Bringing out the best: the challenges and rewards of working with autistic clients

Most of us are familiar with shouting out verbal instructions to clients during aerobic routines, or quietly coaching during weight training exercises. We watch clients comply (or attempt to). But we get a cold splash of water in the face when dealing with a population with a disorder which makes them unable to follow instructions, or relate to other people on any standard level. The disorder is known as autism, and it is one of the most disabling of the developmental disabilities. It afflicts thousands of individuals, and is being diagnosed more commonly.

The Disorder

Autism was first diagnosed in the first half of the 20th century. From birth, or within the first 18 months of life, pervasive developmental difficulties are noted in children with autism. Although tremendous levels of individual variation are seen with the disorder, some of the most common characteristics include the following.

* The individual, despite having normal vision and hearing, may be so unresponsive to the environment that adults fear he or she is blind and deaf.

* The individual may engage in repetitive behavior, such as body rocking or hand flapping, for several hours at a time. This is called "perseverative" behavior. In extreme cases, it may take the form of self-abuse. The individual engages in tissue damaging biting, hitting or tearing of their own skin and hair.

* Up to half of autistic individuals do not develop spoken language without intensive training. Most of the rest merely repeat previously heard statements, behavior known as "echolalia." Even for those who learn to talk, oddities of speech such as pronoun reversal (e.g., using "I" for "you", or perseveration on an irrelevant topic (e.g., endless talk regarding a television program), may be displayed.

* The individual may be oblivious to dangerous situations, and engage in potentially lethal behavior such as wandering into traffic.

* Individuals with autism often score in the retarded range on IQ tests, probably because of an inability to take exams rather than any real intellectual deficit. The Rain Man persona of savantism (having a special skill such as counting or memory) is rare among people with autism.

* There are no physical abnormalities associated with autism. An individual with autism cannot be diagnosed based on anything but his/her behavior.

What to Do

Applied behavior analysis has made great strides in the treatment of autism. Data indicate up to half of autistic individuals can learn to become indistinguishable from anyone else in the population, provided they have help early in life.

Due to the particular behaviors associated with the disorder, individuals with autism rarely get enough exercise and may not have a healthy diet. The procedures of behavior analysis were designed for teaching language and appropriate interaction, and decreasing problems such as self-injury. They can also be applied to fitness.

Bill's Story

Bill is an autistic man in his early 20s. He is described as "moderately functioning." He had a history of self-abusive behavior, including smashing himself in the face widh his fists. His speech consisted largely of echolalia. Bill was in poor physical condition. Taking the stairs rather than the elevator to his apartment left him out of breath, sweating and panting. His strength was below average for his body weight, and he had low muscle tone. To address these difficulties, Bill and I attended a local YMCA equipped with a pool, weight room and track. We embarked on a combination of weight and aerobic training.

The first obstacle to overcome was Bill's unwillingness to try new activities. Another common characteristic of autism is a desire for sameness. Bill would engage in what is known as "avoidance" behavior, or staying away from undesired locations or activities. His avoidance behavior included vomiting, hitting his face, screaming and feigning injury. Avoidance behavior has to be ignored and worked through, thereby "extinguishing" the behavior. An extinction burst in which the behavior gets temporarily worse before it gets better is common. It is important not to give in during extinction bursts because the behavior that "works" will be what is displayed in the future. If you give in to an extinction burst, that's the behavior that will be displayed every time he or she wants to put you off.

In order to encourage Bill to try new activities, incentives were offered. Such rewards, called "reinforcers," can take many forms. At first, food and soda were the only effective reinforcers. Gradually, praise, "high fives" and the opportunity to engage in more favored activities became effective.

Individuals with autism may not be capable of appropriately following verbal cues or gestural instructions ("models"). This is a behavior chat must be learned. Therefore, the trainer must use a behavioral technique known as "shaping." Shaping is accomplished by reinforcing a crude approximation to a desired behavior, then reinforcing closer approximations until the behavior is correctly performed. Special care must be taken not to allow or reinforce dangerous approximations to a desired exercise. Begin with exercises and weight levels where slightly improper execution will not be dangerous. Safety must always be key.

Behavior analysis of personal training, particularly with the autistic population, requires writing detailed plans. These plans must state how the behavior is to be accomplished. Your client may not always understand what you mean when you give instructions. Don't count on your client being able to remind you if you've forgotten a step in the breakdown of an exercise or a "task analysis."

Sample Task Analysis: Bench Dip

1. Place two flat benches approximately leg length from each other.

2. Sit on one of the benches and place hands, palms down and approximately shoulder length apart, on the near edge of the bench you are sitting on. Fingers should grip the bench you are sitting on, knuckles facing the opposite bench.

3. Rest heels comfortably on the bench opposite you.

4. Slowly lift your buttocks off the bench you are sitting on by straightening your arms.

5. Bend your arms and slowly lower your buttocks until you nearly touch the floor.

6. Straighten your arms to raise buttocks until they are level with the benches.

7. Repeat steps 5 and 6 for the desired number of repetitions. When the exercise becomes too easy, you may try placing a barbell plate on the thighs. Have a spotter add the plate between steps 3 and 4 of the task analysis.

