Rehearsal Strategies for Anxious Students
- [Shelley] Marlene Breitenbach is a special educator and a Board Certified Behaviour Analyst with more than 30 years of experience teaching individuals with Autism Spectrum Disorder.
She was a member of the consensus panel selected by the New York State Department of Health, which authored Clinical Practice Guidelines for Early Intervention: Autism Pervasive Developmental Disorders.
From 2001 to 2012, Marlene collaborated in research with Queen's University to study the prevalence of autism in Canadian provinces.
Marlene served for more than 10 years as Special Education Autism Coordinator with the Prince Edward Island Department of Education, Early Learning, and Culture, where she guided the implementation of the provincial autism strategy, provided staff and consultant training, supported complex cases, and helped to build and facilitate our own interprovincial online ASD and Behavioural Interventions An Introduction for School Personnel.
And I know many of you have participated in that training.
Marlene's the author of PlaySteps books, picture instructions for constructive play, and Basic Skills Checklists: Teacher-Friendly Classroom Assessment.
And Marlene now works in private practice, providing supervision for BCBA candidates and consultation and training to professionals and caregivers who work with individuals with ASD and challenging behaviours.
And we're thrilled to have Marlene with us this afternoon.
So, Marlene, take it away.
- Wow, sounds pretty good Shelley.
Thank you for introducing me and I really appreciate the opportunity to be a part of the professional development efforts of Autism in Education.
It's a wonderful effort and it's certainly grown so much in the past several years, so it's great to be a part of that.
And it's also really nice that so many people signed on, but it's great that I can't actually see you 'cause I would really need these relaxation strategies.
Okay, so I'm gonna just jump right in here.
I will try to stick within the time frame we have allotted.
First I wanted to just do a quick thank you to some colleagues and mentors who've provided some input in the content here, and as we go along I'll probably try to point some of those out to you.
But it's always great to have colleagues who are willing to share and tell you what some of the challenges are.
We've divided this up into two chunks.
It's really about teaching rehearsal strategies, but looking at the two different main kinds of methodologies that we often use in the school system and also with young children.
We've divided it up into the social narratives part and the relaxation piece, and we'll do the questions and the answers in between these.
I guess the first question is: why should we be talking about these?
These are, for the most part I think, familiar topics to most of you.
You're not beginners from what I understand, you're professionals working in the field.
I think if we were to ask how many of you are using social narratives, social stories, scripts, relaxation strategies, a large number would say, "Yes, we are."
But if we asked the second question: what evidence do we have that they're effective?
Things would be a little bit shakier.
'Cause I think we're often using them without necessarily monitoring is it helping, is it not helping?
So today, what my intent is, is not to do an introduction to these strategies, but rather to work from where you already are and perhaps deepen your knowledge a little bit about some of the behavioural principles that are involved in rehearsal strategies.
And by doing that, help us better identify which strategies are gonna be effective for which children.
How do we match them to the student and the kinds of things that we're trying to teach?
I think by more clearly differentiating them we should be able to encourage a better implementation and hopefully be more effective then.
I wanted to start off with some of the guiding principles that underlie the use of rehearsal strategies, and the first one is that these are strategies where we are trying to teach the child a rule.
It's based on the idea that a rule can be a verbal, or in some cases a written statement, and it implies that if the person performs that behaviour it will lead to reinforcement.
And we all learned from a very young age about rules.
Don't touch a hot stove and don't speed on the highway and all those kinds of things.
Those are rules and just because the rules exist doesn't necessarily mean that we follow them, but this is the principle upon which the strategies that we're gonna talk about today are based.
A new skill is, I think this is sort of the quandary when you think about sometimes how hard it is to get kids to learn through the use of a social story or a rehearsal booklet.
Because really we're trying to teach a new skill by describing something, by describing what might happen if you do something as opposed to actually reinforcing them when that happens in the moment.
If you think about all the times we are usually trying to figure out what's gonna be reinforcing the child, we're using token systems, and if they do xyz, then they get their computer time or their special treat or more recess time or whatever the reinforcement happens to be.
But how much more difficult is it then to teach kids those rules and have them following it when they aren't actually contacting the reinforcement?
It's just something to get to stir the pot a little bit, I guess.
Rule-governed behaviour, the contingency, so what we would consider then the consequence of the behaviour might just be implied, it doesn't have to actually even have been experienced earlier by the child.
Like when you say, "Don't walk on thin ice," it's implied that something will happen, you might fall in, you might get hurt.
Even though the child hasn't yet experienced that, we're expecting that they will follow that rule.
We go out of our way to teach kids to learn to say the rules using some of these narratives and scripts that we're so fond of and we get really excited when the kids can say, "When I feel upset, I'm going to take a deep breath."
And we think, oh, that's great, he knows the rule now.
But just being able to say it, of course, doesn't mean that the child will actually do it.
We have to really give some thought to that in our teaching and make sure that we're paying attention to it.
These rehearsal strategies are based on the principle of behaviour rehearsal, which means that we're practicing appropriate responses, usually under simulated conditions first.
So not under this stressful situation that the child might be concerned about or have difficult behaviours around, but practicing it when things are relatively calm.
And sometimes these strategies involve the child just thinking about doing something, as opposed to actually doing it.
Again, it's not as straightforward I guess as just saying, well we'll put that in a social story and then if we do, the child will do it, or we put it into a script.
But the way that we teach it is through behaviour skills training.
We know that there's a lot of evidence to support teaching new skills in this way, through instruction, modeling, role play, rehearsing it, and then giving feedback to the student as they're trying to learn that new skill.
That kind of encapsulates the underlying principles that we all need to be aware of when we're wanting to use some of these strategies.
The first one that we're gonna take a look at within that narratives category is scripts.
There are different types of social narratives, but what we wanna know is how do these variants or variations compare to each other?
And what's the best way to approach our decision making about which ones to use?
One of our principles is if we're gonna take time in a classroom or in a childcare center, wherever you're teaching, to use instructional time for something we wanna make sure we're not wasting our time.
We wanna make sure that the student is actually learning.
These are the three that I've chosen to focus on in terms of the narratives for today.
I think scripts and social stories are used probably much more commonly than cognitive picture rehearsal, but I think comparing and contrasting these together will give you a little bit of a broader picture and be able to not just have it more solidified for yourself, but also when you're describing it to people that you're supporting, whether it's teachers, childcare workers, or parents, what some of these differences are.
