DAN doctors. Chelation. Let's talk about this.

Since I have been back to Malaysia, I have come to realize that biomedical treatment in Malaysia is a huge treatment of choice for autism. I am very surprised and deeply saddened by this.

Firstly, let me start by stating that Autism is a diagnosis that is diagnosed and defined behaviorally. When a pediatrician looks to diagnosis a child with autism, the pediatrician observes a child's behavior, conducts formal and informal assessments and makes conclusions based on those evaluations in place. There are no blood test, saliva swabs, MRI's etc involved in the diagnosis of autism. The cause for autism is unknown.

So the dilemma is this, when choosing a treatment for you child, what should a parent do? In Malaysia, there is still no organization to date that supplies parents with information on autism treatment. So, finding the correct treatment for your child becomes even more difficult. The thing about treatments is this, there are many treatments out there for autism but the effectiveness to each treatment is always not clear. It is not always based on evidence, outcomes and science. Instead it is a form of pseudo science. Parents really have to research and that's why we have google !! It is an amazing tool, and we should feel very empowered to use it. No knowledge is better than the knowledge we learn ourselves. The more we know, the better it is for our children. There are several things to look out for that we call red flags in regards to those ineffective treatments,

1) Most pseudo scientific/fad treatment claim to "cure" autism: the main problem with this is that there is not cure for autism.

2) Caregivers are not provided with a whole lot of training.

3) Non-individualized treatment: the problem with this is that autism affects each child differently and one single general treatment that is not individualized, will not yield effective results because each child is different.

4) Effectiveness of treatments are usually based on testimonials and case studies: the problem with this is that there are no evidence to back up claims therefore making the treatment questionable. 

Let's use an analogy, if you were trying to lose weight,and had to choose a method of treatment, 1) diet and exercise (proven to work and yield results) or 2) random weight loss pills ( supported by mostly testimonials you see on tv). What would you choose for yourself? I would hope it would be 1, because choosing diet and exercise not only will treat your weight loss, it will also improve your quality of life. Therefore, to relate this back to autism, choosing a fad treatment or a treatment that is not effective will only be a waste of time, money, and always remember that wasted time can never be returned. Time is important when it comes to treating autism, the faster we treat with a treatment that valid, the faster we see results. Lastly, choosing an effective treatment will improve the quality of your child's life.

So what are some fad treatments out there?

1) DAN doctors: DAN doctors claim that autism is the result of biomedical factors such as toxins and immune system deficiencies. DAN doctors often prescribe treatments and diets that mainstream doctors and scientists do not usually agree with.  Till date, there are no published evidence there are or  research studies supporting the effectiveness DAN doctors. In addition, many of the techniques practiced by DAN physicians are considered to be harmful by the medical community, for example, chelation therapy. Lastly, DAN doctors, only have to attend one day workshops to get certified. Wouldn't you want a specialist to do more than that for your child? Where is the peer reviewed research? and Where is it published that autism is caused by immune system deficiencies?

2) Chelation therapy: Chelation was used to treat autism in the early 1980s. It claims to stop further damage that is caused by mercury poisoning. They basically remove these foreign metals by IV or oral medication. Chelation is used in the medical community to treat lead poisiong or any other heavy metal poisionong. There is no evidence to support that autism is caused by heavy metal poisoning, therefore making chelation therapy a big NO NO in the treatment for autism. In 2008, research on chelation was stopped due to dangers associaiated with the treatment. The cause for autism is unknow, it is not caused by heavy metal poisoning, therefore chelation is not a good treatment for autism. There is no published evidence to date to support that chelation "cures" autism. This leads up to the third point, which is autism and mercury.

3) This is from the Association for Science in Autism Treatment website, mercury in vaccines do not cause autism. Which further proves that chelation is not a good treatment for your child

National Organizations and their positions on Vaccines:

The Centers for Disease Control and Prevention (CDC)	"Many studies have looked at whether there is a relationship between vaccines and autism. The weight of the evidence indicates that vaccines are not associated with autism."18
The National Institutes of Health (NIH)	"There is no conclusive evidence that any part of a vaccine or combination of vaccines causes autism, even though researchers have done many studies to answer this important question. There is also no proof that any material used to make or preserve the vaccine plays a role in causing autism. Although there have been reports of studies that relate vaccines to autism, these findings have not held up under further investigation."19
American Academy of Pediatrics (AAP)	"Scientific data does not show a link between vaccines and autism."20

Parents, my advice to you is to please do your research. If you need help, please don't hesistate to email me for information. I will provide you with all the help I can get. Remember, time wasted in treatment cannot be returned. Always look for evidence based practices that present peer-reviewed articles/research that can be replicable. Last but not least, always question who claims the treatment will help?