A behavioral goal needs to be explicitly written. It must include the following.

* A description of the behavior to be performed.

* The amount of behavior that must be performed.

* When and where the behavior will be performed. For example, "Run three miles at the track after work on Friday evening" specifies the behavior, how much of the behavior, and when and where it will occur. It's also useful to indicate the reinforcer that will follow completion of the goal.

A behavioral goal must be written in concrete terms. The best way to know if you're being concrete is to figure out whether or not the description calls for the body to move through space. "Will run for 20 minutes is part of a well-written behavioral goal. "Will try to get to the gym" is not.

For Bill, it was necessary to have weight training and aerobic goals. For the latter, more general goals were appropriate. Using what is known as "changing criteria," Bill increased the number of minutes he engaged in appropriate aerobic activity (e.g., riding his stationary bike or kicking in the pool). His aerobic goals changed in several gradual steps from, "Bill will ride his stationary bike at 70% of his maximum heart rate for eight minutes on Sunday, Tuesday and Friday evenings, and then will receive a diet soda," to "Bill will ride his stationary bike at 70% of his maximum for 20 minutes on Sunday, Tuesday and Friday evenings, and then will receive his choice of a diet soda, video or alone time."

Following the program, Bill had more than doubled his strength in all but one of his weight exercises. He was bicycling for up to a half hour at a time without becoming winded. The opportunity to engage in exercise became a reinforcer.

Choosing reinforcers is a crucial step in ensuring goal adherence. There are several types of reinforcers.

* Primary reinforcers are consequences that make the client more likely to engage in that same behavior in the future. They don't need to learn to appreciate these reinforcers because they are inborn.

* Secondary reinforcers are behaviors clients have learned to appreciate because they were paired with primary reinforcement in the past.

* Generalized reinforcers are secondary reinforcers that can be "traded in" for primary reinforcers. This often takes the form of a "token economy" with points being earned that can be traded in for items from a "menu".

You can construct a list called the "Premack hierarchy" after observing how much time an individual spends participating in activities. The activities engaged in most often are highest on the list, and those that are engaged in least often lowest on the list. The Premack hierarchy uses activities higher on the list as reinforcers for activities that are lower on the list.

"Satiation" occurs when a reinforcer is no longer effective because the individual has grown tired of it. This is most common with primary reinforcers like food. Have lots of different reinforcers available.

The most important thing to keep in mind about reinforcers is their individual nature. Never assume that what is a reinforcer for one person will be for the next, or that what is a reinforcer during one session or in one situation will be again.

Behavior analysis requires us to adopt a particular way of looking at the world. Aspects of behavior analytic thinking include the following.

* Determinism

All behavior occurs for a reason. It is governed by laws that are discoverable and useful in changing behavior.

* Treating individuals as single subjects.

Each client is a new case, and compared to his or her own past performance rather than that of another individual.

* Graphing and feedback.

Data are constantly graphed because the subject matter is a socially rather than statistically significant behavior change. This change should be easily visible on a linear, time-series graph.

* Emphasizing reinforcers rather than punishers.

Punishers lead to avoidance, counter-aggression and failure to learn what to do instead of merely what not to do.

* Observable behavior.

The focus is on behavior that can be seen and will be relevant to fitness goals. Focusing on anything else, such as plans that do not allow you to constantly measure progress, or even appropriate "attitude," can be distracting.

* Focusing on the here and now.

Concentrate on the variables currently maintaining behavior, and not on things that happened in the distant past.

* Placing emphasis on learning theory.

The principles of behavior analysis are based on the laws of operant conditioning, classical conditioning, modeling and verbal instructions ("rule-governed behavior").

* Using specific criteria.

Behavior to be performed, how much and under what circumstances, is always set before-hand.

* Internal and global states (e.g. "laziness") are not used as explanations for behavior.

A search is made for environmental factors controlling behavior. If a client is not making progress, the instructor examines the teaching program rather than the client.

* Behavior analysis is not manipulative.

All techniques are discussed with clients.

Working with individuals who are autistic can be frustrating, but it is rewarding. While behavior analysis requires us to learn to think differently about our discipline, it can be effective. Its principles and techniques can be used with any population.

While anyone can learn and effectively use applied behavior analysis techniques and principles, please heed one word of caution. Keep in mind that you should not use your knowledge of behavior analysis to play the role of an experienced analyst.

As an AFAA certified personal trainer and continuing education provider, Bobby Newman, PhD., is also a behavior analyst specializing in early interventions for children with autism. He is on staff with the Wellness Institute of Long Island, and co-founder of the Room to Grow agency, providing behavioral services to the autistic. Bobby can be reached at Orca Dragon Kenpo, Suite 346, 38-11 Ditmars Blvd., Astoria, NY 11105. Vanetta DeSanto and Lori Reeve, Ph.D., are AFAA certified personal trainers.

COPYRIGHT 1997 Aerobics and Fitness Association of America
COPYRIGHT 2004 Gale Group