They have some common features, and I think that's where we sometimes, things get a little bit muddy because we're looking at all the common things and not the differences.
Some of the key features of narratives are usually it's presented both in pictures or illustrations and text, and it's usually quite brief.
That goes across most of them.
Usually they're describing a situation or outlining steps in a sequence, so that's pretty straightforward.
And they're always individualized.
They're mostly written from the perspective of the learner, what the learner would see or do in a particular situation.
And they're introduced and modeled through repeated practice.
That's the behavioural rehearsal that we were talking about because we want kids to be accurate in how they do something and then work on fluency and generalization after that.
One thing that is a real advantage to all these or most of these narratives is that the topic can vary extremely widely.
It can cover just about any content area.
It isn't always just about social interaction or just about life skills, it can be much more individual, which is great for us.
It usually will describe appropriate behavioural expectations or it may, and sometimes includes the perspective of others.
That is particularly unique to social stories, as you probably know.
But the goal of all of these in the narrative area is to teach a new skill, and sometimes it's in order to change a maladaptive behaviour or replace that with something that will be more functional for the child.
Here's the graphic that I wanted to make a couple of points about.
Over time, and as you heard I've had quite a number of years, so I've seen a lot of these strategies coming down the pipe, so to speak.
Which is great that we're always developing new ways to support kids, and there are of course others that are not even listed on here.
But just in terms of a historical perspective, cognitive rehearsal booklets were probably among the first, then scripts evolved around that same time.
Later, social stories, now power cards and comic strip conversations.
But as many things do happen in special education, sometimes the thing that people are talking about the most sort of blends together with everything else.
I think we did a really good job of teaching people about using scripts and social stories, but what happens is that when it gets into the special education funnel there, sometimes they just all become social stories.
I think often it's a watered down version.
It's not even an accurate social story.
So it's important for us as educators and professionals who are educating others to make sure that we're clear on some of the differences and to share some of that information with the people we work with.
A script is, as the first one it's also probably the simplest one to create.
It's important to know that it predates social stories.
Social stories were a very, very specific way to address some particular issues, but a script came before that.
Typically it's a description of a routine that you really want the child to know first you do this, then you do that, then you do this.
Mostly a script is about a particular sequence or a process, a familiar routine.
Sometimes it's actually in an outline format or a list format.
It can be put into a little booklet, can be in a checklist, but the purpose of it is to provide those cues so that the learner can organize themselves and follow a process.
If they were able to do it without that then they didn't need it, then that would be great.
And eventually we would hope to be able to fade it.
However, in the beginning these are prompts or cues that the learner can use to help organize themselves.
When you're ready to create a script, usually a task analysis is needed as a starting point.
That kind of goes along with almost regardless of what the topic is.
If you're doing a cooking project or if you're learning how to go to the movies or if you're learning how to put your seat belt on or tie a shoe, you still need to know exactly what those steps are in order to illustrate it in the script and text as well as in the pictures.
I think it's often more likely with scripts that we might start in a natural context.
I'm thinking for example about tooth brushing or something that's a self-care routine.
Wouldn't necessarily make sense to practice it at a desk or a lesson area when you could be practicing it in the bathroom in the natural context.
However, going to the movie of course, you're probably gonna be practicing that with pictures or photographs first before you actually go to the movies.
Scripts don't necessarily require social interaction.
They don't require a description of the maladaptive behaviour.
Mainly they're a sequence of the behaviour that's expected or hoped for in a particular environment that you want the child to be going into.
A couple of examples here, I'm sure you guys have lots of examples.
This was just a banana split, pretty simple, just the steps.
You'll notice that we didn't put all the steps in for cut banana, so pick up the knife, cut once, we're breaking it down.
But certainly if you're doing the task analysis for a child who needed more steps then you could put more steps in.
Clear language and of course it would be individualized towards the students that you were working with.
This is another example and I included this mainly because, well, it does illustrate the step-by-step process, but also just a reminder that SET-BC has many, many visual supports.
Of course, now that we have the internet, there are images of all kinds of scripts like this, but I thought this was a particularly good description because the picture is there, the steps are there, and I like the fact that they include the finished with the finished sign at the end.
Again, the purpose is to show a sequence or a process that we want the child to follow.
Now I wanna show you one that is perhaps not as commonly used, but it fills all of the requirements, if you will, for being a script.
This is a way to rehearse time out.
Not when the behaviour has happened, but before the behaviour happens.
I wanted to preface this by saying this is not intended to say everyone should be using time out or everyone should use a quiet room or anything like that, but if time out of any sort is being used, whether it's just turning away from the child or sitting the child in a separate spot, whatever it is, rehearsing time out procedures ahead of time when the child is calm can be very helpful.
I included down at the bottom the reference, and it's also in the last slide there for the Autism in Education paper on time out because if you're interested in learning more about the research, that's a great place to start, great summary.
So again, this is not about social interaction.
This was used to explain to some students in a particular classroom what this particular routine was like, along with other routines.
So when we have lunch, this is the routine.
When we go to our lesson area, this is the routine.
When we have time out, this is the routine.
The way that this was taught was when the student came in to the class in the morning, different routines were explained and the teacher sat down and went through this, describing and reading it to the student, one by one, just as a way to describe it.
Then the teacher took the student and showed the student what it would look like for the teacher if the teacher was following this.
Then they practiced it with the student, including setting the timer, including sitting down for three minutes.
There's no behaviour happening so most kids are gonna sit for a couple minutes.
So you get to practice the whole thing in sort of an aura of calmness, that it's not so much about something that might otherwise be a little bit upsetting if the child's already upset and then you're moving them into a quiet area or such.
Just to give you another way, but it's still a script.
In this case, because this student could read very well, there wasn't a need for visual supports, but you could put some pictures in there as well if you chose to use that.
This is another one that's the same idea.
Dave Maloney shared this one.
He was working with a child in a childcare setting who had autism and quite aggressive, self-injurious.
He had quite a few behavioural issues.
What they did was they established a little mat area where he would be able to go and sit.
This was the one that was created for him and you'll see obviously he wasn't a reader also, so when they practiced, this was put into a little booklet for him and the teacher or the aide would sit down and read it with him and point to the pictures with him.
And then they would practice it by going to the quiet area, sitting on the floor, setting the timer for three minutes, standing up and going back.
So again, this would all take place before the child was actually upset about anything.