Please please please, email me with questions or go on asat website for more information http://www.asatonline.org/treatment/treatment.htm Choosing the right treatment will only help increase the quality of your child's life. Help yourself be informed.

Look into my eyes.

The eyes are the window to the soul. Everyday when we are having a conversation with someone, we look at them while they talk to us. We also engage in other non-verbal body language such as nodding, smiling, frowning, etc. These are all requirements in order to have a successful social relationship with a person. Why do we look at people when they talk? What contingencies have we learned from not looking?

Why do we look at people when they talk?

This is because, we as typical developing human beings have contacted the social reinforcing qualities associated with looking. For example, when we look at our friend talk, we are being a good friend because we are showing interest in what they are talking about and in return, we get our friend's approval. We feel good about ourselves when we are good friends. In addition, we also look at a conversation partner out of respect. It is socially acceptable to be respectful to the conversation partner. It makes us feel good when we are playing the right part based on society's standards.

What contingencies have we learned from not looking?

We have learned that when we do not look at our conversation partner, we are being impolite, rude, and disrespectful. We have also learned then when we look away, our conversation partner stops talking. Unless we want to be the snob of the party and the person that is not interested in anyone else other than themself, I think we have learned then when we look at our conversation partner, our conversation partner continues talking and perhaps, if it is a conversation we don't want to have anymore, he might soon stop. Realistically, if it is a conversation that we are not interested in, we do tend to look away and engage in other non-verbal behaviors such as eye rolling, squirming, etc. Hopefully, these signals get picked up on and the conversation is switched.

Children diagnosed with autism, tend to engage in limited or no eye contact during a conversation. How do we teach children diagnosed with autism to maintain eye contact during a conversation?

1) If your child has limited or no eye contact start by calling his name. If your child does not look, a prompt should be used by guiding your childs head to the same level as your eyes and waiting for eye contact. When your child looks, give him/her a preferred edible/toy.

2) Once your child is looking at you independently when you call his name, in the absence of prompts, you can start teaching your child to look at you during a conversation.

3) Remember to magnify learning and start with little steps. So, start with a sentence that lasts for 5 seconds for example "Hey ___, I like your shirt!".  In the 5 seconds, if your child looks away, pause your voice and wait for him to look at you again so you can finish your sentence. So if you say "Hey ___, I" and your child looks away, pause your voice, and when he looks back at you say "like your shirt". If your child looks, deliver a small amount of reinforcer. Reserve the big gun reinforcer for when he looks at you the entire time.

4) When teaching eye contact during conversation, a good environment to start teaching your child is in an environment where there are no distractors and your child is not engaged in an activity.

5) Once your child is maintaining eye contact for 5 seconds, keep increasing the time and changing up the environment. Introduce distrastors, talk to your child when he/she is engaged in an activity, initiate conversations in the community to asses the generalization of this skill. If teaching is needed in the community bring your child out and practice with him/her.

6) Once your child has established eye contact with you, you can teach your child to respond to his peers! Next blog entry will be on teaching your child to respond to his peers!

Like always email with questions please :)

Update on workshop

Hi Everyone !

Wanted to remind everybody that is interested in attending the workshop to sign up quick !

Good news ---> We have discounted the price of the workshop to MYR 75 per person and payment can be made the day of.

The most important thing is to email littlestepsmalaysia@gmail.com to register, or call 010-221 4028.

Registration must be made by October 10th.

Thanks and Hope to see you all there !!

Below are the topics that will be covered, hands on training will be provided to attendees.

Topics that will be covered: 1.  Brief Introduction to Applied Behavior Analysis (A.B.A) 2.   Relationship Building 3.  Managing Contingencies using Applied Behavior Analysis 4.  Increasing your child's independence at home Details Venue: D'tandoor Restaurant Subang Jaya, No.7, Jalan Ss 15/5A, 47500, Subang Jaya, Selangor  47500 Price: MYR 75, payment can be made day of. Price includes coffee/tea and light meal Stationery and workshop packet will be provided to parents/educators. See you all there ! Please send your name and contact details to littlestepsmalaysia@gmail.com or call/text 010-221 4028

You do what I do.. Imitation.

