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- [00:00]
A
Foreign.
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B
Hey, everybody. Welcome to ABA Inside Track, the podcast that's like reading in your car but safer. I'm your host, Robert Perry Cruz, and with me, as always, are my fabulous co hosts.
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A
Oh, hey there, Rob. It's me, Jackie McDonald, not Perry Cruise.
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C
Hi. And it's me, Diana Perry Crews.
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B
No, thank you.
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C
You know, how are you, Rob?
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B
I'm doing fine. Oh, do you have a set? You have a segue to start us?
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C
No. Well, only that Jackie and I have been walking down memory lane reading past transcripts, and we used to ask each
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D
other how we were.
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B
That's true.
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A
You know, we never do that anymore.
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B
Even that. We never just talk anymore.
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C
We don't talk.
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B
We don't just talk. We don't, like, sit and talk. Okay. So how. How are you guys? How are you all? Sorry.
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C
Fine. How are you?
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B
You know, we got some ice dam issues, so it's pretty, pretty cold. How about you, Jackie? How are you?
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A
You know, I am doing better than you all since I don't have a hole in my ceiling. So I'm winning over here.
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B
That's good.
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C
Yep.
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B
That is good.
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C
Totes. But guess what? We're not alone today. No, we have a guest.
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B
We do have a guest.
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D
I love that we're not alone today.
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B
Before we introduce the guests, we should make sure everyone knows this is not a home improvement podcast because that's the last you'll hear about the ceiling. It's a podcast about. Well, we'll see about behavior analysis and behavior analytic research, where every week we pick a topic and discuss it at length. And I don't believe we have, like, Bob Vila on. On the Line to talk about home improvement. We're talking about a much more relevant to our field topic, which is what we like to do here, and that is down syndrome and aba. And to do that, we have a very special guest who's written and. And practiced on the subject, Dr. Kathleen Feely. Kathleen, thank you so much for coming on the show today.
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D
You're welcome. Thank you for having me.
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B
So question number one. What do I do with this hole in my roof?
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A
Wait, on an aside.
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C
Ice dam. Ice dams.
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A
Right. As an aside, I do want you to know that I used to have a super crush on Bob Vila.
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C
That's right.
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A
Like, so bad. And so every Saturday morning, me and my dad would watch Bob Vila home improvement shows, but I would watch it because I thought he was so cute, and my dad would watch it for information. So there you go, young Jackie. And I also wanted to put out that this episode Was a Regis College graduate request?
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C
It was. Yes.
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A
Thank you, Morgan. Yeah, Morgan sent us an email and said, hey, everyone, now that Massachusetts allows us to bill insurance for behavior analytic therapy for people with down syndrome, what do I do? Where do I get the information? And so that is why we decided to do this episode, because we've not done it before and we don't know anything about it.
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B
Well, speak for yourself. I know a little bit, but not enough to do a whole episode. That's why we have Kathleen here. She's the expert. So, Kathleen, how did you become the expert? Please. We'd love to hear more about your professional journey.
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D
I started my career as a New York City Department of education classroom teacher. Very excited about that. One of my most proudest accomplishments. While I was teaching in New York City Department of Ed, I was working with many children who didn't speak. And they had a very, at the time, very progressive AAC program where they were giving students augmentative communication devices. And that was in the late 80s. So I. Yeah, I was 22, 23, and started looking into doctoral programs for AAC and in. I was in New York City area at the time and couldn't study in AAC in programs in the Northeast because it became. It was under speech pathology. But the Midwest was incredibly progressive in terms of letting you do cross study. So that in. At the University of Minnesota, where I actually ultimately went, you could be an education doctoral student, but study with individuals in communication disorders. So Dr. Joe Richley was there, and I interviewed with him over the telephone at the time and then flew out and. Yeah. Enrolled in the doctoral program at the University of Minnesota. And there are a lot of behavioral analysts there. So this was pre BCBA days, right?
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C
Yeah.
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D
And yeah, so my whole area of study was behavioral oriented, Although I don't ever think I took a course on applied behavior analysis. But my dissertation looked at generalization gradients in learners. So I think I'm a certified behavioral analyst, behavior analyst because of that.
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C
I always think about the rats. The rats, the noses. Right?
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A
Yeah.
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C
That's the generalization gradient, right? Yep.
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D
Yeah. And colors and. Or. And pigeons, where. Where pigeons tap when they're taught to tap red. Where they stop tapping was fascinating.
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C
It was.
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D
It was absolutely fascinating.
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C
And then.
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D
Yeah. So we did a study with preschoolers with intellectual disabilities looking at generalization gradients with requesting. So that was dissertation. I came back to New York and. And was really challenged by the extent to which we segregate children with disabilities, particularly in this region. It's mind boggling. It was in 1995 when I returned, and it continues to be really mind boggling. With that said, I opened a center. My colleague Colleen Fallon and I pursued a lot of external funding and have technical assistance centers, regional technical assistance centers from New York State Education Department to make change. That's what led me right here in the world of applied behavior analysis and down syndrome. I opened a program for young children with autism and then was asked by a gentleman to start to think about other populations on Long island that could benefit from applied behavior analysis. Decided on down syndrome, and here we are.
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C
Excellent.
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D
That was a lot. Right? Sorry.
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B
There was a second where I almost thought you were going to say I was going to get my doctoral dissertation in aac, but there was like a typo or something and it just put ABA instead and I just got stuck.
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D
No, I studied with a gentleman who was an applied behavior analyst and an AAC specialist. So.
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B
Yeah, beautiful. So I, I think, Kathleen, when we talk about working with different populations, different levels of competence, certainly I, I don't want to speak for Jackie and Diana, but, you know, when I started getting into the field and I started learning about behavior analysis, my knee jerk reaction was like, all human organisms will benefit from this. And I learned to do it with this population, therefore it's going to be true for everybody. But I think in, in looking at the works you have, and some of my own experiences, some of them by, you know, overgeneralizing what I thought I knew.
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C
Stimulus control.
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B
Yeah, that's not exactly the case. Would you mind. You know, I'd love to kind of start our conversation off by talking a little bit about some of the differences in terms of, you know, the behavioral phenotype that comes up in working with children with down syndrome that you sort of had to, you know, study more about or think about or put into your treatment plans. Because even though the principles are true to all humans, it doesn't mean that we can apply them exactly the same way across disability categories and expect the exact same results.
