Autism Interventions and Teaching Strategies

Mary Barbera: You’re listening to the Turn Autism Around podcast, episode number 63, and I’m your host, Dr. Mary Barbera. I’m thrilled that you’re tuning in today and this episode is a special interview with Tracy Vail. And we’re going to be talking all about the various autism treatment modalities and approaches and things that we can learn from each modality and talk about the treatments and the different camps. So we’re going to get to that in just a second.

Mary Barbera: Before we do, I’d like to give a listener shout out to someone who left a five star rating and review on Apple Podcasts. She said, “I wake up every Tuesday morning waiting to hear Dr. Barbera’s new podcast. I’m a physician mom and I spend most of the time listening to her podcast while driving. My insight into the management of autism and understanding my son has changed significantly after I started listening to the podcast. I also bought the VB bundle course online, which is another very useful resource for parents. Dr Barbera, this is a wonderful initiative and your experience as a registered nurse and an autism mom truly shows in your determination to help these children.”

Mary Barbera: So thank you so much. The name is Asca9999 and I’m not sure who that is exactly, but thanks so much for taking the time to leave a five star rating review. This really helps me spread the word and I’m so happy that you joined the verbal behavior bundle course for parents and professionals. And if you are listening and you don’t know anything about the verbal behavior bundle, or you know a little bit about it but are interested in finding out more, you can attend a free online workshop at marybarbera.com/workshops, whether you’re a parent of a very young child with signs of autism, or older child, or professional. I am pretty sure I had a workshop specifically that would be good for you. So that is at marybarbera.com/workshops.

Mary Barbera: So it is now my pleasure to introduce Miss Tracy Vail who is an SLP. She’s the co-owner of Let’s Talk Speech and Language Services and she is in North Carolina. She’s been working with children on the autism spectrum since 1982 in a variety of settings. She served as the president of the North Carolina speech hearing language association and was on the board of directors that started the Mariposa School for Children With Autism many years ago.

Mary Barbera: So Tracy… The reason that this interview is focusing on the treatment maze and the different modalities is because Tracy has postgraduate training in the use of many these models including the DIR/Floor Time model; the SCERTS model; PRT pivotal response training; the teach method prompt and PECS; picture exchange communication system; RDI, relationship development intervention; as well as a lot of experience with ABA and verbal behavior. So we’re going to talk, we’re going to go through them one by one, figure out what these methodologies are and what we can glean and what we can use in terms of programming and helping our kids on the spectrum. So whether you’re a parent or professional, I know you’re going to love this interview with Tracey Vail.

Welcome to the Turn Autism Around podcast for both parents and professionals in the autism world who want to turn things around, be less stressed, and lead happier lives. And now your host, autism mom, behavior analyst, and bestselling author, Dr. Mary Barbera.

Mary Barbera: So welcome to the show, Tracy. Thanks for coming.

Tracy Vail: I’m happy to be here.

Mary Barbera: Yeah, I think we met a few times in person, but we haven’t chatted at any length, so I’m really excited. Even just talking to you, preparing for the show, I feel like I’ve gotten to know you so much better. So thanks again for joining us. So can we start with you describing your fall into the autism world?

Tracy Vail: Sure. Well I’ve been working with kids on this spectrum since 1982 when I fell in love with my first kiddo. And this was like in the mid-nineties, a parent came to me and said, I’ve heard about this verbal behavior thing, will you go to a training with me? So I went to a training with Vince Carbone. And at first I, to be honest, I was like, man, I don’t know about this, you know… But I opened myself up to learning about verbal behavior and how it affects communication and so much was making sense. The more I learned and the more I investigated that I just really, I like to dive into things deeply when I feel like they resonate with what I’m doing and what matters to me with kids with autism. So I did some intensive work with Carbone. He really was… I went two weeks with him in Florida with a big group of people that were preparing to sit for the board certification examination. And it was, you know, kind of like this ABA drill time where you weren’t allowed to use any language except for behavioral terminology and, you know, everything you’re reading and presenting. And it was very intensive and it was the kind of learning that I like. So it was a really great experience. That was my foray.

Mary Barbera: And what year was that?

Tracy Vail: That was in the mid-nineties. Want to say like probably 95 or 96.

Mary Barbera: But you had already been a speech and language pathologist?

Tracy Vail: I’ve been a speech language pathologist since 1982. I graduated and I had also worked on… Once I fell in love with my first kid with autism, I went back and worked on my doctorate in early intervention and learning disabilities cause there wasn’t anything about ABA; there wasn’t anything about autism, you know, in the early eighties. So at least nothing that I could get my hands on. And so I’d gone to every training that I could, you know, that as time went on and anything that was about autism, that was my specialty area. I knew that’s why I was on earth and I just went to it.

Mary Barbera: Wow. Yeah. It’s funny because I got involved with the verbal behavior approach and verbal behavior, ABA when my friend flew down to Florida to hear Vince Carbone speak at a workshop in 99 or 2000 shortly after Lucas was diagnosed. So, yeah, at that point, you know, the Teaching Language book by Sundberg and Partington; and the Ables was out in 98. But I didn’t know about that until my friend flew down and heard about it. When she came back, she said, Mary, we have to change the way we’re doing things from our very traditional approach to VB. And so since then what have you been doing with all of this information?

Tracy Vail: Well, a lot of different things. I helped start the Mariposa School for Children with Autism. Once I got that verbal behavior training, I was working with a lot of parents who were going to the same trainings and they wanted to start a school. They wanted there to be an option for kids on the spectrum. So in North Carolina, everything was teach based at that point in time and so they really wanted… And it wasn’t working for their kids in the public school system, so they wanted to have an alternative. And so we worked to start the Mariposa School for Children with Autism. And basically what I did is I took all that information from Vince, plus all the stuff that I’d already learned within the field of speech pathology and kind of put it together into, this is how I would like… If I’m going to be part of it, this is how I would like it to look. So very play based, very socially connected, very based on verbal behavior, but very much in the natural environment and very play-based.

