Written by Dr. John Carosso
Many years ago, starting out as a Psychologist, I came across a Principal who established a ritual with his teachers. At the conclusion of every morning meeting, he would huddle the teachers together and lead a chant “softer and closer” repeated four to five times, before sending the teachers off to their students.
I am hard pressed to contemplate a more significant or relevant mantra for teachers or parents. I have espoused the “softer and closer” approach since that time, and can think of no better way to connect with a child. Getting on the child’s level, moving-in close, and speaking in a soft tone, if not a whisper, is remarkably powerful, comforting, and bonding for a child in any situation, but especially when the child is experiencing a difficulty and needs supportive guidance.
Try it with your own child; rather than standing across the room and yelling, get close, soft, and comforting in tone, and see the difference.
I’ve also espoused time-in rather than time-out. Of course, the latter is necessary at times, but far too often we neglect trying the former. Try it, the softer and closer approach, and see the difference.
Written by Dr. John Carosso
Well, it’s really not so subtle. It’s the difference between labeling your child, or simply describing an annoying and transient behavior.
When we call our kids “lazy," “rude," “liars," “thieves," or whatever, we are defining their character, and suggesting that this is their enduring quality. Okay, so now you’re saying, well, they are! That may be true, but I’ll bet you can think of lots of times when your child is motivated, nice, told the truth, and did not steal. Even if the particular behavior is somewhat enduring, your child is still young; their personality is molding and shaping, and you’re in a strategic position to help shape it in the right direction.
Okay, here’s a scenario for you; you’re young, impressionable, don’t have a solid grasp or sense of yourself as a person, and have a tendency to believe what you’re told especially when told by the most important person in your life. In this scenario, you’re consistently told that you’re “lazy” or a “liar” or whatever. One can imagine that you may come to personally identify and internalize these traits, and expect to consistently behave in that way. Note that kids, and people, often live up (or down) to expectations.
Here’s a better option for you; label the behavior, rather than the child. Quite simply, for example, say “you’re lying” rather than “you’re a liar" or "you’re being lazy" or "you’re being rude." This option is definitely better than directly labeling the child, but it’s still not the best option.
Yes, there is an even better option. Instead of labeling the child or the behavior, simply redirect the behavior, describe very specifically what you want to see, and use the situation as a teachable moment. Think about it, calling your child “rude” does not teach; it simply degrades and disparages. Instead, if your child calls you a name, rather than call him “rude," describe the behavior as unacceptable, explain how he could have better-expressed his frustration, maybe even have him repeat the more appropriate words, and then implement a fair consequence. Same holds for “lazy." Rather; tell your child exactly what you need to see him doing, set a firm limit for him to get started, and then implement a consequence if necessary.
If your child has a particular problem with not being especially motivated, or telling mistruths, or taking items, then pay very close attention to her behavior and praise big-time when your child demonstrates the pro-social alternative. Remember, if you consistently praise a behavior, it is much more likely to be repeated. Sticker charts also do wonders.
You want your home to be a happy, pleasant, and cordial environment, right? Of course. You’ll go a long way to making that happen after dropping labels, describing behaviors you instead want to see, relying on firm consequences without yelling and emotion, and using lots of praise. Not to be redundant, but think about it, how do you feel when you’re called lazy, rude, or a liar? Would you do better calling your spouse “lazy” or simply telling him or her exactly what you need and that they'll suffer a consequence (they know what you mean) if they do not immediately help you?
Hope this was helpful. By the way, if you have any helpful personal experiences, or other good alternatives to labeling, please share at jcarosso@cpcwecare.com. Thanks.
Written by Dr. John Carosso
It’s that ‘back to school’ time. Yes, it’s sad to see the summer coming to a close and definitely time to get back to the school routine.
Need I mention the difference between summer and school-year routines? If you start about 2-3 weeks out, it’s much easier to ship your kids into shape. Otherwise, it’s a culture-shock for your child, and not too pleasant for you either.
God bless and enjoy the rest of the summer.
Written by Dr. John Carosso
One of the biggest challenges facing a parent of a child with autism is, what’s the most effective form of treatment? The choices seem endless and differentiating one from another can be a daunting task. Parents often rely on therapists to know and carry-out these programs, but many parents want to learn as much as they can and be in the best position to help their child. The most common treatments include speech/language and occupational therapy, counseling (for higher-functioning kiddos), and social skill groups. However, from that point onward, to choose between the options can be quite overwhelming.
