Case Studies
Case studies are a great way for therapists to reflect on their work and share experiences and outcomes with other professionals in their field. Parents and caregivers may also find them useful to better understand the choices made in their child’s treatment programs . Below are a selection of my own case studies.
Improving Verbal Language in young learners
Background: Parents want to improve verbal language in their 4-year old son. The household is multi-lingual, and the Learner has not been in school consistently due to the family moving around frequently (different countries). The learner babbles consistently and frequently in his own made-up language, but is unable to greet, make requests, or label objects in English or otherwise. The Learner is extremely busy, and is always moving and running around. When being spoken to, in English, the Learner seems to understand most things being said to him, but is unable to reply in intelligible language. The Learner has not had any prior intensive behavioural treatment, and parents are unfamiliar with ABA principles.
Treatment plan: To begin, I had to pair myself with him and gain instructional control. It's important that behaviour therapists gain instructional control over their learners, because they need their learners to be able to listen and follow instructions in order to learn a new skill. Parents provided gummies as reinforcers, and agreed not to let him have it at home. My first task with Learner was reinforce him for following simple tasks such as "give me a high 5!!" and "touch your nose!". Tasks gradually increased in difficulty, and included "come sit on the green chair", "come sit on the blue chair" (when the green chair was across the room), "say "ah!" ", "say "ee!" ". The schedule of reinforcement (meaning, the rate at which I gave out gummies) was also very dense (I gave gummies very frequently), as I reinforced him for almost everything in order to gain a strong instructional control. Once the instructional control was established, I began the implementing the "Imitate sounds" program. This program began with Learner imitating simple sounds, including all vowel sounds, some sounds of letters, and some 2-letter words ("ma", "ba", "ha", etc). I also decreased the density at which I provided reinforcements (gummies, M&Ms). This was to ensure Learner did not begin to depend on rewards to follow instructions in the future, and that he will learn to be naturally reinforced by being able to communicate. Once Learner showed 90% correct for two consecutive sessions for each sound I introduced, I moved him on to a simple tacting (labelling) programs. Labelling words that were one-syllable, and are items from his everyday life. His program repertoire included labelling colours, food, animals, family members, and kitchen objects. Learner attended a special needs school full time, as well as received 1:1 home therapy for 2 hours daily.
Results: Learner understood expectations quickly and adapted well to each stage of the program. The gummies were incredibly effective, and proved that when parents cooperate with the therapists' recommendations (by restricting gummies at home, other any other advice), the results can know no bounds! At the beginning, the learner did not display any coherent spoken language. By the end of 8 weeks, he was able to follow simple 1-step instructions, imitate sounds, sit when called, sit at the table while doing work, stay focused for up to 1 hour, receptively label 6 colours (red, orange, yellow, green, blue, and purple), label up to 10 everyday items (milk, juice, rice, candy, cup, plate, etc), label up to 10 animals (dog, cat, cow, duck, frog, etc), and request for up to 5 different objects/activities (bubbles, more, candy, etc).
Improving non-verbal language in low-functioning children
Background: The 9-year old learner has no verbal speech apart from "tres bien" (to show he is happy), and does not use PECS (consistently) or other communication devices. Parents report that the learner has developed aggressive behaviours when told no, or when he had to wait for things he wanted immediately. Parents also report that they usually know what he wants/needs, so his daily needs are being met on a regular basis. However, parents installed locks on their fridge and kitchen cabinets due to Learner raiding them when he is not monitored. Learner has not been attending school while the family lived abroad for one year. However, Learner will be enrolled into school again in the upcoming year, and parents are worried that Learner will pose a threat for other children. Parents requested that prepping Learner to be able to communicate appropriately and effectively was of importance, as he will need to communicate to his teachers at school. Learner understands some things when being spoken to, but only in French, and is heavily dependent on sensory-driven activities and objects such as massages, squeezes, Koosh ball, bubbles, pillows, and chewable-toys.