This little boy, he had quite a bit of language, and he understood this pretty immediately and wanted to practice it with the teachers and make them go to time out.
So he got the message right away, but it's still a script.
Basically, although obviously there's an adult involved, but the focus is on what the child is gonna do.
Of course you could put the pictures of that particular child in there if you wanted to.
That's the idea behind a script.
I wanted to show you one example where it did have social interaction as the skill to be taught, but it was still a sequence or a process.
This was a boy with autism in grade two and he had an assigned buddy every day at lunchtime.
They would have lunch and then they would open their Let's Tell book.
Some of the pages were let's tell a joke, some of them were let's tell a story, you know, there were a variety of things in there.
But the idea was that, by putting the knock knock joke in this sequence like this so the child with autism as well as the buddy could both see what they had to say, they would learn sort of a scripted response.
Now, of course, you wouldn't want the child to only be able to tell one joke, but because this was a five-minute lesson that they did together, not lesson, it was collaborative learning that they did together, and because they both enjoyed it the buddies started to bring in other jokes and we would make it up and we turned it into a wipe-off board so we could write different jokes in there.
Anyway, a script is following a process.
You still need to know what those steps are, but you can include social interaction if that's the focus of the script.
That's scripts quickly.
The focus on scripts is using a task analysis before you start as a way to define what those steps are to teach the sequence of a new skill or routine, that's the purpose of it, and then pictures and texts are basically serving as cues for each step along the way.
That's number one.
Number two is the social stories.
So we'll jump right into social stories.
I know many of you would be aware that that's based on the work of Carol Grey.
She has really expanded how we look at what we can include in, who they're useful for.
It's very much evolved from where it was in the beginning.
But it's used by many, many people in schools.
I think it's important to remember that the initial idea behind this was to help a child who didn't understand a social situation of some kind.
It was to take that situation and describe it for the child, explain and try to help the child understand what was going on, rather than say here's what you have to do.
It's a softer approach, if you will, towards changing behaviour.
The theory of mind problem of course is the issue that many of our kids have where everything is black and white and it's mainly what they think that counts, and not really understanding that someone else could be thinking about the exact same situation in a different way.
The social stories were targeting that problem in particular.
She encourages us with social stories to describe the social situation that's problematic for the child and highlight the relevant cues that we want the child to recognize going forward.
It follows a very specific formula.
Earlier on there were only three types of sentences.
Now there are six, and so the formula is expanding as we go.
But this is basically what it looks like.
Most of the social story is going to be descriptive.
It's just saying here's where it happens.
Here's who's there.
Here's what they're doing.
Not anything about the thoughts at that moment, but just creating an environment, if you will.
Most of the statements are going to be descriptive.
The perspective usually has fewer statements, so if there were three to five descriptive statements, there might be one or two perspective.
Those statements are the ones that help describe what other people might be thinking or feeling in the same situation that you've just described.
Sometimes there are cooperative statements, how other people might help.
The cooperative statements is a newer addition I guess I would say in the past probably five or 10 years.
But sometimes having statements in the social story about who people could turn to for help is often included now.
Finally, directive statements.
Those are the statements that are positive statements of what we do want the child to do and usually there are only one or two of those per social story.
They're usually worded in a very positive way and they don't use language like I will always do this.
I'll never do this.
I can't ever do that.
They're more like suggestions.
Maybe I could try to do this.
I might wanna try to do that.
They're very gentle ways to direct kids.
And finally, sometimes we have added to our social stories sentences that the student generates that says here's how I can remind myself to do something.
Sometimes you will see a control statement in there as well.
Let's talk about the social stories.
I guess the narrative is based on, well, let me backtrack.
When you think about the scripts needing a task analysis in order to get started, a social story really needs a teacher, an adult, or parent, whoever's gonna be the author of the social story, to have a very clear understanding of what the misunderstanding is.
If you guess wrong, the social story's gonna be much less effective.
The content of the social story is based on what you think is going on for the child and what part of what the situation is that they're not getting.
It's very reliant on that and I think it hasn't been studied very much to look at how we best figure out the content and where to start with that.
Once you create the social story, the learner's encouraged to read the story or have the story read to them very often.
And minimally, usually anyway, one to two times a day and again at home.
You're encouraging them to memorize that text.
Think back to the rule-governed behaviour, right?
If you memorize a whole sequence of things as well as the suggestion for what you could do, you're learning a new rule.
In the beginning it really was intended to be used with children who were more able, who had quite a bit of language and self-awareness.
As it's evolved, now it's being used with children with no language and more severe cognitive impairment.
Again, the research isn't really clear about the best population where it's the most effective, but in general, the research that I've seen makes it look as though the children who do have language and more self-awareness are more likely to benefit at this point.
When you look up some of the research, and I hope you will look up the research on some of these strategies after, you just kinda get hooked on 'em a little bit.
One of the things to pay attention to is the research itself, and this would go for scripts as well as social stories, is you have to really look at how they defined the social story.
Because if you're looking at comparing a social story to intervention x, but the social story doesn't follow Carol Gray's formula, then really it's not a social story.
It may still be useful, but it's important to recognize those differences.
So when you're looking through the research, pay attention to how the narrative, the script, the social story is defined so that you know how it could be applicable to the children you're actually working with.
I picked out a few that are, well, one in particular that's very, very simple I think.
As you're reading through this, I want you to be thinking about what type of sentence it is.
So when I take a shower, I use a towel.
Towels help me dry off my body.
You can see this is just describing the situation.
I'm in the shower, the towel, it gets wet, goes on the floor, so this is all just describing.
And again, this could be put together one sentence per page with a picture or as a little story like this.
But so far it's all descriptive.
It will make Monica happy if I pick up my towel and put it in the hamper.
This is now a perspective that we hope the child will understand, that really Monica wants you to pick up your towel and put it in the hamper.
And the last sentence, which is the only one in the story that's directive, I will try.
It's a suggestion, I'll try to do that.
Nothing bad's gonna happen if I do or I don't, but it will make Monica happy.
So we're trying to gently move the child in the direction that we want.
Pretty simple and pretty straightforward.
This one is a little bit more complicated, I guess.
This was a little boy who was grade two and his father worked out west, where maybe some of you are.
His father worked out west and he really just couldn't understand why Daddy wasn't there to kiss him goodnight, put him into bed, and do all the bedtime routines.
His mom identified that as an issue and the consultant worked together with him to develop this story.