When I first ventured to America to pursue my undergraduate studies, I had no idea what I was getting myself into. I arrived at the airport, imagined to see big buildings, fancy cars, beautiful large highways, and quite honestly I imagined Hollywood. Little did I know, Indiana was far from Hollywood. I was greeted by a friendly elderly man and was directed to a van. On the way to Bloomington, I saw corn fields, corn fields, more corn fields and finally after 1 hour I saw the  Indiana University Bloomington Campus. It was a beautiful campus with a population of 30,000 students.

A 30,000 student population did not intimidate me. In fact, I wanted to attend a large school. The next day, I excitedly woke up, got dressed and made my way to my first class, "creative writing 101." I pushed open the doors and to my surprise, there were more than 150 students in this huge auditorium style classroom. I was mortified. I did not know what to do. So, I scanned the room for a person that seemed to be in a similar situation to mine, I watched his every move and then I did what any other person in a social situation like that would, I did what he did. I made my way to an empty seat, took out a notebook, said "hi" to the person next to me and then waited anxiously for the class to start.

This is called Imitation. I imitated what another person did when I was unsure of what to do in a social context. Most of us do this whether we realize it or not. Imitation is a huge part of our life. When we exercise with Jillian Michaels, we imitate her moves to stay healthy, at our first day at a job, we imitate our co-workers, when we are learning how to use something, we imitate the person teaching us to use object, when we visit a different country, we imitate the cultures and norms of that country, etc.

Imitation can include a simple task such as copying an action, or a more complex skill such as vocal imitation or learning an entire social routine. Imitation is pre-requisite to having an appropriate social interaction. The ability to imitate others is critical in the development of social relationships (Meltzoff and Moore, 1992)  This is why the first steps in teaching a child diagnosed with autism social skills is to teach them Imitation skills first.  Not only do we teach them how to imitate, we have to teach them generalized imitation skills. This means that imitation should occur across different people, settings, materials and situations without reinforcement that may have followed imitating behavior in the past. An example of this is when a child sees his peer put shoes on a doll may later select similar shoes for a different doll while playing at  home. Here, the reinforcement is naturally occurring and adds more value for the child to imitate other behaviors that he/she might see in his/her environment.

There are several way to teach imitation skills:
(a) video models

(b) live models (Peer or adult)

When teaching imitation, a teacher can go in order of the following :  gross motor imitation, object imitation, verbal imitation of sounds, words and sentences, fine motor imitation, imitation of kids songs, video imitation (objects, toys and social interaction).

If you are a parent, and have successfully built some rapport with your child, you can start teaching your child imitation skills.

1) Choose a time of day when you and your child can sit together to play

2) Choose a reinforcer ( a snack or toy that your child prefers)

3) Make sure your child is sitting across from you and is facing you.

4) Provide the model ( First start with basic models such as clapping or hands up)

5) Provide the preferred toy and snack paired with lots of tickles and social praise

A few things to consider:

If you know your child does not have this skill, anticipate that an error will be made and after you provide the model, come in with your hands and help him clap. This is called a prompt. After you provide a prompt, provide your child with the preferred toy or snack. This is important to remember, if you use a prompt, remember to fade the prompt as quickly as possible. This means that if you have provided your child with a hand over hand prompt initially, it is important for you to fade your prompts to the wrist now. The fading steps could be as follows : Hand over hand, wrist, forearm, elbow, bicep, shoulder and then shadow. If you observe tyour child acquiring the skill faster and not needing prompts, feel free to start fading the prompts quicker. This is just a suggested sequence. In addition, if you are fading your prompts and your child makes an error, always go back to the previous prompting level where your child was last successful. Don't forget to provide reinforcement in order for your child to stay motivated and on task.

Please remember like any other skill, everything takes time and you want to make learning a fun experience. Start small and build up to big.

Once your child has learned to imitate basic motor imitations, you can feel free to introduce more complex set of models for your child to imitate and transition into video models as well. 

Here's a great video of Imitation and how to teach it. Please watch it as you will be see prompting strategies. As usual, if you have any questions or are interested to know more about Imitation, please email us at littlestepsmalaysia@gmail.com

Imitation Video






Little Steps | 

We are what we learn to do..

I was browsing on the internet and I found this picture about "tantrums" and "autism meltdown." This picture describes two separate behaviors that parents often observe among their children diagnosed with autism. These behaviors are also often observed in children of typical development.

This picture paints an inaccurate image of how behavior should be observed and does not provide an accurate reflection of how most behaviors function. Behaviors be it a tantrum behavior or an "autism meltdown" is a function of the environment. Because each child with autism is affected differently by autism, each behavior is unique. We as human beings also respond differently to the same set of environmental conditions.