It seems that there are two primary camps when it comes to treatment focus. One camp focuses on helping the parent and child build their relationship, i.e. working on making the parent ‘center-stage’ in the child’s world (as opposed to the child fixating on some random object) and working toward ‘joining’ with the child and becoming an integral part of the child’s sphere of interest.
The other camp focuses on helping the child to learn the basics and developing specific skill-sets such as mimicking, labeling, following simple directives, increasing attention to task, being able to request a desired item, expressing short phrases…
Some of the more popular commercial programs that focus on building the relationship include Relationship Development Intervention (RDI); Greenspan’s FloorTime; The Son-Rise program; and the Early Start Denver Model. There are other options including the aforementioned traditional outpatient counseling, and social skill groups, but the former programs tend to be the more well-known of the publicized commercial models.
The primary strategy for building specific skills is Discrete Trial Teaching (DTT), which focuses on skill development via repeated trials that reinforcement specific responses. Some may say that DTT also helps build relationships given that many of the skills are, in fact, relationship-building (sustaining eye contact), but ultimately there are marked differences between the two camps.
As a side-note, don’t confuse Applied Behavioral Analysis (ABA) with DTT. In that respect, DTT is a specific approach based in principles of ABA, but ABA is far broader in scope than DTT in that ABA is set of systematized techniques to analyze behavior and determine effective treatment regimens that typically rely on differential reinforcement.
There is limited research to suggest one Relationship-Builder is better than the other and, in my opinion, they all pretty much do the same thing in different ways. If you spend some time investigating the different programs, you’ll quickly see that they all have their merits and notable overlap in approach. In fact, there is so much overlap that it’s often difficult to differentiate one from the other. They all have their own confusing lingo and varying degrees of structure but all target building the relationship.
As I mentioned earlier, other relationship-builders include traditional outpatient counseling, offered here at Community Psychiatric Centers, to work both individually and with the family to promote social skills through talk-therapy, role-playing, and rehearsal of social situations. There are also social skill groups that can be very productive and many children, and their parents, find such groups to be invaluable.
No, relationship-building programs are not better than DTT, they’re just different. It’s comparing apples to oranges. However, it should be noted that the only modality that is genuinely research-backed and evidenced-based is DTT. Nevertheless, in my opinion, the best approach is to use both. In that respect, the relationship-building techniques can be done any time throughout the day, during any given activity, to build the relationship. It’s true that DTT can also be carried-out any time and in a play-oriented manner, but it’s most often conducted more formerly at a table (“table-time”). Consequently, the ideal approach, from my perspective, is putting aside time, each day, to carry-out sessions of discrete trial drills to teach specific skills and use relationship-building ‘joining’ activities throughout the day when carrying-out daily tasks.
Well, actually there is. It’s called Pivotal Response Teaching (PRT), which is essentially an off-shoot of DTT in that it uses differential reinforcement protocols to teach specific skills and to development the relationship. It’s a fun approach that is structured and regimented, as would be expected from any program based in DTT, but also child-centered, free-flowing, and naturalistic. It’s an approach worth exploring. However, ultimately, I perceive PRT as more of a skill acquisition approach than relationship-building, but others may disagree.
I hope that helps to explain and differentiate some of the more common approaches. I’m looking forward to providing more details in future posts to help your child build relationships and develop specific skills. In fact, I plan on providing a live workshop in the near future for that very purpose.
Please don’t hesitate to reach out to me with any questions along the way. In fact, I’d love to hear your opinion about the strategies and programs you’ve found to be most effective, and I can share them with others; email me at jcarosso@cpcwecare.com. Thank you.
God bless you and your kiddos, your entire family and have a wonderful rest of your summer.
Written by Dr. John Carosso
We spent the past few posts discussing the diagnosis and treatment of mild autism. By the way, your subsequent comments and questions have been remarkable and very thought-provoking; thank you. At this point, you already know the general signs and symptoms of autism (if not, just check-out any number of my prior posts at helpforyourchild.com), so let’s transition to a discussion about the treatment of more notable autism. In that respect, as a parent, if you have good practitioners to help, that’s great, but you don’t want to be completely dependent on therapists for your child’s well-being. If you know the following two approaches, you will, in fact, be quite prepared and capable.
You’ve undoubtedly heard of ‘applied behavioral analysis’ (ABA) and that ABA is ‘best-practices’ when it comes to the treatment of autism. However, it’s important to note that ABA is a systematic approach to developing and implementing treatment methods, not a specific strategy per se. In any case, I’ve written about ABA in prior posts (to read one, click here) and how it is used as a foundation for the two specific strategies described below.
