Teaching Children and Adults with Autism to Answer “Yes” and “No”

The ability to respond “yes” or “no” to questions is a very complex skill involving different operants. It has been my experience that a child needs to master yes/no mands (Answering yes or no to “Do you want a cookie?”) before you should attempt to introduce yes/no tacts (Is this a bed?) or yes/no intraverbals (Does a cow say quack?). Assessing yes/no within each operant is a good place to start.

I've done a lot of work with teaching yes/no mands to my son with autism as well as several other children. Teaching a child to say “no” or to respond with a head shake NO can be taught early to replace problem behavior such as crying or pushing items away but teaching a child to say “yes” should not be done until important prerequisites are in place.

I recommend not teaching "yes" mands until the child is spontaneously manding for dozens of items in and out of sight and manding for several actions too. I've see many children who have a defective yes mand because someone taught them to answer “yes” too early. The main issue is that they say "yes" when someone offers them something (Do you want candy or Do you want a tickle) but they cannot ask for those items (candy) or actions (tickle) spontaneously by using the item or action name. This often leads to problem behavior.

Once children can spontaneously mand for many items and actions out of sight, this is how I start teaching yes/no mands. First, I gather three things the child loves (and will almost always mand for or take) and three things they don't like and would usually push away (raisins or another non-preferred food item and certain videos). I then use these items during short (10-15 minute) yes/no mand sessions. I ask “Do you want a ___?” while holding one item and prompting yes/no and doing a transfer trial. For some children I have used textual prompts which are the written words "yes" and "no.” Textual and/or verbal prompts need to be faded carefully though by using transfer trials.

Here is an example of a prompted trial followed by a transfer trial:

Hold up a raisin (non-preferred) and say “Do you want a raisin?” prompt NO verbally, with a head shake and/or the word NO written on an index card. The child needs to say or head shake “no.” Then immediately complete the transfer trial by taking away the textual prompt (if used) and asking the question again “Do you want a raisin?” The child says “no” without any prompt and the item is removed.

I create many contrived situations, alternate between things they want and don’t want, and take trial by trial data during these short yes/no mand sessions. Once this skill is solid with the 6 items (3 items they like and 3 items they don’t like) in sight, I then specifically work on generalizing to other items and moving mastered items out of sight.

You also have to be careful about not accepting sloppy responses such as "pretzel, yes." The answer has to be yes or no when teaching yes/no mands. Be careful also not to overuse yes/no questions outside of these yes/no mand sessions when the child is just learning this skill. Otherwise, the child may lose the ability to spontaneously mand for items.

Yes/No tacting (answering “Is this a pen?” or “Is this blue?” or “Am I standing?”) is a much harder skill and should not be introduced until the child can indicate yes/no for mand items out of sight (Do you want ketchup on your hot dog? Or Do you want ice cream?). He or she also needs a solid tacting repertoire for items, features, actions, etc.

For children with the ability to respond yes or no with manding but who have yes/no tacting difficulty, I have had success with teaching yes/no tacts within the mand frame. When my son was learning to tact yes and no and would mand for cheerios spontaneously, I pulled out cheerios and asked "Are these cheerios?" He said "yes" and then got the cheerios. Once he had this skill solid I pulled out a different box of cereal when he manded for cheerios and said "Are these cheerios"....then he said “no” and I pulled out another box and asked "Are these cheerios?" and he said “no” then I finally pulled out the cheerios. Eventually (and in random order) the answer was “yes” and he received the cheerios. I then moved on to presenting yes/no tacts with flash cards without a mand component. When I started with flashcards I used “Is this an apple?” as the only question and had a mixed pile of apples and other things that were very different from apples. Once yes/no tacts are mastered (Is this a bed?, Is this a car? as you present random pictures), you’ll need to also teach children to respond to yes or no to tacts involving feature, function and class (“Does this have wheels?” or “Can you eat this?”).

For yes/no intraverbals, it is important that the instructor know the answer to the question they are asking. For example, asking “Have you ever been on a boat?” is not a good question if you don’t know whether the student has ever been on a boat. There are many children and adults with autism who answer “yes” often (and incorrectly) because they don’t understand complex language. For this reason, I usually don’t focus on teaching intraverbal yes/no responses. I directly teach yes/no mands and tacts and let the intraverbal yes/no responses develop more gradually (and only teach basic, functional and important yes/no intraverbals).