Tracy Vail: And that’s where the training manuals came from. It was just handouts that we were doing because we were training teachers and training staff that we were going to start the school with. And they were the handouts at the end. The director of the school said, can we put these all together and create a manual? Sure, we can do that. You know, but we can’t sell it because it’s not referenced. And it’s, you know, it’s not a professional document, but you want to put it on the website and give it to people, that’s fine. And the cool thing about it is now that I’ve had at least eight different requests that manuals be translated into at least eight different languages.

Mary Barbera: Wow. And the manual you’re talking about is the Mariposas School staff training manual, which was actually published by you and someone else in 2002.

Tracy Vail:  It was never published. Yeah, it was created by pulling together a bunch of handouts and then at the time the director of the school, Cindy Peters, had just edited altogether and said, can we put this online for people to have for free? It was just the handouts so it was never a professional thing.

Mary Barbera: And we are going to have that whole manual in the show notes for free. And it’s funny because I, the night I messaged you to ask you to be on the show, you know, we’ve met in person and we’ve, you know, dialogue. I see you a lot online. But I was cleaning off a bookshelf and I found the Mariposa manual in a little three ring binder that I kept and actually I paged through it. I saw your name on it and I was just like, you know what, she’s been such a leader in the field and this is such a great manual. I learned from it, it really broke down the different operants, and even started me thinking a lot about the transfer procedures that I was using, you know, which led to my transfer procedure article, which published in 2005 with Rick Kubina.

Mary Barbera: And Rick has been on the show. We’ve talked about that transfer procedure article. We can also link that in the show notes as well. And then, you know, eventually when I wrote my book, I mean by that point, by the time I wrote my book, you know, I had been working with hundreds of kids through the Pennsylvania Verbal Behavior Project. But I really do think that, you know, I mean you obviously were in the beginning of verbal behavior as it was. I mean it was like the wild west where really when we switched from a Lovaas approach to a verbal behavior approach, it was kind of scary because there was not really a lot of people that knew how to implement that in a really good way. So, you know, it’s great.

Mary Barbera: But I do want to spend a lot of time today and really focus on the different treatments for autism; the different camps; the different approaches to treating autism. Because I recently had Jim Christie on the show and he’s an autism dad and he made a play, created a play, and is now making a movie based on some of the turmoil that parents go through when they do get a diagnosis. And depending on, say you’re in North Carolina, then you’re going to get teach. And if you’re in, you know, this county in Pennsylvania where there’s big time Floor Time people around, then you’re going to, you know… And so it seems to be this really complicated maze. There seems to be a lot of disagreement about what intervention should be had for which children, who’s going to fund it, you know, funding. And it becomes this tangled web of politics and funding and really approaches that in some ways can be combined and aren’t that dissimilar. But in some ways they’re very dissimilar.

Mary Barbera: So I know you’ve had training in a lot of these models. So I’m going to just list them and then we’re going to talk about each one separately. You’ve had training in the DIR model, which is also called Floor Time; the SCERTS model; PRT, pivotal response training; TEACCH; and then verbal behavior and applied behavior analysis, which we’ll leave until the end because if you’re listening, you probably are very much aware of ABA and verbal behavior. So we’ll leave that til the end. But we’re going to go over like more of the social emotional models first. We’re also going to go over communication models. Oh, we’re also going to talk about RDI: relationship development intervention. And then I also want to talk about, because you have training in PECS, the picture exchange communication system as well as RDI. And already you know there’s lots of alphabet soup. And if you’re driving and or exercising and listening, you’re probably like, oh my God, stop with all these acronyms. As you can imagine, these are really confusing for parents and professionals. So let’s go down one by one. First we’ll talk about more of the social emotional approaches.

Mary Barbera: So the DIR model or Floor Time, can you tell us just like in two minutes, three minutes, what that is, how it was created and kind of when you see it used most.

Tracy Vail: Yeah. So for me, and what I’m going to really talk about is what I took from learning about these. Because everything that I went to, if I can find a nugget of what I consider the truth or something that yes, this is works with what I know about autism, then that’s what I take. And what I think I really took away from the Floor Time at that time, what was called Floor Time. They didn’t even use DIR yet until a little bit later. I came into that when a psychologist said came and watched me doing therapy and she said, where did you get your Floor Time training? And I was like, well, if I’m doing it, I’d better learn about it. Right?

Mary Barbera: What does DIR stand for?

Tracy Vail: Developmental individual differences and relationship-based… I think I’m not real good with that acronym.

Mary Barbera: Okay. And that was developed by Dr. Stanley Greenspan. It’s also called Floor Time. So your therapy as a speech pathologist looked like Floor Time to somebody. So what is it?

Tracy Vail:  Absolutely. So on the floor, engaged with the child, following his motivation, looking at what he was looking at, trying to create interactions with him. They call it circles of communication. Now I might call it units of discrete trial within play, right? But looking at there’s something that happens, it’s how am I responding and then am I getting him responding? And trying to increase that back and forth of responding. So for me, what the real value out of that is learning how can I make sure that this child is with me, and is attending, and I’m attending to what they’re doing, and I’m doing it in a natural way that follows really their motivation? Especially early on in therapy. Right? That’s a big, big goal for me.

Mary Barbera: And there’s like levels of certification within the Floor Time model?

Tracy Vail: Yeah. You know what? I’ve never been a certification person because everything I’ve experienced is once you get a specific certification, you kind of have to do things their way. And there’s some criteria involved. And I’m more… maybe it’s my rebel personality and more, maybe it’s that I just see value in a lot of different approaches being combined and put together. But I didn’t ever want to be married to a specific approach because I think that there’s just too much out there that we don’t know yet. And combining is important.