I'll let you read through it.
So far we're just describing the situation, right?
And hoping that the pictures will help the child make those connections.
When this is the situation, then I don't see Daddy at night.
So it's still pretty factual.
I miss Daddy.
This is now the child reflecting, and he was able to say that.
When he would read this story with Mom, they would of course say it together as they read the story.
So it continues.
Now, this is what I was talking about before where it can kind of embed some support, but without really telling the child they have to do something.
When I am thinking of Daddy, I can ask Mommy for a hug, I can say hi to Daddy on the phone, or look at the calendar.
Again, some suggestions and when they were reading this together, the mom would let him choose which of those he wanted to do.
If she wanted to call Daddy then they would call Daddy, or they would look at the calendar.
She was able to practice as they were reading the story together.
And of course, if you look at the calendar, she had a wipe off on the date and then whenever Daddy was coming home they could put the new date in.
I will be happy to see Daddy and he will be happy to see me.
Again, that's trying to explain the perspective of Daddy, but overall it's trying to help the child understand a social situation.
Daddy's not here.
Daddy comes back.
That was very stressful to him.
And it was quite effective and it was done pretty much every day that the Daddy was gone with the child in the home.
As we're looking at these examples, this one is probably the most complex.
I need to give you a little bit of history with this one.
This was a boy who had autism, was nonverbal, and his brother, who was typical, and the mom passed away very unexpectedly.
The family asked if we could write a social story or something that would help.
The way that this was put together is one or two sentences per page, and the actual pictures of the family members and the activities that are described in here.
Obviously I wasn't gonna put their pictures here, but it was put together into a little album format.
The other thing that's important to note is not only is it individualized from the perspective of the child, but from the family.
So the statements that are in here are statements that reflect the family's spiritual slash religious beliefs and the activities that the family valued and that the son would have recognized as part of their everyday routines.
I'll let you just read through that.
I think if you are exploring social stories and you want to be creative with them and at the same time try to meet the need of whatever the child or their family is, there are many, many examples on Carol Gray's website.
One of the things she talks about is that explaining disasters or very difficult occurrences to kids is one of the ways that she feels social stories can be quite effective.
In this case I think the younger brother who was a neurotypical child probably benefited more than the child with autism.
But I don't know.
The family, however, appreciated it.
I put this in as an example that I think we can be creative, but as long as we are calling it a social story, we do need to pay attention to how much is it descriptive, how much is it cooperative, and how much is it directive, if we really wanna stay within the framework of a social story.
Social stories, still coming back to our comparison chart, it does use a more specific formula.
It describes the social situation that is difficult for the child.
And usually will include perspectives of others because that tends to be the part that the kids are having difficulty with.
And non-directive, non-judgmental is a key piece of this.
Okay, onto the third example of rehearsal strategies.
This one is called cognitive picture rehearsal.
It's an instructional strategy and it's closely aligned with the use of relaxation and visual imagery.
I guess I should point out that, regardless of which of these strategies that you're using, there can be relaxation and visual imagery, a part of a text that is in a social story as well as in a narrative, a script.
But in cognitive picture rehearsal it pretty much goes hand in hand.
You don't usually find a cognitive picture scene booklet that doesn't use one of these.
It's based on the early work of Dr.
June Groden and it was extended.
The Groden Center became very well known and Dr.
Groden's done lots of trainings.
Some of the books I've referenced in the final slides there if you're interested.
And really, she's very relaxing to talk to.
I can vouch for that.
One of the things that is really important about this is that it evolved as a way to help people with significant developmental disabilities, including autism.
And the focus of this was that the person who was, where they were using strategy, did not have to be verbal, did not have to have a level of particular cognitive ability, but needed to be able to sit and pay attention for a short period.
The focus was on replacing maladaptive behaviours.
Again, if you think about social stories gently suggesting appropriate ways to think about things and understand them, the focus of cognitive picture rehearsal is on very specific behaviours and changing them.
A rehearsal scene or a script is written and it's illustrated.
Sometimes it's just a series of flash pictures with the text on the back and the picture on the front, but there's all variations of that.
Notice that what is required here is a functional assessment of the problem behaviour before you start.
With a script we're looking for a task analysis.
For a social story we're looking to really understand what the misunderstanding is.
But for cognitive picture rehearsal, we need to know what the function of the behaviour is, or at least have a pretty strong hypothesis about that.
The pictures and line drawings in this strategy illustrate both the antecedent and the target behaviour, as well as the possible consequences and reinforcement.
And by virtue of that it's quite directive as well.
Relaxation and imagery is often incorporated into the script, but relaxation is taught first as a separate skill before it would be incorporated into this.
I wanna show you some examples.
Again, I have to give you a little bit of history here.
This was a boy who was very echolalic.
When we did the functional behaviour assessment, one of the pieces that we were concerned about was trying to catch behaviour before he became aggressive.
One of the indicators of that was he would be speaking very repetitively at a quiet level, and as his voice got louder, louder, louder, when it got to the very loud point is when he would become very aggressive.
We wanted to try to stop it before we got to that point, so the idea was to help him be more aware of the level of loudness of his voice and to give him a strategy when he could perceive that it was moving in that direction.
This was the cognitive rehearsal booklet.
It was put together in a little booklet format for him and was read to him several times a day.
When the teacher was reading it to him, the teacher is also modeling the voice level.
When he'd say, "In school we use a quiet voice. A very quiet voice is a whisper like this, shh."
And then they would point to the number one.
And because he was very echolalic, he would immediately echo exactly the same way back.
Sometimes I ask questions.
I use a louder voice like this.
And then he would imitate it.
If I'm upset, my voice gets too loud, like this.
Uh-oh, time for a break.
They would practice this and he would imitate it.
And then this is where the relaxation was built in.
Stop, take a deep breath, and when the teacher would model this for him, he would model the breathing.
They had practiced the breathing separately, but it actually worked better in his case because he was very willing to imitate everything the teacher did.
So he would do the deep breathing, and sometimes it was three or four breaths, and sometimes he could relax with two.
We waited until he was calm and then we would read this part.
"When I am calm, I come back to work. My voice is quiet."
Time for a high five.
You see the antecedent in there when he's upset, the voice getting louder, and then the relaxation to teach the replacement skill, and when I am calm.
Now, the high five was very reinforcing for him, might not be for another child.
You could have a different type of picture in there of something that was very reinforcing for that particular child.
