When you tell MONK to do something, he should do it in a timely manner. Why should I be so concerned about this odd behavior? This could affect him academically and socially and later, employment as well.
It had come to the point that OCD was taking over my son’s life. I was taking a graduate course at Johns Hopkins and made MONK my project. By doing that it helped me understand what his behavior of concern was, why he was doing it, and hopefully help him to control his OCD tendencies.
I did a thorough background examination of him by reviewing his records, conducted interviews, made several observations and collected data. I used charts and diagrams to visually see what MONK was doing which enabled me to break down the information that I collected. I then summarized my findings, discussed the setting/event, and antecedents, consequences, and function.
The behavior of concern was then determined and I came up with possible interventions and consequences for this. I also discussed the function of why he was probably doing the behaviors and interventions that could help.
Keeping a third person perspective on the project helped me tremendously by not focusing on my personal feelings and the battle at hand. Keeping to just the facts helped me see what I was doing wrong as a parent and what I should have been doing.
Summary
The behaviors of concern were to find out why it took M so long to clean the cat box and take a shower. After observing M, it was found that he was capable and could clean the cat box and take a shower independently, but he would be only on task 48.8 % of the time. When M was off task, it was because he was lining things up neatly, staring off into space, wandering or rocking. It was also noticed that M could perform these skills in a timely fashion and correctly when on task. His average time on task for cleaning the cat box was 10 minutes (49.6% of the time on task) and 25 minutes (49.8% of the time on task) for the bathroom. Because M was frequently off task, it would take him on the average, 22 minutes to clean the cat box and 50 minutes to take a shower (together 1 hour and 13 minutes). He would be off task 51.2 % of the time (averaged 12 minutes off task for the cat box, which was 50.4 % of the time and 25 minutes off task for the bathroom, which was 50.2% of the time).
Setting/Event
It was found that the setting/event of being at home, just after dinner, and having all his homework done had no effect on his behavior. However, the behaviors of concern were found to be exhibited at certain events/settings. M would usually come off task while cleaning the cat box (he would stop and repeatedly straighten things in the den, stare at cat box then go back to cleaning cat box and get off task again and wander around the den and bathroom). He also went off task during transitions (from cleaning the cat box and throwing the bag away to getting ready to take a shower). He usually would stare at the garbage can and wander around a few minutes before he would come back into the house. After he washed his hands from cleaning the cat box, M would stare and wander around the house prior to taking a shower. He also has a hard time keeping on task while removing his clothes, putting them away, and setting up the bathroom for his shower. He would wander around and stare at things and line things up precisely where he wanted them. While he was taking his shower, M would repeatedly be off task and would engage in staring, rocking, and making noises.
Antecedents
M’s behavior was not affected by the incentive to receive free time; he must clean the cat box and take a shower first. Other antecedents that M had were verbal prompts from his parents, which were very infrequent and M would usually go back on task for a few minutes then would engage in off task behavior. One time his mother told M that she was going to take a shower. He did not resume on task behavior, but stared at the hamper and wandered around his bedroom.
Consequences
The only consequences that M has for the behaviors of concern were verbal reprimands, which were very infrequent and if he took a long time cleaning the cat box and taking a shower, he would not have free time before bed. M would not be allowed to use the computer, watch TV, play video games, etc. (his favorite activities) until the cat box was done and he has taken his shower. If M has quite a lot of homework, he would not have time after school to do his favorite activities. The only time he would be able to do his favorite activities would be after he has done the cat box and taken his shower.
Function
The functions of the behavior could be due to anxiety, which M has shown in the past to have problems with. The behavior M exhibits might be calming to him and he therefore does them to feel better. The behaviors of concern may also be to relieve tension that he is feeling. When M was asked why he does those behaviors (lining things up neatly, staring off into space, wandering or rocking) he said he had no idea and/or to check that he did something correctly.