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D
Right. So key areas, definitely motivating operations. Really thinking about what you need to keep in mind when you're working with individuals with down syndrome. And that really goes into several areas, one being medical complications that kind of go hand in hand with down syndrome. So increased incidence of hearing impairment, visual impairment. Right. Cardiac issues that really are life threatening early on, so changes really the, I believe, the dynamics when you have a baby that has all of these issues and then they make it so sometimes it might change the way we interact with that child. Because of those confounding things, like it's a miracle that they survived. And so a little bit of that and then increased likelihood for upper respiratory infections. And a lot of this is just my decades of working with so many kids with down syndrome. Right. But, you know, getting a cold and having it for a long time, so not necessarily just coming and going within a week, but kind of lingering. So all of those things play into how effective your treatment's going to be and how impactful your reinforcers are. So definitely keeping in mind medications that they're on, low muscle tone, the intestines are a muscle. Right. So you might not have regular bowel movements. And that's going to impact kids. So. So that's one whole piece. That whole medical. There's medical practice guidelines that anyone who works with children with down syndrome should really take a very good look at. So that's one area. And then it's that behavioral phenotype that increased likelihood of desiring attention and just wanting lots and lots of attention. And we've known that forever about kids with down syndrome, how social they are and a social strength. So when you're thinking about reinforcers, pairing them up with the social reinforcer is probably going to be really impactful. Also, strong desire to escape difficult tasks. They're not going at a task the way a typical learner would, even in very young ages, avoiding things that are just slightly more difficult. What seems could be just this easy thing to ask a student, if the student has down syndrome, it might be a little bit more difficult and therefore they may react quite drastically because the. Yeah. So the value to escape that activity is really high. So, yeah, I think those are the ways that we should. What we should know about down syndrome before we try to, you know, change a lot about them.
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B
I think, Kelly, one of the things I'm always struck by when either I'm speaking to individuals who either work with individuals with down syndrome or parents of children with down syndrome, or. Or when I've sort of read up on. On various materials I sent, is how it seems just everyone's kind of fast and loose with referring to kids with down syndrome as, oh, they're stubborn, they're so stubborn. Is. Is that just one of those weird social. Like it's just been allowed for so long or it's just such a part of the behavioral phenotype that everyone kind of just shrugs and. And uses that term? Or is that just something that's kind of falling out of the. Out. Out of favor? Because I know it was mentioned in the studies as like this keeps coming up and you put it in quotes because it's not the, you know, it's not great to refer to any group as any sort of type. But I just was sort of struck by that as is it because it's, you know, because there's a chromosomal piece to some of this that people feel more comfortable throwing these wide net descriptor terms.
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D
So probably. Right. And it's probably been there as long as, you know, down syndrome has been called down syndrome based on Langdon Down's observation of individuals and identifying a whole bunch of kids that looked the same and also said they acted the same. So I think it's just this long history of doing that. There's also in individual students a long history of getting a lot of social attention for being non compliant.
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C
Right.
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D
Because if you ask me to do something and you walk away, well, if I throw myself on the floor and stamp my feet, then chances are you're going to come back, you're going to look at me, you're going to bend down, you're going to coax me up, you're going, going to maybe carry me, which is we see a lot of more than we'd like. And boy, oh boy, it pays off to be stubborn in that quote, unquote, gotcha instance. So, so yes.
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C
To be sort of a more easily operantly shaped behavior given the increased value of the social attention.
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D
Yes, yes, absolutely. But, and, but, and then their desire to not want to do things.
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A
Right.
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D
That are slightly more difficult. So then you may see an increase in that behavior. So yeah, you probably see it a little bit more. Right. But certainly not in all kids. And that the key about a behavioral phenotype is there's an increased likelihood. It doesn't mean you'll see it in everybody.
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C
That's exactly what I was just about to say is that I'm sure that there is quite a range. Oops, I hit the microphone. Super professional. Quite quite a range within individuals with down syndrome, how likely you are to see some of these behavioral presentations.
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A
Right.
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D
And we know that there are children with down syndrome that have. Absolutely. And adults who do not have any intellectual disability whatsoever. So, you know, they may not be stubborn.
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B
Yeah. So Kathleen, one of the things that I'm always surprised when I'm, you know, reading about, you know, various behavioral treatments, behavioral interventions is how often there's a sense of, well, there's gotta be so much research and if there are behavior problems and these known motivating operations, whether they're called motivating operations or setting events or just patterns, whatever it might be. There's this sense of, well, of course there's gonna be tons of research, probably much of it using things like behavior analysis or the very least like basic behavior modification type techniques. And you mention a lot in your studies of. There just aren't a lot of really strong empirical studies for behavioral interventions. What's going on there, that this is sort of a known pattern that could occur in a population that it's just, well, let's not write about it. We'll just do stuff. What's happening there?
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D
Well, there was early on, right. So your early studies demonstrating the principles of behavior analysis on human beings, there were. There was a different word that was used then. You can find that word in those studies, Mongoloid. And you can find early work that was really the first work with individuals, with humans.
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C
Right.
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D
And applied behavior analysis. So there's a few early on then for down syndrome in particular, the research people that were specializing in conducting research with children with down syndrome were more focused on demonstrating how similar they were to typically developing individuals. So that there's a huge amount of literature really focusing on the strengths of people with down syndrome and all the wonderful things that they can do. And that's amazing. Right. But what fell apart was that treatment for them. And there wasn't a whole lot of it. There was early work that was placed in a manual about behavioral treatment and was published in a book, and it got a leverage. And then, interestingly enough, New York State Department of Health issued guidelines for early intervention for different disabilities. And those for autism really went viral. And, and even in other parts of the world. And down syndrome, whoever wrote it, they. They didn't talk about applied behavior analysis in there. They talked about operant learning. And it just didn't get the attention that, you know, so we're being a New Yorker, we're pulling all those up and we're saying, hey, look at this. These are the guidelines for all the intervention, it says right here. And multiple teaching opportunities and close proximity and. But it really didn't get a whole lot of attention. So one of the things that Emily Jones, my colleague and I did is we hand searched the Journal of Applied Behavior Analysis, because if you just did a word search and one learner had down syndrome, it was in a table and it wouldn't come up. But if you took a good look at every study and the participant tables, then you would find there were a lot of participants who had down syndrome that were in A lot of researchers studies, but it was just looking at intellectual disability or developmental disability as a whole. So it's there. And interestingly enough, based on the you had mentioned Massachusetts, an agency there reached out to us to help train their behavior analysts, which we're very excited to do. And I'm just entering doing some research with an amazing young woman, Econnell Sussman, who just got her PhD in Applied Behavior analysis. And we just started to continue those hand searches actually today having our students at Long Island University going through the tables and in intervention studies. So long answer to your question.