Okay, so, same boy.
He was quite a challenge.
This behaviour was another one where we were able to use cognitive picture rehearsal pretty successfully.
He was very aggressive when he saw any of the following: a dog, a bird, a baby, or bare feet.
So it made going for walks really challenging, 'cause those things usually, except in the summer, you're not gonna see anything like that in school, but they were very community based for walks and community trips, so we knew that we had to work on this as a behaviour.
Here we go, so this was his booklet.
I see Morgan, Joe, Adam, Steve, and Kelley.
They are happy to see me.
At the end of the day, we go for a walk.
Sometimes I might see a dog.
We had several pages here with the sometimes I might see a bird, dog, baby, bare feet, that we could replace this with.
But when we were reading it, and again we're reading this first and practicing it in the classroom, not on the walks.
Sometimes I might see a dog.
I want to chase the dog, but Joe says, "No, it's dangerous. Stay here."
And of course, Joe being a great teacher was hamming it up, so when he imitated it it came out exactly the same way, as you can imagine.
Anyway, so it's dangerous, stay here.
Then the relaxation to practice the deep breathing.
I listen to Joe and stay with him.
He gives me the high five.
We're really talking about five or six pages, except for the one we kept exchanging with bird, babies, et cetera, and we practiced this a lot in the school setting and then we would practice right before the walk, and then we would take it with us on the walk.
Eventually it was quite successful, but we were left him on the walk saying, "It's dangerous! Stay with Joe!" (laughs) We didn't quite get rid of that part.
But anyway, he wasn't aggressive, so we were happy with that.
This is another one, I really like this one, I think this is a good example.
If you are familiar with Jessy Park or Clara Claiborne Park, Jessy is now an adult who is a very, very skilled artist, but she was working in the Williams College mailroom.
I think she may still be there.
She would get extremely upset if things weren't where they were supposed to be, somebody came in and put something in the wrong spot.
Her mom took her down to the Groden Center and June Groden and Jessy created this, or something similar to this.
It's probably not word-for-word.
I match all the names and addresses.
I like to put all the letters in just the right spot.
And that's how she would say it when she was reading this.
Sometimes somebody puts a package in the wrong spot! I start to feel really angry.
She was very expressive and she read quite well.
That was the antecedent, that's the problem about to happen, and this was the strategy.
They taught her the relaxation strategy.
I stop what I am doing and sit down, so that was the first step.
I close my eyes and breathe long and slow.
I think about how I feel when I am painting a picture of the sky.
This is one of Jessy's painting there, the Chrysler Building in New York.
It was enough for her to imagine the reinforcement of how she felt when she was painting.
This is an example of how imagery can be built-in to some of these cognitive picture rehearsals.
I put her website there if you want to see any of her incredible paintings.
If you notice in the top, she always puts the solar system or accurate constellations in just about all of her paintings.
It's quite wonderful.
This is the last part of that story.
I say to myself it's no big deal.
Time to get back to work and put the package in the right spot.
Of course, right?
This little card in the bottom that said NBD, after Jessy had memorized that story and learned how to do the relaxation and the imagery, she carried a card in her pocked that said NBD.
So when she was working in the mailroom and something like that happened, she could reach in her pocket and it would prompt her to go ahead and go through her sit down, do her breathing, et cetera.
Sometimes a very concrete reminder like that can be quite helpful.
So cognitive picture rehearsal.
Quite different from the other two.
It requires an FBA, or a good sense of what the function of the behaviour is.
Definitely need to know the antecedent behaviour consequence because it actually describes that within the picture scene itself.
It also includes the replacement behaviour as well as whatever will be reinforcement, and of course it can include relaxation and imagery.
I think when you see them side-by-side like that, it sort of helps hopefully to solidify some of the similarities and differences there.
I wanted to mention aside from the NBD card that Jessy used, very creative teachers have come up with other things to help kids remind them when to use some of these strategies, as generalization still is a problem for some kids.
If you have something concrete that the child can keep in their pocket or on a little wristband or somewhere where it's handy to get out, it can help.
The reason I put the pipe cleaner one on there is one of the teachers was doing lessons on flexibility, teaching kids how to be flexible.
I think it came from the Unstuck and On Target book that Shelley was mentioning before.
Anyway, so she did it with the whole class, even though it was really the two children with autism who were having the most difficulty.
But she gave them all a pencil and a pipe cleaner and she had them wrap the pipe cleaner around it and then remove the pencil, and then that was their little symbol for flexibility.
So when something would happen where anyone in the class was being really inflexible, she would have them all get it out from their desk, their little spring, and model, I mean this was grade one children, but sort of model what it looked like to be flexible and then talk about right in the moment, a teachable moment, what could we do that would help us be more flexible here.
Anytime you have something concrete that can cue the children to use these strategies that we're talking about, I think it can be helpful.
So we've got some similarities and differences.
The purposes are pretty much, even though they're all teaching a new skill, they're doing it in quite a different way.
And certainly the kind of content that you're putting in, teaching procedure, is very similar.
So that's narratives.
Here are some things though to be thinking about.
Regardless of which of these strategies you're using, you still need to understand the behaviour.
If it's a social story that you're trying to figure out why is that behavior happening?
The more you understand about the skill you're trying to teach, the better it is.
I think selecting the type of narrative that you wanna use really needs to be based on the purpose.
And when I say name it accurately, let's call it what it is so that the people we're encouraging to use it will also call it what it is.
Spread the word, in other words.
Match the number and level of abstraction of statements and illustrations to the learner.
I know that kind of goes without saying.
And, this is a caution I guess, don't assume understanding of emotions.
Even in the one where we say Daddy will be happy to see me or Mary will be happy if I pick up the towel, I think we put that in there because we're trying to help the child understand it, but we have to be careful in just assuming that because we wrote it that they did understand it.
And providing adequate practice.
The rehearsal means that really, if you're not practicing it two or three times a day outside of the impetus for the actual story, you're probably not gonna see the carryover that you need.
And cautions, this I think is the big one.
Because we know that these types of narratives can be very helpful, I think we have a tendency or maybe teachers have a tendency to go in for any behaviour that's happening and say, oh, well let's just write a social story.
Sometimes that's really not the best way to approach it.
I think we need to be more thoughtful about it.
And also to not introduce several things at the same time because, again, each one of these, even if you're only practicing it several times a day, it takes instructional time.
So we wanna make sure that we are being responsible and using that time well.