Several observations without M knowing that he was being watched were done to find out why it took him so long to clean the cat box and take a shower. After observing M, it was found that he was capable and could clean the cat box and take a shower independently, but he would be only on task 48.8 % of the time. When M was off task, it was because he was lining things up neatly, staring off into space, wandering or rocking. It was also noticed that M could perform these skills in a timely fashion and correctly when on task. His average time on task for cleaning the cat box was 10 minutes (49.6% of the time on task) and 25 minutes (49.8% of the time on task) for the bathroom. Because M was frequently off task, it would take him on the average, 22 minutes to clean the cat box and 50 minutes to take a shower (together 1 hour and 13 minutes). He would be off task 51.2 % of the time (averaged 12 minutes off task for the cat box, which was 50.4 % of the time and 25 minutes off task for the bathroom, which was 50.2% of the time). It was found through several observations that the reason M takes a long time to clean the cat box and take a shower was a specific behavior. The behavior of concern was not staying on task because of his anxieties and OCD tendencies.
Since M is high functioning, the parents could discuss with him what they have seen while he was cleaning out the cat box and taking a shower. The parents could show M the data sheets and graphs and discuss with him the findings while using the following behavioral interventions.
It was found that the setting/event of being at home, just after dinner, and having all his homework done had no effect on his behavior. However, the behaviors of concern were found to be exhibited at certain events/settings. M would usually come off task while cleaning the cat box (he would stop and repeatedly straighten things in the den, stare at cat box then go back to cleaning cat box and get off task again and wander around the den and bathroom). He also went off task during transitions (from cleaning the cat box and throwing the bag away to getting ready to take a shower). He usually would stare at the garbage can and wander around a few minutes before he would come back into the house. After he washed his hands from cleaning the cat box, M would stare and wander around the house prior to taking a shower. He also has a hard time keeping on task while removing his clothes, putting them away, and setting up the bathroom for his shower. He would wander around and stare at things and line things up precisely where he wanted them. While he was taking his shower, M would repeatedly be off task and would engage in staring, rocking, and making noises.
Observations also found that when parents reestablished M’s attention to the task at hand, he reengaged in appropriate behaviors for a short period of time. It is therefore advisable to have parental interaction to influence behaviors and have an impact on the behavior of concern especially during these times.
Social Autopsies
The behavior of concern of not staying on task could be due to what is expected of him is not clear to M. Social autopsies have been successful with ASD individuals and are particularly well suited to interpret social and behavioral situations. Parents can use social autopsies developed by Rick Lavoie to help M understand his social mistakes. The social autopsies could be used to dissect his social incident so that M will learn from his mistakes. In a non-punitive fashion, the parents and M will identify his mistake and determine who was harmed by it. M would then develop a plan to ensure that the error does not reoccur (Myles & Simpson, 2001). Parents could do this intervention with M to help him understand his social mistakes and what is required of him.
SOCCSS
Another intervention that the parents could use with M for his behavior of concern that has been successful with ASD students is the SOCCSS (Situation, Options, Consequences, Choices, Strategies, Simulation). SOCCSS strategy was developed by Jan Roosa to help students with social interaction problems put social and behavioral issues into a sequential form. This adult directed strategy lets M see that he has to make choices about a given situation and that each choice has a given consequence. M’s parents can do the SOCCSS and follow the six steps to help M understand cause and effect and realize he can influence the outcome of the situations by the decisions he makes (Myles & Simpson, 2001). This intervention could be used if a more detailed explanation of M’s social problems are needed. As with social autopsies, SOCCSS could be used with M to help him understand what to do and how he can influence the outcome.
M’s behavior was not affected by the incentive to receive free time; he must clean the cat box and take a shower first. Other antecedents that M had were verbal prompts from his parents, which were very infrequent and M would usually go back on task for a few minutes then would engage in off task behavior. One time his mother told M that she was going to take a shower. He did not resume on task behavior, but stared at the hamper and wandered around his bedroom.
