燧石自閉癥講座系列： Understanding Principles of Reinforcement 認識行為強化的原理
講座日期：2016年8月9日
主講人：Tracy Shepler MA, BCBA行為分析師
技術支持：徐藝珊 臨床心理博士
主持人：趙海雄
群主：周衛宇
筆記整理：雷春
英文稿通過Tracy認可，中文稿得到薛敏醫生校閱，特此感謝！
主講人簡介：Tracy是有執照的行為分析師，在這個領域有10多年的工作經驗。她有一個18歲的兒子是自閉癥。Tracy is a board certified behavior analyst and has worked in the ASD community for over 10 years. She has a son who was diagnosed with ASD.
The main topic is to address the importance of understanding the principles of reinforcement and how to apply it when parenting a child with ASD. The “child” includes both young and adult children. 講座的主題是講解認識行為強化的原理
的重要性，以及如何用于養育自閉癥孩子。這里的“孩子”包括幼小和成人的孩子。
Introduction介紹
Applied behavior analysis is a scientific approach to improving socially significant behavior. “Improving socially significant behavior” means changing an actual behavior that is meaningful, and does not mean changingany behavior just because we can. In the 1970s, applied behavior analysis used negative behavior change procedures such as electrically shocking the patients. However, the practices have changed significantly over the past 40 years. Nowadays, positive reinforcement and none punishment procedures are used to create behavior changes in a meaningful way. Procedures derived from the principles of behavior are systematically applied to improve socially significant behavior. Understanding what is being reinforced for the individual and how to use the information is very important. It is very important to be able to demonstrate experimentally that the procedures were responsible for the improvement in behavior instead of individual and unknown variables, so that the procedures can be used repeatedly and create consistent behavior outcome. 應用行為分析法是用科學的手段來改善具有社交意義的行為。“改善具有社交意義的行為”是指有目的地改變一個有意義的行為，而不是根據能力而隨意改變一個行為。十九世紀七十年代，應用行為分析法使用了很多負面的手段來改變行為，比如：電擊病人。但是，過去的四十多年間，其療法發生了本質的變化。現在，我們有效地使用正相行為強化法和非懲罰性的措施來改變行為。從行為原理中衍生出來的方法會系統地應用于改善社交意義顯著的行為。了解什么個人行為得到了加強并且如何將此信息得以運用是非常重要的。只有實驗數據證明是某項行為療法使得某類行為得以改善，而不是個體差異和未知因素的結果，這個行為療法才具有重復使用的意義。
1. The basis of behavioral intervention行為干預的基本原理
It is essential to understand the concept of competing reinforcers. Individuals with autism spectrum disorders often do not naturally pay attention to the most relevant stimuli. They are more easily distracted by others such as a piece of lent on the carpet or flicking of a light than the words spoken to them. Autism Behaviors are characterized by behavior excesses and behavior deficits that indicate we want less of some behaviors and more of others. Behavior researches linked between environment factors and behaviors gave us understanding of the competing reinforcers. 要從根本上理解競爭性行為強化物的概念。自閉癥譜系內的孩子不會自然地關注我們需要他們了解的社交信息。在我們和他們說話時，他們很容易受到干擾，比如：地毯上的一個線頭，或者閃爍的燈光，從而無法理解話語的意思。自閉癥行為有兩大特點：行為過多和行為不足。對于過多的行為，我們要減少；多于過少的行為，我們要增加。系統的行為學研究使我們認識了環境因素和行為的直接關系。這是真正理解“競爭性行為強化物”的科學依據。
2. Influencing Behavior影響行為的因素