Mary Barbera: Yeah. And I see the Floor Time model really being used a lot in the birth to three programs. Very little kids. I’ve seen it being used… And one of the things I’ve seen is too much time kind of following the child’s lead and too much time, you know, there’s very little data from what I’ve seen and very little targets. So I had one of my first clients, you know, he did ABA and he did Floor Time. There were different providers coming in and I have videos of him within my online courses that is like him doing table time with, you know, more of a traditional ABA approach that actually wasn’t looking very good. He was crying, they were reinforcing the wrong things. Like the skills were too hard, you know, just looked pretty bad. And then I also have clips of him doing Floor Time with Floor Time, you know, trained people. But they were, you know, it just looked like pairing and there wasn’t data. And the child, despite our very early diagnosis, really didn’t make any progress for our year with either approach. So how do you know if you’re just wasting time with it?

Tracy Vail: I think, again, what I got out of it was… My psychologist friend kept calling me now “Floor Time with the focus”. “Tracy does Floor Time with a focus”. And it’s exactly what you said of, you know, I use different terminology because my goal is to establish reinforcers to find something that the child really likes to create a context for communication. And then I’m going to teach what behavioral, what behaviors do I want to teach that are communicative within that interaction? Right. So it is exactly what you said that, that pairing, right? And the establishment of not only that activity as a reinforcer, but me as a reinforcer. And then I’m going to choose targets out of that. So I had more explicit targets and I had more… it might be teaching a child the point are teaching joint attention or teaching, you know, understanding that now I have a reinforcer. Right? So it’s not that the procedures were inappropriate. I think they were wonderful. They worked beautifully, but then it’s what next? And where are you going to take this? And how are you going to measure it?

Mary Barbera: Yeah. Yeah. Okay. So let’s move on to the SCERTS model, which isn’t that dissimilar from Floor Time?

Tracy Vail: No, it wasn’t. And again, that’s where I think that was my first training with a meat, whether it be in very present early on. What I took really out of that is again, that communication happens in a social context. It’s more than just the words, it’s the relationship between people. And we know that with kids with autism that we can teach them to say words, but if they’re not using those words functionally, then that doesn’t really matter. Right? And so understanding the role of that communicative context was imperative. The other thing I took from SCERTS was understanding parent training and the ability to use supports that transactional supports throughout the day of, you know, what can we do at lunchtime for parents? What can we do at bath time? What can we do… What are ways that we can encourage communication in these contexts?

Tracy Vail: And again, then I didn’t have the verbal behavior knowledge. So it was just about establishing communication. So what does that look like? Right? Training parents that. So that was a really important part. And also the emotional regulation of, you know, let’s not get them too hyped up right before bedtime and let’s make sure that he’s here and ready to learn and let’s observe what is happening in the environment and how that affects his behavior. You know, I use different words now, but we were doing that early on. I’ve been very the stressed at kind of the direction that SCERTS has gone in, in some areas. I think it’s one of the big areas where we’re starting to see some encampments and I don’t think that’s helpful for children and for families.

Mary Barbera: Some what, Tracy?

Tracy Vail: Some encampment. Like the SCERTS people, I’m right. This is the way you have to do it.

Mary Barbera: Oh, the different camps, yeah. In fighting among the camp.

Tracy Vail: Yeah. Yeah. And then calling out other people as wrong or bad. That’s, you know, just tell me what you do that’s good and let’s put it together and research it and do what works for the child.

Mary Barbera: Yeah. And I’ve actually had some training on many of these models that we’re going to talk about too, because early on I was as a mom to Lucas, I will go anywhere to any talking about autism to see what I can glean. But I think once I became really knowledgeable and an expert on verbal behavior, I remember one time at the national autism conference at Penn State, which is an annual conference held in early August every year. And you know, years I’ve presented or gone and attended. And I remember one year after I was well within the verbal behavior project, you know, probably in between, not quite right writing my first book, but I remember thinking, you know what, I’m going to go to these social emotional lectures.

Mary Barbera: And I just couldn’t… I just couldn’t stay, you know what I mean? Because like everything, they do make sense, but I felt like it was a lot of that, you know, this is the right way, but without a behavioral focus, without measurement. And it just kind of like, okay… So do you know what S C E R T S stands for?

Tracy Vail: Social communicated emotional regulation transactional support.

Mary Barbera: Okay, wow. Yeah, that’s a mouthful.

Tracy Vail: Making sure the kids regulated; use teaching language and their social context; and supporting the environment. I mean the basic structure is not that different than what you’re do in good natural environment training, verbal behavior program.

Mary Barbera: Right. Okay. Let’s move on to the RDI approach, which is relationship development intervention. And that was created by…

Tracy Vail: That was created by Gutstein and Shealy. And I did that. I went through the first two levels of certification and then you literally had to sign an agreement that you wouldn’t use any other approach. And they were moving everything online, so you could get the goals and then you couldn’t get the next goals until you submitted your videotapes and the powers that be approved it. And I’m like… yeah, no thank you.

Tracy Vail: But I did, again, I learned how it was more information on how to support parents engaging with their child throughout the day. Because as you and I both know, one of my opinion I guess is that we can’t have a support person coming in 20 hours, 30 hours, 40 hours a week, and not having parents understand what’s happening; or not having parents being able to engage in the same, get the things, same things from the child, you know? And I hear, Oh, you can make them do that, but I can’t. Well, what good is it then what value?

Mary Barbera: I’m a huge proponent of the parent becoming captain of the ship, and being the team leader, and knowing exactly what’s happening and directing it. Because I have found over my more than two decades in the autism world is that is a huge factor in how a child’s going to do. And you can have the best professionals in the world, but you won’t be able to afford them. They’re not gonna come over to your house on a Sunday morning and you’re… if you don’t learn how to treat problem behaviors, how to teach language, how to teach social skills, how to teach self-care skills like showering, how to advocate for your child, how to know what goal is good, what goal is bad, how to know what professional needs to be replaced, what to do when people quit and you know, it’s summertime and they’re not going to school…

Mary Barbera: I just don’t see any other way in terms of now, you know… I understand some parents work full time, both parents work and they maybe can’t take as active as a role. But that’s one of my passions and one of my missions is to educate parents alongside professionals. You know, my first course was autism ABA help online training for professionals and gungho parents. Because the gung ho parents, like my friend who flew down to Florida to hear Carbone and myself, who was like, you know what? Nobody knows what they’re doing. I’m just going to go to these professional conferences. Lucas had bad sleeping problems. So I got to sleep in my own bed through the night at a hotel if I go to a conference which was super reinforcing. And I would just anywhere I could to learn about autism.

