Today I am continuing my ABA confessional with a discussion of how I’ve integrated ABA practices into my sessions all along. Unlike the previous two “lessons” which offered revelations about the similarities between ABA and Floortime, Lesson #3 focuses on ABA and how it’s different — sometimes strikingly different — from a Floortime approach.
Let’s talk about STRUCTURE during a therapy session.
When I say that my sessions are “structured” like ABA, I’m not talking about the actual “set-up” for therapy. I don’t belt kids into special seats or even high chairs. The only time I sit in a chair at a table is if that’s where my particular little friend wants to sit to play or eat or read or whatever we’re doing. (Some ABA therapists don’t use a table and chairs either!)
What I mean by STRUCTURE is having A PLAN. Some of you may be thinking: “This is silly to discuss. All therapists, no matter what the discipline, develop treatment plans when a child is assessed. We all determine goals.”
That’s not what I mean by PLAN either. I mean a PLAN for the day, for that specific session.
ABA therapists base everything they do in a session on what’s next on the child’s plan, whether it be a VB-MAPP (Verbal Behavior Milestones Assessment and Placement Program) or ABLLS (Assessment of Basic Language and Learning Skills.) I hope all of you BCBA people are impressed that I know your tools!
I’ve found that many SLPs who do home-visits have done away with having a set “plan” for a session. It’s even frowned upon in some state EI programs. A therapist can slide in to whatever is going on in the child’s home, consult with the parent, and then slide out while seamlessly fitting in to a family’s routines. That works fine for many therapists…
Except when it doesn’t.
Recently I was talking with a mom and asked her to describe her child’s speech therapy. She rolled her eyes and said that the bulk of time is spent “doing a whole lot of nothing.” When I asked her to clarify, she said, “My SLP is very sweet, but she doesn’t interact with my child at all. She’s more interested in telling me to do what I already do rather than teaching me something new. I don’t feel like she really knows my son at all.”
That’s not an indictment of the consultative model as a whole, because the theory of making a family’s priorities the focal point of treatment IS a very good idea, but sadly this story is similar to what I’m hearing from families across the country who contact me for advice at teachmetotalk.com. Somehow in this new age of early intervention and coaching, the child is getting lost.
It’s not even an indictment of the particular therapist. What it tells me is that somebody forgot to tell that SLP that she’s STILL supposed to treat the child, not just ‘coach’ Mom. I’ve attended meetings where state agency folks — who are usually administrators and not therapists — say things like, “Don’t touch the child. Don’t take toys. Let Mom lead the session. Spend your time working with Mom.”
My question to them is this: How do you know what to coach if you don’t know what works and what doesn’t with your client? (The client is still the child, by the way.)
All of this brings me full-circle to my point of having a PLAN for each session.
My plan is not to lug in my bag of toys, sit down to play with the child, let mom check out for an hour, and then hurriedly give her a quick update at the end as I’m headed out the door. (We will not tackle the dreaded “toy bag” issue. I do still think that’s an acceptable way to gain a busy toddler’s attention for some children and some families, but that’s a discussion for another time.)
Let me just say, too, that if your only PLAN is to play with whatever you happened to stuff in your giant toy bag, and you used the same toys in the same way for all five kids you see in one day, that’s not a very good PLAN either. (Although it does beat not playing at all!)
When I say PLAN, I mean that I know before I set foot in the door that, no matter what activity we do — whether it’s me joining a kid in the backyard, or sitting down beside him as he lines up his 35 favorite trains, or hanging out with him and mom in the kitchen for a snack and then playing in the cabinets — I know what goals we’re working toward and the specific strategies I’m going to model for Mom as we ‘do whatever together.’ Based on her child’s responses, I can then coach her to be sure she understands what it is we’re supposed to be doing.
Let me give you an example:
I’m seeing a child and his most important goal is working on social engagement. So, no matter what we’re doing, I’m showing Mom how I position myself to maximize opportunities for eye contact and joint attention. This child also has a receptive language goal of following one-step verbal directions, so I’m modeling those types of simple commands, seeing how he reacts, and giving Mom feedback as we go — showing her how I’m cueing him so that he completes the requests. I’m pointing out how I adjust my own language — by slowing down, using fewer words, and pointing to what I’m talking about. When she’s ready, I encourage her to jump in and do it, too. This way, we can tweak our plan so that it works for her too.
What the PLAN isn’t: I’m going to walk into the next child’s home and do whatever it is this kid is doing and just see what happens.
What the PLAN is: It doesn’t matter what happens; I’m there to work toward that child’s goals and support mom as she learns to do it too. The events or toys aren’t STRUCTURED, the setting may not even be STRUCTURED (Note that for some children, you DO need to structure. More about that below…) but I am most assuredly structured.
