Yelling at people with ASD to stop their loud voices?!?

I belong to a group on LinkedIn begun by PediaStaff where (primarily) OTs and SLPs ask each other questions, pose dilemmas, share techniques, and recommend products – it’s a wonderful resource for getting help, giving help, and bouncing ideas off of your peers.  A recent post described a situation at work for one OT – she reported that staff were using “aversive yelling” in order to extinguish the loud volume of their students on the autism spectrum disorder (ASD).  When I first read this, I thought, “What?!? Is this a joke?”  But I soon found out it was not, and these people truly believe this is an effective treatment.  The OT disagrees and is offering alternative treatments, but they refuse, citing lack of evidence (the ol’ “evidence-based practice” dogma we are required to follow when choosing therapies for our clients/students/patients).  So she posted a plea for evidence-based research backing up other therapeutic approaches, such as visual (e.g., hand motion, cards with different icons depicting the volume level, the “5-Point Scale”) or audible cues.  I felt compelled to help this woman, as well as having the desire to find this answer myself.  I often have students on my caseload who are “loud-talkers” and have tried the “5-Point Scale” in the past with some success, but have found that it didn’t carry over into the natural environment.  I wondered if I wasn’t using the technique properly, or enough, or long enough to see results.  So I wrote to the author of the program/idea and she graciously wrote back to me within a day with some helpful information which I have copied below:

Self-Management is an EBP and the scale is a form of self-management (specifically increasing self-awareness, awareness of others, self-management and relationship awareness).  In this sense, the 5-point scale has been referred to as an ‘evidence based practice’.  I find it hard to believe that a program would, on one hand, worry about EBPs, and on the other, use an aversive approach to teaching an issue of self-regulation.  I am sure you are familiar with the national autism center’s word on EBP:

I don’t see aversive yelling mentioned anywhere in the EBP literature.  If the school is not comfortable with something that sounds too much like an “approach”, try to help them understand that self-management is the ticket and they can use many different teaching methods (including other scales) to teach self-regulation and voice volume recognition (self-awareness).  Aversive therapy is not a teaching tool, it is a behavior “control” tool and behavior “control” tools, to my knowledge, are not recommended in current educational literature.

Using the Scale:
It is important to remember that a scale is a teaching tool.  It is not simply another behavior management strategy nor is it a miracle that you can just post on the wall and hope things change.  We recommend you follow these steps when creating a scale:
1.   Determine the problem.  What is the person doing that you wish he wasn’t?  What is the social situation he seems to be confused by?
2.   What skill or social concept does he need to be taught in order to do this better?
3.   Break that concept into 5 parts.  Make #1 the smallest and #5 the biggest (avoid good and bad).
4.   Use a story or a simple memo or even a video to help the person understand how to use the scale.
5.   Practice using the scale prior to predictably difficult times or when needing to be in predictably difficult environments.
6.   Use the scale in real situations by prompting the person with a small portable scale.  Create a portable scale for the person to carry as a reminder.
Here are just a few examples of concepts or situations that have been successfully taught with a scale
-personal distance                           -perspective taking
-voice volume                                    -is it a problem?
-speed in the hallway                           -touching
-worry levels                                    -anger
-asking for help                                    -how other people think
-emotions                                             -words we use
-who is a friend                                    -breaking the law
-sexual behavior                           -classroom rules
-self-advocacy                                    -bus rides
-energy level                                   
The Ultimate Goal:
The primary goal of the scale is to teach social and emotional information that often eludes the person on the autism spectrum.  Initially the caregiver might need to gather information about the problem and create a scale.  This is often the case for very young children or nonverbal individuals.  As soon as possible, you want to prompt the person, regardless of age or ability, to interact with the scale.  Perhaps they are checking in regarding anxiety levels, or simply pointing to a #2 on a voice scale and modeling a whisper voice.  This can lead to another goal of the scale, teaching self-management.
Although a story, memo or video is often used to introduce the use of a scale, after the system is learned, scales can be developed as a way of “debriefing” after an unexpected problem.  Once learned, a scale can even be used in the moment to clarify information for the person in a functional, non-threatening and nonverbal way.
After one scale has been used successfully, you can use other scales in the same way.  For example, once you have made a worries scale, if the person has difficulty with voice volume you can show him how to use the scale for voice volume.  The scale then becomes a predictable system for teaching and learning difficult concepts.    
A big thanks to Kari Dunn Buron for replying to my query so quickly and sharing a section of the new, updated “5-Point Scale” with me.  I am eager to get this book and try it out in a more systematic manner to see if I get better results.  It surely has to be better than yelling at children who may not even realize how loud they are, AND are sensitive to loud stimuli!  The only time I would use a loud voice would be to model the student’s volume so they can hear how loud it is when it’s coming from another direction.
I’ll keep you posted at how this pans out…
A good day!

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