Seeing is Believing

Editor’s Note – The following article was written by Amy F. Hobbs, Training Coordinator with the Autism Society of North Carolina.

Research shows that video modeling is an effective strategy to use with individuals with Autism Spectrum Disorder to improve social and communication skills. As a trainer, I frequently emphasize the importance of showing children with autism what you want them to do as opposed to just telling them. Verbal directions are typically difficult for individuals with autism to process as their visual processing skills are more advanced than their auditory processing skills. Video modeling or the process of instructing through watching a model therefore provides an excellent opportunity for students to actually see the behavior or the skill that is requested and therefore better understand it.

Not only is video modeling time and cost effective, but it can be rehearsed and rerecorded until the exact skill or behavior desired is captured. This is a much cleaner method than live modeling and can be watched repeatedly until the skill is learned as well as used as a tool for maintaining the skill. In fact, video modeling is a practical method of instruction for teachers that can be used with multiple individuals needing practice on the same skill.

As with computer screens, video modeling takes away the interpersonal component present in 1:1 teaching that makes learning more challenging for individuals with autism. It offers instead a mode of instruction that is highly motivating and fosters independence.

Video modeling has been used to teach many different social, academic, behavioral or functional skills from iPod use to how to give a compliment. Many studies show the success of video modeling in teaching challenging social skills such as recognition of emotions, perspective taking, social initiations, eye contact, social greeting, sharing and engagement in social conversation. My goal here is to demonstrate the simplicity of the video modeling process by giving some basic steps to follow.

1. Determine if the child has the perquisite skills needed to ensure success. These include basic imitation skills, normal visual and hearing acuity, and the ability to attend to a video for at least one minute.
2. Teach a skill that can be easily modeled and observed. An ideal target skill is one that the child is able to do with prompting.
3. Decide who to use as models in the video. Peers, siblings or other children of a similar age are good choices. Once the skill or behavior is learned, videotape the child with autism displaying the target skill or behavior (video self-modeling). This can be a powerful tool for increasing the child’s self-efficacy (Bray & Kehle, 1996) as well as reinforcing the maintenance of the skill.
4. Write the script for the models and keep it short. Three to five minutes is recommended, but it can be shorter.
5. Video the models making sure that the important actions are clearly visible and that the audio is clear and free of distracting sounds. Keep it simple.
6. Intervention includes:
   a. Showing the video model to the child with autism several times and then
   b. Providing a time and place to practice the skill.
   c. Monitoring and keeping data on the child’s progress.
   d. Testing to see if skills generalize to other settings and people.

Often video modeling instruction is paired with another method of teaching such as peer mentoring, social skills groups, self-management, reinforcement, role modeling and other applied behavior analysis techniques to ensure success. Below is a list of research articles that demonstrate success using video modeling.

References:

• Bray, M., & Kehle, T. (1996). Self-modeling as an intervention for stuttering. School Psychology Review, 25, 358-369.
• Other research:
• Bellini, S., Akullian, J., & Hopf, A. (2007). Increasing Social Engagement in Young Children with Autism Spectrum Disorders Using Video Self-Modeling. School Psychology Review: Volume 36, Issue No. 1.
• Charlop-Christy, M.H., & Daneshvar, S. (2003). Using Video Modeling to Teach Perspective Taking to Children with Autism. Journal of Positive Behavior Interventions: Volume 5, Issue No. 1, pp. 12-21.
• Charlop-Christy, M.H., Le, L., & Freeman, K.A. (2000). A Comparison of Video Modeling with In Vivo Modeling for Teaching Children with Autism. Journal of Autism and Developmental Disorders: Volume 30, Issue No. 6, pp. 537-552.
• Corbett, B.A. (2003). Video Modeling: A Window into the World of Autism. The Behavior Analyst Today: Volume 4, Issue No. 3.
• Corbett, B.A. & Abdullah, M. (2005) Video Modeling: Why Does It Work for Children with Autism? Journal of Early and Intensive Behavior Intervention: Volume 2, Issue No. 1, pp. 2-8.
• D’Ateno, P., Mangiapanello, K., & Taylor, B. A. (2003). Using Video Modeling to Teach Complex Play Sequences to a Preschooler with Autism. Journal of Positive Behavior Interventions: Volume 5, Issue No. 1, pp. 5-11.
• Goldsmith, T.R. & LeBlanc, L.A. (2004) Use of Technology in Interventions for Children with Autism. Journal of Early and Intensive Behavioral Intervention:Volume 1, Issue No. 2, pp. 166-178.
• Hine, J.F. & Wolery, M. (2006). Using Point-of-View Video Modeling to Teach Play to Preschoolers with Autism. Topics in Early Childhood Special Education: Volume 26, Issue No. 2, pp. 83–93.
• Hine, J.F. & Wolery, M. (2006). Using Point-of-View Video Modeling to Teach Play to Preschoolers with Autism. Topics in Early Childhood Special Education: Volume 26, Issue No. 2, pp. 83–93.
• Smith, C., Williamson, R. & Siegel-Robertson, J. (2005). Implementing Technology to Teach Social Skills to Students with Multiple High-Incidence Disabilities. Unpublished University of Memphis research study, 11 pp.
• Wert, B. Y., & Neisworth, J. T. (2003). Effects of Video Self-Modeling on Spontaneous Requesting in Children with Autism. Journal of Positive Behavior Interventions: Volume 5, Issue No. 1, pp. 30-34.
• Williams, C., Wright, B., Callaghan, G., & Coughlan, B. (2002). Do Children with Autism Learn to Read More Readily by Computer Assisted Instruction or Traditional Book Methods? Journal of Autism and Developmental Disabilities, Volume 6, pp. 71-91