For more information about improving verbal behavior in children and adults with autism, go to my web site: http://www.vbapproach.com/.

Mia’s Journey with the Verbal Behavior Approach

I am happy to announce a series of you tube clips that I posted a few days ago that may make getting started with the Verbal Behavior Approach a little easier for both parents and professionals! There are now three short (6-8 minute) You Tube clips on the assessment and beginning ABA/VB intervention for Mia, a 2 year old lgirl recently diagnosed with PDD-NOS.

I have permission from Mia's parents to post these clips on you tube so that others may benefit from my work with Mia. Hopefully these clips will be the first three in a series of videos that I will post as Mia makes progress!

Clip #1 shows Mia's problem behaviors and poor instructional control at baseline. Clip #2 demonstrates for parents and professionals what to do to help Mia and Clip #3 shows me reviewing Mia's VB-MAPP and Barriers with her mother. All three clips were filmed during a 3-hour initial assessment in June 2010.
Clip #4 was filmed in July 2010 and shows progress in 3 weeks.
Here are the links:

Clip #1/Mia's Baseline Problem Behavior: http://www.youtube.com/watch?v=FCbBLhLjoXA

Clip #2/ABA/VB Interventions to Start Immediately: http://www.youtube.com/watch?v=rPUII8DWlCo

Clip #3/VB-MAPP: http://www.youtube.com/watch?v=8zgn3Tqy8nM

Clip #4/Progress after 3 weeks:  http://www.youtube.com/watch?v=665jj4i29Ag

I’m looking forward to watching Mia progress on her journey with ABA/VB! For more information about the Verbal Behavior Approach, go to: http://www.verbalbehaviorapproach.com/

The Importance of Ruling Out Medical Issues Before Treating Problem Behaviors

As both a Registered Nurse and a Board Certified Behavior Analyst (BCBA), I find myself frequently reminding people that some behaviors are caused by medical issues and cannot effectively be treated behaviorally.

Here is a little review of the four main functions of problem behavior. Two functions are Socially Mediated which means that other people have been involved in the past that have reinforced the behaviors. The other two functions are Automatic which means that no other person needs to be involved. The child or adult engages in problem behavior because the behaviors are automatically reinforcing. Here are the four main functions broken down further:

1) Socially Mediated Positive Reinforcement (Attention/Access to Tangibles). In the past when the child engaged in problem behaviors, things were ADDED such as attention and tangibles.

2) Socially Mediated Negative Reinforcement (Escape from Demands). In the past when the child engaged in problem behaviors demands were REMOVED (or delayed or made easier).

3) Automatic Positive Reinforcement (Self Stimulation). The child engages in problem behavior because in the past when they have engaged in this behavior pleasure/reinforcement has been ADDED.

4) Automatic Negative Reinforcement (Pain Attenuation). The child engages in problem behavior because in the past when they have engaged in the behavior, pain was REMOVED (or lessened).

In Chapter 2 of my book (The Verbal Behavior Approach), I cover the first three functions in pretty much detail but I don’t explain Automatic Negative Reinforcement too well except to mention that children with problem behaviors which come on suddenly or which you suspect might be medical should see a physician. In many cases, however, it is difficult for you or any physician to determine if a problem behavior is caused by a medical problem, especially in children with autism who cannot fully communicate about pain or discomfort.

I had an experience with my own son in the past few weeks since I wrote my last blog which I decided to write about to illustrate the importance of looking at medical issues when evaluating a child for the first time or when an established client experiences problem behaviors which start abruptly or increase without a clear explanation.

Lucas, who is 13 and has moderate autism, showed an increase in self injurious behavior (SIB) over the past few months. While in the past he would occasionally bite his knuckle at school, the rate and intensity of his knuckle bites went up significantly (from approximately one knuckle bite a day at school to 10 knuckle bites occurring both at home and school). This increase occurred in the past two months and at times, in addition to the knuckle bites, Lucas would sometimes hit his head and cry.