Treatment plan: I had 7 weeks to work with this family, and increasing his independent communication skills was the most socially significant program. As I told that he used PECS inconsistently, I decided to implement the Pyramid's PECS program from the beginning (Phase 1). He mastered this phase quickly, and we began Phase 2 (distance and persistence) after only a few sessions. Because this learner was so heavily dependent on receiving deep pressure massages, squeezes, bubbles, tickles, and other sensory-inducing activities, I used this MO to spend several minutes each day working on requesting for them by exchanging a picture. The distance to the therapist and the book gradually increased, until we reached a maximum threshold of 10 feet. For the remainder of our time together, we stayed on Phase 3 (discriminating between pictures). Food was also a high motivator for him, and edibles were used to teach other self-help programs. He was able to independently use the toilet, however, he was required to exchange a toilet picture immediately prior to entering the washroom to encourage naturally occurring teaching opportunities that can be generalized to the school and community settings.
Results: At the beginning of treatment, the learner engaged in a lot of aggressive behaviours when he didn't know what was expected of him. However, he was only able to access edibles and deep pressure massages contingent upon exchanging a picture. I would regularly designate 20-minute blocks throughout our daily 6-hour sessions to give him squeezes and massages, as well as other opportunities for requesting. This allowed for over a hundred independent exchanges and many opportunities to assess for success. He was able to look in his PECS book for the correct picture and exchange independently, but needed an occasional prompt to go to his book as well as carry it when we were out in the community. By the end of the 7 weeks, Learner's aggressive behaviours decreased dramatically, and ability to exchange with therapist and parents increased. He was also able to independently exchange the toilet picture before going to the bathroom, and showed increased tolerance (up to 1 minute) in waiting for reinforcements.
Assessing environmental factors in everyday life to improve behaviours
Background: Learner does not have diagnosis of ASD, but is followed by a psychologist from Holland Bloorview (Toronto, Canada) for ADHD. The psychologist from Holland Bloorview asked that the family's social worker from Children's Aid Society (CAS) seek out a behaviour analyst to assist with Learner's maladaptive behaviours and implement strategies in the home. The learner lives with his mother in a small 1-bedroom apartment, and stays with his father every other weekend. The mother reports that the learner destroys items in the apartment and can be argumentative at times. The father does not report of maladaptive behaviours when he sees the learner, however, there has been history of marital issues, domestic abuse, and mental health issues with the mother. The learner also has a younger sister (2 years old) who lives with the father, with whom he generally gets along with. The learner is energetic, verbal, and 4 years old at the time of treatment, in junior kindergarten.
Treatment plan: When I first began working with the learner, I spent a few days observing and pairing with him, engaging in pretend play, and following his lead. I also observed the interactions between the learner and his mother, and conducted a functional assessment in the areas of concern, as parents reported that the learner has difficulties in staying still and tends to destroy items in the home and mother's possessions. I began implementing the Zones of Regulation program in order to teach him how to identify various feelings and equip him with "tools" to self-regulate when he experienced negative or heightened emotions. From the observations and functional assessment, I determined that the learner had difficulties expressing verbally what he wants/needs from his mother. Furthermore, I noticed that when the learner got upset, he sought privacy and isolation in the any small space ( bedroom closet, hallway closet, bathroom with the door closed, and behind the couch) in the apartment in order to calm down. During these times, the learner was uncooperative and It was clear to me that this learner desperately needed his own space. Unfortunately, the mother did not approve of her son hiding in closets and small spaces, and usually made him come out. I suggested to parents that giving the learner his own space that he could call his own was imperative in his self-regulation of negative and heightened behaviours, as well as acknowledging his emotions as valid. Furthermore, I suggested that the mother needed to engage with the learner in a more playful manner. Playing and following your child's lead (allowing them to narrate play) is an important part of learning and growing, not to mention it is integral to building positive relationships between parent and child.
Results: Following 8 weeks of treatment, I recommended the Children's Aid Society put in a request for the family to purchase a small play tent and a small trampoline. I explained to the parents and social workers that the tent was important because it gave the learner the opportunity to be able to have a space to call his own. He can put pillows and toys in there and treat it as a hiding place when he needs to cool down. I further rationalized the purchase of the trampoline to be of importance so that it can allow the learner to exhaust some energy in an appropriate manner. Redirecting the learner to the trampoline when he starts to run around the apartment or jump on the sofas is a safer choice, and is an age appropriate activity.