Tracy Vail: Those are the kind of parents I worked with when we started the school. Yeah, we’re taking charge of this. But I think where the RDI really… What I learned out of that was the importance of being able to integrate treatment with, you know, we’re raking the leaves; we’re putting dishes in the dishwasher; we’re doing the laundry because parents can’t always just stop life, right? They’ve still got stuff to do. So how do we bring our child into that? How do we create a pattern of interaction; of a back and forth; the child has a role and I have a role in this. And again, I can look at that from a beat through a behavioral lens, but learning that key parent coaching component and adding that into life, daily life was a real value to me of learning the RDI. But again, I’m not gonna sign over and say that’s all I’m going to ever do.

Mary Barbera: And I have found that the RDI approach is, in some of their books, their workbooks and stuff, they are nice kind of ideas for how to do recipes and how to, you know… I remember something from RDI where if you’re walking with your child or even with your mother or whatever and you start, you know, going backwards a little bit, are they going to just keep walking? And just teach teaching those like new on social skills that a lot of us forget. And then with within recipes and within games to pause and sabotage the situation so you get more spontaneous language. And so there’s so much good in RDI for behavior analysts and speech pathologists to pull out of. So I mean, any of these approaches really do have some golden nuggets in them.

Tracy Vail: Emily and I where I use RDI still to this day the most, I use the workbooks. But I use it with my higher functioning kids that have a lot of language and really poor social skills, or I use it with my really low level kids. I’m trying to get some kind of pattern interaction of or use of gestures or, you know, the things that I think we do forget about a lot in behavior analysis; that early communicating gestures are important and nonverbal communication, non-vocal communication is always important. Right? And sometimes we have to take the words out of it for our older kids and really just look on our how are they responding to gesture, what are they responding to in the environment? And that’s where I use a lot of the RDI materials.

Mary Barbera: Yeah. But I still see a lot of behavior analysts… Like if you bring up the work of, you know, RDI or Michelle Garcia Winner’s books and work, you know, they’ll be like, that’s not evidence-based, dah dah, dah, dah, dah. You can’t use that. It’s like, excuse me, you know… That’s why I was excited about doing this episode because like let’s not get on our high horse and exclude any work of any professionals and really look to see what we could use and how we could put a behavioral spin on things.

Tracy Vail: Right. And I think you’re exactly right. Sometimes we have just stimuli; the Gutstein and Shealy books that have the games on them. I think that would be a great thing to include in the show notes because there’s a lot of games in there that it’s a good resource. You don’t have to buy into their whole theory of what is going on, but some of it’s just playing the development of social skills, right? It’s all researched based, but you don’t have… You can use stimuli. You know, Michelle Garcia Winner stuff is great if you use it as a tool in the right conditions for the right kids. And you… I think for me the importance of ABA is knowing how am I going to measure this? What do I expect the child to do? What behaviors am I looking for? So that I’m not just inputting stuff, right? Like I’m just reading a social story. I’m telling you what needs to happen or doing a behavioral map, but then when, where am I taking it next? What do I want the child to do? How am I going to reinforce that? How am I going to measure that it’s actually working, right? That’s the piece that we need to tie into whatever it is we’re doing.

Mary Barbera: Yeah. Okay. So those are the really big social emotional models that parents may have to choose from. Let’s move on to TEACCH. So you are in North Carolina where TEACCH was pretty much was created and is still being used a lot. So do you know what TEACCH stands for?

Tracy Vail: Well, it’s something like… Teaching education with kids… I don’t remember what it stands for to be honest with you. But basically what it is, is the structuring the environment, using structured teaching, structuring the environment to make things easier for kids with autism. So when you look at environmental modifications that might be to a classroom, it might be to work. So that it’s very visually predictable or that the routine is very predictable and again… it’s not that it’s not valuable information. I use it all the time. I when I have kids that are highly anxious, creating predictability and routine is something very important for them. Teaching independence, teaching independent work system, once I teach something, I put it into an independent work system because I want them to be doing something instead of stemming when they don’t have direct intervention with somebody. Right? If they haven’t developed a lot of really good place skills yet.

Tracy Vail: So using the information about the importance of environmental support, the visual supports in the classrooms, classroom organization and structure, so kids have a limit of where they need to go and what they need to do, using structured teaching and work tasks, baskets, that kind of stuff is all very valuable. Again, looking at it through a behavioral lens, I can see when I need to use that tool and when it’s maybe not so necessary. Like I’m going to give you an example of even just a visual schedule.

Tracy Vail: I use a visual schedule for kids that are very anxious and very routine based and they get really upset and they’re not able to even be with me when they don’t know what to do. But early on I set up my own internal thing, like I’m going to take a turn and you take a turn. First I follow your lead for a while, establish reinforcers, now I’m going to take a turn and play with your reinforcers, then I’m going to start bringing my own in. Right? So I established the predictability but it’s in a more natural social context. That’s what we do with our friends. I take a turn and you take a turn. So it’s not something I have to use all the time, but it’s a tool that I can add in to make life easier when I need to for a particular child.

Mary Barbera: Right, right. And you know, I also use it with independent leisure activities, independent work tasks. My son is now 23 so he goes to a day work pre-vocational program and he’s actually really great with that. But when a whole school or school program is based on TEACCH, you know, some of the components that may be missing, maybe, you know, teaching language, teaching social skills and it becomes too rote of just the kids spending time.