Lucas’ teacher and aid at school kept careful ABC data and the behaviors usually appeared to be related to access to tangibles and/or escape. But the demands were not higher than usual and sometimes he would engage in problem behavior without a clear antecedent. The professionals who worked with Lucas for years were all concerned that his behaviors were worse than ever. I was concerned too and noticed that sometimes at home when he engaged in problem behaviors, he cried real tears (and engaged in SIB) while on reinforcement. At these times when I asked him what was wrong, he would almost always say “eyes” but I didn’t know if he was saying eyes because he was crying or if he was truly in pain.

I finally took him to the pediatrician who agreed to do a battery of blood tests and a CAT scan of his head and sinuses. Because we knew Lucas wouldn’t tolerate a CAT scan without sedation, the doctor had to arrange a CAT scan with anesthesia. The MD and I agreed that is everything came back normal; we would chalk up Lucas’ problem behaviors to puberty and treat it behaviorally.

While the blood work and CAT scan of the head were within normal limits, Lucas’ sinus CAT scan showed “sinus disease” which has responded well to antibiotics and allergy medicine. I’m happy to report that Lucas’ problem behaviors are now back to baseline and we will work hard to implement behavior procedures to get rid of his SIB altogether.

For more information about reducing problem behaviors in children with autism, please read Chapter 2 of my book (http://www.verbalbehaviorapproach.com/), listen to a radio show on reducing problem behavior (http://old.autismone.org/radio/?archive=5729) and/or read my previous blogs.

Getting Started with the Verbal Behavior Approach

An ongoing challenge is how help parents and professionals get started with the Verbal Behavior Approach. Several months ago I published a short article entitled “Getting Started with the Verbal Behavior Approach” in Autism File magazine I think it is great for both parents and professionals who are brand new to the VB Approach and want a very brief overview. The article appears on the home page of my web site in the lower right hand corner. Here’s the direct link: http://www.verbalbehaviorapproach.com/autism_file.pdf
I do have permission to copy and distribute freely so feel free to pass it along!

In addition, there are many other free resources on my web site including Frequently Asked Questions Regarding VB and Frequently Asked Questions Regarding Potty Training. These two FAQ articles are available in both English and Spanish:  http://www.verbalbehaviorapproach.com/faq.html

Go to: http://www.verbalbehaviorapproach.com/ to access information to help you (or a parent or professional you know) get started with the Verbal Behavior Approach.

Why do Students with Autism Have Such a Difficult Time with Transitions?

Imagine you are at the beach on a beautiful sunny day having a cold drink and reading a great book. On a scale of 1 to 10 with 10 being the most reinforcing activity, you would rate being at the beach on this day to be a 10. Without warning, I abruptly come up to you and say “all done beach, time to load heavy boxes in a truck.” You would most likely not like this at all and might start displaying problem behaviors in the form of arguing, stomping you feet, and slamming your chair onto the sand. You might even refuse to leave your preferred activity and literally dig your heels into the sand. What I want to illustrate is that we all have problems with transitioning from high preferred to low preferred activities. The key is to ease transitions by not asking a child to transition from a 10 (a highly preferred activity) to a 2 (work) constantly throughout their day. I will briefly describe five techniques to ease transitions.

1) Dangle the carrot (the reinforcement) before problem behavior occurs.

In the beach example above, if I would have come up to you and offered you $50 to help me load 5 heavy boxes in the truck that would have been fine but waiting to offer cash until you start stomping your feet and refusing to move is a very bad idea. Remember any behavior that is reinforced will maintain or go up. Propose the reinforcement while you place the demand to transition not after problem behavior occurs.

2) Don’t physically move a student from one location to another (even if they are small enough to carry or move).

I wouldn’t even think about physically dragging you off the beach to help me load heavy boxes as this could lead to me getting arrested for assault. It amazes me that some people try to physically move students with autism from one activity to the next. If you try to prompt the child to move and he or she resists with equal but opposite pressure, this is considered a physical restraint. If you are currently using too much physical guidance for transitions, you need to stop and implement some other appropriate interventions.

3) Whenever possible, give choices.

