Jennifer Howe, SLP started with RehabVisions in 2011 and for nearly five years has been treating patients in a hospital setting in eastern Iowa. Part of her caseload includes autistic children who come to her for supplemental treatment, beyond what is provided at school. Her pediatric patients refine their communication and learn additional skills that are transferable as they progress through the education system and into adulthood.

“My clients diagnosed with autism need a lot of shaping,” says Jennifer. “You’ll do lots of teeny-tiny steps forward and accept responses that are close, then keep molding and molding behavior until it’s more accurate.” Shaping is changing a response to a more desired behavior through trials and rewards. It can be very successful when trying to establish strategies for parents to cope with undesirable patient responses.

Sometimes a therapist will need to work with the parents on developing a strategy for their child to perform a non-preferred activity without a tantrum. Once the strategy is established in therapy it can be applied in the home and school to redirect inappropriate behaviors. For example, Jennifer’s patient, whom she has been working with for a year-and-a-half, required a number of shaping strategies.

“If you have a patient with autism who is easily aggravated, it can be hard for him/her to reorganize. I started out by extinguishing ‘bad’ physical contact and reinforcing with appropriate behavior. A lot of times that requires helping them reorganize,” says Jennifer.

Jennifer uses Brain Gym, essentially a type of sensory management system, to get the patient’s brain prepared to do work and think. Examples that were successful with her patient:

• Deep pressure massage on the back
• Joint compression
• Have patient lay down on floor and do plantar extension and flexion

Jennifer sees the tension melt away while performing these treatment techniques. And it helps them to reorganize and perform the non-preferred task.

The non-preferred task in this case was writing, and it would often result in anger or tantruming. In addition to the sensory-management strategies, Jennifer also worked with the patient on turn-taking:

• Use visuals to present the non-preferred activity and then one preferred activity in sequence.
• After completing the non-preferred activity, the patient can mark it complete on the visual and move on to the preferred activity (for this patient that was Legos).
• The patient learns the concept of turn-taking and over time will adjust and adapt as he/she learns to self-regulate and no longer needs this as a coping strategy.

In addition to Brain Gym, Jennifer likes to incorporate movement into her sessions. With school ages this can be particularly effective because they have been expected to sit at their desk and be attentive all day. If a patient needs to work on writing, have him/her write while sitting on an exercise ball. Or lay on the floor. Or after a writing activity they get to jump on the trampoline.

“For a long time with a particular patient, I had visual choices on the wall that I called ‘Take a Break’,” says Jennifer. “This can be done easily with sticky notes to create a no-tech, low-key Picture Exchange Communication System (PECS) system.” This very gradual shaping helped her patient as he progressed through school. Examples of how the treatment strategies progressed:

• Initial sequencing of activities began with options drawn on a sticky note and posted at eye-level on the wall (fast, inexpensive, and can easily swap options). For this patient, his preferred “Take a Break” activities were a big bouncy ball, trampoline and tickle, because he loved for his neck to be tickled. After completing a non-preferred activity, he could select one sticky note.
• As the patient started learning how to write at school, Jennifer updated the use of the sticky notes to draw a #1 and then draw an image representing his preferred activity. Then sticky note #2 and so forth and lay them out in sequence on the table.
• When the patient was comfortable with words, it evolved into what he was learning to write, such as “book” or “puzzle.”
• Next Jennifer evolved it into sentences, “[Name] will do _____.” Patient would complete by writing “puzzles” or another activity.
• Then the patient would come in and number and write down three sentences himself and pick his own activities and his choice of structured therapy tasks.
• As school progressed they worked on changing the verb, moving from, “[Name] will do,” to, “[Name] will play,” or “[Name] will read.”
• Eventually the patient transitioned away from the sticky notes entirely and could use paper to number and write out his three preferred activities and structured therapy. This list facilitated staying on task.

“That was a neat progression as the patient learned to read and write at school and we were able to incorporate the sequencing of activities. I rarely have issues with meltdowns now, and he’s learning to organize himself and manage his sensory system,” says Jennifer. “It’s become more of an adult task that can go with him into adulthood. With a piece of paper and a pencil he can make a list, develop a plan, and predict what will happen in his world and prepare himself for it.”