Daily Exercise
An intervention to help combat M’s behavior of concern is daily exercise. R.L. Koegel & Koegel (as cited by Volkmar, Paul, Klin, & Cohen in 2005, p. 900) found that having the antecedent of daily exercise reduces the frequency and severity of behavioral problems of persons with autism and other developmental disabilities. Gabler-Halle, Halle, and Chung (as cited by Volkmar et al., p. 900) state that the benefits also may include improvement in physical health and increased task engagement. Elliott, Dobbin, Rose, & Soper (as cited by Volkmar et al., p. 900) has found that the exercise regime must be vigorous to be effective. It is therefore recommended that when M comes home from school, he should engage in strenuous exercise to help promote increased task engagement.
Task Analysis, Demonstrate/Model, Time Management
To keep M on task, a simple task analysis (step-by-step) list of how to clean the cat box and take a shower could be used. The parents would go over the list with M step-by-step and demonstrate/model how to do the desired behavior. It would also be discussed what a reasonable time to do each step and listed beside the step (his average time on task for cleaning the cat box was 10 minutes and 25 minutes for the bathroom). The parents and M would practice doing each step in the time allotted by demonstrating and actual modeling using M’s watch with a timer (the alarm sound is soft and it does not startle M). M can read what step to do on the list and time himself using his watch. Parents would teach M how to program his watch and how to time himself. M is familiar with timers/clocks and uses one independently to wake himself up each morning. When M has completed each task, he can check off the step from the list. A daily monitoring chart of performance would be posted on M’s bathroom and den door (examples attached) so all involved could see his progress and whether or not the program needs to be changed (Misra, 2005). When M shows an understanding of what is required of him, he would start the program.
Priming
Another intervention to keep M on task is priming. Wilde, Koegel, & Koegel (as cited in Myles and Adreon in 2001, p. 62) identified priming is an intervention that introduces information or activities prior to their use or occurrence. The purposes of priming are to (a) familiarize the youth with the material before its use; (b) introduce predictability into the information or activity, thereby reducing stress and anxiety; and (c) increase the student's success. They also recommend that the actual teaching materials such as a worksheet or textbook be used in priming. However, in some cases, they have been successful at priming using a list or a description of the activities to take place. Therefore, priming sessions with M should be conducted right before the activity is to take place and the parent will review the daily monitoring charts that show what he will do and in what time and M will be reinforced for attending to the material. Priming would also be faded back as M demonstrates achievement in each skill and activity.
The only consequences that M has for the behavior of concern were verbal reprimands, which were very infrequent and if he took a long time cleaning the cat box and taking a shower, he would not have free time before bed. M would not be allowed to use the computer, watch TV, play video games, etc. (his favorite activities) until the cat box was done and he has taken his shower. If M has quite a lot of homework, he would not have time after school to do his favorite activities. The only time he would be able to do his favorite activities would be after he has done the cat box and taken his shower.
Prompting/Cueing
When M is off task prompting/cueing should be used. Prompting/cueing is an intervention that stops disruptive behavior before it starts by drawing attention away from inappropriate behavior and redirecting attention to appropriate behavior. Prompting should be done when M starts the behaviors of concern. To be effective, the parents need to be very explicit and concrete about the skills they want M to do and about drawing his attention to them. Parents should focus their comments on the specific skill and try to phrase suggestions positively, giving examples of what M can do to improve, rather than focusing on mistakes and using a lot of “don’t” statements. Verbal prompting (example: check your list, what do you need to do, etc.) for M should remind him of the task at hand (Smith, 1995). It is also advisable when M becomes off task to wait five seconds to prompt him to reengage in appropriate behavior. This could be done by giving them the prompt of “Go on” or “What is the next step to be done” (Misra, 2005).
Physical prompting is not advisable with M due to his acute tactile sensitivity. M will become upset or anxious when students bump or brush up against him because the touch is perceived as uncomfortable or painful to him.
Verbal prompting by M’s parents should be more frequent at first, then gradually faded back effectively by establishing a specific prompt hierarchy that is specified for each objective or set of objectives appearing under an annual goal. Select the lowest level prompt capable of eliciting the desired behavior, and move toward greater independence, keeping in mind that the selection of prompt levels is always governed by student performance. The prompts for M should start with verbal cueing, then manual signs/gestures or visual cues, and independent performance/initiation. When M has reached a desired, consistent level of response, parents should begin fading out the prompting. Gradually design the prompting to be less intrusive, maintaining the level of response until the cue is no longer necessary (Twachtman-Cullen & Twachtman-Reilly, 2002).