There are many factors influencing behavior. The key factor is motivations: We all have 9 natural motivations in life (hunger, thirst, fatigue, discomfort, etc.), which do not require any previous training or learning experiences and are naturally reinforcing. It is important to use these motivating factors whenever possible. For example, if you want to introduce a child to a new food, it is best to do it when the child is hungry or has not eaten for hours, using natural motivation of hunger. The sequence is very important as well. When you are offering a child a less desired food, it is best to also provide a highly preferred food right after so that the child can access something quickly that they will enjoy. For example, if a child really likes mashed potato but not peas, you can say: “If you have a bite of the peas you will have mashed potato.” And make the mashed potato present. As soon as the child gets a bite of the peas the child will be able to enjoy the preferred food. This method can also apply to neuro typical children when teaching them to say “please” and “thank you”. They usually spontaneously say “please” before they learn to say “thank you”. The motivation is quite less after they have received the item! 影響行為的因素很多。最主要的是內動力因素：我們所有的人都有9種自然內動力因素，其中包括饑餓、口渴、疲勞、不適、等等。這些天然的內動力因素不需要經過任何訓練或學習，而且會自然地得到強化。我們要盡可能的利用這些內動力因素。比如，如果你希望孩子嘗試新的食物，最好是在孩子饑餓或者很久都沒吃東西的時候，這就是利用天然的內動力因素——饑餓；類似，如果我們想讓孩子吃他們不太喜歡的食物，最好是同時準備好孩子愛吃的食物，在目的達到后，孩子很快會享受喜歡的。舉例子說明，如果一個孩子特別喜歡吃土豆泥但不喜歡吃豌豆，你可以說：“如果你吃一口豌豆，你就可以吃土豆泥。”同時要把土豆泥放在孩子看得見的地方。孩子吃一口豌豆后就能夠享受喜歡的食物。這個方法對普通孩子同樣有效，特別是在教他們說“請”和“謝謝你”的時候。他們通常會先學會說“請”而不是“謝謝你”。因為，他們一旦得到了想要的東西，動力就少了很多！
Transitioning inside after playing outside can be a difficult transition time for ASD children. Thus, it is one of the most challenging tasks for many parents. They can play very well in the park for long time but as soon as it is time to leave, they will throw huge temper tantrum. We can attempt to capture the natural state of thirst, hunger, temperature (if a natural deprivation occurred while playing outside). Purposely not bring any food or drink to the park. When it is time to go to the car, simply say, “Let’s go to the car and have some water.” Then, to transition from the car to the house, you need to have some preferable food at home, and say, “Let’s go inside and have some snack.”對于自閉癥孩子，在室外玩了一段時間后，很難回到室內。這是家長們面臨的最困難的挑戰之一。他們在公園可以忘乎所以地玩很長時間，一旦要離開，就會大吵大鬧。我們要盡量利用自然的口渴、饑餓或天氣變化等內動力因素來達到目的。故意不帶水和食物去公園。要上車走的時候，只是說：“上車去喝點水吧。”然后，回到家時（事先要在家里準備好孩子喜歡的食物），說：“進屋去吃些點心吧。”
3. Learning history學習歷程
It is helpful to understand previous learning history and how that impacts behavior (antecedents and consequences). Antecedents are things in environment before behavior occurs including varieties of stimuli. Consequences are what happen after behavior: the kid gets the preferred item or not.了解孩子的學習歷程（前置因素和后果）和對其行為的影響非常有用。前置因素是在行為發生前的環境因素，包括很多種類的刺激信號。后果是行為發生后的結果：孩子是否得到了想要的東西。
One frequently heard complain from parents is: The items or activities that my child were highly motivated to work for lost reinforcing properties over time. It is because when parents are too excited seeing their child engaging in things they enjoy, and then allow the child to have unlimited access to the items or activities without any depravation stage it will loose its reinforcing properties. To help the child motivated by the stimuli, the access to the reinforcingitems need to be limited and controlled by the parents and other support providers. Limit access to reinforcers. If there is a history of engaging in an activity or task that is not liked by the child, then we want to use highly preferred reward for engaging in the task.經常聽到父母抱怨：很多物質獎勵或活動獎勵，原本對激發孩子的行為很有效，但經過一段時間后，漸漸失去了效果。這是因為，當家長看見獎勵的效果后高興過頭，使孩子們隨時都能得到這些獎勵，沒有空檔期，從而失去了新鮮感和行為強化功效。為了保證激勵效果，家長和其他成人要限制孩子得到獎勵的條件。如果讓孩子做一件非常不喜歡做的事，就必須提供孩子非常喜歡的獎品作為鼓勵。
