I am a behavior analyst working with an 18-month-old recently diagnosed with autism. Do you have any suggestions on how to work with such a young client?
Answered by Peggy Halliday, MEd, BCBA, Virginia Institute of Autism
Tristram Smith, PhD, University of Rochester Medical Center
By now most of us have become familiar with the importance of early intervention because of the favorable results of outcome studies and efforts to promote awareness, such as the CDC Act Early Campaign (“Learn the signs. Act early.”). It is therefore both exciting and challenging to be given the opportunity to work with a very young child who has been given an autism diagnosis, or labeled “at risk” for an Autism Spectrum Disorder. The excitement comes from the expectation that we can be particularly effective by starting early. The challenges lie in working with a child who is in many ways still an infant with an infant’s unique needs.
Research on intervention for toddlers with autism is still at a somewhat early stage but two comprehensive interventions have shown promise: early intensive behavioral intervention (EIBI) and the Early Start Denver Model (ESDM). EIBI was originally designed for slightly older children (beginning at two to three years old). However, it has been implemented successfully with a younger age group by making some adjustments that take into account the child’s developmental level.
Early Start Denver Model was developed for toddler-aged children, but is still new, having been tested carefully at only two research sites. ESDM is an “eclectic” autism intervention that combines ABA-based with non-ABA-based approaches. The manual specifies that ESDM “has clear ties” to ABA approaches such as Pivotal Response Training (PRT), incidental teaching, and milieu teaching. Other approaches are described as “developmental,” meaning that the focus is on providing intervention in the context of social interactions that are similar to those in which most other children first learn to interact and communicate. Descriptions of ESDM emphasize that in this model a wide range of intervention approaches is constantly available to children. We eagerly await further replication of this intervention and future research to help us understand its most effective elements.
Regardless of the age of the client, it makes sense to rely on the same tactics needed to create any good behavioral program (e.g., Fovel, 2002). First, it is necessary to assess a baseline of skills across the full array of domains such as social interaction, play, communication, and self-help skills. This will enable you to specify appropriate goals and corresponding curriculum. From there you can develop teaching strategies that will give the child frequent learning opportunities and will promote the generalization of skills across situations and people. And last, you will want to continuously evaluate progress. A good program is committed to collecting objective data, analyzing it and using it to make data-based decisions.
As with any other child, it is good practice to begin by administering an assessment to determine the child’s baseline skills and deficits. One assessment tool that is often used in ABA intervention programs is the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP) because it contains measurable milestones balanced across multiple skill areas such as social behavior and play, motor imitation, and spontaneous vocal behavior. It divides skills across three developmental ages, 0-18 months, 18-30 months, and 30-48 months. This is helpful in setting reasonable, age-appropriate goals. Once you have set the goals, you will be ready to create age-appropriate programs based on both discrete trial instruction and incidental, naturalistic teaching. Most authorities recommend that the child is offered enough teaching time to have frequent learning opportunities (20-25 hours a week, not 40, as in some ABA programs for older children, given the child’s young age).
Parent participation and support is especially critical when working with a toddler. Parents may be reeling from the shock of the diagnosis and are also often frustrated because they may be uncertain about how to play with their child. A typically developing infant teaches her parents how to play with her by reinforcing their behavior. For example, a mom says “Peek a boo!” to her infant and the baby smiles and giggles, so the mom does it again. A baby on the autism spectrum may not have the same interest in social interactions, and sometimes parents give up this type of play when their child continues to be unresponsive. In addition, the toddler may show frustration at his inability to communicate well (not at all unusual for any 1½ to 2-year-old, hence the nickname “terrible twos” for tantrum prone 2-year olds). Parents, in their desire to make their child happy, may, with the best of intentions, fall into a pattern of inadvertently reinforcing the child’s tantrums by giving their toddler whatever pacifies her.
A high priority, then, when beginning to work with a young child, is to help the child learn a functional way to communicate, whether by pointing, signing, handing a picture, or making a verbal approximation. Teaching parents and caregivers not to give in to the tantrum but rather to respond only to appropriate communication, is critical. At the same time, it can be enjoyable to teach parents how to relax and have fun with their toddlers through play. Parents and interventionists become partners in discovering ways to gain the child’s attention, and then make the most of it. Working together to find out what the child likes, and using those activities and objects in creative ways will enable you to teach the skills you have identified in your goals.
Another important priority is for parents to speak to the toddler in ways commensurate with his or her level of receptive language. Succinct statements made in context and repeated across similar situations to promote predictability may go a long way in advancing comprehension.
Adaptations for the child’s young age in ABA programs include scheduling around naps and postponing instruction on pre-academic skills such as counting. Specific teaching depends, of course, on a particular child’s baseline functioning. Early learning skills which are the building blocks for more advanced skills may include such tasks as requesting, simple labeling, responding when name is called, simple direction following, exploring toys, motor imitation, and vocal behavior. Working on interaction and play skills in order to develop social relationships is essential.
Reinforcement is one of the most critical elements of therapy. A goal is for the child to be having so much fun that he has no idea how hard he is working. This means short periods of work are interspersed with short periods of reinforcement. Reinforcement can come in many forms such as movement like bouncing or swinging, playing with bubbles, singing a song, or silly things like pretending to sneeze. Incidental teaching should incorporate the practice of embedding instruction on target skills into preferred activities all throughout the day. Doing the same preferred activity over and over for just enough of a reward to be reinforcing is a great way to get in lots of practice. For example, a child who loves to swing may sit in the swing and say “Go!” in order for the swing to be let go. The child may practice “Go!” 15 times before losing interest in the swing.
When people think of early intensive ABA, they often get an image of a child sitting at a table doing “drills.” While some seatwork may be helpful even for toddlers, sitting on the floor, playing in beanbags, on swings, outside on the grass, taking walks and exploring, and crawling through “forts” should also be part of the picture. Other activities might include performing finger plays to “Itsy Bitsy Spider” or filling in the last word to a line of a nursery rhyme. If the child is fortunate enough to have older or same-age siblings or close neighbors, you might borrow them for part of every session. While toddlers are too young to be expected to play elaborate make-believe games together, they often enjoy activities such as playing alongside each other and imitating each other’s actions. Also, older siblings and neighbors can demonstrate play and communication skills. They can be excellent teachers! As with teaching older clients, you will rely on the data to help you evaluate the program. If the data tell you something isn’t working, try something else. Starting early gives you the time to really get to know your young clients and learn and grow with them.
McEachin, J. J., Smith, T., & Lovass, O. I. (1993). Long-term outcome for children with autism who received early intensive behavioral treatment. American Journal on Mental retardation, 97, 359-372.
Green, G., Brennan, L., & Fein, D. (2002). Intensive behavioral treatment for a toddler at high risk for autism. Behavior Modification, 26(1), 69-102.
Fovel, J. T. (2002). The ABA program companion: Organizing quality programs for children with autism and PDD, New York, NY: DRL Books, Inc.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., & Varley, J. (2009). Randomized, controlled trial of an intervention for toddlers with autism: The early start Denver model. Pediatrics published online Nov 30, 2009.
Sundberg, M. L. (2008). Verbal behavior milestones assessment and placement program, Concord, CA: AVB Press.
Citation for this article:
Halliday, P., & Smith, T. (2011). Clinical corner: Working with 18-months olds. Science in Autism Treatment, 8(2), 7-8.