Engaging the Enemy

The water flowed like liquid silk across his hands.  He placed his face in the water and it was like communicating with a whisper.  Hushed sounds filtered through...the hum of the vacuum...the whir of the the microwave.  Often these sounds were painful to him but with his face and arms immersed in the cool clear medium in the sink, the aversive noises were muffled.  

Something stomped nearer and nearer, with a quick pace, and then abruptly, he was yanked hard out of the sink.  "Steven!"  The familiar comfortable lady had a strange expression on her face.  It scared him.  He emitted a lonely wail, "oooooo."  The lady who cuddled him and fed him was making loud painful sounds at him.  He did not understand what she said.  He began to cry.  The lady tried to hold him close but the sensation was smothering and tight.  It hurt.  He wriggled free and ran to the sliding glass door.  It was closed.  He pressed his face to the glass and let the smooth predictable feel of the glass soothe him.  

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"Randy, he could have drowned!  He had half of his body in the sink, and the bathroom is flooded!  I didn't even know he knew how to turn the faucet!"  She hung up the phone.  Randy, on the other end, could do nothing but experience an increasing sense of helplessness as he watched his son drift farther and farther away from them.  

Jane was upset.  She understood that Steven had autism.  She did not, however, understand Steven.  Every instinct she had for dealing with him seemed to be wrong.  Why did her son do such unusual things?  And why didn't he respond to her comforting the way his older brother did?  She looked at her beautiful baby boy, who knelt in front of the sliding door licking the glass, and felt something inside her heart tear.  It was just too much.  She had quit her job to become the full-time manager of Steven's program.  She spent her days scheduling behavioral aides from the agency and religiously trying to fill any absences to ensure that Steven received the magical 40 hours of ABA therapy that the research prescribed.  

No matter how little sleep she had received the night before, no matter how many hours she had spent sobbing in the bathroom so as not to disturb Randy's slumber, she answered the door with a smile.  They were her saviors.  They knew what to do, how to help Steven.  The progress he had made over the last three weeks had been so slow, and he was so very far behind.  And when the door to the little room downstairs squeaked shut, she struggled to ignore Steven's tantrums as he adjusted to his rigorous schedule.  

The most recent program involved something they referred to as PECS (Picture Exchange Communication System).  The trainer had introduced small laminated cards with line drawings of various items:  a Skittle, a pretzel, a juice box, a Koosh ball.  The target behavior was for Steven to request desired items by handing the card to an aide.  Progress had been slow.  It appeared that Steven did not associate the line drawing with the actual item, hence the trainer suggested taking photos of the items instead.  Over and over, the aides worked on the skill. Steven's responses were so inconsistent that they were considering placing the program on hold.  

As she contemplated the probability of Steven learning this behavior, there was a crash from the kitchen.  She rushed in and was greeted by the sight of trash strewn across the floor.  Steven flapped a red wrapper in the air and made a repetitive sound, "Eeeee!"  He was covered in coffee grounds.  With a heavy heart, Jane turned to reach for the dustpan.  She felt a gentle push against her knee.  Steven held the red bit of trash and pressed it against her.  As her eyes focused on what he held so tightly, a novel feeling rose up in her chest.  She hesitantly held out her hand.  As he pressed the discarded Skittles wrapper into her hand, she recognized the new feeling...it was hope.      

Lesson 2: How to Conduct a Discrete Trial

The war on Steven's autism began in earnest in a small downstairs bedroom.  On this first day that I would work with Steven alone, I felt a twinge of anxiety run through me.  Would I be able to wrestle the target behaviors from the small boy who sat with his back to me, rocking his body to a rhythm only he could discern?  As I reviewed the program binder, which listed 25 teaching protocols individualized to Steven's needs, I felt daunted.  We were starting at a level I had not even recognized existed.  

Examples from Steven's Program List:

1. 2-D Identical Matching

2.  1-Step Gross Motor Imitation

3.  1-Step Non-Verbal Imitation with Objects 

4.  Come Here 

Following the discrete trial protocol we had been trained in, I prompted Steven to the table and ran through each program, taking care to log my data in the program binder so that the next therapist on the schedule would know where I had left off.  I also took detailed notes on Steven's general demeanor, degree of attention, and self-stimulatory behavior.  

Example of Discrete Trial Protocol:

1.  Give clear, concise instruction

2.  Allow 2-3 seconds for child's response (correct, incorrect, non-response). 

3.  Provide feedback as described below:  

a.  If correct, provide praise paired with primary reinforcement (e.g., Skittle)

b.  If incorrect, provide informational "no" and follow with prompted trial

c.  If non-response, follow procedure for incorrect trial.  

The discrete trial protocol originates from behavioral learning theory which proposes that all behaviors are learned, observable, and are the result of interactions that occur in the environment.  From this theory, behavior change is evidence of learning.  Learning theorists often refer to the A-B-C model (Antecedent, Behavior, Consequence) to describe how learning occurs.  Internalizing this framework for how to interpret behavior became the basis for my ability to facilitate learning in both public and private settings.  Parents, educators, even wives (!) can learn to use this method by reviewing the example above.  

The discrete trial technique became the underlying strategy that we would utilize.  It allowed us to infiltrate Steven's autism and reach him beyond layers of camouflage and barriers.  Each time we created the association between Steven's behavior and reinforcement, we were defeating his autism, one battle at a time.  As Steven's skill set increased, something amazing began to happen...he began to engage the enemy himself.