By Dr. Anthony Hollander

I hope that you didn’t just give in to the dog days of summer as soon as school let out. I know, worry about summer camp, supervision, kid’s activity schedule, vacation, family activities, etc. All of these thoughts tend to get into the way of effective planning for September. Please don’t let the start of school in September be the first step in a wasted academic year. I have constructed some thoughts about what to do right away in September to make sure that everything gets going in a productive direction from the get go.

You have an IEP, you sat there, listened, participated, contributed, and now it’s September and the IEP is the plan for the school year. The sooner you and the school ensure that the anticipated progress is, in fact, actualized the better.

Are you sure that everyone that will be working with your child really knows the child? This is especially critical if the child attends anything in a “mainstream” or “inclusion” setting. Personnel need to know the IEP and the accommodation. All staff have to sign a paper that specifically states that they have been prepared to work with your child. Often times, with all of the confusion on the school’s part, people tend to blend one child with others, and the subtleties of the uniqueness of your child becomes lost.

It is important for you to know, and keep in mind, that there are only two reasons to learn anything in life. We learn some things because we intuitively learn/know the benefit, and the benefit is highly desired. We learn by approach. In this process, learning to tie one’s own shoes leads to/is associated with something that is highly desired. Motivation and incentive leads the child to approach the process. In other cases, we learn something because we intuitively know that if we don’t learn it, life will be quite unpleasant at the least. We learn by avoid. In this process, we will never get to play with the computer, or DVDs, or get the caregiver to go away if we don’t learn this shoe tie process. We learn how to tie shoes only so that we can eventually avoid the unpleasantness of not having what we really wanted in the first place. In this case, nagging is really okay, as long as stopping the nag is always associated with the learning of the process. When you look at all of the various systems of instruction, each one is simply a method of either learn by approach, or learn by avoid.

What follows, is a very quick overview of methods. Take, for example, the goal/objective that your child will learn to tie his/her own shoes. The first question is “what methodological teaching approach will be used to teach my child how to tie shoes?” When you think of this simple question there are all kinds of ways to answer. Here are a few to consider: behavioral; cognitive behavioral, humanistic, TEAACH, Floor Time, developmental modeling, rehabilitative, and on-and-on it goes.
The behavioral method employs a system of proactive and reactive methods for the various parts or steps of shoe tie. Cuing (prompts) systems, data-based, task analysis, all combine here to develop a method of steps for the teacher, or a protocol. The protocol is measured, progress is charted, changes are made based upon a coupled of weeks of using the method.

The cognitive behavioral method (CBT) employs similar procedures, but the onus of performance is put onto the child. The child knows that this particular skill means a great deal to his/her level of independence in their daily routine. The sooner the skill is mastered, and maintained, the more independence the child has to make other kinds of decisions. Here in CBT, there is a semblance of a contract/agreement that the child will learn this new skill.

Lack of follow through by the child has immediate consequences based upon the data derived from the performance. In CBT the child is part of the decision-making process. It is important to note here that using either bribes and/or threats is really not a part of the overall process in these methods. So, if people are using bribes and threats (some call this the “grandmother rule” but it is really the Premack Principle out of learning theory - and was never used as either a bribe or threat) this is usually a clue that the method is not working very well.

The humanistic approach tries to develop incentive/motivation by looking at the child’s needs systems. This process is often confused with aspects of incentives/motivation, but it really is a different process. Children on the spectrum simply do not know how to belong. Having your shoes tied will facilitate being like the others, and lead to fitting in. This process has been shown to be somewhat effective with a more neuro-typical child than a child on the lower functioning end of the spectrum.

The TEAACH process, which I often refer to as the Montessori of Autism Spectrum Disorder treatment, is really nothing more that allowing the child to find something quite interesting, and then associate that high level of interest with less interesting things/curricula.

Floor Time, just like I had predicted in the opening of this column, is another veiled learn by avoid approach. In this process the child finds something highly desirable. Then, that item is removed putting the child into a high incentive mode to earn back that item. The high incentive is associated with the performance of a new skill, which then leads to getting back the desired object. Again, learn by avoid paradigm.