Tracy Vail: The other thing is one, one time I was in very early on in the verbal behavior project, probably my first year, my first classroom, maybe even my first few visits I was in. And this one, you know… I was meeting with the teacher and this one child was sitting you know, a little bit away from us and he was like sticking his hand in his mouth, almost like down his throat. And I was like, what is he doing like over there? Like what, what is he doing? And she’s like, oh, that’s independent work time. And I’m like, that’s independent STEM time.

Mary Barbera: If you are going to use it, again, it’s gotta be like set up. You’ve got to take data to make sure they’re progressing. You’ve got us, you know, switch out the materials so it doesn’t become too rote. Make it challenging enough that the child is interested, make it motivating enough to put motivators in between. I mean there’s just so much that goes into it. So what I found is sometimes when you set up independent work activities, it can become real rote real quick because if you don’t keep up with, you know it’s changing it out, get it, it can be really bad.

Tracy Vail: Yeah. So, but for an example, I’ve set up classrooms where we might have, you know, one area that’s just a play area; that one center where the TA or whoever’s in that center for the day is doing nothing but playing and establishing new reinforcers and teaching early communication skills. And we have another center that they’re all doing VB and doing some paperwork for the kids that are ready for that; and another center of where some kids are doing some independent work. So it can all blend in together. You’ve got the social emotional, you’ve got the heavy duty language hitting, and then you’ve got the independent work that can all come in the same classroom. There’s no reason why it has to be one thing or another.

Mary Barbera: Yeah. Good point. Okay. Let’s jump to PECS and prompt. So PECS is the picture exchange communication system developed by Andy Bondy and Lori Frost. Tell us a little bit about that. I have also been trained in that.

Tracy Vail: Yeah. So both PECS and sign were my two go-tos for our kids on the spectrum for early communication. I still am a strong believer that we have to give them a way to communicate and work on speech at the same time. But if we’re waiting for speech to come in, then we often see some of the development of some real problem behaviors because there’s not… They don’t have another way to communicate. So picture exchange was the first thing I learned before I really did a lot of work with Carbone and learned about sign language. But the importance of the picture exchange for me, for the kids with autism, was just really getting the importance of initiating right; of the child being the one that talks first, right, of coming to you and bringing you the card.

Tracy Vail: That was like a game changer for me when I was looking at requesting for kids with autism. Because a lot of them would use words, but they were so prompt dependent on somebody asking what do you want? Or being right there or reaching for the item first and then hearing a model of it. Right. So it gave away for the child to really be the initiator. That was the first foray. And then learning about sign language on top of that really had me look at… So which one is going to be better? Now again for this individual child in front of me, not better, like in the world of better and worse, right? But which one is going to be the most effective for this child? And I did database decision making on that. Like, let’s pick three of your favorite things to teach as a sign; three to teach us PECS, and you tell me which one you’re going to learn to do independently with nobody asking you anything, which one goes first. And then that’s going to be my primary.

Tracy Vail: But I also at the same time am always working on speech, right? Working on vocals. And we don’t give up in our clinic, we don’t give up on vocals. Because I’ve had kids that sometimes it might be 20 words that they can say clearly enough for people to understand. But they have 20 words, right? Always at their disposal. Unless they’re really stressed and they need a backup system. But they always have a backup system, too. So you know, one of the things Carbone and I disagreed in and talked about a lot is I don’t think there is one way that you have to even go with one way. I have kids, for example, that learned picture exchange. Then they learned some signs and then they learned some vocals and they have lots of repair strategies.

Tracy Vail: So this one little girl will come in and she’ll try to say something. If I don’t understand her, she’ll sign it. That’s her next go to. So she’s telling me her response effort hierarchy, right. So if I don’t understand her saying it, then she’ll try to sign it. If I don’t understand her signing it, she’ll try to find a picture of it or take me to it. Right? That’s communication. And that is a kid that’s committed to finding a way to get you to understand your message. Right? So I think teaching multiple forms is fine. Prompt is another one of those areas where…

Mary Barbera: Before we go to prompt, I just want to say something about PECS. And like I was trained, too, and I actually, the school that Lucas went to, the ABA school where he went to when he was in kindergarten, they were a big PECS school. So they wanted to try it on him because his spontaneous requesting was pretty poor. So they tested it. We would take his book, you know, to the pool for him to order and all that. And somebody said, yeah, but it can’t be like a completely spontaneous manned when you have a PECS book. But I’m like, yeah it can, here’s an example. So Lucas would go with his PECS book to order at the pool. Say I want a pretzel or whatever.

Mary Barbera: And the one day we went to the pool, the one night for a swim meet and the pool concession stand was closed. We went around the corner and it was closed and Lucas looks at me, he’s like, I want book. Like he thought the PECS book would actually make the window go up there. There is a spontaneous mand with PECS. One thing that I do not like about PECS now, after many years is the ‘I want’ structure. And I’ve done a video blog on carrier phrases and how I think it’s just a bad idea in general. Because what happens, especially for kids who have a little bit of vocal language, and I’m like you, I am like all about the vocal language. Like I will, you know, if somebody says my child’s nonverbal, like do they say anything? Did they make any sounds or… and if they say, oh, well once in a while he’ll say this or this, then then I am not going to let go. I’m like dog with a bone.

Mary Barbera: And I think one thing that both PECS and augmentative communication systems do when they build carrier phrases is it messes with the vocal. So you know, we have a child too, his name is Nicholas, so they teach him with PECS or with a device to say, my name is Nicholas. So that’s how many syllables? My name is Nicholas. That’s six syllables where he could say ‘Nick’ and or he could say ‘pretzel’, but it might sound like brother. And then you go and add “I want”. And now it sounds like, well duh, duh. And that’s not helping anybody. It’s not helping spontaneous manding. And so, you know, like kudos to, you know, Andy and Lori for creating this and it was something back in the day when it was created and it still is something, this whole reliance on jumping to the carrier phrase, I just can’t wrap my head around it.