Sometimes a concern is that when you write the social story or rehearsal booklet or whatever it is about specific behaviours, sometimes it just brings more attention to them.
Sometimes ignoring can be better.
I'll just plant that little seed.
Social narratives are not effective for everyone and they are usually not adequate if they're the only thing that you're doing.
Mostly we're adding them to other parts or components of an intervention for our student.
We do know that we want to be able to teach functional skills and that social narratives can be very effective, especially if we have kids who are benefiting from visual supports.
And as with any practice that we do, we wanna make sure that we monitor and individualize as much as possible.
Okay, so we'll stop right there and see if there's any questions that we wanna do.
I realize we've used a whole hour of our time, but we'll go quickly in the second part.
Shelley, are there questions or should we keep going?
- [Shelley] I'm not seeing any questions yet Marlene, so if you wanna keep going.
If folks have questions they wanna type in we can capture them maybe at the end?
- Okay, great.
Okay, so part two.
We're just gonna talk about relaxation strategies because these also get used quite a bit in schools, especially teaching kids about deep breathing.
And often we're using it together with some of the narratives that we talked about.
Just wanna spend a little bit of time here talking about anxiety because many of these strategies that we're talking about have to do with behaviour that we're seeing when kids are stressed or worried or they're avoiding something because they're worried about it.
Anxiety can make people, I guess you could say, avoid things that they're afraid of.
When that happens, then we see a body reaction to stress.
We might see increased heart rate, faster breathing, tensing of the body, resistance, moving away from people.
I think about stress as the physical part of it, the body's reaction when there's something that's perceived by the child to be dangerous, threatening, or unpleasant for them.
It's also important to remember that these kind of stressful situations for the child can be, I used the words happy and unhappy, but what I mean is, a birthday party you would think is happy, but could be very stressful for a child who doesn't do well when there's a lot of social demands.
The situation itself, it doesn't necessarily tell you whether it was stressful for the child.
And we all have buffers when we get stressed.
I think based on the recent election there are many, many adaptive and maladaptive responses happening to the election.
But at least we are typically able to respond by talking with friends, whether it be in real life or on the phone or through social media.
We participate in sports, get lots of exercise, and we might do some restful, calming activities ourselves like yoga, get more sleep, medical intervention.
But these are all things that we also need reminders to do.
I think if we were all better at relaxing it would probably be a good thing for everybody.
But when we think about the children and the adults that we work with, they don't have some of these options that we have.
They may not have good communication skills.
They may not be able to express the concerns that they're worried about.
And understanding emotions and the perspective of others, also very challenging.
Sometimes we have kids who have a very limited number of friends and no real support system.
That, together with the fact that they may not get the same level of exercise, or may be as self-aware, contributes to the fact that the strategies just aren't there.
I think that's why in the schools or wherever we're working with students, we try really hard to be proactive, recognizing some of these challenges.
These are some of the statements that we heard from teachers.
He won't use it when he needs it.
He can do the breathing, but he won't do it.
Or how do I find time to teach this?
And is it even important to teach it?
Or I have an older student and he thinks it's silly and he won't use it.
Even when we know that there's effective outcomes from learning how to relax, we see problems when we're actually trying to teach kids how to do it.
We need to know, if we're going to do it, if we're gonna spend the time to teach that child or that adult, then what's the best way for us to do it?
And how can we get the child to generalize?
Thinking about the why part of it first, I think there would be no argument to saying that when we have the skill to relax ourselves, it can have a lifelong impact the better we are at that.
It's not just our children with disabilities.
It's a functional skill that would be well worth teaching if we can help the child actually develop it over time.
Usually a relaxation practice can be used across environments, usually not stigmatizing.
It can be done very quietly.
And the person themselves practicing a relaxation strategy perceives it as pleasant.
It's not a difficult sell, if you will.
It can be guided by parents or teachers and we know that it has demonstrated effectiveness.
I wanna just talk about different types of relaxation.
To some degree, these can be mixed and matched, if you will.
But I wanted you to know some of the historical perspective and how they evolved.
Progressive relaxation, behavioural relaxation training, controlled breathing, and guided imagery.
The goal for all of these is for the relaxation response to occur.
One very simple definition is that the person is physically calm and mentally alert, which means they're not sleeping, but they're very calm and those physical symptoms of stress that we mentioned before, the breathing, et cetera, are not present.
They're all aiming for the same goal here, but they do it in slightly different ways.
The oldest, the earliest methodology was just called progressive relaxation and was not necessarily done with people with disabilities.
The process of picking each body part in a particular sequence, tightening it, and then releasing and paying attention to the feeling, describing the feeling, and really cognitively going through the process and directing yourself through the process through language, I guess you would say.
It's a little bit of a longer exercise and if you were doing that, you would probably want to be doing that in a private space or with another group of people who were all doing the same thing.
But it still had the flexibility of maybe you're just feeling upper body tension and you could only do the upper body.
That was the original progressive relaxation process.
Whoops, I just sorta see a typo.
It's not 2978, it's 1978 down there.
Behavioural relaxation training was developed a little bit later.
The idea was the same.
We want people with developmental disability, who may not have great verbal skills or may be cognitively significantly impaired, we want them to still be able to benefit from this, but they may not understand language in the same way, so we're gonna probably try to simplify it and teach it in a way that will use more physical prompts and their imitation skills.
This was called behavioural relaxation training, and the idea was that the motor response, if we could get the person to demonstrate the motor response, the relaxation response would follow.
That they didn't need to be able to verbally label it or follow a direction, as long as we could get them to actually do that response.
What was demonstrated in one of the studies is that it took only two hours for people to learn these sequence of 10 behaviours, 10 muscle groups.
That was more rapid than the earlier type of just basically progressive relaxation training.
And it also demonstrated that we could do it with individuals who may be more impaired in their skills.
This is available on the internet, it's just one example of some picture sequences that you might use with children, but there are many out there, and some of them are really excellent in giving kids a visual if they need that.
The muscle relaxation process that we talked about, whether it's done as a whole body approach or is more flexible, is probably less implemented in school settings than controlled breathing.
The controlled breathing, I think probably because it's easier, it can be done very unobtrusively.
You still have to practice it quite a bit, but it can be a much briefer action that's taken on the part of the student.
We do see this being used and you saw that in some of the examples that I showed you as well.
Basically the controlled breathing, when we're modeling that and doing our behaviour skills training with it, we're modeling sitting comfortably, breathing slowly and evenly.
