Learning to Respond to People

Once the therapist knows many things that the child enjoys the therapist uses those experiences to increase behaviors that occur more rarely. In other words high frequency behaviors can be used to increase the occurrence of low frequency behaviors. In this case the child looking at someone calling their name is a low frequency behavior because it doesn’t occur very often. A behavior such as jumping on a trampoline occurs a lot. If we limit access to the trampoline, then we can allow access to the trampoline to increase the child’s ability to respond when someone calls their name. First the therapist calls the child’s name in a normal energetic tone. When the child looks at the therapist the therapist picks the child up and places them on the trampoline. If the child does not look up nothing is done. You move on to another try a few minutes later. If the child gets to do fun activities every time s/he orients to the speaker after hearing their name the response of orienting to their name will increase. The child has learned a very valuable skill. Orienting to that specific sound leads to having fun. Providing fun activities for a child every time they orient to their name can be done easily in a play format. When playing the interaction games that the child loves the most place into the existing chain of events an extra demand (the child’s name). When the child looks at you continue the game. If the child doesn’t look at you stop the game for a few seconds until eye contact is made. The important thing here is not the eye contact for eye contact sake. The important aspect of this interaction is the child orienting to their name. We are looking for increased interactive responsiveness and an affective connection to the therapist. This can be accomplished most successfully while engaging in an activity that the child loves. Down the road as these behaviors become ingrained they can be moved to less thrilling activities.

Although we want to establish an orienting response to the child’s name we will not be calling the child to the table using their name. We want to make sure that we can quickly provide fun exciting activities every time the child orients to their name. If we use their name when calling them to the table it will be much more difficult to control the immediate consequence of orienting. The demands associated with coming to the table may undermine the process of orienting to the child’s name.

The next receptive instruction that we want to establish with the child is a response to come here. We usually want to build this response through play. We do a physical activity that the child loves and that they would request if they could. After swinging the child around, for example we would stop the game and walk away. The first thing you want to see is the child following you around the room to get you to continue the activity. When this is happening and you are 99% confident that the child will follow you can say the words “come here” as you walk away. The child comes naturally because you have established that pattern. The child also hears the verbal prompt of “come here” before their behavior. Children usually want to beat a prompt and they use every sensory experience in their environment to predict what will happen next. If the word is the first cue and the word is distinguishable from other words the child will start to respond after the word. This game can be continued during play.

It’s important to make the child’s time with the therapist as fun as possible and also to make the things, especially words, the child learns productive for them. What will be meaningful to a child is anything that helps them accomplish their goals at the level or one step above where they are developmentally.

Once the child consistently comes to the words “come here” we want to consolidate the teaching of “come here” with physical prompts. Coming when a parent or therapist asks is a life saving skill for the child. Imagine a child walking toward a road and not responding to an inhibitory command. Not being able to respond to inhibitory commands places a child’s life in danger. For this reason come here, wait, and stop are taught through positive social interactions and then consolidated as very consistent responses through physical prompting. In the case of “come here”, after the child is consistently coming over we will call the child when they are not engaged and then go get them by the hand and bring them over. After we do this consistently for as long as necessary the response of coming when called becomes almost automatic. Over-learning this response could be life saving.

Next we want to over-learn coming to the point that the child will leave a very attractive activity when the parent calls them. Suppose the child loves dogs and sees a dog on the other side of a busy street. No matter how much the child loves dogs we want listening to parents and coming when asked to be stronger than any external motivating environmental event the child may be faced with in the world. Learning to wait in the same playful fashion and learning to stop can also be life saving. Each of these responses to verbal requests will strengthen the others. In other words, learning other inhibitory behaviors will make each inhibitory behavior more solid.