A specific approach I highly recommend, based in ABA, is something called discrete trial teaching. In my opinion, there is nothing better to teach specific skills including mimicking, labeling, requesting, categorizing, and the beginning of conversational skills among other things. I’ve presented and created videos about this approach on my Youtube channel and on another of our sites, appletreeinstitute.com. This approach is structured, systematic, regimented and predominately done at a table (sometimes referred to as ‘table-time’). There are countless other videos on YouTube describing this approach; check them out!! You won’t find a better method to teach specific skills to your child.
As much as Discrete Trial Teaching is formal, systematic, and regimented, the Early Start Denver Model (ESDM) is free-flowing, in-the-moment, fun, and relationship-building, with strategies that are designed to do just that, build your relationship with your child!! This is especially important in that a primary sign of autism is an aloof quality and a general lack of social engagement. This approach takes everyday events and routines such as getting dressed, eating a meal, changing a diaper, clean-up, reading a story, playing with a toy, and leverages them to become dynamic relationship-building activities that make the parent “center-stage” in the endeavor and in the child’s life. Given that, quite often, a parent’s number-one concern is that they can’t get their child with autism to properly engage with them, this approach is vital. There too are excellent videos describing this approach on YouTube, as well as the excellent resource, The Early Start for Your Child with Autism, by Rogers, Dawson, & Vismara.
So, we talked about DTT and the ESDM as two very different but complementary approaches to build and develop both specific skills and, more generally, your relationship with your child. It’s well worth your time to learn about both approaches.
If you wish to learn more about these approaches and have questions about the specific elements, don’t hesitate to reach-out and email me at jcarosso@cpcwecare.com. God bless.
Written by Dr. John Carosso
Children with mild autism are treated with a very specific approach that involves clearly delineating the problem behaviors and tendencies. In that respect, we need as much detailed information about what goes wrong, and what goes well, in what situations, to what extent, for how long, and how frequently? Detailed written descriptions or, even video can be helpful. The more we know, the more effective the treatment plan.
There are social skill groups for children with autism that can be quite helpful. However, for some children with very mild symptoms, being segregated into groups with other children with autism is not entirely helpful. These kiddo’s need to learn skills amongst neuro-typical peers. So, in those instances, we take one challenging behavior at a time and, in-session during therapy, we practice, role-play, redirect, rehearse, and praise success over and over again, and transfer these skills and strategies to parents (and to the kiddos) to practice in Live situations with age-mates during the week. That one one behavior is targeted and the practicing continues until mastered; the mastered behavior is then placed into a maintenance schedule, and we move onto the next behavior or tendency.
Well, maybe that is somewhat simplistic because, yes, it can get complicated. Some kiddos with mild autism are not entirely in-tune with the need to adhere to adult expectations and daily responsibilities. They have their own agenda and, consequently, getting compliance to role-play or practice can be tough but the child is not being defiant, they just ‘don’t get it.’ In those situations, we may use what’s called ‘pairing’ to promote completion of daily tasks, and rehearsal, and to get the kiddo onboard with the program. There are a host of other behaviors that may surface, and subsequent strategies that can be employed but, ultimately, the approach described above can be quite productive. In fact, treatment for mild autism is very effective and the outcome for these kiddos is exceedingly promising.
I trust you’ll find that this targeted approach will be helpful but please feel free to contact me with any specific questions about your child’s progress, treatment regimen, problematic behaviors, or specific strategies. God bless.
Written by Dr. John Carosso
The process of diagnosing autism is rather straightforward, such that it’s a wonder that so many kids are misdiagnosed. It may come as a surprise to you that, from my clinical experience, the issue is under, not over-diagnosis. In that respect, time and time again I have kids in my office for whom there has been ongoing struggles and difficulties in the home, school, and in the community, and parents are dumbfounded why their child is having such difficulties. In that respect, their child has been evaluated elsewhere and diagnosed usually with anxiety, ADHD, or ODD. However, again, time and time again, parents come to me with a suspicion that ‘something more is going on’ and, by and large, they’re right.
Okay, why does this happen, especially when, in some cases, the prior evaluation incorporated ADOS testing, which is considered to be the ‘Gold Standard’ in autism diagnosis. Well, it happens because children with mild autism usually present pretty well in the structure of an office. They will do well in the areas assessed on the ADOS including eye contact, social referencing, topic maintenance, empathy, general quality of social rapport, and play skills. Also, while the ADOS is supposed to be objective, at times it can be quite subjective as to whether the kiddo actually is, or is not, showing those abilities. This is why a score on any specific test, including the ADOS, is usually not a particularly good barometer of whether a child has autism. I’ve found, countless times, that the ADOS, GARS or CARS may indicate not having autism when a child does, in fact, have autism, or vice-versa. It’s vital that the practitioner use their judgement and experience while conducting a comprehensive evaluation when making these determinations and not rely solely on the outcome of any individual test protocol.