Praise/Positive Comments/Feedback
Praise/positive comments/feedback as reinforcement should be used when M is on task by parents to increase the frequency of desired target behaviors. Praise/positive comments from the parents should be used when M displays the appropriate behavior or immediately after it is displayed. Praise should be natural and enthusiastic. If possible M’s name should be used and eye contact made. Praise should be specific and refer to the appropriate behavior. It should also be given for the greatest level of achievement M has been achieving (Misra, 2005). Praise/positive comments should be faded back as M demonstrates achievement in each skill and activity. These strategies will help facilitate independence and efficiency with M. Successful performance is not only rooted in the appearance of a particular skill, but also in the degree to which M is able to perform that skill independently (Twachtman-Cullen & Twachtman-Reilly, 2002).
Feedback is given during the time M has stopped the behavior of concern and is reengaging in the appropriate behavior. Feedback is a way of encouraging M to refocus on the display of appropriate behavior at a time praise in not yet earned. Feedback should be given in a neutral tone of voice and should be specific and behavioral (Misra, 2005).
Shaping
To keep M on task, shaping is very effective for increasing positive behavior. For M to progress at the fastest rate he is able, shaping is a technique by which a student is reinforced for exhibiting closer and closer approximations to desired behavior. It is useful in teaching new desired behavior and is a natural way of encouraging the student to increase the prevalence of desired behavior. The biggest advantage of shaping is that it focuses your attention and the student's attention on positive behavior. It recognizes progress and helps the student feel good about him or herself. It creates the opportunity for positive interaction between the student and teacher/parent, something which may not be that common for a student who exhibits high rates of problem behavior. Additionally, the effects of shaping are long lasting and become a solid part of the student’s repertoire (Smith, 1995).
Shaping is easy to implement and, since reinforcement is natural, it does not draw undue attention to the process of behavior modification. As each step is achieved, the behavior is taking a “shape” closer and closer to that of the goal. These approximations represent modification of the behavior. Positive reinforcement is provided for each step toward the desired behavior. Reinforcement is delivered naturally in the form of praise and recognition. It is the student's interpretation of your reinforcement that motivates him or her to change. As a student moves closer and closer to achieving the desired behavior, only the new step, which is being learned is reinforced. Previous steps no longer need to be specifically reinforced as they have already been achieved (Smith, 1995).
The functions of the behavior could be due to anxiety, which M has shown in the past to have problems with. The behavior M exhibits might be calming to him and he therefore does them to feel better. The behaviors of concern may also be to relieve tension that he is feeling. When M was asked why he does those behaviors (lining things up neatly, staring off into space, wandering or rocking) he said he had no idea and/or to check that he did something correctly.
Daily Exercise
To relieve stress and to keep him on task, M should engage in daily exercise. As stated in setting/events, daily exercise is extremely beneficial. R.L Kogel et al. (as cited by Volkmar et al., p. 900) found that daily exercise reduces the frequency and severity of behavioral problems of persons with autism and other developmental disabilities. Gabler-Hale et al. (as cited by Volkmar et al., p. 900) state that the benefits also may include improvement in physical health and increased task engagement. Elliott et al. (as cited by Volkmar et al., p. 900) has found that the exercise regime must be vigorous to be effective. It is therefore recommended that when M comes home from school, he should engage in strenuous exercise to help promote less tension and uneasiness and to help keep him on task.
Priming
Another intervention to relieve stress for M is priming which is used for the antecedent as well. Wilde et al. (as cited in Myles & Adreon in 2001, p. 62) has shown that priming introduces predictability into the information or activity, thereby reduces stress and anxiety. Therefore, priming sessions with M should be conducted right before the activity is to take place and the parent will review the daily monitoring charts that show what he will do and in what time and M will be reinforced for attending to the material. Priming would also be faded back as M demonstrates achievement in each skill and activity.