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B
But it's kind of that history and branding and all sorts, all the things that, you know, kind of a problem.
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C
I was going to say it's a lot of work, but some graduate students got to do it. Oh.
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B
Going through table stuff.
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D
Well, I did it.
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C
I did it too. I know, too, right?
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D
And I did it past being a doctoral student.
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C
But
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B
one thing I realize people might want to do after they listen to this episode is look at some of the research. And we haven't actually. That's my bad. Diana, would you mind sharing what articles will be kind of. This is a good segue because we're going to talk more, more in depth about the articles.
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D
Sure.
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C
I realized that I think at the same moment that you did is that we hadn't reviewed what they.
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B
You started the segue. Usually I start the segment. We're all off.
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C
We're all okay. So we have three articles that will be sort of background reading for our discussion today, and they include addressing Challenging Behavior in Children with Down Syndrome, the Use of Applied Behavior Analysis for Assessment and Intervention by Feeling Jones that was published in Down Syndrome research and practice 2006. Also strategies to Address Challenging Behavior in Young Children with Down Syndrome by Feeling and Jones and published in Down Syndrome Research and Practice 2000, 2008. And finally, advancing Imitation and Requesting Skills in Toddlers with Down Syndrome by Feely, Jones, Blackburn and Bower. That was in Research and Developmental Disabilities 2011.
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B
So, Kathleen, I'd love to kind of jump into some of your, the article with, with your case studies because I think that really nicely captures a lot of the questions that, you know, kind of our, our listeners given us. And I think we always have sort of, hey, I get the principles which you lay out really, really well. I really love, you know, great article. When I, when, when I see, you know, I'm kind of, you know, whether it's from a different field or whether it's just for a different population, I love seeing how people sort of describe behavior analysis to an audience that hasn't studied behavior analysis. You know, here are the key components which, you know, it's heading events, it's a decedent control, it's, you know, you're prompting, it's your reinforcement. Right. Just putting it all out there really nicely. But I think what would help is I'd love to talk a little bit more about some of the kind of interventions, case studies, we don't have to get into exact detail of each one. But really looking at, through your career, through your work with others and training, sort of what are some of the markers of working with an individual with down syndrome that folks who may have experience using ABA techniques with say, you know, either typically developing children or children with autism that they really should be taking into account for the specific needs of a child with down syndrome. Like, you know, what should they be doing? What could they do? Right? What might they do wrong?
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D
Right. So realizing that the many children with down syndrome are both attention motivated and escape motivated. So it's the student that tries to elope, but goes to the doorway and then looks back to make sure someone's chasing them. If, if no one's chasing, chasing them, they stay right where they are because they'll get more attention for staying. Right. But if someone's chasing them out the door, they go. And I think that's really one of the key areas to address is that attention motivated behavior that's probably also escape maintained. Right. So also thinking about how effective antecedent strategies are, and we don't see a lot of antecedent based strategies. When we're looking at, for example, behavior support plans, we see a lot of reinforcement strategies being used and lots of times it's just switching up the antecedent that is incredibly effective for children and spouses and everybody. Right. How you ask a child or a person to do something could make the world of difference. So I think that is really key pre specifying the reinforcer or collaboration offer of collaboration because that inherent collaboration is attention. Right. So we kind of know those are going to be incredibly effective or a high probability request sequence because you're getting all that feedback and then they want to continue that social interaction. So those antecedent strategies are really impactful. So are just basic functional communication training and realizing getting clinicians to realize that they need to prompt it before the prompt behavior, not after. Right. So it's one thing to write up a plan and hand it over and then it's a very different thing to go into the classroom or into the home and model it. And I would definitely say that's just best practice but really impactful also the way we respond if there's an error. I think that for children with down syndrome the most, one of the most impactful ways to respond is not to respond or just to turn away after a problem behavior occurs because any type of interaction is going to be reinforcing. So close proximity, eye contact and we see a lot of that clinically, you know, telling the child what they did wrong and trying to fix it and yeah, so really just turning away and even when. So there's lots of components here. So one addressing problem behavior. But what Emily Jones and I have laid out is how to use those principles just to teach skills, any skills, self care skills, toileting skills, cognitive skills. And it's very much built into intervention in that way so that your consequence isn't try again or it's just really turning one's head. And that sometimes isn't very palatable to interventionists. But what we've found there's families are like oh yeah, if it works, we'll do it. And so you know, parents don't have an advisor or academic necessarily people to be accountable to. So why they can't do something, you know. So it's been really nice working in homes with families but so definitely how you consecrate would be really strongly impactful in terms of not having it have attention linked to it.
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C
It's really interesting.
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B
One piece I really loved kind of going back to you to talking about antecedent strategies. I think you laid out so nicely the home to school log as an example of an antecedent strategy in that study of just knowing what could be going on outside of school and just shifting programming slightly in the day just being such a huge kind of see change in terms of and it's going to be a great day. Now do you mind talking a little bit about kind of, you know, how how one might develop those or sort of what are some of the key areas you might want to be thinking of in terms of creating that log?
- [25:16]
D
Yeah. So anytime I do a training I learn more from my participants. Right. So we do a lot of work in schools and so we had this teacher say well at parent teacher open at school night when all the parents come, I give handel with care passes and every parent gets five or six handle with care passes. And if they have had a rough night at home with their spouse or their child in the morning, the child can come into class with the Handle with care package. Pass. And there goes the log, right? So you don't even need that. But with the log, it would be great, right, if people read it and note it and you don't even have to say what it is, right? You don't have to say, well, we were up late because my high schooler did blah, blah, blah. Right. It's just, you know, Charlie didn't sleep well.
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C
Right.
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D
So it'd be a rough one. Yeah. And you know, teaching assistants, in my experience, they know, right? They'll say, oh, that kid had a look in his eye. Right? And they many naturally change the way they interact with that person. But we just need it more globally done, right? And then we. And understanding that if that happens, what can you do? And sometimes it's just feeding the child a little snack if they miss breakfast, or having them just put their head down on the desk for 15 minutes and take a little cat nap. And then sometimes it's just giving lots of reinforcement for the first 10 minutes of the day. And then all those things disappear. So it's also getting people to understand the value of it. And, and that's sometimes hard. And then the value of realizing that some families just don't have the time to report. So is there another way? Can it be a text or a phone call or a handle with care pass.