The developmental model is based upon the concepts of developmental milestones. Everything is done in a step by step process. Shoe tying could mean learning to identify the end of the lace, or right and left, or all kinds of other concepts prior to even trying to tie one’s own shoe. The developmental method has shown to be a very cumbersome, lengthy, time consuming method. Plus, we already know that these kids can learn all sorts of stuff without having to learn basic concept labels for everything prior to doing the process. Another type of developmental method is that of modeling. However, with modeling you use another child to show the child how to tie shoes. Or you give all of this attention and good stuff to the child that ties the shoes, and the child that can’t tie sees this, and thus, learn by approach sets in, and the child wants to learn how to tie his/her shoes.

The rehabilitative method of teaching is one that a lot of people gravitate to without even thinking about skill development. You want your child to tie his/her shoes on their own.
What?!? Are you nuts? Why go through all of that when there already exists Velcro and elastic laces that are always tied. Forever! This method relies on inventing, or providing adaptive devices to substitute for the problem.

The parents need to know the method of teaching that will be employed with the child. The parents also need to know what system of measurement will be employed by the team. Make sure that the measures being employed actually fit the goal/behavior that is being addressed. Many times I find that the goal being worked on does not have a true measure, or that the measure is wrong for the behavior. The parents need to know how frequently the measures will be analyzed to determine the relative effectiveness of the method. Remember, just because something may appear to be working, that appearance may be faulty, and that there still may be another method that will speed up the progress. The parents also need to know the system to be used at home as part of the home program.

At this point, you may be a bit overwhelmed with the oversight expectations. The fact is that once you start off on the right way, it makes everything much easier over time, and the resulting progress will soon over-shadow the effort of coordination on your part.

A Change for the Better

By Dr. Anthony Hollander

The No Child Left Behind legislation, coupled with the revised Individuals With Disabilities Education Act, and Response to Intervention have created a climate of change. Let’s all hope that this climate promotes constructive changes for everyone.
There are several issues about these new Federal and State initiatives that are eliciting both cheers and fears. We have to recognize that the teacher is the hub of the entire process.

So, a great deal of pressure can be brought to bear on the teacher if we do not practice careful forethought. At this point, teachers are responsible for a tremendous balancing act: keeping the state/school curriculum going for each child; working on the IEP goals for each child; incorporating the goals and objectives of the various special services into the classroom; and employing both classroom management and individual behavior intervention plans for children in the classroom. This is a major undertaking. In my experience, some teachers are just not ready for this responsibility and need help in terms of training and supervision in order to get on top of this process. I know of one teacher who simply dropped most of the goals on last year’s IEP, having never been met, and created a brand new IEP with a drastic cut in the total number of goals/objectives for next year. The family thinks this was done to get out of being more responsible. I, being the perpetual optimist, am hopeful that this was done in order to be more effective with the child. Only time will tell.

Parents, due to multiple factors, are becoming much more demanding, more aware, and better able to represent/advocate for their child at EI-IFSP, CPSE and CSE meetings. The parents are asking—sometimes in a more abrasive manner than we would like—questions about the issues surrounding the goals/objectives, methods/process, measurement of outcomes, and documentation to see such measures at the time of meetings.

All professionals, but especially the teachers, are now being required to create and maintain folders on each of their children that contain samples of work from each of the stated IEP goals, that clearly show the learning, or lack thereof, on the part of the child. This is a pretty big job and will require some extra effort on the part of the teacher and the classroom staff. The upside of this is objective documentation about the child’s performance. In the past, I have called for cleaning up IEPs. They are both too lengthy and vague. Goals are not written in behavioral terms, and the methods and measures associated with the goals are frequently unattainable due to the lack of clarity of the goals. For example, how does one really measure the percentage or level of mastery of a particular goal? Pick any one goal at random. Ask yourself, “what is the actual method of attaining this goal?” How is the material being presented to the child in a measurable manner (by “measurable” I mean how do we measure both the child’s response to the materials, and the teacher’s input into the process). By simply reducing the numbers of goals on the IEP, looking for the most important skills/concepts that will subsequently enable the child to move forward, we can eliminate a lot of extra work. By looking at what we do in order to teach the child, and how this process can be objectified for each student, should also speed up learning, and hopefully retention of learned information, and promote better learning for the future.

Along with all of the data-based, objective information being required in the classroom, there is a carryover into all of the other school-related services being provided. Of particular concern is the area of Parent Training and Counseling services.

What is the intent of Parent Training and Counseling? The laws were written to provide services that teach the family how to better work with their own child. Yet, I know of families that think they should have all kinds of services even though the child does not represent a major danger to self or others in the home/community. Having a child on the spectrum does not guarantee that unlimited services are to be provided in the home. We are about to see increased objectification of the process surrounding home services. With that comes increased attention to developing profiles about the child’s behavior in the home.