What I see in children whom are I ultimately diagnose as mild on the autism spectrum is, first and foremost, a subtle but notable social awkwardness; in that respect, the child may be quite social and engaging but their manner, affect, and sometimes even posture has a rigid if not mildly robotic quality. It’s interesting to note that, in many circumstances, especially when younger, these children may have lots of friends. In that regard, despite being somewhat quirky, these kiddo’s can be well-accepted by peers though being perceived as somewhat “different.” However, parents are often unaware that their child is perceived as a bit unusual by their age-mates. Sometimes this social issue becomes more of a challenge in later grades when peers are less forgiving. Second, almost invariably, these children have a distinct and notable classic autism speech cadence. Third, while they can often maintain topic and are quite conversational, they tend to ramble, are detail-oriented in their conversation, and are not especially mindful of the need for back-and-forth conversation. However, some of these issues can be very subtle; in that respect, if overt, then the diagnosis would be clearer.
That’s a great question, given that a diagnosis cannot be made unless the signs and symptoms are actually causing problems. This is where the history and parent-report come into play. In that respect, parents are instrumental in providing the details about what appears to be only minor social awkwardness in the office but, in the real-world, manifests in the child being alienated. What appears to be minor rigidity in the office may, in actuality, be driving parents nuts with routines and compulsions that must be played-out to precision to avoid a tantrum, and on and on it goes. The ADOS, for example, focuses on what is happening in the office between the child and the practitioner; but that’s just one piece of the puzzle.
Children with mild autism are less likely to overtly hand-flap, toe-walk, or spin. They may demonstrate those behaviors but, if they do, they are likely easily diagnosed without confusion or misdiagnosis. In that respect, it’s tough to miss such blatant signs. However, more often these kiddo’s do not demonstrate those classic signs of autism but, rather, are obsessive; they tend to fixate on a particular interest, fear, need for reassurance, or change in routine. They may also be quite particular (everything needs to be in a particular place), be routine-oriented, rule-oriented, and sensory sensitive.
Parents see their child from birth to the day of the evaluation. It’s not uncommon that peculiar behaviors and tendencies, seen every day, become mundane and not so peculiar. Also, it’s often easy to explain-away these behaviors and find alternative rationales, especially if a practitioner also provides an alternative diagnosis. Consequently, my heart goes out to parents who are often annoyed, confused, and understandably skeptical when told different things, and provided different diagnoses about their child by different practitioners. My goal is to conduct a very thorough evaluation, with a detailed history and understanding of the current behavior and explain my findings with such detail that it’s easy to comprehend and accept.
I hope that explanation helps to some extent to explain the process, variables, challenges, and reasons for false-negatives. You can always email me at jcarosso@cpcwecare.com with any questions about your specific concerns or questions; never hesitate to do so. God bless you.
Next, we talk about treatment of mild autism.
Written by Dr. John Carosso
You get into an argument with your spouse. You know your point is valid but you’re having trouble getting your mate to acknowledge your view; instead, he just wants to “move on” and “forget about it.” So, he tries to change the subject and you’re left feeling unheard and misunderstood. You’re simply not ready to “move on” and you feel ‘stuck’ and frustrated. As you’re stewing over the problem, you think that, if only your point of view was acknowledged, even in disagreement, you’d feel more at-ease and prepared to move-on. Well, the same thing happens every time you want to “move on” past your child’s disappointment, frustration, anger, or problem.
Okay, here’s the scenario: your child complains that he does not want to stop playing that new video game, you just purchased for him, to empty the trash. You abruptly respond, in irritated fashion, for him to follow your direction “NOW” and ignore his obvious frustration. Okay, I know what you’re thinking; there are situations when there is simply no time for discussing the matter; nevertheless, you may find that, just as with your prior argument with your spouse, that a simple ‘reflective’ comment, acknowledging your child’s feelings, would help him to more quickly move beyond his feelings and carry-out the assigned task. For example, a comment such as “I understand it’s frustrating to be taken away from your new game. After you finish the chore you can return to playing” may prove to be quite helpful. Feeling ‘heard’ is extraordinarily powerful; it bolsters a sense of comfort and then allows for moving beyond, and past, the problem at hand.