4. Reinforcement Procedures行為強化的方法步驟
There are different procedures we can do to influence behavior: Reinforcement and Punishment. Reinforcement increases the occurrence of a behavior by either positive reinforcement or negative reinforcement. Punishment decreases the occurrence of a behavior by either positive punishment or negative punishment. The terminologies can be quite misleading and confusing. In ABA, “positive” does not mean pleasant and “negative”does not mean unpleasant, they have very different meanings. 我們可以用不同的方法步驟來影響行為：強化和懲罰。強化是通過正相強化或負相強化來增加一個行為發生的頻率。懲罰是通過正相懲罰或負相懲罰來減低一個行為的發生頻率。這些術語會非常容易誤導和難理解。“應用行為分析法”所指的“正相”不代表“高興”，“負相”也不代表“不高興”，它們與我們常用的意思不同。
Positive reinforcement means that stimulus is added to increase likelihood of future behavior. When behaviors or items such as high fives, pad on back, verbal praise, food,candy result in helping a child to do more of something, we call them positive reinforcements. 正相強化是指通過增加外界因素而提高未來行為發生的可能性。當行為或物品，比如：互相擊掌、拍后背、贊美、食物、糖等，能夠幫助孩子多做需要做的事時，我們就稱之為“正相強化物”。
Negative reinforcement is the most misused and misunderstood term, even by professionals. However, as a parent herself, Tracy believes that it is important for parents to be equipped with the knowledge and apply it to their daily practice at home. Negative reinforcement means that removing stimulus from the environment results inincreased behavior. For example, if crying results in eliminating or delaying a child’s homework, then the behavior of crying will be reinforced by eliminating or delaying the homework. Another example of negative reinforcement for an ASD child is that when a certain social situation is aversive to the child, then the situation is removed when the child engages in certain behavior, such as stimming (rocking, hand flipping, making certain noises over and over again). It is very common to see an ASD child making very loud noises when in noisy and or uncomfortable environment. In this example, noise making is being negatively reinforced when the child does not haveto listen to annoying social stimulus. Another example is taking a medication to relieve pain. Because taking Tylenol will remove the pain, thus removing the pain will negatively reinforce the likelihood of taking that medication. 負相強化是一個最難理解和應用的概念，甚至對于專業人士也是如此。但是，作為自閉癥孩子家長，Tracy認為家長需要掌握這一知識并且應用到日常生活當中。負相強化是指通過移除某個環境因素而導致某個行為頻率的增加。比如，第一個例子，如果哭鬧會使孩子達到不做或延遲做作業的目的，那么，哭的行為會因“不做或延遲做作業”的結果因素而加強——也就是，從此以后，每一次要做作業的時候，孩子都會哭鬧。另一個自閉癥孩子特有的負相強化的列子是，在某種不喜歡的社交場合時，孩子會專注于某個行為，比如自我刺激行為（不停地搖晃、擺手、發出噪音等），來逃避社交。自閉癥孩子在噪音大或不喜歡的環境，通常會大叫。他們大聲叫喊的行為，由于自己的聲音屏蔽了環境中的噪聲而得到了負相強化。第三個例子是吃止痛藥，由于吃Tylenol會使疼痛消失，止痛的事實就負相地強化了吃藥的行為。
http://media.psychology.tools/worksheets/english_us/operant_conditioning_en-us.pdf
https://wikispaces.psu.edu/display/PSYCH484/3.+Reinforcement+Theory
http://psychology.jrank.org/human-behavior/pages/cmxyrryar7/social-child-parent-aversive.html
Positive Punishment means that stimulus is added to decrease the behavior. Scolding and or spanking a child are common examples of positive punishment. We need to avoid punishment procedures at all cost because they can have a lot of unexpected side effects. 正相懲罰是指通過刺激物的加入來減少行為。打罵孩子是很常見的正相懲罰的例子。我們必須最大限度地避免使用懲罰措施，因為它們往往會產生難以預料的負面后果。