The family is being considered “parents as partners” in the process. The family trainer is there to get the family to function as independently as possible; they are not there to move in with the family for the rest of the child’s life in school. Home services will now come under the exact same scrutiny as those services in the school setting. What are the qualifications of the person(s) going into the home? Who has the ultimate responsibility for oversight of that person? What kind of supervision should this person have? What kinds of goals/objectives are being worked on in the home? Who has developed those goals/objectives? Where are the measures of those goals/objectives? How can we determine to what extent home services should or should not be provided? These are all tough but necessary questions that need to be answered and objectified for everyone’s benefit.

As a person who has been around for some years, I have gone through the entire change process at multiple points. I have been through the institutional years, all of the many crises in health care for individuals on the spectrum, all of the decision-making pursuant to why we need to change, development and implementation of the first State Plan and PL 94-142, and the changes associated with determining what the best methods of treatment/teaching, and all that has led us to the place we are today.

In my opinion, we are at a major crossroads in terms of quality of care. I truly believe that what is being required is the right stuff, albeit difficult, frustrating and laborious. I sincerely feel that changes are taking place in best practice issues that are showing up in more kids in district-based schools, actual jobs, better trained personnel, and many more successful outcomes for the child, the family, and the professional community as well. All of this leads to a better future. I, for one, remain both totally committed to the implementation of these changes, and optimistic for the future.

What does this term mean to you, me and our community?

By Dr. Anthony C. Hollander

Over the past couple of weeks, I seem to have been inundated with families and school administrators/teachers who are using the phrase “that’s totally unacceptable” when discussing a certain type(s) of stereotypic behavior(s) of their child.

Some recent examples: one child refuses to be wiped clean after a bowel movement; another child, who smears feces at night despite being put into a one-piece, zipper in the back, full body suit when being put to bed; another child enters into a fast food establishment and immediately steals food from other patrons.

So, just what does the phrase “totally unacceptable” really mean? It might mean that the child has just performed a behavior that is a direct confrontation to the values of the family/community. It may also mean that the child just performed a behavior that has reached the limit of tolerance of the family/setting. It may reflect an undercurrent of thinking on the part of the family/community to ultimately provide enough logic to consider placing the child into a more restrictive setting. To me, as a provider, it reflects a total lack of appreciation for the priority of specific needs of that family/community setting.

When providers are confronted by a challenge that also confronts their own values, likes, dislikes, and shakes the very foundation of their own limits of tolerance, someone needs to step in and take charge to try to change the aberrant behavior. Issues of personal hygiene, human sexuality, overt aggression/destruction, and a seemingly total disregard for other people’s values places a real challenge to the limits of energy on the part of the family/community. Some blame for this lack of responsiveness to these issues can be placed on imagined and real legal issues. Does Part 200 of the Regulations really say that you can not touch a child? No. Does Part 200 of the Regulations really say that you must always use Positive Behavioral Support Behavior Intervention Plans? No.

I just read an article in which a father was being interviewed and stated that he found his wife in a total breakdown situation—crying hysterically—upon returning home from work. When he inquired why, the wife explained that the daughter did something “totally unacceptable” and the mother told the child “time out” and tried to send her to her room. The child, in turn, told the mother that she would not go to time out, and, if the mother tried to force her then the child would call 911 and report the mother for child abuse. Clearly, this situation is now “totally unacceptable.” Dad then went to talk to/confront the child himself. The child was playing on the computer. As soon as dad began the conversation, the child reiterated her statement about no time out, and that she will call 911 if her father tried to force her into time out. With that, dad unplugged the computer and threw it out the window. He then turned to the child and said that her TV would be next. The girl apologized to both mom and dad, and went to her room for time out.

Do we, like doctors have recently done, need to train a specific brand of therapists called “interventionists” who are able to work with any situation—especially those situations that others will not do? Do we need to invent a totally new set of behavioral plans that are specific to these types of totally unacceptable situations? No, we already have such intervention strategies. What we don’t have is the steadfastness to carry these strategies to their end.

How many of us would be willing to toss the computer out the window? Not many, I guess. The situation then leads to some sort of threat, or bribe, instead of a real consequence. In the case above about the computer, the father simply stated that he did not provide these toys for the child in order to get more disrespect from the child. So he eliminated the competition. This is called a Response Cost Paradigm.