Otherwise, we tend to feel ‘stuck’ in the argument. Reflective listening is vital in all relationships, for topics that are both positive (“I’m so happy for your accomplishment, you worked so hard…”) and negative (“you’re feeling sad that your friend didn’t show-up, that can be disappointing”). In regards to this latter situation regarding the friend not showing up, the child will sense his feelings were acknowledged and more likely be willing to move forward to problem-solving, e.g. “why don’t you call your friend Timothy and see if he wants to come over instead.” In the absence of reflective listening, there is a tendency for your child to become argumentative (“I’m not calling Timmy, I wanted Jim to be here…”).
You can more readily avoid such conflicts with your child, and with any other person in your life, by listening for, and acknowledging, their feelings. Try it; you may find yourself feeling happier too. God bless.
Written by Dr. John Carosso
How many of you can relate to the dismay of darkness settling-in as early as 5:00 pm? I know it gets me down in the dumps. For some, however, it’s more than just feeling somewhat ‘blue’ in mood; some struggle with severe bouts of depression during this time of year, known as ‘Seasonal Affective Disorder’ (SAD). This depression differs from it’s more typical counterpart in that the onset is rather predictable, usually around September or October, and corresponds with the shortening of daylight.
As would be expected, depends on where you live. If you’re lucky enough to live in the cold Northern regions, rates go as high as 20%, but as low as 2% in brighter climates. Oh well, guess that’s bad news for all of us here in Pennsylvania.
This is not an adult-only malady. SAD usually begins in the teen years and strikes girls four times more than boys. Interestingly, teens born in the Spring or Summer are more likely to suffer from SAD than those born in the colder months. Not sure why, but may be because of how a child is light-programmed from early-on their life.
Well, short of moving to Florida where it's still dark but at least it's warm and not so cloudy, treatment involves the systematic use of light. Guess this makes sense given the problem is based in lack of light. The ‘phototherapy’ involves sitting briefly in front of box that emits intense light, or the use of a Dawn Simulator; both are quite effective as well as traditional cognitive-behavioral talk therapy, and medication.
If you’re feeling down, lacking in motivation, and blah in mood, or you notice your kids being exceptionally moody or agitated during the Fall and Winter months, then please do not hesitate to get help. You can reach me at jcarosso@cpcwecare.com or call 412-372-8000. You can find out more about SAD in an article on the e-Edition of the Exponent Telegram where I was interviewed about this form of depression. Check it out at www.exponent-telegram.com
God bless.
During this very special time of year, in what has become a tradition, I am happy to re-post this special Christmas message. Here's wishing you and your kiddos a wonderful and blessed Christmas Holiday.
As a psychologist, I’m expected to talk about traditional and clinically-relevant approaches to help kids, and parents, work through difficulties. This of course would include helping people to think in more reasonable ways (cognitive therapy), behave in ways that are productive and healthy (behavioral approaches), be emphatic (Rogerian techniques), stay in-the-moment (Gestalt), incorporate the family (systems approach), and use praise in systematic ways (Applied Behavioral Analysis).
Well, yes there is. I’m usually not expected to discuss spiritual options but, in some cases, it’s like watching somebody drown and tossing a small life preserver when I have ready access to a large life-boat. Don’t get me wrong, the life-preserver is effective but, well, wouldn’t you rather be in a boat?
During this Christmas season, it seems fitting to offer a reminder that God gave His Son not only to rescue us from sin, but also to rescue us from ourselves and, in the process, heal us, soothe us, and relieve us during our times of stress, burden, and strife. Think about it, in Scripture, He’s referred to as our Advocate, the Almighty, All in All, Breath of Life, Comforter, Counselor, Cornerstone, Creator, God Who Sees Me, Goodness, Guide, Hiding Place, Hope, Intercessor, Keeper, Leader, Life, Light of the World, Living Water, Loving Kindness, Maker, Mediator, Our Peace, Physician, Portion, Potter, Teacher, Refuge, Rewarder, Rock, Servant, Shade, Shield, Song, Stone, Stronghold, Strength, Strong Tower, Truth, Wisdom, and Wonderful to cite just a few of His names. Hmmm, I wonder if maybe God is trying to tell us something about turning to Him for help?
Those strategies I cited above (cognitive-behavioral…) are undoubtedly worthwhile and helpful. God gives people like me lots of ways to help and give relief (not to mention that most of those strategies have a basis in Scripture). However, there is something quite powerful and life-changing about tapping directly into the Source (another one of His names, by the way). Give it a try, what have you got to lose? May God deeply bless you and yours during this Christmas season. I’d love to hear your comments at: jcarosso@cpcwecare.com