As the response of coming over when called is becoming strong we can chain to that request the request of sitting at the table. As the child comes, pat the chair, and pause until the child sits. The child can be prompted to sit if he/she doesn’t do so naturally. As soon as the child sits, praise the child, and engage in a very rewarding behavior with the child, such as swinging them around. After the energetic reward, continue playing with the child, trying to maintain normal emotional attachment and gesturing. The key here during the downtime play is to increase the number of back and forth interactions between therapist and child. These interactions may be looks back and forth, gestures, or words. As long as the child is reacting to your actions and verbalizations the interaction should continue. After about five minutes of play go back over to the table and call the child again. Continue alternating interactive play with requests to come over to the table.

When the child is running over to the table and eagerly awaiting your playful interaction, you can start to introduce the wait. When the child comes and sits down, delay the energetic play for five seconds and then reward with play. You need to be able to read the child at this point. Starting to delay from 3-5 seconds is usually possible. The goal is to work up to a delay of about 10-15 seconds. This may take a few weeks. It is important to go slow and not rush extending the wait time. Here the child is learning about delayed gratification. All we are trying to accomplish here is for the child to learn the concept of wait. After the child is consistently waiting for 15 seconds, you add the receptive instruction of wait when the child comes and sits down. You only add the instruction when you are 99% confident that the behavior will occur without the instruction. Once the instruction is added you will want to physically prompt the child to wait if they try to leave the chair before you tell them they can go. Once you have the child waiting for fifteen seconds in response to the instruction practice a fifteen second wait over the next few months in many situations at the table and around the house. Responding consistently to wait in as many environments, as the therapist is creative enough to come up with, will teach the child that what is learned at the table has practical implications in the real world. What the child learns is that he/she has control over contingencies in the world. They are learning how to recognize and respond to contingencies. In other words the child is learning how to learn and problem solve.

At this point the child can respond to the request to come and wait consistently in many environments. We will also, at this time, want to start playing a stop game. This can be done in many ways. The most basic way to teach stop is to play an interactive chase game with the child. While running and playing with the child freeze your movements. Wait for the child to freeze. As soon as the child stops moving energetically pick the child up and swing them around (or do any other behavior that will be very reinforcing to the child). After swinging the child around start the chase game again and freeze your movements. Wait for the child to freeze and then engage the child with either swinging them or continuing the chase game. Here we are targeting the freezing behavior and selectively increasing that behavior by providing continued activity. I’ve (EJL) been asked when explaining this process “what do I do if the child doesn’t freeze”. My answer to that is that the child will freeze. There will be some time when the child stops their movement. It might be slight. The therapist needs to recognize the slightest stop in movement and reward with continuing the chase game or some other energetic fun activity.

At this point we should mention that we often use lively interactive play to motivate children. You do have to take into account the child’s preferences and some children may need a less energetic strategy to remain optimally engaged. Once the response of freezing occurs the therapist must use the already learned wait response without requesting it to delay a few seconds at a time before continuing the enjoyable activity. The goal is to get the child to stop and then increase the time before the enjoyable active continues. Since the child already has experience with wait they should wait as a strategy to evoke continuance of the play activity. After the therapist has the child stopping and waiting for 10-15 seconds at a time the word stop can be introduced before the behavior. This game should be played on a daily basis. This can be changed into the socially appropriate preschool games of red light/green light, freeze tag and statue. Again these games should be practiced in many environments. You will want to make this stop behavior very consistent through continued practice. Ideally it can be paired with come and wait to make the response even more consistent. For example if the child is moving toward a road. Being able to say stop and having the child stop is a life saving response. If you can add come here or wait you have more learned behaviors to rely on in protecting the child.

While we are working on strengthening the receptive instructions of come, wait and stop we can also start to work on object cued receptive instructions. We will have an item on the table such as a block and the therapist will hold out their hand and say “give block.” If the child does not reach for the block and hand it to the therapist the child will be physically prompted to pick up the block and hand it to the therapist. We rely on physical prompting to keep the child successful and guide physically to help the child understand the verbal request. We always try to use the least invasive prompt. For example if all the child needs is for the therapist to point to the block, pointing to the block is all that the therapist would do. The other extreme would be a full overhand prompt where the therapist takes the child’s hand and places it on the block and then moves the child’s hand to the therapist’s hand and takes the block. With object cued prompting we can teach give x, pick up x, open door, close door, turn on light, turn off light and the position cued responses of sit down, and stand up.