And this is the hard part, most people aren't necessarily aware of or practicing in through the nose, out through the mouth, and that tends to be a little bit trickier to model for kids, but if you don't do that, what you end up is teaching kids to hyperventilate.
You get kids who are going.
(frantic gasping) It is really an important component to keep in mind.
And continuing until calm.
Even if the child doesn't count to three, you can use other nonverbal cues to help them do it more slowly.
That's controlled breathing, and again, there's lots of picture symbols on the internet to help teach kids the difference between in the nose, out the mouth.
It does take practice.
It takes practice for everybody, but if you're gonna have to do it through imitation or using reinforcement when your kids do it correctly, then you do what you have to do.
This is another one I think.
The square breathing, I believe it's on the Gevena Centre website, and it was just a way to illustrate the sequence without the kids having to really understand it from a verbal language perspective.
Any of these types of things, when you're first starting to teach children about the breathing in and out, can be very helpful.
So that's relaxation.
Now, here's the problem.
Not the problem, but the challenge I guess you would say.
It goes back to that question about well we taught him how to do it, but then he won't do it.
Or we taught him how to do it, but he still doesn't use it by himself.
I think if we go back to what we've learned about how to help kids generalize from one situation to another, I think when we've taught about the breathing, we've skipped some of those steps.
This is a reminder of what I think are minimally some of the steps that we need to be aware of when we're teaching kids, especially the breathing, but even if you're using progressive relaxation.
First we have to identify the events that are associated with the problem behaviour, 'cause otherwise why are we teaching it?
We want kids to use it when they need it.
If there are many different possibilities, then start with one that might be generalizable.
For example, let's say that the child is very anxious and tends to avoid any situations where there's gonna be a lotta noise, or where there's gonna be more than two people present, or where there are dogs.
You still have to identify those situations and that's what you're going to use as you teach and practice the relaxation process.
You still use behavioural skills training, but you're building in a description of the situations that are problematic.
Notice that it's underlined here in calm situations.
When you're teaching this skill, the relaxation skill, whichever version you're teaching, you're not doing it first in the situation where it's needed.
You're doing it outside of that situation because the child has to become accurate before they can become fluent.
Once the child is fluent in calm situations, then you would start by priming the child.
For example, in the earlier example where we were talking about going for a walk and anticipating seeing the dog, right before we go on the walk we're going to use priming.
We're going to read that story, practice the relaxation, right before the identified target situation.
And then as soon as we start to see the dog, we're gonna prompt the child to use it, and then reinforce them.
We're making the move from a calm situation that is simulated to moving into the target situation that will likely evoke the behavior, but we're gonna do it with support.
We're gonna prompt the child and reinforce them when we do it.
And then next we have to say, okay, well now when he goes into the gym, he uses that.
Even though that's a very noisy situation, he's been able to use that.
Now let's find another noisy situation.
Now it's when we go in to watch a movie with the whole class, or now we have to go into the cafeteria.
So now we're going to choose another setting and do the same process that we just did.
Still prime the child, practice it right before you need it, right before the cafeteria, go in to the cafeteria, prompt the child to use it, and reinforce them for using it.
You would want to repeat that until you start to see that you're not having to prompt the child, and then gradually not having to prime them before you go.
That's when we start hopefully seeing some spontaneous use where we still want to make sure that we reinforce the child for using it.
I don't have research to support these steps except that it makes sense from what we know about how we can best teach children to generalize from one situation to another.
And it makes sense from the behavioural principles that are involved there.
Here are some tips around that.
Use role play and practice together a minimum of three times a day when a child is not anxious.
I want to point out at the bottom there the reference to Chalfant.
Her book, I put the reference in the list at the end, it's called Managing Anxiety in People With Autism, and it's an excellent, excellent book and it's written very well for parents, teachers, mental health professionals, and really pulls together all the research about how to support children who are anxious.
Some of these tips came from her.
The minimum of three times a day when not anxious I think is fairly important.
And also the duration of that, we can't expect that kids are going to learn because we've done it three times a day for a week.
She suggests that six to eight weeks is a better marker for whether or not it's moving in the right direction.
Using visual, text, or concrete supports if helpful for understanding.
And providing checklists to ensure practice occurs.
If you have a goal of practicing three times a day, maybe you have a little checklist so the child checks it off when they do it at school and then the parents of the child check it off when they do it at home, and maybe that could go back and forth.
Really important to involve parents.
We want them to be aware of it because they will also be part of the reinforcement system when it occurs in the natural environment.
How can we make it more accessible to learners with language or cognitive challenges?
Teach fewer steps.
Starting with as basic as just hug and release.
Teaching only gross motor muscles first, then later small muscles might be a way to do it.
Teaching through imitation or physical prompts and avoiding a lot of talking when you're doing it.
Keeping your language very simple.
Combining with visual supports, which we talked about that also with the narratives and strategies that we mentioned before.
And using really consistent language.
One of the things that, regardless of which narrative that you're using, it's encouraged that you use the same language every time you read this cognitive rehearsal booklet, or you read the social story, or you cue the child using the script, that the consistent language is part of what can be helpful in teaching them rules.
If the child has a lot of difficulty with the breathing, sometimes kids will do better if you use counting prompts.
And modeling, I think the slower and the quieter you model it for them, the easier it is for them to learn it.
It may take more practice than for a child who picks up on it really quickly.
Physical prompts, and also props actually.
If the child had difficulty understanding the blowing out you could use straws, balloons, windmill toys, things that you activate with blowing, birthday twizzle things, to help the child understand the difference between blowing out and breathing in.
The teacher, I think we get this fairly frequently, they start to teach it but they give up and they think it's not working.
We really encourage people to think about six to eight weeks of very regular practice, and then going through the steps that I've outlined there to see if they've all been followed.
You really shouldn't skip any steps.
And also looking at the visual supports, maybe there's a different way to present it visually.
Maybe simpler or maybe more with pictures than with words.
This one was an example that a couple of my colleagues brought up.
Sometimes pairing with a peer model or using video modeling might be a help for an older student.
Talking about it as top secret and engaging the child around a special interest.
That's where sometimes power cards could be useful.
And identifying concrete reinforcers, so thinking about what it will do for the child if they're able to use it and thinking about what could we do that would actually motivate them to use it.
Sometimes the social interaction part is what's more motivating to them if they think that if they can stay calm they might be able to build more friendships.