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B
I like, I like, I like that idea. Just, just hey, here it is. Switch to plan. It's education plan B today. You know, do the educational games, not the educational drill and drills. You know, something like that.
- [27:21]
D
Exactly, exactly.
- [27:36]
A
Hi, do you want to be a bcba, also known as a board Certified Behavior Analyst?
- [27:41]
C
Sure, we all do.
- [27:43]
A
Now you can come to Regis College in Weston, Massachusetts to get your graduate degree just minutes outside of Boston.
- [27:50]
C
Choose from any one of these Masters
- [27:52]
A
of Science in Applied Behavior Analysis, Master
- [27:55]
C
of Science in Special Education, dual degree in Special Ed and aba.
- [27:59]
A
Or be eligible for your postmaster's certificate.
- [28:02]
C
You can complete your degree and be ready to sit for the exam in two years.
- [28:06]
A
And our 2022 graduates had a 92% pass rate on the BACB exam.
- [28:12]
C
Come enjoy approved fieldwork placements, ethics mini handbooks, PhD levels, professors, small class sizes, and a service trip to Iceland if interested.
- [28:21]
A
And don't forget, our program is accredited by the association of Behavior Analysis International or ABAI as a Tier 1 master's degree program.
- [28:29]
C
Don't delay. Supplies are limited.
- [28:32]
A
Learn more at regiscollege.edu Again, that's www.regiscollege.edu
- [28:38]
C
regiscollege.edu One more time.
- [28:42]
A
Www.regiscollege.edu See you there.
- [28:47]
C
Bye. Hey, everyone.
- [28:54]
B
Sorry for pausing the episode, but I want to remind all of our listeners that Abi insidetrack is ACE and Quaba approved. By listening to this episode, you're able to earn one either dual diagnosis CEU or one learning ceu, depending on which body you're working under. And to get those, whatever the CE is going to be, you're going to need to click the link in the podcast player or go to ABA Inside Track and go to this episode. You're going to need to know some key information about our episode, information that you have learned, as well as two secret code words that we're going to put in, one right here and one a little bit later. And these are secret guest code words from Dr. Feely. The first is scarf. S C A R F. Now, you might think, oh, it's like when I shove a bunch of food in my face. No, you're wrong. It's the one that you put around your neck. Dr. Philly was very clear about this when we were talking about it.
- [29:46]
C
Yeah.
- [29:46]
B
So we'll know if you meant the one where you stick the food in your mouth. We'll figure it out. Even though they're spelled the same, we'll just know and you won't get credit. So make sure you're writing the scarf that you put on your neck.
- [29:56]
C
All right.
- [29:57]
B
Anyway, let's get back to the episode, shall we?
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C
I really just loved the whole context of the positive behavior support plan and the way that it is laid out in here. I don't know if I had seen it laid out, like, just so clearly as it was here. So everyone should, like, pop over to take a look at just the arrangement of it. It's really nice. Yeah. Like, I spend a lot of time with my students talking about how important the antecedent side is, because the. The consequence side, you know, independent of anyone's, you know, diagnosis, if we're dealing with some type of challenging behavior, then we have some things that we can do consequently. But they're limited, really. Right. And. And especially, as you're saying, if we're worried about potential potentially, you know, building larger repertoires of attention, maintained behavior. Right. Then we may be kind of limited in what we can do there. But this breaks down for us, like, three different areas that kind of fall on the antecedent side. So it's, you know, looking at those setting events, like you said, so what might be the background likelihood of behavior occurring due to any Number of capacities, the in the moment antecedent strategies. So like choice making opportunities that could be presented and then skill building strategies as well. So making sure we're building in FCR opportunities, etc, like all of that is so great because it's not, you're not getting into those like tricky, you know, consequent areas at all. It's all about setting, setting someone up for success really. And I just loved the way it was broken down. It would be so such a great exercise like provide to your BTs or your teachers and having them fill in what goes in each of these components. So everybody go check this one out. Yeah.
- [31:37]
D
And o' Neill and Horner's early functional behavior assessment book that maybe before your time, but it was a hard covered navy blue book and now it became a manual with a green soft cover. It was one of the first things I studied at the University of Minnesota in my doctoral program and a very, very intricate way of doing a functional assess observation which I still use. So yeah, it's kind of laid out there as well. And if, if you look at state regulations for implementation of the FBA and BIPs, at least new York State is, is pretty closely tied to that. And so yeah, it's a great model. Make sure you check all of those boxes.
- [32:21]
C
Yeah. Thank you. I don't know, I mean we've talked about PBIS before, but I just, just, you know, sometimes things just come to you and in that moment you're like, this is the one. That's just how I felt about this. That's how I felt about figure three on page 159.
- [32:34]
B
Kathleen, another, you know, kind of, we talked a little more about antecedents. We're going to talk about, I want to talk about skill acquisition. Certainly you have a whole paper on some like really clever and really, really thoughtful ways to do scope and sequence for skill acquisition. But kind of going back to consequences, you know, you mentioned sort of what's the correction procedure, how it might, you might want to make it different for a child with down syndrome due to the, just the potency of the attention. But you also brought up in the study the idea that a lot of times adults will really infantilize children with down syndrome. And I've certainly seen that with a lot of students across, you know, with or without disabilities. But there is that sense of a lot of times children with down syndrome will do something and everyone's response is like, oh, you, you're being so naughty. Let's make a big. And I'm always like, why, why are we treating this problem behavior different in this context than we would for any. Because any other time you'd be like, that's not okay, we're going to do this, or let's move on. And why is this like a funny, hilarious show we're all enjoying? Do you have any tips for what to do when people do that? Because I've sort of given them that hey, I think what you're doing is ridiculous statement. And it's not, it's very ableist. People don't like it when I tell them, you're being able to stop that. They don't like that when I tell them, this isn't effective. You're being ridiculous. They don't like that. What should I have done instead?