Next we move to gesture cued receptive instructions such as “give me five”, where the therapist holds out a hand, palm up, and the child slaps the therapist’s hand. This can also be physically prompted originally to teach the child what is expected with the cues. We can continue to work on come here by holding out the arms and a second after saying come. At this point all of the non-verbal imitation items can be revisited with a verbal request occurring a second before the gesture prompt. In essence we replace the “do this” request in the NVI program with the receptive instruction. In doing receptive instructions in this way we take advantage of the child’s prior learning which demonstrates to the child the value of what was previously learned. We are also taking advantage of the behavioral principle of a discriminative stimulus predicting the presence of contingencies which will lead to desired outcomes. The child learns to predict that the gesture will occur from the receptive instruction. The gesture cue can then be eliminated and the child is responding to receptive instructions.

As we teach the child receptive instructions many of which were already learned in the non-verbal imitation program we also teach the child a variant of come, wait and stop in teaching a child to stay near. Here the child is taught to stay near a stationary object and then to stay near a moving person and to reference their location in relation to a moving person. To teach the stay here to a child we rely on past learning of wait and stop. We start by teaching the child to stay near a certain object such as the car. This can be done by bringing the child near a car and saying wait. Eventually we will bring the child near the car and say, “stay here” – “wait”. Then we will eventually remove the wait. Once the child is very good at staying at a location we start to vary the locations so the child can be told to stay here in reference to many places.

The next step is to teach the child to stay near. Here they have to reference the parent or therapist and follow them. This can be taught in a game format building on the previous wait and stop programs. Within the game of running and chasing and playing statue the therapist yells out stop as the child moves more than five feet away from the therapist. The therapist then says go while moving away. Once the pattern is established, of the child following the therapist and responding to stop the therapist can start to say “stay near” before the stop request to establish prediction in the child of what will come next. The process of moving in the game and controlling the child’s position with stop statements within the game will transfer over to the stay near request. Stay here and stay near should continue to be a focus in therapy through games. “Stay near” and “stay here” are two additional inhibitory games that when acquired strengthen the other inhibitory requests.

From here we move on to multiple word requests. We can chain previously learned receptive instructions such as touch nose and clap hands. We want the child to be able to listen to a chain of instructions and then to complete the requested actions. Some examples would be touch chair, go give mom a hug and then jump up and down three times. This program can be fun and the main thing the therapist is looking for here is that the child is listening to multiple instructions and completing the multiple instructions. This program builds on the child’s ability to listen to instructions and then to plan the motor actions and follow though with the motor actions to complete the instruction. Delayed gratification, motor sequencing and planning, focused and shifting attention are all being targeted simultaneously. Here the therapist should be moving to more natural and varied requests. We will often make a list of possible ways to give the request so the therapist is focused on varying the way the request is made.

After children are able to chain receptive instructions with good consistency we move on to teaching a child to respond to deictic instructions. Here the child is taught to respond to right and left receptive instructions.

Once they can respond to right and left receptive instructions we move on to negated instruction. Saying the receptive instruction with a “don’t” before the instruction. For example “don’t touch your nose”. We alternate negated and normal receptive instructions so that the child is listening to each part of the instruction. Here the child is being taught that little differences in language can be very significant. This can be made into a game like playing Captain May I.

We next want to focus on time related instructions and teach the concepts of first- next-last, before-after, etc. The child is given the chained receptive instructions with modifiers. Some examples are, before you knock on the door give mom a kiss, after you tough your head touch your tummy. We want the child to become flexible with listening to the instructions and paying particular attention to the modifiers. Having a focus on time related concepts creates a more fluid attentive focus which will help the child negotiate the complex verbal interactions of their peers.

We also want to focus on the child learning to respond to implied receptive instructions. When focusing on implied instructions the therapist makes comments such as “it’s too bright in here,” leading to the child shutting off the lights. Other implied instructions could include, I’m cold, I’m thirsty etc. Implied instructions teach the child to listen for unspoken meaning behind what is said.