Or if they can stay calm, cool, and collected and relaxed, they might be able to sit next to that girl that they really like to sit next to.
Just some ideas there.
The teacher doesn't recognize early enough when they should prompt.
The important thing there is that you've clearly recognized the precursors to the behaviour or the situations in which that child is likely to need to use the relaxation response.
If you're not recognizing it early enough, maybe go back and do some direct observation again and involve the learner if they're able to have that kind of discussion with you through an interview process.
And again, evocative situations, we want to practice in a safe way so that the child won't be afraid of trying to do it and it won't make them stigmatized in any way.
Relaxation skills can be really useful in stressful situations for all of us.
It is a life skill.
It can be taught one on one, in a group.
I know there are several teachers now who are making some very simple relaxation strategies a part of the whole class's day at a time just before they're going to go into something where they've come from something very active like recess and so now she wants them to settle down, so before they settle down they just do a little bit of a breathing practice, so that can be very helpful.
And it's used usually to complement other intervention components.
We know that it does take some time, but it can lead to significant positive benefits, so we hope you will give it a try.
- [Shelley] There are a few questions, Marlene.
One question was around fading narratives.
Somebody wondered how and when do you suggest fading the narrative as the desired behaviour starts to increase and the problem behaviour starts to decrease?
- Oh, that's a good question.
I guess the answer would be a little bit different for, well let me back up.
First of all, in order to know whether the behaviour is changing, we have to have measured something, right?
It's not enough to say we're using a social story and when we have the social story in place the behaviour isn't happening, because we know that that's still a prompt in a way, right?
We would like it to be faded out.
We want to either be measuring the skill we're trying to teach, or we want to measure the replacement behaviour, or both.
Let's go back to scripts for a minute.
If I was trying to teach shoe tying, for example, then I'm probably going to only take out each one of those pages after the child has mastered it.
It could be very closely tied with a chaining procedure, if you were using chaining.
Obviously for a functional skill like that you want the child to be independent, and you can do that by fading out the pages as the child masters, or the particular cards.
That should become clearer as the child is working on a particular skill.
For something like teaching the child to go to the movies, practicing it first with those visuals up until the point where the child is able to either act it out independently or tell you the steps independently, before you go into the natural environment is probably helpful.
And then there practicing it with the supports, and then gradually without.
I think it becomes mostly clear because the child stops referring to the social story.
I think that's really what happens.
But, let's say for example, the picking up of the towel would be a really simple one.
If the mom or the caregiver kept a chart of whether or not the towel was being picked up, you'd know pretty much that that was happening, and then you could start fading it out.
I don't know if that answers the question, but I think it's measuring the behaviour, both the skill you're trying to teach as well as what you're trying to replace, is probably the key that tells you when you can start fading that.
- [Shelley] Thank you very much.
I'm gonna skip back to a question from the earlier section.
Somebody was wondering if you could expand a little bit on power cards.
- Yes and no.
A little bit, I haven't used them myself.
I've seen many examples of power cards.
The research is just really emerging now.
It looks like it can be a helpful strategy.
Basically the idea is that you choose from the child's special interests, you choose a hero, Spider-Man, or Iron Man, or one of those characters, ninja, and using a narrative process, you describe the behaviour you want see by making the main character the superhero.
So the superhero encounters the problem and then it's what would the superhero do?
The idea is that it's a way for engaging the child and helping to motivate them to do it.
But I would encourage you to look at some of the research examples.
I think it probably could be useful for some kids.
- [Shelley] Great, thank you.
A couple more if you don't mind taking them.
Do you find that real photos tend to work better than drawn photos or is there a difference in the type of picture that's used?
- That is a great question and it's really, really important to know that.
When we were talking about narratives, well, really for everything we were talking about, the importance of individualizing based on the level of abstraction for the child.
Now, with digital cameras it's a lot easier to use real pictures, but for many years the go-to thing was to use Boardmaker picture symbols or line drawings.
When you think about the level of abstraction being an actual object first, and then a photograph, and then an outline, and then at the very top something that's more abstract like a hand drawing or a picture symbol.
Picture symbols are actually more abstract usually, some are iconic, but usually they're more abstract than photographs.
The answer to the question is you have to use what the child understands.
If you're showing them a picture of an apple, but he doesn't know that an apple is, compared to a real object, that he can't match an object to a picture, then it wouldn't make sense to use that.
If they're very comfortable with picture symbols and you've used them in their schedules and they respond well to those, there's no problem with using that.
The caution that I would say is if you use real photographs, you have to be very careful because if you, let's say you were trying to illustrate a scene of the boy who goes into the cafeteria and it's very noisy and he doesn't wanna go into the cafeteria.
When you go and take a picture of the cafeteria, it's a big picture with a lotta people in it.
That doesn't necessarily tell that child that you're talking about the cafeteria.
You have to be very careful to make pictures, photographs if you're gonna use them, that are very clear, usually with a very clear background, and only the action you want the child to see or the person you want the child to see on the picture.
Again, if it's a child who has no difficulty with figure-ground discrimination then you can use a wider variety, but you do have to be careful about that.
And also, especially for things like shoe tying, if you're gonna use photographs then use their shoes.
Use familiar objects from the natural environment that the child would see very frequently.
- [Shelley] Perfect, thank you so much Marlene.
There are a couple of other questions and if it's okay I'll capture those maybe and send them to you by email and then we can share the responses with the group.
I'm just cognizant of the time here.
But I really, really appreciate you taking the time to answer those questions and I'll let you finish off.
- Well, I guess mainly what I wanted to say is, take a deep breath.
I appreciate very much, I know this is a real busy time of the year.
I hope that you will find some ways to de-stress of that stressful time yourself.
And I hope that some of these strategies will be useful to you.
My email is at the bottom of the PowerPoint and I'd love to have your feedback or any questions that might have that are outside of the webinar.
Thank you very much, Shelley, and for the Autism in Education group, I really enjoyed it.
- [Shelley] Thanks, Marlene.
We appreciate your time and your sharing your experience and your expertise with us this afternoon.
For folks still on the webinar, I will send you a follow-up survey in just a few minutes here this afternoon so that you can provide us with some of your feedback.
And we'll certainly share, I'm watching lots of positive comments come in through the chat box, so I'll certainly share those with Marlene.
So thanks very much and we'll look forward to seeing everybody for the next webinar in January.