In fact, such a consequence is part of the Token Economy Process. However, most people only use the Response Gain Paradigm (where the child can earn token, but never lose them due to totally unacceptable behavior). Okay, so don’t throw the computer out the window, but, put the computer into a safe place until earned back. But, what about the use of the computer for school work? Use the computer at school, or the public library. What about the use of the computer by other people in the house? Well, this could be a major sacrifice for the family, that, when effective, will bring about a much more satisfying state of affairs. If you let these arguments get in the way, then the impact of the consequence becomes watered down to being ineffective.

When you hear yourself using more and more threats, and more and more bribes due to increased frequency/intensity/duration/rate of totally unacceptable behavior, then you are at a loss with regard to effective consequences. If you are at a loss for effective interventions/strategies, then you need someone to help you out at home. The person for the home has to be ready, willing, and able to work with the totally unacceptable behavior in order to establish a plan, demonstrate the plan, and ultimately supervise the family in the effective use/implementation of the plan totally independent of the therapist. The family/community should not look upon the therapist as a new member of the family/community specifically dedicated to any and all totally unacceptable behavior that might occur.

Another important element to these totally unacceptable behaviors is the timing of the behavior. An over-correction positive practice session prior to bedtime will enable the child to void prior to going to bed. Okay, yes, this could take a long time, at a time when everyone is tired. The length of time taken should lessen with practice, and the end result, a cleaner house, would be well worth the energy expenditure. But, what about the sensory need to play with feces?

Well, perhaps the child could earn the opportunity to play with an appropriate, age/stage substitute form of expression? You know, like non-toxic finger paints. Make sure that the mess associated with play does not become another totally unacceptable form of behavior. Another element of this timing issue could be something like this: Everyone wants fast food, so everyone goes for fast food, and the totally unacceptable behavior takes place. Why not a few dry run, treatment sessions of going for fast food first?

Why does the totally unacceptable behavior have to impact everyone else in the family/community? Why not isolate the behavior, and do several practice runs, with built in consequences (e.g., as soon as the impulsive behavior sets in, the stolen food is taken away from the child, a token is removed from the child’s pocket, and the child goes back to the car for a time out session, coupled with a task to perform in order to earn a token that enables the child to try again). Once the child can perform the sequence of events that are expected, then it is time for the entire family/community to attempt the trip.

Totally unacceptable is totally changeable with an effective intervention strategy. Don’t lose your inner-strength and conviction.

P.S. Did everyone happen to see the Autism Speaks logo and name on the back of the pace car at the Daytona 500 NASCAR race? I wonder how much that cost? I wonder how much good that did for the overall cause/mission of Autism Speaks, and families all over the world that have donated that money?

A deeper look into the process of a better prognosis

By Dr. Anthony C. Hollander

As we look deeper into the process of working with children who have autism spectrum disorders, there are several truths that emerge:

1. The sooner you begin, age-wise, the better the prognosis;
2. The sooner you get language, age-wise, the better the prognosis;
3. The more structured you are, the better the prognosis;
4. The sooner you get compliance to cues/prompts/instructions, the better the prognosis;
5. The sooner you get the child to look for alternatives to solve problems, the better the prognosis;
6. The sooner you get the problematic behaviors under control, the better the prognosis;
7. The sooner you desensitize the child to new situations, events, foods, people, the better the prognosis;
8. The sooner you discover a durable, long lasting, effective reinforcer, the better the prognosis;
9. The sooner you get basic social skills under control, the better the prognosis.

How about another truth? How about the truth that as soon as you are able to put all of this stuff together into one, systematic, understandable, doable approach—one that attempts to work on all of the above using a data-based approach—the better the prognosis. And the better the sanity for everyone involved.

What I am referring to here is a therapeutic frame of reference (FOR). A systematic, recipe, or formula, if you will, of how to go about meeting the above truths. I know, I know, no need to jump up and down back there. Yes, Applied Behavior Analysis (ABA) is one such structured systematic approach. However, as I go from school to school, and observe these newly designed ABA classrooms I am constantly amazed at what people are calling ABA. Before I go off on one of my tangents, let me first say to those non-ABA folks, I am more than aware of the many alternative “systems” that are out there. In fact, I often refer to myself as a “humanistic behaviorist.”