If I would have come up and stated that I needed help with some heavy boxes and asked you when would be a good time for you to transition, you would probably have been a lot more cooperative. You may have suggested that we load the boxes when you finished your drink or after you read to the end of the chapter in the great book you were reading. We make a lot of choices throughout the day, especially when we are faced with difficult or unpleasant tasks. We need to give our students with autism as many choices as possible to ease transitions.

4) Sandwich harder activities between two preferred activities and consider using schedules and timers.

Some students benefit from visual schedules and the use of timers to indicate that one activity is over and a new one is beginning. The use of a “promise” reinforcer is also successful for many students. A promise reinforcer is used when it is time to transition to a less preferred area. The child is approached with a favorite toy or a small edible reinforcer and this is used as the “carrot” and a visual reminder that reinforcement is available for a smooth transition. Some students need several small edible reinforcers on the way to a less preferred area. It is also important that all the hard activities are spread out throughout the day and placed in between reinforcing activities. In the beach example, if you knew that you would be at the beach from 1 to 4 pm then you would spend 10 minutes helping to load boxes in a truck followed by going home for pizza, the task of loading boxes would not have been such a big deal.

5) Make sure all “work” stations are paired with reinforcement and avoid the word work whenever you can.

Some of the best classrooms and home programs I have seen have strong reinforcers at every “work” area. Each area has some electronic device (a computer, DVD player, or music box) as well as a separate box of toys and items kept on top of a rolling cart that can go with the student and his instructional materials to each area. I often tell professionals and parents to avoid the word “work” for students who have difficulty with transitions and to spend a few minutes at the beginning of each session pairing yourself and the materials with reinforcement. If students are not running towards the next activity or at least moving there without problem behavior, your demands are too high and/or your reinforcement is too low.

Check out chapter 2 and 4 of my book (The Verbal Behavior Approach) for more tips on easing transitions! http://www.verbalbehaviorapproach.com/.



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Reducing Problem Behaviors

I often get questions like this:  My child  displays problem behavior (screams/argues/ bites/kicks/flops to the ground ) when a demand is placed ( it is time to take a bath/do homework/go to bed).   The answer to the question is similiar no matter what the problem behavior or demand. 

Whenever problem behaviors occur, I believe the demands are usually too high and/or the reinforcement is too low.

The first thing I would recommend is to take data (how many times the behavior occurs per hour or per day and take some ABC data too, if possible). Next I would look at activities when the problem behavior almost always occurs (when it is time to take a bath) and when it never occurs (while your child is playing on the computer).

You then should look at ways to “re-pair” the bathing routine (get foam for the tub or bath paint/toys for instance) and try to sandwich harder activities with fun activities (first bath then computer). A heavy focus on pairing and manding as well as an 8 to 1 ratio for positive to negative comments is usually helpful too.

Continuing to take data while you intervene is necessary to make sure the behaviors are decreasing. If problem behaviors are severe you may need a Board Certified Behavior Analyst (BCBA) or someone with lots of experience with problem behaviors to help you. My book (The Verbal Behavior Approach) --specifically chapters 2, 4, and 5 explain these ideas more fully.  Check http://www.verbalbehaviorapproach.com/ for more information.

The Big Three Skills for Individuals with Autism

I’ve been consulting with children and a few adults with autism for seven years now and I had a revelation about two years ago soon after I published my book. I now believe that there are three main skills every child and adult with autism needs to be successful. These skills, I believe, are the most important skills regardless of the person’s age or level of functioning.

The Big Three are:
1) Problem behaviors at or near 0
2) The ability to request wants and needs
3) Independent toileting

Whether your child is 5, 15, or 50 years of age, I think without these three skills, he or she will have little opportunity for inclusion at school or in the community. In addition, without these three skills, parents often cannot access babysitters, respite providers, schools, or work opportunities for their children. They also have a difficult time taking their children to pools, restaurants, on planes and even to visit friends or relatives.

If you or other people are working on different skills (double digit math or reading for instance) but your child has not mastered “The Big Three,” think about suggesting some additions and/or changes to your child’s program.

For more information, check free resources on my web site: http://www.verbalbehaviorapproach.com/ and read my book (The Verbal Behavior Approach) specifically chapter 2 (reducing problem behaviors); chapter 4-6 (pairing and manding) and chapter 11 (toilet training). You can also access radio shows on these three topics on my web site.