Tracy Vail: Yeah. Well from a speech language development perspective, it is really not effective either because when we look at, you know, increasing length and complexity, we want to make it matter, right? And unless a child is saying, Hey, look at that plane, then I want the plane doesn’t have any extra value. We don’t need to discriminate. If he says plane it’s because he wants to the plane and he’s not yet commenting. So it adds length and complexity with no extra value. So when I look at language, I’m going to look at, you know, what matters to him? Because if he likes the big plane better than the little plane, then let’s teach big plane. Does he like the blue plane better than the red plane? Then let’s teach him to say blue plane. Right? Whether that’s with a PECS or whether what that’s with an AC system.

Tracy Vail: Now I do want to touch a little bit on that system because I do, now that we’ve got the ease of iPads thrown in there, the topography of an AC, whether it’s sign or PECS or a voice output device, it really has opened up for a lot of kids. And there’s so many special considerations for kids with autism that we don’t think about in the AC world if you don’t have training explicitly with autism. And that’s something that we have to consider. We want kids to be able to use augmentative systems and communicate while we’re working on their vocals. But it’s always not going to be a voice output device that’s going to be the in their best interest for that moment in time. There’s a lot of different factors that I use to make that assessment. So I think, you know, I’m a little concerned about the idea of everybody running out and getting an AC system and yes, everybody needs to have a way to communicate. So it’s that balance of being able to get a good assessment by somebody that understands autism as well as voice output systems.

Mary Barbera: Yeah, it is a very tricky, tricky thing. Okay, so the prompt method, tell us briefly about that.

Tracy Vail: Yeah. Well prompt is really… The way I use it, is about being able to find where sounds are produced and use tactile prompts to help evoke sound and to help evoke movement. Because speech really one of the problems I often see is people working on isolated sounds too long, right? If they are working on isolated sounds, then that’s not speech. Speech is really a movement from one sound to another. Right? So we can get vocalizations, but we want to make sure that we’re getting movement between sounds. So prompt is a way to help transition between movements and to provide tactile prompts on the face or some kids it just serves as a prompt.

Mary Barbera: The speech therapist hand actually touches the child’s face in different ways to make, it’s not… It’s not like you’re prompting the cheeks to go together or anything.

Tracy Vail: No, you are. You’re kind of pushing here, you’re pushing the tongue up here, you’re pushing…

Mary Barbera: And this is a very, you need to be trained. It’s not just like you can’t just read a book or watch a video and be at kids’ faces because like touching kids’ faces in general…

Tracy Vail: A lot of kids are very sensitive to that.

Mary Barbera: You need to know what you’re doing in order for it to work. So this is something that requires a good bit of training and… Or is it true that only speech therapists can be trained as prompt providers?

Tracy Vail: Only speech therapists are allowed to go to the trainings the last I heard. Yeah. But I look at, for most of my kids that can’t handle touch, I use a lot of hand cues. And… I think I’m saying her name right, are coming out with an article on the use of those hand cues. But we’ve been using them for years; just hand signals to help a child know where to produce sound. And that can serve as the same purpose. So if you look at… If you buy into prompt and say, this is a therapy that I’m going to go and I’m going to get certified in this, I’m going to do this, then I think you run into problems because especially for kids with autism, because there’s a whole lot more to consider.

Tracy Vail: But if you recognize that tactile cues or tactile prompts can help for some kids that aren’t sensitive to touch, to evoke sound, then, great. You know, is it getting you where you want to go is, you know, deciding what is it that I want this child to do? Is this serving as a prompt to have them do it? And I’ll use it and then fade it out. That’s the other problem with prompt is you have to fade it out. You’re not going to have your therapist with you manipulating your mouth to say words. Right? So it has to be faded.

Mary Barbera: Okay. Let’s move on to the ABA approaches. PRT, pivotal response training, I would consider an ABA approach.

Tracy Vail: Yeah. Well to me, it’s a really nice blend of the social, emotional and the ABA approaches. So it’s, you know, basically you’re using ABA in a Playbase format and your focus is on some specific what they consider core behaviors that are necessary for kids. And I think that it’s important to look at the role of motivation. Now they don’t use verbal behavior categorization of language, but it’s almost all manding at least on the early… That’s what motivation is, right? Or if you’re working on motivation and you’re working within the context of motivation, then you’re really working on mands. But Heather Forbes just published a paper on trying to look at all of their research and there’s no way to tell exactly what verbal operants are being addressed in it. So I’m assuming, at least when I learned about it, it’s mostly mand training, right? Some high intensity mand training and commenting based on motivation is kind of part of it.

Mary Barbera: That was developed by the Kegels. There’s a certification with that, too. So.

Tracy Vail: And I didn’t get that one either.

Mary Barbera: Yeah, no, I can see.

Tracy Vail: But I learned about it and it’s excellent. It’s really good information about, again, expanding that play. At looking at motivation, looking at being able to mand for information really early as a big on; asking what’s that, right? That’s one of those skills that if you teach a child to ask what’s that, then they can learn on their own, even if it’s that with a point, right. Then they can learn. They start acquiring their own vocabulary. So it’s looking at, what are these important things that we need to really focus on? So that’s the value for me from PRT.

Mary Barbera: Yeah. So lastly, let’s just talk very briefly about traditional ABA, Lovaas type approach and verbal approach and kind of, I’m sure you have the experience with both.

Tracy Vail: Yeah. Yeah. Well, I think my experience with the traditional approach came from collaborating with a Lovaas replication site. And the concern I always had about it is, as a speech pathologist, and again, my big thing is social communication happens in a social context. The come work with me at the table and then go play. Where’s the social context of the communication you’re in? And also the kind of the rigidity of the programming. And again, I know it’s a replication site, but what would happen for example is I had a little girl who had apraxia speech clearly, and she had mastered 150 receptives but the next thing was the expressive, right? And so say car and see if they dah, say car, no, say car, duh, no, say car. And then pretty soon, what is she doing?