I was recently called in on a “very important, major case” at a school. The child in question is coming into district with a page-long list of things wrong with him! Not a single thing on the list had to do with his behavior. He has every kind of allergy you can imagine. In addition, he has immune system problems, sensory regulation problems, auditory processing problems, and on and on. This case is so important that a new nurse had to be hired just for the child. Obviously, the child’s diet was of vital importance, and where and how the child had snacks and lunch became major issues. I am not saying that there was no authenticity to this case, or that the case was really not as important as everyone has been led to believe. The staff at school from the principal down, really jumped into place, all sorts of controls were put into place, and every safeguard you can imagine was taken, including signs posted, and meetings with anyone who might come into contact with the child. On the second day of school, the family sent in a lunch for the child that included several items that were meant to be kept away. I was asked “how could this possibly happen?” Well, maybe the mother switched lunches with another sibling by mistake? Maybe the family was setting up the school for a test of their safeguards?

Once these items in the snack/lunch box were noticed, an urgent call to the home was placed. The mother reported to the teacher and nurse that she lets the child “cheat” every once in a while. After all, it was holiday season, all of the other children were going to be eating all sorts of goodies, and the mother didn’t want her son to feel totally left out of the new group. One would think that a system, especially one that emphasized a “medical” condition, would be much more rigid and structured. Now we have to have a system in place to replace the system in place in order to “cheat” every once-in-a-while.

On the one hand, this is an example of a major violation of the “system” that was put into place to help the child. While most systems are not marked as “urgent” or “medical,” it is equally frustrating to set up a system, and then find all of the problems with keeping the system running. Other concerns keeping the system afloat include holidays, sick days for both the kids and the staff, staff turnover, replacement/substitute teachers, and all kinds of little crises that take place from minute to minute.

So, okay, maybe I am being a bit unrealistic to think that the FOR is something that should be kept in place until the data proves that the system needs to be changed. However, just how many little issues should we allow to screw up the process? Is there a point at which the FOR is either bound for success, or bound for failure? Can these bumps in the road of a good system be meaningless bumps? In fact, a recent article was published that stated that most families are trying multiple types of interventions all at the same time, and not telling the various professionals they see about the other systems they put into place. In fact, someone recently told me that her theory is that no real system is in place for any kid, and we will never really know what is working and what is not working. To go a step further, this person hypothesized that if you got two kids that were basically identical in terms of skills and age, and one went off to a very “structured setting” while the other went to a facility that had to real system, there would be virtually no difference between the two kids 10 years later. Personally, I couldn’t disagree more with that hypothesis. We have come a long way since institutions.

Where does all of this leave us? Given all of the confusion and chaos surrounding what to do with these children we have to stop and think of the science and the truths. This information should give us a foundation and a basis from which to make subtle changes in the system. My advice? Use a system! It not only gives you a reference point, a clear picture of no progress, some progress, or major progress. And, the system by virtue of how it is set up, gives you clear actions to take in order to change the system when necessary. Good luck.

Recent advances aren’t all they say they are

By Dr. Anthony C. Hollander

I would first like to congratulate everyone at Autism United for their efforts, and the successful walk held recently at the Belmont Lake State Park here on Long Island, N.Y. This organization has a fresh look and mission into providing services and resources to families. The bringing together of people from all over the place on relatively short notice demonstrates the clear and present concern for the future of families and children with autism. On the other hand, however, it brings together people from a wide variety of philosophies, practices, and opinions having to do with etiological and treatment priorities. Although I really do enjoy such conversations and dialogues, it also brings out just how desperate for answers families have become.

I am totally flabbergasted at all of the “most recent advances” in early detection and diagnosis of autism, and all of the “advances in treatment” approaches to overcome the aspects of the nature of autism.

Before I get started, let me say that I truly believe that most people are really interested in helping both the families and the children themselves. There is, however, a growing population of individuals and groups that are simply preying on these families and children and making tons of money without providing the anticipated results—or research—to support their claims. Making such claims without producing the expected outcomes is just plain fraud.

One of the things that got to me is the recent news coverage of Autism Speaks’ new Web site that clearly shows the differences between a neuro-typical child and a child with early childhood autism. The claim is that these differences make for early recognition and diagnosis, and subsequently, better early intervention. I have to point out that the professional community is not all that supportive of these comparisons. For example, what about a child with a hearing deficit? What about a child with another type of congenital problem? Is responding to his/her name the most important criteria for such a diagnosis? Not so. The syndrome is just that, a series of behavioral and perceptual deficits that span the broad base of “typical developmental milestones” that ordinarily typifies normal growth and development. So let me immediately caution both parents and professionals to view these snippets with a great deal of awareness that deficits could mean several different areas of concerns, not just autism.