Amy can be reached via email at ahobbs@autismsociety-nc.org or by phone at 828-236-1547.

Action Needed: Personal Care Medicaid Changes Threaten Group Home Residents

Recent news reports have shed light on changes that will have a negative effect on individuals with Autism Spectrum Disorder and other disabilities who receive assistance through Medicaid’s Personal Care Services (PCS).

Please note that the Personal Care Services described in this blog are not the same personal care services delivered to individuals who are in the Community Alternatives Program for Intellectual and Developmental Disabilities (CAP-IDD) or those in the Innovations waiver program. – Editor

By Jennifer Mahan, ASNC Director of Advocacy and Public Policy

North Carolina recently changed the Medicaid eligibility criteria for people with disabilities to qualify for Personal Care Services, which is one-on-one care assisting people with things like eating, dressing, bathing and other daily living activities. These changes were prompted by a Medicaid rule that PCS delivered to someone living in their family’s home or an adult care homes have the same eligibility requirements.

Several options for eligibility criteria to use were presented for consideration during the 2012 legislative session. The one passed in the most recent state budget raised the eligibility criteria for PCS across the board which “saved” Medicaid several million dollars, but also resulted in making thousands ineligible for PCS. Here’s why:

• Residents of some group homes (often referred to as the 5600 or DDA group homes) for people with developmental disabilities and mental illness need Personal Care Services. Without the Medicaid funding for those services, group homes can no longer afford to provide care to their residents and support their operation. Simply put they have lost part of the revenue needed to keep the doors open.
• This month along with the loss of services, people began getting notices they must move. These people with disabilities, living on social security disability payments and unable to provide for much of their own care, now have nowhere to go.

You can read several new articles explaining how this crisis developed here:

• North Carolina Health News Coverage
• Charlotte Observer Coverage
• WRAL TV Coverage

On November 30th, the Speaker of the North Carolina House, Representative Tills, sent a letter to the Governor requesting that she call a special session of the Legislature to deal with group home funding and in the letter he promised that no other bills would be brought up for vote. The Autism Society of North Carolina thanks Speaker Tills for recognizing the critical nature of this situation in which thousands of people with developmental disabilities and mental illness may become homeless.

Now, the Governor must agree to the special session and Legislators must agree on how to fix the crisis. The Autism Society of North Carolina is working with the Arc of North Carolina and other advocacy groups to urge elected officials to call a special session of the NC General Assembly before December 31, which is when PCS services for many will end and threaten the loss of housing for thousands.

As of the posting of this Blog (Sunday, December 9) there has been no action on a special session. ASNC is asking individuals interested in this issue to become involved in the discussion. Here’s what you can do:

1. Sign the online petition to urge The Governor and Legislature to solve the Personal care crisis now!

2. If you prefer to contact elected officials directly, information is below. As always, please personalize your message by using your own words.