Priming is most effective when it is built into the student's routine and should occur in an environment that is relaxing and given by a primer who is patient and encouraging. This will help with M’s anxiety problem and he will be more successful in achieving his goals and objectives. Finally, the priming sessions should be short, providing a brief overview of the expectations for each skill and activity (Myles & Adreon, 2001).
Social Autopsies and SOCCSS
The function of the behavior of concern might also be that M has no idea what is expected of him and using social autopsies and/or SOCCSS would be beneficial for M to help him recognize his social mistakes and what is required of him. These interventions with M will help him understand what to do and how he can influence the outcome.
Task Analysis, Demonstrate/Model, Time Management
The function of the behavior of concern might be because M needs to learn how to follow instructions and to do it in a timely manner. As stated above under antecedents, using task analysis, parent demonstrating/modeling the desired behavior and having M practice this in a specified time will teach M how to keep on task. Using a daily monitoring chart posted on M’s bathroom and den door will allow him to see what he is supposed to do and in what time. Teaching M to use his watch to time each step will teach M to do the steps in a timely manner, thus teach him to follow instructions more efficiently.
Self Management
To keep M on task and to teach independence his parents could also teach self-management and allow M to self-monitor and self-reinforce. The parents would slowly fade themselves out and allow M to self-monitor and do self-reinforcement in an unsupervised setting. Parents could do this by reducing their prompts for M to self-monitor. The amount of time M spends self-managing should be increased as well as the number of self-recordings responses expected before reinforcement should be increased. The schedule of reinforcement would be reduced by increasing the duration between times when self-recording is expected. M would also be taught to access his own reinforcement for successful self-recording. Eventually, the self-management materials are also faded so that M is able to demonstrate self-control completely independently (Smith, 1995).
It is also important for the parents to monitor their own behavior vigilantly when working with M. Each time a parent prompts/cues M to redirect his behavior, an opportunity to reframe the moment in terms of M's need to develop alternative skills through a means such as self-management training may be lost (Smith, 1995).
Cognitive Behavior Therapy
The goal of cognitive-behavior therapy is to teach people with OCD to confront their fears and reduce anxiety without performing the ritual behaviors. It also focuses on reducing the exaggerated or catastrophic thinking that often occurs in people with OCD.
During cognitive behavior therapy the therapist might start by just getting to know the child and parents. The therapist might ask about favorite activities or TV shows, pets or hobbies, or particular sports. The therapist will also ask some questions about problems with worry and rituals that the child has been having. Then the therapist will explain about OCD and how the cognitive behavior therapy works to help it get better. The therapist will help parents understand the child's OCD and what they can do at home to help it get better, too. In cognitive behavior therapy for OCD, kids learn different ways to deal with their worries without doing a ritual. At first, it may seem hard to stop doing rituals, but the therapist can teach kids how to feel safe enough to try. It's definitely tough at first, but if they stick with it, kids begin to feel stronger and braver against OCD. After learning about ways to get their worries under control, kids start to practice them. As with anything new (such as playing the piano or kicking a soccer goal), the more someone practices, the better he or she can do it. When kids practice what they learn in behavior therapy, they find out it actually works. Kids with OCD usually go to therapy about once a week (or sometimes more often) for a while, then less often as they begin to get better. Getting better can take anywhere from a few months to a few years (Sheslow, 2008).
End of paper.
NOTE: We used the strategies that were listed above (except for cognitive behavior therapy) and M made some progress, but it was obvious that more extensive intervention was necessary. During the summer of 10th grade to help reduce his OCD tendencies, M went to cognitive behavior therapy in Silver Spring, MD. His OCD behaviors stopped with their interventions and when school resumed, so did his therapy due to it being a 2 hour drive one way. Since then, when his OCD at times becomes apparent, he refers back to the techniques that he learned and makes adjustments. So far it is working, but this will probably be a life long struggle that he will face from day to day.
2 comments:
I have OCD. I admit it. It annoys everyone around me and I know it. No matter how hard I try I can't stop it.
Bitsy-
I think everyone has a little bit of OCD. I like things a certain way too, but at least I don't go nuts like MONK when things are not just "so". UGH!
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