- [33:51]
D
So reminds me of a young child with down syndrome who was pulling hair, right? And he was about 3 years old. And we, we had a lot of parent training projects, so we were training the grandparents actually. And so it's, you know, it's really important that when Matthew pulls hair, you know, you don't give him all of this attention and like, oh, it doesn't hurt so bad. And, and I knew from being in this family's home that they had a next door neighbor who was the same age as Matthew. So I just said to the grandparents, well, what if Charlie walked in and pulled your hair like that? And right away was like, oh no, he would never do that. He knows better than that. Same age, same birth month. Right, but, and, and I think that's the best way to draw people's attention to it is that this child's age is, you know, 6, 7, 5, 14, 23. Therefore, let's look at all of the 23 or below, you know, kids, you know, that are that age and are they doing it and then let's really be thinking about how we could change this behavior for this child. I think that's one of the best ways. Also, I'm a huge proponent of inclusive education. So we see less of that in inclusive settings because there's a lot of people in that environment who will say, no way, he can't do that. No one else is, no one else is coming off the line from kindergarten to give their last year's teacher a big hug and a kiss. But, you know, so, so once a child's included and there's this understanding that the same expectations should be on that child, particularly social expectations, than the rest of the class, then that's a way to handle it. And then one of the things we noticed is And I don't know if there's any research on this, but children engage in motherese as well.
- [36:03]
B
Yes, I have seen that firsthand. And it's, it's like the same almost as hard as with the adults of like, no, no, no. Your response is making this where it's confusing how you're responding to these things you say you don't like, but you look like you're having a great time when you know your hair gets pulled.
- [36:19]
D
Right, right, right. So one of the things that we do in classes with children is we find the one kid that doesn't do that. It doesn't speak to the child like a baby. And then we make a huge deal out of that so that everybody knows that's who they should be emulating is the kid that just walks in and says, yo, what's up? Right? Did you have fun last night? And it's like, you know, when a fifth grader says that to another fifth grader, it's a little odd. So we've been doing a lot of reinforcing of kids that just treat the child, you know, like a same age peer.
- [36:56]
B
So you look for, you look for your models in the environment or you have environments that to tend to want. I never thought I'd be excited to be like, oh hey, it's a teacher that's like, no, I'm consistent and I have the same expectations for everyone. But you know what sometimes sounds like it's actually a benefit.
- [37:10]
D
Well, for behavior. Yes. Academics, for some kids with town syndrome, we need a little leeway there and that's not always so easy. But we're getting there.
- [37:19]
B
Maybe that's a good segue to talk a little bit more about skill acquisition. So I know that you put together in, in the 2011 article just a really great scope and sequence for teaching language, teaching requesting skills. But I did want to sort of pull out one part of that. In specifically talking about some of the prompting strategies you mentioned in terms of like error correction, trying to minimize the amount of attention given is like, that's not the right answer. And I think it was pretty clear just kind of the turn away, turn back, you know, present, present the correction trial. But you also had used, especially for language development, some physical prompts. I'd love to sort of hear how you determined though. Like did that come from sort of your background working a lot with speech and language and aac? Are those ones that you would recommend behavior analysts learn more about or more that's wait for your speech pathologist to help you out there. Like how do those physical prompts come into play with, with the language acquisition?
- [38:16]
D
So one thing. So we. When we first started our work with children with down syndrome, we had early intervention programs. So we had a handful of kids who were newborn, handful of kids that were one, handful of kids that were two, handful of children that were three. And that was amazing because at the same time we got to see all these different ages. And we also looked at skill acquisition and typically developing children to kind of model that off of. One of the things we told families right away is to desensitize their child to touching their lips. Right. So that you could actually physically prompt a child really early on at one or one and a half and they weren't adverse to it. So they didn't move away because they were used to their family, you know, putting lotion or on their face and tapping. And is my favorite really early on when you put your hand up to your mouth, people aren't seeing me but. And then our hand up to their, the children's mouths. So we did it simultaneous us and them. And, and so that hand up on their mouth was actually a prompt vocalize. And we didn't have to put it all the way up. We could just raise it. And they knew.
- [39:31]
C
Yeah.
- [39:32]
D
And it worked really well. Now more recently, Eesh o' Connell Sussman had had a little bit of challenges in a recent study. Her dissertation actually is getting kids to respond to that. So it may not always work. It's not a fail safe prompt, but it works. Worked for the, for the students that we had at the time, it worked really well. And we're still using it with lots and lots of kids. So that, that's one way is to just establish that prompt so that you can get them to vocalize so that when they vocalize they can receive reinforcement. So that was one of the key areas that we did in terms of prompting and then lots of visual prompts. Right. I know just in general for, for kids with down syndrome tend to be really good at understanding and remembering what they see. As many visual prompts as you can. And we also, there's a, a system called prompt that SLPs know where they prompt. And we worked with a speech therapist early on who was prompt certified and she shared with us a few. But we've done some really idiosyncratic ones like with a, a snake for this sound. And as soon as we would put our hand up with our two fingers together, the child right away goes, it's not a whole lot of Problems with kids with down syndrome generalizing their skills. I have to say they're really good at general generalizing it, but they definitely need that prompt in order to get it fully within their repertoire.
- [41:08]
B
All right, well, and speaking of kind of that, that overall sort of, you know, the, the scope and sequence for requesting, I'd love to sort of just hear the genesis of that as an idea, because sometimes you read an article and you're like, yeah, of course. That makes sense. Use. Use what a child is good at. Use their strengths and then build on that skill. That makes sense. But I don't, you know, I know a lot of folks don't always think about teaching communication as what's the scope and sequence? So, like, I don't know, it's all the same thing. Get a motivating operation, you know, maybe do a couple mass trials. Make sure that there's a reinforcer, potentially a tangible reinforcer, paired with the natural reinforcer. Bobbing. There you go. That's how it works. And I think your scope and sequence really took advantage of what you knew about. Where are the most potent reinforcers for the students we're working with. So would you mind sort of like talking about how you developed that? Sort of. Talk a little bit more about what it. What it was and how you kind of taught those. Those functional communication skills.
- [42:03]
D
So when, for one study, we. When we were recruiting participants and we. There was a school in this region for children with down syndrome, and it was apparent that they all had the same speech therapist because they would look at what they wanted and would sign more while looking at the item that they wanted, which is really interesting to see a child just look at something and sign more with no gaze shifting to other people in their environment, which is getting someone's attention and then looking back at what they want and then looking back. Right. Kind of like joint attention, but it's a form of requesting, right?
- [42:45]
C
Yeah.