Tracy Vail: She’s hitting herself. And she had no way of requesting. So she, well she did have a way but it wasn’t very functional, she would take her knee and hit it to her forehead over and over again. So she had this big goose saying, and I’m like, guys. You know, this is not clearly not working for her. She can’t say these words. She’s trying really, really hard, but you’re asking her to do something she can’t do and she’s getting really, really frustrated. And then you say, go play. Right? And you’re telling her, no, you’re wrong, you’re wrong, you’re wrong, but you’re not helping her. So we pulled her and they agreed. They understood that she was six years old and it took me a while to undo that, right. Like people were seen as a problem in her life and so just sitting on the opposite side of the room with her and playing with some toys, and I’m waiting for her to move closer and closer, and then we would start shaping. I used hand signals from her because she couldn’t be touched… PECS, I couldn’t touch her. She had a lot of…

Mary Barbera: Aversion to people and you have to repair all of that. Which really, when we did use a traditional approach where you also use a replication site. We had a really good consultant who had a lot of early intervention background, early intervention masters and so, and Lucas always had language and he really didn’t have severe problem behaviors ever when he was little. So it all worked out. It’s just that the focus was really on receptive and imitation. Even though he had some pop out words, there really wasn’t the focus on manding and echoic and all that with my early learner programs that are in my toddler course and my early learner course. I mean everything is like a multiply controlled, mixed operate easy procedures. We want to get as many, you know, trials in and make it fun.

Mary Barbera: I’m a big proponent actually of table time, but my table time is half net and half intensive teaching stuff all rolled into one. And so it’s… we want all the good things at the table. We want, you know, to just get control. Because I do think that some of these social emotional programs that recommend for time and following the child’s lead, you’re just not getting enough trials in. You’re not able to teach parents and other junior therapists how to be as good as you are with, you know, 40 years as a speech pathologist. Or you know, it’s like, it’s really hard to get good at nat and sabotaging and prompting and error correction in the natural environment while you’re trying to control the child’s movement and motivation. So I actually, you know, I see one of the, one of the big problems of the more traditional ABA approaches not pairing also the language, the manding and the echoics and working on verbal, vocal verbal behavior and not using just nonverbal operants shaping them all.

Mary Barbera: Like right now, you know, to teach body parts to a vocal learner. I’m going to teach the tact and the receptive at the same time, and I’m going to be transferring. I mean, this is one big thing. I interviewed Mark Sundberg at the beginning of the year, episode number 53, and we were discussing this and I do think that part of the key that’s missing in some of these ABA programs, no matter what you call it, and I’m not trying to throw one approach under the bus here, no matter what you call it, if you’re not aware of the verbal operants and transfer procedures and errorless teaching, then I think you’re missing a big part of the analysis of ABA.

Tracy Vail: I think you’re missing a big part certainly from verbal behavior about the analysis of communication for sure. But I also want to say that I do have kids in that have gone through traditional approaches in that same site that did beautifully, right. And it’s mostly kids that don’t have apraxia that have a lot of social or motivation; or the kids on the other end that have so many self-stimulating behaviors and so much that they need to have like this paired down environment almost, right. That that structure and that very clear instruction that is very clear discrete trial has worked beautifully for them. So I don’t think any of them are all good or all bad, but we have to pick and choose and when it’s not working, we need to look at a different approach for a child. If you decide that whatever way you decide, right. Take measure, take data on it and measure, is that working for this kid? And if it’s not switch. We can’t just stay married to one thing because that’s the way we do it.

Mary Barbera: Okay. So how do parents or professionals tell if a program, whatever we’re going to call it, the ABC program, how do we tell if it’s working, say the child’s been in there for six months… What are some of the components that you would look for?

Tracy Vail: Well, first when I get a parent that’s asking me about approaches, I say, you know your kid, go and observe. Go and watch what they’re doing. If it doesn’t feel right to you as a mama, then don’t go that way. Right? If it makes sense and you can see your child in that kind of a setting, then go for it. And then you’re going to look at what are the goals. Now, not just the are they including you in that goal selection? Like what is it that matters most to you and your family’s life right now? What matters most to you in your child’s life? What skills can they learn right now that are going to make the biggest difference in everybody’s life? Right? And let’s put those down and let’s agree on how we’re going to measure it. And then let’s look at the data. Let’s follow the data. Are they making progress? If you’re seeing some flat-lining and it’s not working, what can we do? What can we bring in? What other tools are there? Maybe from a different discipline, maybe from a different environment, but what can we do to change that?

Tracy Vail:  So I get concerned when there’s ever any place that says this is the way and the only way to do things, right? Like if I’m going to…I love the VB-MAPP. I think it’s wonderful work. And I think when you’re first starting out you kind of almost need a recipe book, but then you got to let loose of that a little bit and say, okay, I don’t care if 32C is the next thing on the list. Right? What’s affecting the child’s life the most, and let’s move to that direction.

Mary Barbera: Yup. I think that’s great. Now we are running out of time here, so I think this has been really good. I think there is a lot of confusion and we don’t need to have knee jerk reactions to everything. The other way I know you besides you know, online and through the Mariposa, a staff training manual, which we’re going to link in the show notes, is you are one of the Mariposa for ABA Skill Share, which is a Facebook group with over 25,000 professionals and some parents who really are very like-minded with what we’re saying. What I’m saying, what you’re saying. We’re both very active on there and you’re a moderator so that that ABA, Skillshare, we’ll link in the show notes, too. You can request to join. Ashley Rose from episode number 18 was on social skills. She started the group a few years ago and it’s a closed group. So I just love that group. So what are some of the struggles you see on that group being posted by professionals?