To contact Governor Perdue you can email her via the Office of the Governor email: governor.office@nc.gov

The message to the Governor is simple:
Please call a special session of the General Assembly and/or worth with Legislative Leadership to find a solution to the Personal Care Crisis for group homes and people with developmental disabilities.

To contact the Senate Leadership you can email Senator Phil Berger, President Pro Tem of the NC Senate at Phil.Berger@ncleg.net.

The message:
Please work with other Legislative leaders and the office of the Governor to find a solution to the Personal Care Crisis for group homes and people with developmental disabilities.

To contact the Speaker of the House Representative Thom Tillis, use email address Thom.Tillis@ncleg.net

The message:
Thank you for asking for a special legislative session and your commitment to finding a solution to the Personal Care Crisis for group homes and people with developmental disabilities.

We also encourage you to contact your own NC General Assembly Senator or House Representative and let them know of your concerns. To find your elected officials click here.

If you have any questions about these or other public policy issues please contact Jennifer Mahan, Director of Advocacy and Public Policy at jmahan@autismsociety-nc.org or 919-743-0204,  extension 1116.

Staying 2 Steps Ahead: Safety in the Community and at Home

This week’s Blog post comes from Autism Society of North Carolina Parent Advocate/Trainer Judy Clute.

Parents worry about their children’s health, happiness, and well-being, but parents of children with autism spectrum disorder (ASD) must look at their environment closely and take great care to ensure that their kids are safe both inside and outside the home. Why is safety for the person with ASD different from any other safety measures you would put in place for any child? Here are some things to consider:

• Communication – Whether there is a lack of language or whether language is limited, this is the top reason we need to think ahead for our family members with ASD. Can they communicate to someone if they are lost or hurt? Will they be able to ask for help? Even if they are verbal, will they be able to communicate appropriately and effectively?
• Judgment – Consider that sometimes people with ASD have poor judgment. They may not recognize who is safe to go to for help. Do they know where to seek out help? Do they know who in the community is safe to go to?
• Sensory issues – People with ASD may run toward something of interest (ie: a train, a sign, music, water) or run away from something that is overwhelming (i.e. : music, loud sounds, too much commotion, lights). Needless to say, this can be a safety issue.
• Problem solving skills – Such skills may be impaired by rigid thinking, lack of perspective and/or anxiety. If your child were lost or hurt, would they know what to do next?
• Different learning styles - How can you teach your child about safety issues? Because of poor communication skills, many individuals with autism cannot share information verbally, some use visual cues, some use technology. How can they use these things in case of an emergency?

Children with ASD can be much more impulsive than neurotypical children. They may run away or wander off more than their typically developing peers. This can put them in greater danger of becoming lost, getting hurt, and becoming vulnerable to strangers. So what can we do?

“An ounce of prevention is worth a pound of cure” but for parents of a child with ASD, it may feel more like a pound of prevention is needed. But the saying holds true, it’s better to prevent a problem than trying to fix it afterwards. Here are some tips for caregivers to consider:

1. Do not isolate yourself – Inform you neighbors about your child or family member with ASD. Educating your neighbors about your child and their challenges can help if he/she ever wanders out of your home or yard. Give them your contact information and let them know what your child likes and dislikes.
2. Contact first responders – Go to your local police station, fire station, and EMS. Take a current photo of your child along with a personal information handout (available in the ASNC Safe in the Community Kit). Include as much detail as possible about your child.
3. Plan and rehearse – Does your loved one with ASD know what to do in case of a home fire? Are you prepared? The National Fire Protection Association has a great website that can help you and your family member with ASD be prepared. Their website has activities for children and a social story that can be individualized for your child. Another important skill to know involves teaching your child when and how to call 911.
4. Securing your home – Consider putting safety items in place such as a home security alarm system, window locks and/or alarms on windows and doors to alert you if someone is trying to open them. Sometimes putting a “stop” sign on doors and windows can prevent a person with ASD from going any farther. If your child runs or wanders, consider putting a fence around your home with locked gates. If you have a pool, make sure the pool is not accessible without supervision. Teaching you’re child to swim is important, but it isn’t a guarantee that it will save someone from drowning.
5. Communicate with your school – Discuss with your child’s teacher your concerns about your child’s safety. You may want to suggest that they offer a “Safety in the Community” workshop or other such training. Make safety part of his or her IEP goals. Work on how to safely cross the street, learn to recognize street signs (like “STOP”), and discuss who is a safe person and who is a stranger.