- [42:45]
D
So then just modeling what typical kids do, right? Which is they see something that they like, they find a communicative partner in which to request the item, and then they communicate to the communicative their partner, and then they're reinforced by delivery of that item. So that was really the skill sequence. And we knew that children. We could teach verbal imitation. And that's a core challenge with children with down syndrome. They're pretty really good at imitating what they see, but they're not very good at imitating what they hear. Our early work and Emily Jones and I worked in an intensive behavioral treatment program for children with autism ages 18 months to 3 years of age. And then a gentleman by the name of Mike Darcy asked us to kind of expand that work to other disabilities. So we did. And we did it with children with down syndrome. And then we realized that even older children, 4 or 5, 6, didn't have, and had lots of speech therapy, didn't have basic verbal imitation or vocal imitation skills at all. We've met elementary school students that didn't verbally imitate, like, wow, that's just your basic skill. So let's just wind this back a bit and let's do some imitation training. So of course we do this, do this gross motor imitation, then do this. And lo and behold, we were teaching 2 year olds with down syndrome to imitate 18 months to imitate what they heard. So now we have them vocalizing. We could prompt them because we desensitize them to the touch to get the, to close. So it went from an ah to a mm. And then lots of teaching opportunities. Which is another thing that doesn't make sometimes applied behavioral analysis palatable because there's a lot of folks saying, oh, it should be child directed and not teacher directed. And well, you know, if you watch a typical child learn, they do the same thing over and over and over again, right. And I watch my own kids do that now I have a grandchild and it's funny, he does the same thing over and over and over again. Right. So we were able to work with intervention is to say it's okay, you can take this one skill and you can do it again and again and again and again and no one's going to get hurt and we're not breaking any rules here and it's an okay thing to do. So that was part of our treatment is, you know, can you. And we just truly did 10 because it was easy to get the percentage for success. There's no magic numbers.
- [45:22]
C
I hear that. Yeah.
- [45:24]
D
You know, can you shoot for this? And, and it was easy on a changing table in a high chair before and after a meal to gather the child and, and sneak in 10 teaching opportunities. So we weren't doing six hours of discrete child training, right. We were doing these intensive treatment like a high dose rate teaching opportunities. And, and that I think is huge for the, for behavior analysts to understand because look, we, we refer to as context for instruction or the level of intensity of treatment. Lots of kids with down syndrome are just going to learn because they're in circle time, right. If you're talking about preschoolers, they're going to pick up lots and lots of things, but there's lots of things they're not going to pick up that way. So really thinking about where their strengths are and where their weaknesses are, and can you increase the number of teaching opportunities for areas of weakness? And then, lo and behold, that's. That's what we did. And then we looked at typical skill sequences. And then I. I have to mention Deborah Fiddler's work. So she does a lot of work comparing different disabilities and identifying characteristics of behavioral phenotypes. So she would identify the weakness. And then Emily Jones and I would be like, I think we could fix this, you know, if we increase teaching opportunities and break down the skill. And yeah, that's what led our work and continues to lead her work because she's just doing fabulous things. Did I answer your question?
- [46:56]
B
Yeah. And I think that makes perfect sense how you came. And so you had the vocal imitation piece going along with the gaze shift to the requesting sort of the attention of the interaction before moving on to the more, you know, socially less social interaction, asking for help. I guess there's some social interaction there. And while I know, you know, you mentioned in the limitations that it wasn't, you know, you certainly weren't proving. Aha. They'll never. No one will learn to ask for help until they've learned to ask for the interaction. It did seem to kind of move the skill along relatively fast. And there was that sense of acceleration, especially with the vocal limitation of. Once they learned a few with the same procedures by like, number three. Barring that one participant who had the kind of the mouth deformity or the mouth.
- [47:41]
D
Right. The palate. She had a lot.
- [47:43]
B
The palate.
- [47:43]
C
Yes, that's right.
- [47:44]
D
Yeah.
- [47:45]
B
They were able to learn those skills and use them and maintain them, too. The maintenance data was really great in that study.
- [47:52]
D
Yeah. And generalization. We had another study where we taught a little guy to say bless you when someone sneezed. And he was the third of four boys or the second of four boys. And his dad came in for a meeting, he goes, I don't know what you're doing with this kid, but he's the only one in my house that says bless you. And so we. So I think kind of the difference in with other disabilities is children with down syndrome want to communicate and want to be social. They don't necessarily have this skill sometimes. Right. So when they have the skill, boy, they use it. So I think that's where there's a little difference. There's not. You don't have to concentrate too hard on those generalized behaviors, because once they get the skill, there's a lot of generalization. And we have the videotape of the mom doing the probes, the generalization probes, and her face says it all, because she taught the other skills and she did not teach that particular sound. And when she said E and the baby said E, yeah, it's really exciting.
- [48:55]
C
That's really cool. And I just really appreciate this. This conversation that we're having, because I think a lot of students of behavior analysis are only learning about behavior analysis in the context of providing services to kids, kids with autism. And the science of behavior is one thing, and then the application of it to assistance in a particular population is another. And everything that you're saying, it fits within the science of behavior. Right. But it. It involves us needing to remind ourselves, to zoom out. Right. And our understanding of how, you know, how behavior operates or what our expectations should be with respect to, I don't know, you know, DTT or varying types of EOs has often been colored by our experiences working with a particular subset of individuals. And those EOs, it's. It's all about that setting, event that you talked about. Right. Like, those EOs could be quite different for person to person, as well as, you know, providing this additional, like, piece of background information. So we have to zoom out and think about, well, what are all the factors that may be relevant for working with this individual? And some of the assumptions that we could have about the EO that could be in place could be quite different depending on who we're working with. So I think that it would be fantastic for everyone to work with a variety of individuals from a variety of backgrounds, because some things that we're thinking are like, oh, I, I know. I know how this is going to go. It might not go like that. Right. And the more varied, as, you know, like, the more varied exemplars you get, the more that we can really distill that back down to our understanding of how behavior operates at its principal level. And then the application of that to. To different individuals we work with is going to be, you know, more easily done, I think. Yeah.
- [50:52]
D
Yeah. I think an illustration that our personnel that were working with kids with autism, then we started a program for kids with dance syndrome, and they switched, and it was quite different for them.
- [51:04]
C
Yeah.
- [51:05]
D
And then we had a lot like, he just doesn't want to do this. I mean, like, all right, then play with him. You know, like, play a game and then embed it within the game. And it's okay. He's not in his chair. He could be sitting on the floor. And changed a lot of things. And then took data on just naturalistic teaching, just naturalistic learning opportunities. And kids were learning some things at a high rate just by sitting around with their typical peers. But then there were other things that they weren't learning, and that's where we needed to increase the intensity of instruction.
- [51:41]
C
So.
- [51:41]
D
Yeah.
- [51:42]
C
Yeah.
- [51:43]
D
Without removing them from the gen ed setting for their entire life.
- [51:46]
C
Life, yeah.