Therefore, to say that a tantrum is "Want directed" for example is a generalization. It can be "want directed", but we don't know this until a formal functional assessment is done. Some children with autism, tantrum due to routine changes, unexpected events, sickness, etc. We will never know why a behavior happens until a formal assessment is done. Therefore tantrum behavior and the antecedent for that behavior will depend on the child and the child's current environment.

In addition, I don't quite comprehend what is an "autism meltdown". All behaviors in our environment especially when dealing with a child with autism, should be objective and well defined. In other words, how do we know if a child is "overstressed or overwhelmed?" How do we measure this subjective behavior? But, we as behavior analysts can measure screaming, crying, shouting, etc and based on those observable behaviors that can me measured, will determine why the child is doing what he/she is doing.

"As each of us experience varying contingencies of reinforcement, some behaviors are strengthened and some are weakened.....We are what we do and we do what we have learned to do." ( Cooper, Heron & Heward, 2007)

We do what we have learned to do. Children with autism have learned to do what they do through contingencies set by their environment. Behaviors have four functions:

1) Attention maintained
2) Escape maintained
3) Automatically maintained
4) Play maintained

A functional behavior analysis should be done to determine the function of a behavior. In other words, if you child is engaging in "tantrum behavior" or an "autism meltdown," a good behavior analyst should determine the function of these behaviors through (a) a functional analysis, (b) descriptive assessments and (c) indirect assessments. Please ask your provider about these assessments when looking at behaviors of concern such as the above. The less assumptions we make about behavior the more effective teachers we will be to our children.

For more information on these assessments, please feel free to email littlestepsmalaysia@gmail.com

psst...excuse me..

I have a 5 year old little sister and she is a ball of energy. She's very enthusiastic, loves talking, constantly asking questions, loves soccer and she thrives on social attention. She's constantly urging us to look at things that are interesting to her and asking us questions about it. She's constantly engaging us and seeking to share her excitement. I am always so amazed with her.

My amazement lies in how hard we work to teach these skills to children with autism. Yet, my five year old sister has learned social contingencies just through observation. It is truly incredible. Once again, like everything else, I start breaking it down in my head. In learning social contingencies there's so many pre-requisite skills a child must have for example, eye-contact, generalized imitation skills, pointing, labelling, responding to initiations, following rules, giving/receiving directions and most importantly, learning the value of social contingencies.

To illustrate my point better, here's another story about my sister.  Yesterday, at the grocery store,  she saw a man in a wheelchair. She stared at him briefly and then pulled me aside to make sure the gentleman in the wheelchair was not looking at her. She pulled my arm down so she could get closer to my ear and whispered, "why is that man in the chair?". How does a typical 5 year old know that if she says that loud, she might offend him or hurt his feelings? Where has she learned to whisper? or to pull my arm down discretely to get my attention making sure the gentleman was not looking at her? Where has she learned this social contingency? Through observation, imitation and perspective taking.

Children diagnosed with autism invariably experience difficulties with social skills (McConell, 2002). From an early age children diagnosed with autism find it challenging to initiate and maintain social interactions with peers and adults. This impairment in social interaction in one of criteria used to diagnose autism ( American Psychiatric Association, 2000).

Important social skills that a child with autism should know are:

1) Conversational skills ( commenting, asking questions, imitating, initiating conversation, joining in)
2) Co-operative social behaviors (helping others, including others, following directions/rules)
3) Non-verbal skills (giving/receiving affection, smiling, Identifying emotions)
4) Pivotal behaviors ( eye contact, joint attention, perspective taking, empathy)
5) Play skills (turn taking, sharing, sportsmanship, pretend play)

Every social skill intervention used should be individualized to a child's needs. If a child has limited verbal repertoire, perhaps it will be more useful to teach you child eye contact, smiling appropriately, getting attention appropriately, sharing, joint attention, empathy, helping other, waiting, etc. If your child has significant language, social interaction can be more focused on play, sharing, joint attention, sportsmanship, etc. For the next few days, I will be discussing each component of social interaction and will be giving you an overview on how to teach your child specific skills based on your child's verbal repertoire.

Any comments and questions are welcome !

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Little Steps | 

More than words..

Language  is a very complex skills. Applying language to a social context is even more difficult. For a child with autism, initiating conversation is challenging. This is because they have a language deficit and a social deficit. In other words, children diagnosed with autism have not contacted the reinforcing qualities to engage in a conversation.

In general, children with autism find it more reinforcing to engage in self-stimulatory and repetitive behaviors such as spinning a toy non-contextually, engaging in body rocking, hand-flapping etc. Because of this, teaching your child appropriate language and behavior is so important. We want to help our children look more like their peers and engage in social behavior just like how we do.