Negative Punishment means that stimulus is removed to decrease the behavior. Timeout is a common example of negative punishment. 負相懲罰是指通過刺激物的移除而減少行為。Timeout（關黑屋子）是最常見的負相懲罰的列子。
If we want to decrease aggression, can we just implement a punishment strategy to decrease aggression? No, and it’s not the treatment of choice anyway!如果我們想要減少攻擊行為，我們能通過懲罰孩子來減少攻擊行為嗎？絕對不行！
Side effects of punishment include懲罰的負作用包括：
1. Resentment over being punished commonly by being scolded, spanked, excessive timeout etc. 打罵和長時間的關黑屋子會導致怨恨情緒。
2. Attempts to escape the punishment/avoid the punisher: when trying to avoid timeout, a child may aggressivelyattempt to escape. 企圖逃跑或避開懲罰人：當試圖避免被關黑屋時，孩子可能竭盡全力地企圖逃跑。
3. Expression of pain and negative emotions associated with punishment due to spanking. 被打了之后，孩子可能因疼痛和負面情緒而嚎啕大哭。
4. Recognition by the punished individual between the punishment and the person delivering it—The person mostly likely a parent delivering the punishment becomes paired (respondent conditioning) with an aversive/punishing experience. When the person (punishment condition) is not present (available) the child will more likely to act up (increase undesirable behavior). Thus, in the end, punishment procedure does not teach the child what we want them to do. On the opposite, positive reinforcement and negative reinforcement procedures give the child clear signals what we want more of their behaviors. Both positive punishment and negative punishment procedures must be implemented by board certified behavior analysts or at least licensed professionals who were adequately trained in behavior change technics. The extreme harmful self injure behaviors, which may need punishment procedures to decrease, are very rare and definitely need licensed professionals to monitor. 孩子可能會把懲罰人（大多是父母）與被懲罰的事件對應地聯系起來。當懲罰人不在的時候，孩子可能會變本加厲地做不該做的事。因此，最終，懲罰不能教會孩子我們想要他們做的事。與之相反，正相強化和負相強化策略能清楚地告訴孩子我們要他們做什么和怎么做。正相懲罰和負相懲罰必須由經過專門訓練的有執照的專業人士執行。那些非常危險的自殘行為需要使用懲罰的方法來減低，但是這類行為極少，而且一定需要有執照的專業人士來監督。
5. Functions of Behaviors行為功能
There are only four functions of behaviors that individuals can demonstrate. Before we target a behavior for change, we have to identify the function of the behavior. The four functions are access attention, escape/avoidance, access items and automatic reinforcement. Attention does not have to positive. Negative attention is still attention. After all the chaos (temper tantrum) settles down, did the individual access an item? It is also important to understand: Escape/removal of attention; Escape/removal of items; Positive automatic reinforcement; Negative automatic reinforcement. 總的來說，所有的人類的行為都可以歸類為僅有的四種功能。在我們改變孩子的某個行為之前，我們必須知道這個行為的功能是什么。這四種功能是：得到關注、逃避、得到東西和自動強化。孩子想得到的“關注”，并不一定是正面的關注；負面的關注也同樣是“關注”。在哭鬧之后，孩子是否得到了想要的東西？那么，“哭鬧”的功能就是“得到東西”。同時，家長也要了解逃避關注及避免事件的功能；還有，正相自動強化和負相自動強化功能的概念。
Parents and even teachers regard scolding as punishment. But it is actually a function of access negative attention which reinforcing the behavior. Accessing attention can be both positive and negative attention. 大部分家長甚至老師把“罵”孩子當作“懲罰”。但是，這實際是滿足了孩子“負面關注”的需要，反而會強化孩子的不當行為。記住，孩子要得到的關注，可以是正面的關注，也可以是負面的關注。
To escape from something that they don’t want to do, or to avoid something they don’t like is a motivation for ASD children to change their behaviors. 逃避做不想做的事是自閉癥孩子改變行為的一個動機。
