal of arrogance among ABA therapists, and they may charge off like gang-busters at meetings, pushing around the related service provider. This is unfortunate and wrong for so many reasons:

- Most ABA providers, have not read the research and cannot speak fluently about the research. This puts them in a position to make many claims about their therapy, and not able to defend them. By not being able to explain a program with the defense "research supports" this turns off families and providers.

- Just because a discipline hasn't researched a technique, does NOT mean the technique is ineffective. This cannot be understated. There are hundreds of strategies that have not been researched, yet are used and may be very effective. An ABA therapist may dismiss this and say "it is not research-based". I like to add "yet". Fortunately, ABA is a science that can analyze the effects of just about any discipline. The occupational therapist wants to put a weighted vest on? Maybe it isn't a published research based strategy, but that doesn't mean we can't try it, identify what we think will change, and measure and analyze the behavior to see if it had an impact.

- Because of the research leading to arrogance, some ABA providers may have a difficult time maintaining an open mind to other disciplines. This is unfortunate again and will only hurt the child. I am not a certified speech and language therapist. I do not have a fluid understanding of the speech mechanism, sound production, tongue placement, speech disorders, to create programs, etc. I don't even know enough about speech disorders to ask questions about them. It is necessary to have a speech and language provider as a collaborator on an ABA team to guide program development.

- It is the role of the behavior analyst or ABA provider to identify a way to analyze and account for behavior change. This does not mean isolating programs to a purely ABA world. It means applying the principles of behavior analysis to all measurable behaviors: preposition usage, tongue placement, feeding, referencing, joint attention. By working with related service providers, our discipline can only be enhanced. In my experience, rarely is a program on "joint attention" implemented as one of the first programs when working with a child with autism. However, this was brought to my attention by a speech therapist. Had my mind been closed to it, the child wouldn't have had the opportunity to practice this very important piece of social interaction.

The bottom line is that he collaboration and openness is necessary. If each member of the team doesn't have collaborative input, those members will slowly drop out of discussion, and slowly drop out of team meetings. ABA has a lot of research, true, but no one discipline has all the answers and they should use each other to try and find the answers to programming and language development that might be more elusive. Collaboration on teams of professionals working with children with autism and developmental disabilities is essential.

ABA Therapists from the Perspective of a Related Service Provider- by Diana Almodovar

Angela's latest entry on this blog brought up many interesting issues. The interactions of all the therapists that are working with a child can be challenging. The importance of a cohesive team cannot be stressed enough, particularly when working with children with Autism. Consistency and structure are key, and when there is discord on the team, things are bound to fall apart.

Collaborating with Professionals:

I've had (and still do have) a good working relationship with ABA teams. I also can tell of countless negative experiences that I've had. There have been times where I have worked with ABA therapists that are as inflexible as the children they work with, and are so rooted in the theory and "rules" of the therapy, that they are not amenable to seeing another way. I've seen these therapists be dismissive of other approaches, such as incorporating sensory work performed by the occupational therapists, consulting with the speech-language pathologists on language programs, etc. A child's progress can be facilitated by incorporating an interdisciplinary approach.

How do we go about this? Here is one way not to: There have been so many times that I have worked with school-based and home based teams where the program is set by the ABA program coordinator (the lead ABA therapist on the team that creates the majority of the programs). The SLP (speech-language pathologist) then basically "runs" the programs that are created by the ABA therapist. There is some consultation, but main decisions are created by the ABA team. Everyone following the plan created by one discipline is not the way to work together.

I actually consulted once with a school-based SLP who was working with a child that I was working with outside of school. I visited her at the school to see what she had been working on and had been told that she basically follows whatever the school-based ABA team plans for her. Their focus was on teaching the child to use PECS (Picture Exchange Communication System). He had been making minimal progress. The child was 6 years old, nonverbal and completely uncommunicative. Later on in the school year she asked to observe me. I had been working on prelinguistic skills that are important precursors to acquire language- nonverbal communication (pointing, head nodding, gesturing), cause/effect, joint attention. She ignored what I was doing and basically came to my office to hand me a list of words that they were using to teach him PECS.

This child was not communicating on the most basic level, and therefore was not able to understand what the pictures were used for. There was an insistence that he learn those words, yet he still didn't understand that the picture symbol was related to a concept and that he could use these to communicate. I later met with the home-based ABA team to discuss this. They had shared my concerns. It ultimately became a power struggle between the home-based and school-based teams on what the goals should be. At some point, we came to an agreement, and the child began to (for the first time in 6 years), tap on a person to gain their attention, nod his head yes/no, and request using PECS and through pointing. A good six to eight months were lost getting to that point though.

We need to respect the knowledge that we all bring to the table, be willing to listen to each other and observe each other at work. I always make it a point observe the therapists working with one of my children so that I can incorporate their techniques into my therapy. We never should stop learning from one another. As an SLP, I can not achieve my language goals if the child's attention and behavior is not allowing the learning experience to occur. Utilizing the behavioral techniques employed by the ABA therapists provides the child with consistency and structure.