In addition, some children diagnosed with autism have a limited verbal repertoire and some children are non-verbal. These children have a long history of gesturing for what they want when they want it. And guess what we do as parents and teachers? We give them access to these things as soon as they gesture for it. What's wrong with this? The problem here is that your child is learning that his/her gestures are getting him/her access to what they want. Therefore, why talk when I can tug at your hand and show you what I want?

Parents always have a concern that their child has had a long history of gesturing. Thus, if they change their behavior, they are afraid their child will engage in tantrum behavior. So parents want to avoid that and "give in". So what do we do now? How does a parent prevent "giving in"?

1) Don't be afraid: You are your child's number one advocate. You are the only person that can teach your child what is appropriate and what is not. I always ask parents this " What if your child was not diagnosed with autism? Will you be teaching him appropriate behavior?" and the answer I always get is "yes". So my rationale is that autism or no autism, you child is capable of learning. He/she deserves the right to learn and this requires you to be a warrior. A warrior is someone who is brave and not afraid to address change. Therefore, don't be afraid. You are a warrior and you can do this. :)

2) Magnify teaching and start small:  If your child is non-verbal or has limited language repertoire, start small. We do not want to frustrate our child and make language punishing. The first steps to teaching language is to teach small sounds that you know they can make. Some example are "m," "aah," "oo," etc.

3)  Now we will use "incidental teaching" to teach language. Incidental teaching is defined as a method for increasing expressive language by observing what your child initiates for in their environment and we are required to respond in a way that requires language or more language from your child.

Here are the steps we will use:

• The child initiates
• We ask the child to elaborate & prevents access to the item
• The child eloborates
• The child gains access to what he/she wants

Here is an example:

• The child initiates for a cookie by gesturing
• The adult looks at the child and request an elaboration  "cookie" & prevents access to the item
• The child says "cookie"
• The child gains access to the cookie

Initially, your child might engage in tantrum behavior or other behaviors of concern, so when this happens, remember to lower the expectation for your child.  By doing this, you are setting your child up for success. Do not give your child access to any preferred item when he/she is engaging in tantrum behavior. This is very important. You do not want to teach your child that when your child engages in inappropriate behavior, he/she will gain access to the preferred item.

So this is a suggestion as to what you do if and when your child is engaging in tantrum behavior.

• The child initiates for a cookie by gesturing
• The adult looks at the child and request an eloboration "cookie"
• The child tantrums or starts crying

At this point, go back to a word or sound that your child knows, say "coo" or "o". If your child is still engaging in tantrum behavior, do not let your child escape this situation. Wait till your child is quiet or is not engaging in tantrum behavior, offer your the cookie again and expect only eye contact. When eye contact is given, give him/her access to a small piece of cookie. Remember, he/she only gains access to the whole cookie when he/her emits a sound or language. Also, remember WE DO NOT WANT TO PUNISH LANGUAGE.  Now, if your child has been engaging in tantrum behavior for awhile, but now has calmed down and has given you eye contact and gained access to the small piece of cookie, let him/her go play for awhile come back to teaching later.

The next initiation for the cookie, expect language even if it is a sound, and when your child finally emits the sound/language, give him/her that whole cookie and celebrate that success ( give him two cookies if you'd like!)  You always want to end with success and you want to make it clear to your child the expectations you have for him/her. You do not want to punish learning or language. Always keep that in mind. Start small and build up on that, so your child can be successful.

Raise the bar when you observe an environment  that is going to co-operate with you and lower the bar when you observe that the environment is not co-operating with you.

Practice makes perfect, therefore with more practice, learning occurs more frequently and your child is slowly learning a new repertoire of behavior.

You can use incidental teaching for learners that are more sophisticated in acquiring language. Here's an example of that: 

• The child initiates for a cookie by saying "I want cookie"
• The adult looks at the child and request more language  "Mommy, can I have a cookie please?" & prevents access to the cookie
• The child says "Mommy, can I have a cookie please?"
• The child gains access to the cookie

Remember, language is an important part of our life and we want to continue teaching our children language daily and keep embedding it in their behavior repertoire. Be your child's language warrior and you will see with the right contingencies, your child will start learning what they are supposed to be learning. Last but not least, I can't stress this enough, make learning fun. This is something new your child is going to be doing and the last thing you want is to make learning  language feel like a challenging process. 

I hope this was not too much information for you, if you have any questions, please leave a comment and I will try my best to help as much as I can. Thank you !!