Another thing that has me completely baffled is the complete lack of objectivity that is so pervasive in the autism community. I simply find it incomprehensible that in this day and age, with all of the internet resources available to us, that the level of panic and despair, and the urgent need for answers, has led us to make decisions on the part of the child (I always hear, “in the best interest of the child”) based on little to no outcomes, efficacy, or solid research to support those decisions. I will give some examples.

At the walk I had the opportunity to talk with the manufacturer/salesperson of pencil grippers. I asked if there was any research to support the use of these grippers and was told that they are currently getting ready to conduct some research. I introduced myself (he never heard of me), and asked if I could see the protocol for the research. I also volunteered to look at the design and subsequent data to lend a hand in the interpretation of the results. He very politely gave me his card, a catalogue, and told me he would be in touch. Well, that was several weeks ago. Some time ago, with professional students and parents and kids involved in my office I did several demonstrations of the use of pencil grippers. I got all kinds of colors, shapes and sizes of the grippers, and even went out to a local stationary store and purchased all kinds of fat pens and mechanical pencils (even a very expensive Sanford PhD Gold Rollerball pen). For each child I worked with I placed this assortment on the table in front of the child. I gave the child a blank piece of paper with no direct instructions other than to “make something on the paper.”

Repeatedly, time and again, the child would try a variety but settle on a standard pencil or the standard mechanical pencil (they like to click the pencil). The theory is that if the gripper were naturalistically reinforcing, thus enabling the child to perform better, the child would select that pencil. Not the case. In another demonstration, I simply directed the child to use a gripper pencil, and requested that the child do a near point copy of a couple of simple words. I then asked the child to use the pencil of his/her choice, and copy a couple of other words of similar size and complexity. After this I graded the two sets of words looking for the following: “floaters” (letters that are supposed to be touching the bottom line, and were not), “sinkers” (letters that are supposed to stop at the bottom line, but went below the line), “errors of insertion” (where the child put in additional letters that did not belong), “errors of omission” (where the child simply left a letter or two out of the words), and, just to be a real pain, I graded the spaces between the words to see if they were adequate to see where one word ended and the next word began. Each child got a score for the gripper and a score for the non- gripper. Children that had fine motor planning issues, thus, very poor penmanship, did equally bad on both samples; no statistically significant differences between samples. I never published the results until now in this article.

Another thing that got me was a classroom observation I was asked to do. The child in question has ADHD and oppositional defiant disorder (ODD). “He is in constant motion,” I was told, and “never able to attend to accomplish anything.” There I am observing and taking data on the child. I am counting the number of cues given to the class by the teacher, the number of direct cues giving to the child (verbals, visuals, and tactiles), and I am coding the child’s response to cues in terms of correct or wrong. In addition, I am also counting the number of times the child volunteers an answer, calls out, gets out of seat, drops things on the floor, as well as some other things such as sitting next to classmates, etc. The child in question was given a pencil gripper (no comment necessary here) and a seat cushion. Now, the child is in pre-kindergarten, and, in case you might have forgotten, the seats in the room were very small. The cushion kept sliding off the seat, and the child was constantly trying to fix it; this made him look very hyperactive. The child, spontaneously, let the cushion fall to the floor. He sat down and was doing his work, when the classroom aide came over and instructed the child to put the seat cushion back on the seat. At this point the “hyperactivity” resumed. By the way, despite the “constant motion,” after two observations of the child, he had compliance ratios to cuing and spontaneous participation of 100 percent on day one and 82 percent on day two. Day two was the day with the seat cushion. Where is the research to support the use of the seat cushion I asked? Not available, I was told.

Stop being the victim of hearsay, opinions, and pressure to do something now. Be a better advocate for the child. Be a more informed consumer. If you are a professional, be more critical of yourself and what you are doing with the child, and saying to the parents. If you are a parent, be more critical of outcomes, and the desired expectations from the treatments being provided. Everyone should start going to various Web sites for more accurate information such as: www.Pedmed.org, www.Quackwatch.org, www.CDC.org, even www.webmd.org, or a Web site specific to the diagnosis of the child. Stay up to date on what is considered to be best practice guidelines. You would be shocked to hear how many people I run into who never heard about response to intervention!