The Autism Society of North Carolina’s “Safe in the Community Kit”

The Autism Society of North Carolina can provide you (free of charge) “Safe in the Community” kits that contain some simple stickers to put in your windows to let first responders know if there is someone in the home with ASD. This simple sticker can make a huge difference in case of emergency. The kits include personal information sheets that can be shared with caregivers, first responder agencies, and others as well as ID cards that you can teach your child to carry with him or her at all times.

Kit Contents

Here are some great websites for resources to help you keep your ASD family members safe.

• www.AutismSociety-NC.org — We can help with education, resources and provide “Safety in the Community” kits
• www.mypreciouskid.com – has safety items for home and community (i.e. Signs, ID bracelets, home safety items)
• www.AWAARE.org – has several caregiver resources and tips

Adult Issues
What about adults with ASD or those with High Functioning Autism or Aspergers? These people may have wonderful spoken language but may not respond appropriately to a first responder or neighbors. They may be anxious or afraid. It is important to teach these individuals what to say in the event they are lost or hurt. They should be taught who they can trust – like a police officer, a fireman, a teacher. Introduce them to neighbors and family members that you trust. Help these individuals learn to self-advocate.

Another thing to consider is bathroom etiquette. You may wonder what this has to do with safety? Well, does your child go to the bathroom in restaurants or public parks by themselves? Most women do not realize that there is different bathroom etiquette for men than for women. Women frequently make conversation with others they may not know in a public restroom. This is not true for men. Children, especially boys, need to know not to talk to strangers in public restrooms and what to do if a stranger approaches them. Again, do they know who a stranger is? If not, teach them. They need to know how to address or respond to a policeman? They may be in a situation where it would be important to disclose that they have autism and need help. Teaching self-advocacy skills is extremely important.

Another consideration is internet safety. Many individuals have poor social skills and social judgment. For these individuals safety measures should be put in place to manage internet access – whether at home, school, or in the work place. If you have a child/young adult who is visual, place instructional picture cards directly on the computer. If they can read and understand written language, keep those rules right next to the computer and negotiate an internet use contract. Check with your ISP on safeguards. The NC Department of Justice has a website that contains several safe guards for internet safety: http://www.ncdoj.gov

Be proactive! Contact the Autism Society of North Carolina and let’s work together to keep our children and loved ones with ASD safe and sound.

Judy Clute is a Parent Advocate/Trainer in the ASNC Raleigh office. If you have any questions or concerns, please do not hesitate to contact her by email at jclute@autismsociety-nc.org or call 919-865-5091.

Medicaid Waiver (CAP IDD) Changes Take Effect Soon – What you need to know

Editor’s Note – The following update was compiled and vetted by Autism Society of North Carolina Senior Director of Quality and Programs Kerri Erb and Director of Governmental Relations Jennifer Mahan. Both these ASNC staff have been following changes to Medicaid Waiver services for quite some time.

Last year, the State of North Carolina submitted applications to renew its Community Alternatives Program (CAP) for people with intellectual and developmental disabilities (IDD), known as the CAP IDD or CAP MRDD waiver to the Federal government. This waiver program allows people who are eligible to receive Medicaid services through an intermediate care facility (ICF MR) to instead utilize those services in home and community settings. This community-based waiver has to be re-approved every 3-5 years.

North Carolina is in the middle of transitioning Medicaid services for people with Intellectual and Developmental Disabilities to a managed care model under another waiver called a 1915 b/c waiver (which for people with IDD is called “Innovations”). Given this transition to managed care, North Carolina officials asked for the current CAP IDD community based waiver to be extended several times. The state was hoping that it could transition to managed care Innovations at the same time so that those on CAP would not have to change services from their current CAP program, to a new CAP waiver program and then to Innovations.