Tracy Vail: Mostly with professionals the things that we get asked for a lot are teaching strategies. Like, this isn’t working. Does anybody have any other ideas? And brainstorming, things like that. From parents, it’s mostly behavior and you know, it’s kind of this tough situation because you want to provide support. But in this particular group, this was, you know, I joined late in the game and it was Ashley and Heather and Karen’s decision that we’re not gonna offer any clinical advice here. I respect that. That’s the hard thing. You know, that you want to help so bad, but I understand the ethics of it too. You know, we need to know more information about it and we don’t want parents really getting their primary information online. So I think that the benefits of it is we have a wonderful group of sharing individuals that share materials, ideas, resources, just brainstorming, you know, here’s a toy, what could we do with this?

Tracy Vail: And those kinds of things that we can expand the use of ABA in a lot of different disciplines. We have OTs on there and we have speech pathologists. And the one thing that we’re really trying hard to do is make it a safe and respectful place that, you know, it’s not a place to come and just stout that, you know, well that’s not evidence. Like, okay, well how can we make it evidence-based? What can we do to look at, you know, it doesn’t have to have every little thing you’ve used doesn’t have to have a strong research study behind it. So that’s just not the real world. So what considerations do we need to keep in mind to make it use evidence based strategies with it? So that’s been kind of the struggle and that’s been the blessing to have that group.

Mary Barbera: Yeah. And I do like have a lot of resources. So when parents want to know, well what do I do? My child’s on the floor. Yeah we can’t, because we don’t know all the specifics, give them advice. But we can say…

Tracy Vail: Look at this, look at that.

Mary Barbera: Google ‘Mary’ ‘autism’ ‘tantrums’ and there probably are five video blogs that I’ve done over the past three or four years that will pop up and may just get them on the right path. Cause I think, you know, when parents ask questions, whether it’s that group or other groups, and you either have like train wrecks where you know people are giving bad advice or advice here, you know, go back and look at some research. Well parents, they don’t have the, you know, time or the inclination and they’re not able. And that’s really where I come in, where I’m doing podcasts and video blogs and getting the message out that, yeah, this is informational purposes. You know, I’m not telling you what to do but I am telling you what to think about. And so I always, if you’re listening out there and if you’re in groups, whether it’s ABA Skill Share or other groups, if somebody has a question, don’t even find the link for them. Just say, you know what? Google ‘Mary’ ‘autism’ ‘potty’. Because I know Mary has a free guide and you can get it. You know its like people tag me sometimes, oh, I know Mary Barbera has it. It’s like don’t tag me, I don’t have a lot of time to be posting the links. How about people search Mary autism and whatever the topic is? And if I don’t have a video on it, let me know and I might create one.

Tracy Vail: Yeah. And I love your podcasts. I listened to those on the way to work. You and I, you don’t know this, but we share coffee and conversation almost every morning when I’m going to work. I listen to the podcast and I’m talking back to you as if you were, you know, there.

Mary Barbera: So what has been your favorite episodes so far?

Tracy Vail: Oh well I love the one with Mark Sundberg, but Joanne is one of my heroes in the field of autism. And I worked with her on that book, wrote a chapter for them in the ABA for SLP book. And so listening to her I’m going, yeah, yeah. And I really enjoyed the one on Sundberg. I was very interested in the one on your speech, the speech one, increasing vocalizations, you know, I had some ideas and I was like, Oh, we should try this and you should try it. So I’m kind of adding to you even though nobody can hear me. It was pretty funny.

Mary Barbera: Well, that’s good. That’s good. And that’s awesome. Okay, so part of my podcast goals are for parents and professionals to be less stressed and lead happier lives. So do you have any, as we wrap up at, do you have any tips for parents and professionals listening?

Tracy Vail: Have fun. Have fun and play, make play part of every day. Play with your child, play with your spouse, play with your sailboat. That’s where I am today. You know, I think just keeping the big picture in mind that life is supposed to be fun, and creating fun wherever you are, you can be in line at the grocery store with your child and create some fun. You know, what, how can I do to make this fun? So that, that’s my biggest thing. The more I laugh, the less stress I have.

Mary Barbera:  I love it. So how can people follow your work? I know you’re going to do great things in the future, too.

Tracy Vail: Yeah. Well I’m kind of, you know, I’m 61, I’ll be 62 this year and I have a lifelong dream of living on the boat with my husband, so we’re going to stop doing winters, but… So I’m kind of phasing out. But my daughter is a speech pathologist, Jene Gerrett, and she’s also studying to be a BCPA and she has… I feel I’ve got this little seed of what I’ve taught her and then she’s just learning, learning, learning, all kinds of new things. So she’ll be continuing. And she and I together are working on a project called Play BA where we’re writing a book and kind of combining all of the knowledge from all of these different approaches and putting it through the behavior analytic lens and looking at how do we take the best of all of them, and the heavily researched pieces of all of them, and have a developmentally appropriate but also very scientifically measurable way to to work with kids. So that’s our next step. I’ll be writing on the sailboat while she still keeps working with kids and doing the research.

Mary Barbera: Nice. And what’s your website?

Tracy Vail: It’s, LetsTalkSLS, like speech and language services, .com.

Mary Barbera: LetsTalkSLS.com. Yeah. Okay. We will link that in the show notes. If you don’t wanna write that down or can’t write that down at the moment. So this has been a great episode. I hope you all enjoyed it. If you’re listening and if you would like more information about my online courses and my approach, you can go to Marybarbera.com/workshops where you can sign up for a free workshop, whether you’re a parent or professional with a toddler just showing signs of autism all the way up to a teen with severe autism. There’s a workshop there for you, a free one at marybarbera.com/workshops. Thanks again, Tracy, for your time today and I look forward to spending more time in your car with you on your drives. But thanks a lot for sharing your wisdom.

Tracy Vail: Thank you. Thank you. It’s been a pleasure. Bye bye.

Thanks for listening to the Turn Autism Around podcast with Dr. Mary Barbera. For more information, visit Marybarbera.com.