- [51:48]
B
So, Kathleen, have you seen more adoption of kind of ABA interventions in EI in general education settings, special education settings, since some of these, like your publications in 2008, 2011, has there been a shift there? Does it still kind of feel like you're constantly trying to convert people to like. No, there's a lot of good research. Come on, folks, let's change it up. Like. Like, what's the status right now, at least in your scope, where, you know, where you're able to sort of see programs.
- [52:19]
D
Yeah. I think on Long island here there is definitely a shift due to an advocacy organization, the Down Syndrome Advocacy Organization that does a lot of trainings and I've presented there and Eilish has. And Emily has Emily students from Queens College. So there's a lot of information getting in the hands of our early interventionists and families to ask for it. So we do. Particularly with down syndrome, we do see that. And we're seeing more behavior analysts in our schools regionally here, because New York State, a behavior analyst isn't a licensed professional that can work in the schools. So it's tricky. You need to be something else and be a behavior analyst. But I've done some work in the state of New Jersey where they have lots of behavior analysts and lots of kids are benefiting from behavioral interventions. So it's really kind of a mix. I'm not seeing as much as I would like to, but we did manualize this and we published it with a publisher that went out of business during COVID Oh, sad. Yeah. Right at. I think we published it in 19. 20, 19. And then it went out.
- [53:44]
C
Oh, my God.
- [53:45]
D
But Brooks Publishing, hopefully we're in.
- [53:48]
C
Yeah.
- [53:50]
D
Picking it up.
- [53:51]
C
So we're sending vibes out. Good vibes. We're hoping Brooks is a great publisher.
- [53:57]
D
Yeah.
- [53:58]
C
I always like what they publish, so I hope that that gets picked up.
- [54:02]
D
Yeah. So I. So, yes, I do believe we see an increase in it. I get a lot of people that reach out to me from all over the country that. And it's interesting because oftentimes it's a parent who is a BCBA or a parent who's a special ed teacher and then has a child and says, I really want my therapist to do this. I'm not seeing it in preparation program. At least here regionally, they're still learning very, very different models of intervention that aren't necessarily evidence based, our early interventionists. So, yeah, hopefully that's shifting.
- [54:41]
B
Oh, well, that seems like a good.
- [54:43]
C
It rolls us right in.
- [54:44]
B
That's what I was gonna say.
- [54:46]
C
I just really want to preempt all
- [54:47]
B
of your segues to dissemination.
- [54:49]
C
Today. We're in a segue race, right. And my segue has pulled ahead of yours.
- [54:53]
B
Before we started recording, I said, does anyone want to do some of these segues? And everyone says, no, Rob, you do it. It's fine. And then cut out from under just
- [55:01]
C
because I've been watching a lot of Arrested Development and oh, okay. You know, I got job segue on my mind.
- [55:06]
B
Oh, okay. Yeah, it's an old show. Proceed for folks out there.
- [55:10]
C
Go right ahead.
- [55:11]
A
Well, here we go.
- [55:16]
B
We've made it.
- [55:18]
A
Station.
- [55:19]
B
Right. So, Kathleen, I think there's kind of two points that I. I'd love to sort of, you know, wrap up our conversation today. One would be similar to talking about practice programs. If you're a behavior analyst, and you are, either because, hey, that's who your clinic has just as a family with a child with down syndrome, so you need to learn right quick what to do, or if you are interested in moving more regularly into working with down syndrome population. What would you say are the additional steps that are going to be really important to focus on in order to build that clinical competence?
- [55:59]
D
Read our work. I think that is because there's not a lot of people talking about it. And I think particularly more recently, Emily Jones, Nicole Neal, they are really sharing information, continuing to share information. So I think that is one thing, getting a really good handle on the medical guidelines and knowing all of those pieces. I would spend a lot of time with families. That's really important. A student of Ted Carr's. So Ted Carr was right here in my backyard at Stony Brook University, and he had a student who finished after Ted passed away. And I was on her committee, and she wanted to look at relationships between parents of children with autism versus typically developing children. She asked me to be on her committee, and I said, well, I will if you add a third group, children with down syndrome families. Interestingly enough, the families of children with down syndrome actually demonstrated better ties between the parents than the parents who are typically developing children, I think that's really important is to spend a lot of time with families and ask them what their hopes are, what their dreams are, what they can do, what they want their child to do, because they're the best teachers. We've had so much success teaching siblings how to run intensive interventions for articulation training. So they go to a pizza place and the child loves Sicilian pizza and can't say Sicilian. So his brother, who's 9, runs 10 opportunities at a time for a week. And before you know it, the kids walking up to the counter saying, I'd like a slice of Sicilian. So I would definitely capitalize on those components. So medical guidelines, reading what's out there in behavioral work with children with down syndrome, learn about the behavioral phenotype. Deborah Fiddler is a key place to find that information. Yeah. And then speak to any of us. Just reach out to us. We're happy to share information.
- [58:10]
C
So I just loved how New York. That example, I was going to say,
- [58:14]
B
like, we don't do Sicilian pizza stuff. I don't know if we could do that with Massachusetts. I hope so, but. And Kathleen, just from a kind of like a research and practice standpoint, what's sort of next for iterating on sort of the process of improving ei, improving treatment outcomes in terms of research with children with down syndrome or adults with down syndrome for that matter?
- [58:37]
D
Yeah. So historically there's. When you had asked me why there wasn't a lot of research, I was thinking a lot about behavior analysis. But there also, there wasn't a lot of money being dedicated to research for children with down syndrome. And, and that changed fairly recently with a group of families from California who really pushed. And now NIH has its own funding line engaged to, to increase studies because there was, I believe, you know, from my sense and things that people have said to me is like, oh, isn't there a cure for that? I'm that don't they have prenatal testing? Right. So thinking like, oh, we figured that out, but we, we haven't. Right. And it's still a very high incidence, one in a thousand learners, live births or children with down syndrome. And so with that said, it would be really nice. And I wish that we did this right. I wish we dedicated our careers to doing a really good controlled study randomized with a group, you know, match pairs and getting some intensive behavioral treatment and others. But it's out there with other populations. Right. It's out there with autism. So that would be a Great thing. If someone could do that, I don't think I could do because I couldn't withhold treatment to a bunch of kids. Right. So. But someone out there is probably really good at that. And, and the fields of implementation science are, Are you familiar with implementation science? Like, how do you get people to implement what we know works, and it's big in the medical field. We know this work. We know having children with disabilities alongside their typical peers is an effective intervention. We knew it in the 70s for preschoolers, yet we still rely on segregated systems. We know that reinforcement works. We know that functional communication works. Really shifting. How do we get preschool teachers that have had a completely different training to adopt these interventions? I think, I think those are areas. And then also we've trying to shift it from behavior to communication skills, object manipulation and concept determination. So Emily's doing great work in that area. So really looking at different areas of development that we could apply the same things, identify the skill sequence, break it up, and then use effective interventions to address the skills.