North Carolina’s final extension on its current CAP IDD waiver has ended and the new waiver has been approved to start today, October 1, 2012. The state will transition participants to the new CAP IDD waiver starting this month. People on CAP IDD waivers and their families should not worry; CAP IDD services will continue after October 1. The NC Department of Health and Human Services, who are in change of Medicaid and CAP IDD, are working on the implementation plan for CAP IDD that will give direction to Local Management Entities, case managers, families and providers on what needs to be done and when. This plan may not be finalized until later this week.

As soon as Autism Society of North Carolina has more information about the implementation plan we will share it with families, staff and the public. Below are some of the changes in the new CAP IDD waiver that we have reported previously.

The Biggest Changes in the CAP IDD Waiver:

•  There will be a 129 hour per month limitation on habilitation hours for adults and children.
• “Habilitation” includes Day Supports, Supported Employment, Long Term Vocational Supports and Home and Community Supports.
• The 129 hour limit is inclusive of all these habilitation services; the total number of hours of these services cannot exceed 129 hours.
• The hour limit does not include habilitation hours provided in Residential Supports and/or Home Supports.
• Habilitation hours for children in school will be reduced to 20 hours per week. This includes any week school is in session, even for one day, even if the child is not in school that particular week.
• The 129 hour limit is a monthly limit; it is not a yearly average of habilitation hours.
• Enhanced Personal Care and Enhanced Respite will be restricted to authorizations only for medical reasons (not behavioral).
• Home Supports will no longer be a service under the 2011 CAP I/DD waiver. Personal Care and Home and Community Supports may be used instead of Home Supports. Hours restrictions that apply to rest of waiver apply to those transitioning out of Home Supports.
• Family members can continue to provide Home and Community Supports and Personal Care as they did under Home Supports. Other services under the CAP I/DD Waiver, such as Day Supports and Respite, cannot be provided by family members.

For more information go to The North Carolina Department of Health and Human Services web page for the CAP waiver and see “Overview of New CAP Waiver” near the bottom.

To contact Kerri Erb email kerb@autismsociety-nc.org or call 919 865 5053. To reach Jennifer Mahan email jmahan@autismsociety-nc.org or call 919 865 5068.

Structure – an Important Teaching Tool

Editor’s Note – This article was written by Amy Hobbs, Training Coordinator for the Autism Society of North Carolina. To read Amy’s bio click here.

It was Sunday and a new group of campers had arrived in the afternoon. I was called to the old dining hall to assist a counselor who was having trouble getting a young camper back to the group lodge to take a shower and get ready for bed. The four-year old camper who I’ll call Alex was at Mountain Adventure Camp for the first time. It was Alex’s, first time ever spending the night away from his home. Alex did not speak and to communicate his needs he typically cried, flopped to the floor and banged his head. Lucky for Alex, he was attending a camp that was specifically designed for individuals with autism.

Alex was wandering aimlessly around the dining hall, but every time his counselor tried to direct him towards the door, he flopped to the floor. Alex did not understand the pictures that the counselor was showing him that represented the Group Lodge nor did he understand the words used to explain that it was time to take a shower.

The old dining hall had lots of tables and chairs and also lots of doors leading to the outside. When Alex flopped to the floor the next time, we opened the nearest door and simply pulled chairs in around him making a corral with the only opening being a door to the outside. It took Alex about 30 seconds to stand up, look around and then walk straight out the open door.

I remember the look of amazement on that counselor’s face as he watched Alex walk out the door. He never forgot that example of using physical structure and how it helped Alex to understand what we wanted him to do.

Sometimes when students with autism are in inclusion settings, they have trouble attending to their work because of all the distractions in the room such as other students talking or moving around or people coming in and out of the door. Planning seating arrangements for these students to optimize their success in the mainstreamed setting is crucial. It might be that sitting on the front row or away from the main door will be enough to reduce the distractions. Another student might benefit from having a desk that faces the wall to help them concentrate on the work in front of them.

The simplicity of using the physical structure in the environment to address behavioral challenges is sometimes overlooked. However, the first step to addressing a behavior problem or instructional challenge is to make sure that the individual with autism understands the expectations. Often when the demands are clarified through moving the furniture or adding visual supports, then the behavior challenge dissipates.

The training department offers training on using a structured approach to teaching individuals with autism. For more information on this and other available trainings, click here.

Amy Hobbs can be contacted via email at ahobbs@autismsociety-nc.org or by telephone at 828-236-1547 or 800-442-2762, ext. 1501.