Similarly, consulting with an SLP on the appropriate course that the speech/ language goals should take is important. I've seen ABA therapists try to teach a nonverbal severely apraxic child (a child with significant difficulty in motor planning for speech) to request items using the carrier phrase "I want _____"). The child could not even babble. The only speech sound he was able to produce was "b" and some vowels. I've also seen these therapists create lists of rules and schedules without pictures, only using written language, for children who cannot read. Things like this are incredibly aggravating, and it's even more so when they are unwilling to ask for or accept advice.

Before any discipline chooses to criticize another, we should first swallow our pride and acknowledge that the only way to improve our clinical skills is to accept that there is always more to learn. Open discussions of each perspective need to occur among the therapists in order to design appropriate programs and facilitate progress. We each have something unique to offer. Many times it's not through what our schooling has taught us, but also through our individual experiences. We need to keep in mind that it's not a single person that will impact the child's progress, but all of us who interact with him/her. As soon as we begin taking a more unified approach real gains can be made.

Speech and ABA collaboration on goals - by Angela Mouzakitis, BCBA

Consistent with the need to work together and be respectful of each discipline, now what? Working with children with autistic spectrum disorder requires careful assessment, program planning, program implementation, and program monitoring. All of this needs to be collaborated on with the entire team: not only speech and aba, but parents, occupational therapists, physical therapists, and anyone else involved in the child's development and progress. What this translates to is that goals cannot develop on speech, ABA, PT, OT, and parent bubbles.

Usually what happens is that each domain assesses, decides on the goals, decides how they will implement them, and reports on progress to the other domains. This is not sufficient across so many levels:

Assessment: Each domain has something to offer regarding assessing the child and identifying skill deficits. Additionally, priorities need to be identified. If a child is not communicating with any of the people in his environment, communication development needs to take precedence across ALL domains, and all the therapists need to target this area. Additionally, assessment in each area will be supplemented by adding results from all the domains. Speech assessment will benefit from cognitive and physical growth assessment as the speech skills will then be viewed and assessed within an appropriate context.

Program development: The domains need to get together here, and prioritize goals and needs for the child and family. There may be a limited number of goals and targets that can feasibly be addressed. Additionally, related service providers should understand why certain goals are chosen. This is done by collaborating on development of goals.

Implementation: This is another key area. While some goals may be specific to a domain and special training is required (ex. PROMPT certification) all goals should be addressed by all therapists. An occupational therapist working on a pincer grasp needs to also work on and implement the child's behavior support plan. It is un-ethical and irresponsible to assume this is the role of the behavior therapist. In a collaborative and comprehensive program, it is impossible to extricate the goals from each other. They shouldn't be taught in isolation, rather across domains, settings, and people.

Monitoring: This is an area that ABA therapist could support the related service providers, and I'm sure that Diana could speak more to this, but progress NEEDS TO BE MONITORED. Statements like "is responding well" and "appears to be making progress" and "is doing better" are NOT acceptable. How do you know he is doing better? Show me the data. Show me how he is doing today in comparison to yesterday. This is incredibly important.

How to monitor various programs is a challenge. And data collection should not impede program implementation. Not everything needs to be broken down into numbers. Anecdotal data is data as well, but a system of data collection, whether numerical or anecdotal needs to be implemented. If a goal is a particular speech sound, the team needs to ask, "How will we know when he has mastered this goal across people, settings, and times of day". A system to monitor it must be implemented.

My hope is that the next few posts will illustrate how to develop appropriate data collections system for goals in related domains without compromising the integrity of the goal or of the data.

Why a Speech Language Pathologist is Necessary - Angela Mouzakitis

...and thus necessitating collaboration.

Many ABA school programs follow a generalist model. This means that behavior analysis is used to target all domains: occupational, physical, speech, etc. While I agree that behavior analysis is used in all these domains and is effective at teaching and shaping behaviors within all these domains, each professional related to these services, in my opinion, is essential.

As a behavior analyst, teacher and school psychologist, I have training in those areas. While as part of my training I have a decent working knowledge of the speech, occupational therapy and physical therapy, this is not my training or expertise. I need there professionals and their knowledge to create a comprehensive program for a child with autism or a developmental disability. I think it is a mistake to not have these related service providers as members of the team.

That being said, the line between speech and ABA is a little fuzzier. While language development is the focus of a speech language pathologists program and training, it becomes a little more complicated to collaborate because language is ALSO the focus of an ABA program. This is where some of the disagreements may stem from. Each domain may feel like their 'area' is being trampled on and each domain may feel that they know best. It gets touchy.

I rely on the speech therapists that I work with for their expertise in language development, but particularly on their expertise with the speech mechanism, and sound production. I have a good handle on language development, but also look to the speech therapists for developmental model, even if my model is not developmental. I also look to the speech therapist for guidelines on play as it relates to language development and appropriate development. ABA becomes a little more complicated for related service providers to follow as sometimes we follow an educational model, sometimes a developmental model, etc.

To help with the roles and responsibilities of the various team members, at the onset, I think it is important to identify what each team member hopes to bring to the team and what they want to accomplish. When areas are identified that may overlap, those issues can be addressed then and there and compromises and collaborative strategies can be made.

I become concerned when meeting with a school program for the first time, and speech pathologist is not a member of the team. No one domain has all the knowledge and all the answers to create a comprehensive program. Often what I see happening in these models, is parents seeking speech pathologist services in addition to their school program. If this ends up happening, my question becomes, does this program meet the needs of the child? If they can't, a change is needed.