- [60:55]
B
Ah, excellent. Well, Kathleen, like, like you mentioned, hopefully the manual will be back in, in publication soon as, as a resource. In the meantime, if. If folks are interested in continuing their work, learning more about supporting children with down syndrome, is there an email or a place that they could. They could reach you? Whether it's just to ask when the book's coming out again or. Or when the manual's coming out again or. Or just to ask specific questions?
- [61:18]
D
Sure. It's my first and last name with a dot in between. So. Kathleen.feely f s and frank e e l e y@liu.edu sweet hair.
- [61:32]
B
Well, thank you, Dr. Kathleen Feely. Thank you so much for coming on the show. We really appreciated this chance to talk with you about your work and to learn more about supporting this population of students.
- [61:43]
D
Thank you one more time.
- [61:45]
B
We want to say a big thank you to Dr. Kathleen Feely for coming on the show to talk to us, us all about working with children with down syndrome. It was, it's. It's one of those topics that, you know, when you hear about it and you discuss it with someone so knowledgeable, you say like, oh, yeah, no, that makes perfect sense. But until you have that conversation and look at some of the research, there is that sense of like, I don't know if I know what to do it, it might be so different. Right. So I hope you all feel the same way and you're ready to learn more.
- [62:09]
C
Exactly. That's what I was about to say. You could definitely Learn more.
- [62:12]
B
Segue that time, didn't you?
- [62:13]
C
Because, you know, we dedicated many, many, many episodes to working with kids with autism. And so this is our first one that's dedicated to down syndrome. But I bet there's more we could talk about.
- [62:23]
B
I wish there were a way to know what other episodes we've done that have been kind of like similar topics. If there were, like, a section of the show called Pairings where we did, but there isn't. So we're going to wrap up here. Oh, wait a minute, Diana. Oh, what? There is.
- [62:35]
A
There is.
- [62:36]
C
But. Yeah. So this is part of the show is called Pairings, where we talk about past episodes, but we've never had an episode dedicated to this particular topic. So I don't have no, that short. I can't tell you about that. But I can tell you it's possible that you stumbled upon this episode because you're looking for dual diagnosis. And so I can tell you about other episodes that we have in the back catalog that were dual diagnosis ones. And so Those include episode 16 and 209, where we talk about ADHD. Episode 156, we talked about traumatic brain injury with Dr. Meg Hine. Episode 56. And then episode 227, we talked about behavioral gerontology with Dr. Miranda Trehan and Amanda Ripley. Episode 231, we talked about EBDB. Is that right?
- [63:26]
D
EB?
- [63:27]
B
Emotional behavior.
- [63:28]
C
I think I might have gotten too many. Too many Bs in there. EBD intervention with Dr. Joanna Stalbitz. And then also this one's not dual diagnosis, but we talked about early intervention a good amount. Here, episode 84, we review early intervention. Eibi. There we go. Sorry. As a plan. Usually I recommend a snack to go with this episode, but I'm hungry. Yeah, I didn't write anything down. So I have.
- [63:55]
A
I have a good snack.
- [63:57]
C
I'm. I'm. I'm up for hearing.
- [63:59]
B
Jackie, what's the snack?
- [64:00]
A
So our snack is gonna be popcorn and an icy.
- [64:07]
C
Are you going to the movies?
- [64:09]
A
No, but these are things we share together.
- [64:13]
C
Okay.
- [64:13]
B
We share an icy together.
- [64:15]
A
I mean, yeah, I share, I guess.
- [64:17]
B
Yeah. I gotta buy my kids 2 icies. Get lost, kids. Or if I buy them too, they're sharing them with me. Then I get a full ice.
- [64:26]
A
You would also eat those going to the movies. But I was thinking of something that we might share.
- [64:31]
B
Gotcha.
- [64:32]
C
Show.
- [64:32]
B
All right, all right.
- [64:34]
C
And that was pairings. Please enjoy.
- [64:36]
B
It's in the notes. So officially, that is the snack of this episode. All right, well, that brings us to the end of our episode on down syndrome. And Aba, thanks again to Dr. Kathleen Feely for coming on the show. If you like this episode and want to hear more, maybe start with those pairings or just go to our website, ABA InsideTrack.com where you can see all of the episodes we've done. Or hey, just put us into your favorite podcast player and you'll immediately get access to tons and tons and tons of episodes, over 300 episodes on a variety of topics related to behavior analysis. If you're interested in getting even more content ahead of time, you can join us on Our Patreon page, patreon.com abainsidetrack where you can subscribe at any level. But if you subscribe at the $5 tier, you're able to get get access to our votes for listener choice episodes and get access to those episodes once a season for no additional charge. Sorry to the CES for those episodes. And if you're like I love this podcast, but what if books in two hours long? Well, you can subscribe at the $10 and up level to get access to our quarterly book club episodes. We are just about to really actually I think we will have released the Anxious Generation Book Club when you're hearing this. So if you are on the Patreon at that level, you'll get access to that right away. All let's assume it's two hours. We haven't recorded it yet and two hours. It might be more than two hours. Diana wants to add a movie review in there. She just told us today. So it's going to be 17 hours. But you get two CES because 15 hours of nonsense. Two hours of hot content. And so that's the only way to get that now. Otherwise you gotta wait to like re release it on the free feed next year. So again, that's patreon.com
- [66:24]
C
nonsense content. It's called nontent.
- [66:26]
B
Nontent. Yeah, we we try to keep the ratio of content to nontent higher on the content side of things. And of course you can email us@abainsighttrackmail.com if like some of the Regis students, you have an episode you'd love to hear some more about. Some final thanks. Thanks to Dr. Jim Carr for recording our intro outro music, Kyle Sturry for interstitial music, indenthabit of the podcast doctor for his amazing editing work. Before we wrap up though, second secret code word from Dr. Kathleen Feely. It is sinus S I N U s because sinuses can lead to issues with health and illness, which go into some of the motivating operations that you're going to need to take into account when working with children with down syndrome. So it's a code word and also a reminder for y' all out there. All right. Well, we'll be back next week with another fun filled episode. But until then, keep responding. Bye.
- [67:20]
D
Bye.