Teaching Children with Autism to Indicate When They Are in Pain

I recently received a question related to my last blog on the importance of looking at medical issues before treating problem behavior. The question a few weeks ago was “How do you teach children with autism and severe language impairments to indicate they are in pain and to tell you where the pain is coming from?” I remember asking a very similar question to Lori Frost (co-creator of the Picture Exchange Communication System – PECS) years ago when I attended an introductory PECS workshop. Lori’s response was to make sure you label and preferably have your child label (with speech, PECS, or sign) when he has something visible that is obviously hurting him. In other words, when your child has a skinned knee or when he gets a bee sting, make a big deal out of labeling the pain for him. This is an important step with the goal that eventually your child will be able tell you he has internal pain which you can’t see such as a head ache or belly pain.

For a non-vocal or minimally vocal child, you might try -- Boo Boo (with a Band-Aid picture card or the words) on my ______________ or my _________ hurts and have your child fill in the body part by speaking or choosing a picture of a body part from an array. Even if your child is speaking, he or she might need added visual supports to learn this concept. To teach the labeling of pain, I would also recommend you try to put a real Band-Aid on a large picture of a boy (on various body parts) and have your child fill in the blank --boo boo on the boy's ___________ or the boy’s ________ hurts. You could also use the same idea to teach this concept with a simple talking device and/ or with sign language. I have found that receptive body parts and tacting body parts are usually prerequisite skills for labeling pain so I would also recommend working on these programs when your child is not in pain.

I believe the ability to label pain is an important skill which can and should be taught. For more information including details about my book (The Verbal Behavior Approach: How to Teach Children with Autism and Related Disorders), check out my web site: http://www.verbalbehaviorapproach.com/.

A Quick Assessment for an Intermediate Learner with Autism

The term “Intermediate Learner” is very subjective and in the ABA/VB field, this usually indicates that the manding, tacting and intraverbal areas on the ABLLS or VB-MAPP are not well developed. While the intermediate learner can mand for basic items and some actions, he or she is usually weak at manding for attention and information. Basic tacts are solid and the child may have hundreds of tacts but usually has difficulty tacting features, functions, actions, prepositions and more abstract concepts. In addition, intraverbals (answering questions with no visuals) are extremely weak. Basically an intermediate learner is usually able to talk but unable to hold a conversation.

My son is now 13 years old and has been an intermediate learner for several years. At this point many would consider Lucas to be at the cusp of an advanced learner in some areas but most of the years since we’ve implemented ABA, my son has been at the intermediate learner level.  Programming for intermediate learners, therefore, has always been an issue of great importance to me.

A few people have made comments such as “Well if Mary is a BCBA and VB works, then why isn’t her son conversational or why isn’t he recovered from autism?” I write about this in Chapter 12 of my book and I suggest that if it were just about how hard you worked to help your child, Lucas (and many other children with autism) would be long recovered. But Lucas remains moderately autistic and, while his language improves, it does so slowly but surely. I equate it to climbing a very huge mountain with a lot of stuff on our backs.

I often encounter vocal children who appear to be an intermediate learners and I need to assess them very quickly without using a lot of materials and without completing a VB-MAPP or ABLLS.  A few years ago I wrote down the steps I usually use to assess these intermediate learners in a few minutes with only a small amount of materials.

This mini-assessment is not all that is needed for these learners but it may help you get started in terms of knowing which children need a more thorough assessment and careful ABA/VB programming. Intermediate Learners (who do not “pass” the mini-assessment below) need a more thorough assessment such as the VB-MAPP and also need very specific programming.  Ideally, these learners should also have access to on-going consultation by a BCBA familiar with intermediate learner ABA/VB programming.

Here are areas I assess:

For language I focus on assessing mostly the tacting and intraverbal repetoires. While I’m assessing these areas as well as some basic academic skills, I’m also listening for the child to spontaneously mand for items, actions, help, attention, and information.

Personal information/Intraverbals
What's your name, how old are you, what's your phone # and address (assess both knowledge and articulation of these).

Tacts of functional items such as chalkboard, stapler, paper towel, toothbrush (pictures and items).

Tacting body parts/clothing (what’s this called (nose)) and actions (what am I doing (clapping))

Tacting features (use real items)....”What's this called?”...chair. “What is this part called?”....legs/back/seat (also assess: computer...keyboard, mouse, screen, phone....cord, buttons, receiver, and car....wheels, roof, door).

Tacting prepositions....Hold a pencil over a book and ask "where's the pencil?" Do the same procedure for in front of/behind/next to/under/in/on ....the answer needs to be “over the book”...not just “over.”

Tacting pronouns....whose shirt (while touching your own shirt....his answer should be "your shirt" or "yours" ...same procedure for my (clothing or body part)....then test Who has the book (you do or I do) ....test boy/girl and he/she too if the child is successful with my/your and I do/you do.

Yes/No tacts....Is this a bed (show him a spoon)......Does this have wheels (show him a car)...Does this have wheels (show him a bed)....Is this blue (show him something that is yellow)

If the student is successful with Yes/No tacts, I then assess Yes/No intraverbals…does a cow say quack, does an airplane fly in the sky, does a boy where a dress.

Intraverbal feature/function/class and Intraverbal Webbing
Tell me a color, tell me another color, tell me something that is yellow, name two things that fly in the sky, close your eyes and tell me some things that are usually red, tell me a vehicle, tell me a hot breakfast food, tell me something with four wheels, what do you do with a sink.

Math abilities...count to 7, give me three, circle four, what is 2 + 3 (no visuals). What time is it? Check tacting money and adding amounts of money (place a quarter and dime on desk…how much money is that?)

Reading/comprehension ....If child can read, have him read a few sentences or pages from a book. While he is reading, note errors and fluency.  After he is finished, ask who, what, where, when, how and why questions regarding the content.

Writing....I ask the child to write his name (looking at pencil grip, spacing, size).  If the child is successful I might ask him to also write some other words or draw a picture.

During the assessment, I also record the child’s ability to mand for items present and note any ability for the child to mand for help, attention or information during the assessment. If he doesn’t spontaneously mand for information then I sabotage the situation (Hide something in the room and tell him..."I have a swedish fish somewhere in this room"....see if he says "where").....I might also hide something in a box or bag and say "I have something in this bag for you" and see if he says "what."  During the assessment, I also look for barriers to learning including issues with instructional control and problem behaviors.  I record all significant problem behaviors and note which operant or skill seemed to trigger the behaviors.

Once this mini-assessment is finished, you should know if the child or adult needs a more thorough VB assessment such as the VB-MAPP. You’ll also have an idea of some programs that might be useful.

For more programming advice, listen to my radio shows on programming: http://www.verbalbehaviorapproach.com/radio.html

More assessment information and programming advice can also be found in my book: The Verbal Behavior Approach: How to Teach Children with Autism and Related Disorders available at: http://www.amazon.com/Verbal-Behavior-Approach-Children-Disorders/dp/1843108526/sr=8-1/qid=1167954419/ref=pd_bbs_sr_1/102-6326506-0064953?ie=UTF8&s=books.