While teaching negated, time related and implied instruction you will likely see some confusion and a regression in some of the responses to receptive instructions. We want to go back to single instructions and teach the child to flexibly respond to deictic, negated, and then time related instructions as we move back into chaining the receptive instructions. Finally working on implied instructions will open the door to flexible social communication. The programs of verbal responsiveness will continue throughout therapy.

Vocal Imitation

After the child has mastered motor imitation and has started the verbal responsiveness programs we can move into vocal imitation programs. Here we are rewarding the child for attending to, discriminating between and imitating verbal behavior.

We begin by vocal priming. Here we teach familiar animal sounds in a song or statement completion format such as the cow says moo. The emphasis is on making the experience as fun as possible and the sounds as enjoyable as possible for the child. We can also start a phrase completion program where we say a phrase and pause before saying the last word or sound. In these programs the child is primed for a response by repeatedly hearing the phrase. When the child can say the last word of the phrase we use backward chaining so the child says more and more of the phrase.

At this time we also focus on repeating the sounds the child makes and trying to gain some control over the child making the sound. This is an extension of the auditory/verbal discrimination programs and motor imitation programs already discussed. We start with the sounds the child can make and interaction games to get the child responding back to our vocalization. As we get the child making the sound in reaction to the therapist making the sound we gain what ABA calls SD control over the behavior. From here we can start to work on teaching phonics and the use of Kaufman cards to shape language. The Kaufman cards help shape sounds into words along a normal developmental progression. Words are then chained to make sentences with a focus on personal meaning for the child.

Verbal imitation can be further expanded with the help of programs involving imitation of song lyrics and lines from movies. Words are chained into multiple words which are chained into sentences and multiple sentences.

Receptive Labels

With receptive labels we are rewarding the child for attending to the discriminative features of stimuli and matching them to verbalizations. This program builds on and is an extension of the verbal responsiveness and visual discrimination programs. In the receptive labels program the child learns to relate an object to its verbal label. More importantly we are shaping the child’s perception of the world based on socially derived significance. One 3-D object is placed in front of the child and the therapist says give X (give ball with a ball place in front of the child). The correct response is for the child to hand the ball to the therapist. Here the child is learning when the therapist says give ball the correct response is to pick up the ball and hand it to the therapist. The child is praised for a correct response and given a neutral no or “try again” statement for an incorrect response. We make the response easy by only having one object out in front of the child at first. This is called a mass trial. Mass trial teaches the concept of sameness between the object and its corresponding verbal label. The only option is for the child to hand or not hand the ball to the therapist. After the child consistently hands that ball to the therapist we introduce a second object. The child is taught the second object in mass trial format. Once the child has mastered giving the second object (let’s say a car) to the therapist when the therapist says give X (Car) the two learned objects can be put into random rotation. Both objects are placed before the child and one object is requested by the therapist. Here the child is learning to distinguish one object from another. The child learns that one response is correct (handing the ball when the therapist says ball) and one response is incorrect (handing the car when the therapist says ball). The child has to abstract from this process information about what is expected and figure out what stimulus characteristics define the verbal label. The ball may have been blue and the car red. The child may believe that give ball means give blue. For this reason we have to use multiple exemplar training. In other words we teach a number of cars in the same fashion as described above. From multiple trials the child abstracts what stimulus qualities are important to the social abstract world and associated with a particular label which is conveyed through contingencies provided by the therapist. Teaching that multiple cars are all cars also begins to teach the child categories. A car is a car based on certain features common to all and not based on the features that are not present in all cars. The child is learning to rely on social contingencies to abstract what is important about the world he/she sees.