Unlike ABA, I don’t have a “work box” with my checklist and a set of pictures (not all BCBAs do that either!) and like Floortime, I certainly am following the child’s lead to do whatever it is he likes, but it’s not loosey-goosey. I’m not just following the kid around his home. I’m not hanging out on the couch or sitting at the table and observing. I’m not there just mindlessly narrating what a child is doing (or worse, reinforcing the idea that that’s therapy to mom!)
My PLAN is that I KNOW what my goals and strategies are before I arrive, I work toward them while I’m there, and I explain myself in a way that Mom is comfortable doing the same techniques across a wide variety of situations — whether it’s during play with toys, while she’s giving him a bath, or when they’re out buying groceries.
Truthfully, in the last few years, most of my work has shifted to my office, but that doesn’t dramatically change how I provide services — other than that my PLAN must (happily) include my own materials. It will look a little more contrived than a session in a child’s home, but Mom is still there and we’re still looking at the same guiding principles. The treatment setting doesn’t necessarily alter my STRUCTURE for sessions.
Another way I think about structure is to help moms and dads learn how to better structure a child’s learning environment. That’s therapy-speak for helping a parent know how and what to change at home in order to increase opportunities for their child to learn. It’s different for every child, but here are a couple of examples of how we can provide “structure” for a child who isn’t learning from every day routines:
- A child who avoids social interaction with others (doesn’t respond to her name, can’t follow directions because she tunes out language, prefers an iPad over toys) needs to be around other people most of the time so that she doesn’t miss opportunities to interact and hear someone talk to her. This is how she learns what words mean. Sometimes parents don’t understand that a toddler, who they may have described as “such a good baby” because she didn’t clamor for attention, should be with them in the same room most of the day. She doesn’t need to be left alone in her bedroom to wander, stim, and HEAR NO LANGUAGE and have someone there to help her interpret WITH WORDS what’s going on around her. We want to change the structure of that family’s routine so that she’s with other people and not left in her own wordless little world for much of the day.
- A child who doesn’t seem to like any of his toys may be a child who doesn’t understand how to play with toys. I can change the structure of his day by encouraging Mom to carve out time on most days to teach him how to play by showing him over and over what we do with a particular toy. If I don’t tell her how and why to do this, that mother may think she’s wasted lots of money on toys he doesn’t like when that’s not the issue at all. We have to change the structure of ‘play time’ for that family.
- A child who is a sensory seeker, or in constant motion or “wild” as a parent might say, needs consistent opportunities to regulate his little system so that he can sit down to eat a meal or listen to his mom as she labels pictures in a book that he likes but won’t sit for her to read. Without knowing how to ‘structure’ their day around providing regular planned periods of movement, a mom may become exasperated as she polices this child who’s constantly running away from her. Or without knowing how to structure their routine for reading books, Mom may stop trying.
One last word about structure, this time in the traditional sense: Some kids DO need direct teaching, and lots of it, to learn language. One-on-one direct teaching is very ABA-like, and I fully appreciate the benefits of direct teaching for nearly all children on my caseload — always have, always will. Even with the wonderful naturalistic interventions as I’ve described in this post that can be weaved in and out of a family’s day, some children will require an approach that focuses on many, many opportunities to learn a new skill in a one-to-one setting during a very repetitive, almost “drill-n-kill” style, with lots of trials or practice. Repetition is the ONLY way some children learn an elusive milestone. We have to make sure we’re teaching parents how to structure at least some of their time with that child so that he can make measurable gains during very well-defined circumstances, and then generalize that skill to other activities that are less contrived.
Let’s face it, if a kid has qualified for speech therapy, he’s not picking up language the regular way during everyday routines with his parents. In order for that child to make progress, we HAVE to change things for that child and for that family. If what they were already doing was going to work, would they need you anyway? We do that by thinking about how to not only provide STRUCTURE for our therapy sessions but modify STRUCTURE for a child in his home.
We really can teach words anytime, anywhere…but we’re most successful when we have an overall PLAN which is more STRUCTURED than anyone casually observing us might realize. Great sessions may look like we’re just playing, but there’s always a whole lot more going on!
Now… go make some plans : )
If you need more guidance with how to plan effective therapy for toddlers, I have a great tool for you! Teach Me To Talk: The Therapy Manual is a comprehensive book I’ve written especially for SLPs and other EI therapists (and committed moms who are doing lots of therapy at home with their own child) and it covers every milestone for learning all aspects of language from under 12 months to 4.