1/18/08

Updates from Mom: Beginning Sunday, the boys will be comletley off cow's milk and on to Rice Milk. So far the transition has been pretty easy. Once we have them on Rice milk we are going to begin to transition cows milk cheese and cows milk yogurt out of Tyler's diet and begin replaceing them with substitutes. Hope to do this in 1 week. Then the following week we are going to start the gluten free portion of the diet. We've bought hte recommended cook books, etc. and have most of the information we need. The consultant will help us with the rest, including a shopping trip consultation if we need it.

Also, I am really hoping we can get the video clips up this weekend. We have clips of snack time, playing with pop up toys as well as ring around the rosie (i think). One of my biggest fears about letting others watch or play with Tyler is that htey do not realize when he becomes overstimulated and then he bangs is head. We want to help people learn those signs and help them know how to prevent hte headbanging and reinfornce the communication that occured righ tbefore the head banging. We were able to catch that on video today so hopefully next week I'll have a clip. THe signs are subtle, and will be helpful for you all to see it.

Tyler is doing a wonderful job of immitating sounds, including new sounds, which was non existant a few months ago. He's doing so well, we are so proud.

Ben went to social group and had a ball. He was also a very good sharer. At one point a little girl took away a toy and he didn't even make sound. The mom asked her daughter to apologize and Ben said "sorry" so cute! He said a 6-word sentence the other day. I was very impressed.

I'll try to update this weekly.

Interventionist Session Note Summary: Ben joined us doing our session today. addition, some notes on the consultation visit to the social group are also included.

Handwashing Feedback (tyler): The handwashing routine looked awesome. It was great to see Tyler using the stool independently. it was nice that he was reaching for the faucet independently. The primarty goal continues to be to get Tyler to complete specific steps of the routine in a more independent manner. The caregiver continues to do a wonderful job of moedeling key words and actions through the routine.

Snack Feedback Note: The snack routine was also targeted during our session this morning. Although he did not engage in snack for an extended period of time, Tyler did do a good job making choices and indicating when he was finished with a gentle hand push. The caregiver should continue to implement the strategies as listed above with a focus on modeling appropriate requests and providing opportunities for choice making. Ben also participated in snack this morning. Ben was not initially interested in participating in snack, however; when he was offered the opportunity to sit at the "big boy" table he changed his mind. While the "big boy" table is a great strategy to involve Ben in snack in a fun way, I would be careful not to offer it when he is demonstrating some non­functional behavior like whining or yelling. Instead, I would recommend proceeding with snack with Tyler and when Ben is ready to join and is demonstrating appropriate behavior that is when I would offer him the opportunity to sit at the "big boy" table. Ideally, the "big boy" table should only be available when he is demonstrating "big boy" behavior .

General Feedback (Please note that this feedback also includes feedback from the social group observation):
o When re-directing Tyler and Ben from an activity, I would recommend that the caregiver continue to say "No thank you" in addition to providing alternative activity or toy choices.
o Tyler Feedback: Really push for the eye contact and more complex request from
him in the next couple of weeks. Holding out, sabotaging, and surprising him during the
routine are good strategies.
o Ben Feedback: When he yells "No" in a loud voice, I might recommend modeling "No thanks" in a calm voice. When he starts to imitate this model, I would provide him with a lot of social praise in an effort to increase this response. When Ben is having a hard day, I might stay away from asking him wants to do because this a trigger for some non- functional behavior ("NO!" or whining). In might pull out a couple of toys and start playing with them. If he joins you in playing with toys, I would provide a lot of social praise in an effort to increase that response. If he does not join in, I might just let him hang out on his ownfor a while until he is ready to play.

Parent Strategies:
o Continue to adjust the difficulty of a task based on Tyler's arousal level. If he is agitated you may decrease the difficulty and if he is really well regulated you may increase the difficulty of the routine.
Increase complexity of request: During activities when you know that Tyler is highly motivated you will ,vant to increase the complexity of the request by either requiring both a hand pull AND an gaze or by modifying the environmental arrangement.
Modifying the environmental arrangement might include putting an item up on a shelf, which will increase the response effort in that he has to use a larger visual scan to locate the and then has to approach the caregiver for assistance.

Sharing time between Tyler & Ben: In situations where both Ben & Tyler want attention, I might recommend utilizing a kitchen timer with Ben to let him know when it is his turn. You might show him the tll1er and then let him know that when it buzzes that it will be his turn to play. In the beginning, I would recommend keeping the time Ben has to a wait to a short duration (i.e. 2-3 minutes) and providing a significant amount of social praise while he waits. Once he begins to understand the roultine, it will be appropriate to set the timer for longer durations.
Be creative and consistent with transitions.
Vocalizations: A great to evoke vocalizations are during "rhythmic" activities such as
swinging, wagon rides, bouncing on a ball, jumping on a trampoline, etc. During the activity the caregiver would model the word or sound while the child is engaged in the activity and then intermittently pause to see if the child will emit the word or sound spontaneously. If the child emits the word/ sound spontaneously, the caregiver win immediately continue with the activity. If the child does not emit the sound after five seconds, the caregiver will model word/sound and then continue on \with activity.

When introducing new toys, the caregiver should avoid placing demands on Tyler and his interaction with that toy. Instead the caregiver should allow Tyler to explore the toy while also modeling appropriate/functional play.

It might be helpful to pick a couple of signs in addition to those that the caregiver is having Tyler currently practice for modeling purposes only (i.e. The caregiver would only be modeling these signs rather than prompting Tyler to sign them at this point). The more exposure that Tyler has with signing paired with vocalizations the better.

Prior to an activity or routine, the caregiver should have a general idea of what roles he/she would like Tyler to have that
or routine.
Think about making the table a fun place by doing various preferred activities at the table throughout the day.

If you give a direction or place a demand try to follow through with it as much as possible. If it is not a task that Tyler can complete independently the caregiver
should be sure to immediately put appropriate supports for him to be able to complete the task successfully.