As we go through all of the receptive labels the child begins to understand that different verbal labels are associated with discrete objects. When building an item list we want to be very careful to include enough examples of each label with particular attention to including items that appear to be an exception to the rule. For example if we are teaching the label “bird”, we may want to have a robin, ostrich, pelican, hummingbird and any other bird that doesn’t necessarily look like a bird. We want to be as economical as possible with the item list yet at the same time have items that will define the label adequately. There would be no reason to have a robin, blue jay, sparrow and a martin in an item list. All of these birds are so similar that teaching each one separately would be redundant and boring for most children. The items on the item list should each have core attributes that distinguish the item as belonging to the category but also contain attributes that more specifically define the category. The child should master enough items from the item list to be able to label a novel item in the category without being taught the new item. When the child can label items that s/he has not been taught the label of “Bird” in this case is considered to be established in a basic sense. The child has the concept of a bird and can make relational responses to the concept.

We usually begin by teaching 3-D or real world objects. When using 3-D objects the child is given as much information as possible to abstract the relevant characteristics. As we move to body parts, familiar people, shapes and letters each of these can also be real world 3-D objects. When we move on to shapes the stimuli are beginning to pull for certain responses. Here what the child has to recognize is that the only thing that is being rewarded is the shape. In other words we are specifically teaching a child that shape is an important characteristic that should be attended to when labeling objects. In going from real objects and body parts to shapes the child goes from being able to rely on many characteristics of the object to cue them for the label to only being able to respond to one characteristic to have the correct response. In moving from objects and body parts to shapes we are teaching a child that society finds shape important and responding to items in part based on their shape will yield success.

From shapes we move on to letters which are more difficult shapes. Here we are teaching a child that society finds these particular shapes (letters) especially important. After teaching shapes the child is often taught colors. This is usually more difficult. The child has to release the strategy of responding based on shape and move on to disregarding the shape and responding based on color. Here again the child is learning that disregarding shape and responding to color is rewarded by the social community. The child learns that shapes are different from each other and that each shape has a corresponding label. They then learn that shapes can be more and more complex and there can be only subtle differences between the shapes that lead to discrete corresponding labels. Finally the child learns that shape is one characteristic of an object and color is a different characteristic. Each should be relied upon at different times when interacting with the verbal community. The child will also learn to use both color and shape at times when labeling the world. Basically the child has moved from being allowed to personally abstract qualities of an object to having to relate to the qualities that the social community will reward.

After 3-D objects we move on to 2-D objects. When using 2-D objects (pictures of objects) the child has even less information to rely upon as they relate the picture to a verbal label. The child must relate an abstraction of the object (picture) to a verbal label. Here the image represents the object and then the label further represents the picture of the object and the object. Here the child is learning that objects can be represented in many forms. Here the object, image of the object and social label for the object are all linked relationally. The child learns to understand differences between objects on each level, from the object, to and image of the object, to the socially defined vocalization for the object.

When teaching 2-D objects we use the same instruction “give” with the picture of the object such as “give dog” with a picture of a dog on the table. Each label will usually be taught in a mass trial format. After the first two labels have been learned in a mass trial format they can then be randomly rotated. First we teach give dog with only a picture of a dog on the table. The child can either hand us the picture of the dog or not hand us the picture. Handing us the picture is confirmation of success. Then we teach give cat with only a picture of a cat on the table. Once both cat a dog are learned we can have the picture of the cat and the dog on the table and say “give cat” or “give dog” and provide information about success for correct responses.

With 2-D labels we can teach many labels that would be very difficult to teach using 3-D objects. Give elephant would be a little awkward unless we used a picture. With 2-D labels we usually start with objects and then move to shapes, letters, cartoon characters, places, and then colors. We can also work on hierarchies in that we can have multiple dogs out and say “give dogs”.

After the more concrete 2-D labels have been mastered we move on to more abstract 2-D labels. Here we teach more abstract social behaviors through pictures such as occupations, actions, activities, and emotions. We will follow the same procedure and have a picture of a doctor on the table and say “give doctor” or have a picture of someone throwing a ball and say “give throwing”. When the child can flexibly respond receptively to 15-30 pictures of objects, shapes, letters, familiar people, cartoon characters, places, colors, occupations, actions, activities, and emotions and they are starting to verbally imitate sounds they are ready to move on to expressive labels.