If after the tantrum the child gets the item he/she wants the behavior is reinforced. For example: A child was crying in a store for a toy. Even after the parent scolded the child and said no, the child would not stop the tantrum until the parent gave in. Then crying serves the function of access the toy. Next time when the child wants something, it is very likely he/she will cry until he/she gets it.如果孩子在哭鬧后能夠得到想要的東西，那么，這種行為就得到了強化。比如，孩子在商店里哭著要一個玩具。雖然父母責罵孩子，說不可以，孩子還是無法停止哭鬧，直到父母讓步為止。那么，哭鬧就具備了得到玩具的功能。下一次，當孩子想要其它的東西時，很可能會哭到得到為止。
Automatic reinforcement means that the behavior reinforces itself. Stimming behaviors such as hand flapping, rocking are typical automatic reinforcement behaviors. However, when an unwanted task is present, they can have a different function (escape). Thus, same behavior can have different functions. 自動強化是指行為本身有強化功能。自我刺激行為，如擺手、搖晃身體都是典型的自動強化行為。但是，當自我刺激行為，在需要做一個不想的做的事的情況下出現時，就成了另一個功能——逃避功能。因此，同一個行為在不同環境下，可以有不同的功能。
It will be very challenging for parents to understand and grasp the concept of all the 4 functions of behaviors at once. However, trying to think like a behavior analyst will help parents to analyze your children’s behaviors and aware what functions their behaviors serve. Behavior analysts often use different types of assessment tools to understand what may reinforce a behavior and what function a behavior appears to be. 對于父母，一下子理解和掌握這四個行為功能是非常具有挑戰性的。但是，父母還是可以盡量向行為分析師學習，從行為分析的角度思考和辨別孩子的行為，意識到孩子行為的功能是什么。行為分析學家會使用不同的工具來幫助分析和理解強化行為的因素是什么，以及這個行為的功能表現為什么。
1. Access Attention得到關注:
Examples of questions to ask yourself: what functions does this appear to be?每當孩子的一個行為發生時，要問自己：這個行為的功能是什么？
Does this behavior occur when you are talking to other people in the room?這個行為是不是在你和房間里其他人說話時發生的？
Does this behavior occur whenever you stop attending to the child? 這個行為是不是在你停止照顧孩子時發生的？
Does the child engage in this behavior to upset or annoy you when you are not paying attention to him or her? 孩子是否在你不關注他／她時，故意這樣做來煩你或惹你生氣？
Does the child seem to do this behavior to get you to spend some time with him or her?孩子這樣做是否想讓你多陪陪他／她？
If when you were on the phone with a friend your child started crying and pulling your pants, then it is an attention seeking behavior. 如果你打電話和朋友聊天時，孩子開始哭鬧而且拉你的褲子，那么這就是尋求關注的行為。
If you were playing with the child, as soon as you walked away, the child started crying, then it is another indication of attention seeking behavior. 如果在和孩子玩時，你一走開，孩子馬上就哭了起來，那么，這也是尋求關注的行為。
If a child purposely engage in a behavior (such as knocking on the table) to upset you it is an attention seeking behavior. 如果孩子故意做事（如敲桌子）來惹你生氣，這也是尋求關注的行為。
If the child has to sit on your lap while engaging in playing a toy or hug you when with him/her, it means he/she wants more time with you.如果孩子玩玩具時要坐在你的腿上，或者你和他／她在一起時一直要抱著，這意味著他／她需要你花多點時間陪。
2. Automatic Reinforcement自動強化:
Examples of questions to ask yourself: what functions does this appear to be? 每當孩子的一個行為發生時，要問自己：這個行為的功能是什么？
Would this behavior occur continuously if the child were left alone for long periods of time (for example, one hour)?如果孩子自己呆很長一段時間（如一個小時）這個行為是否會一直持續著？
Does this behavior occur repeatedly, over and over, in the same way (for example, rocking back and forth for five minutes)? 同一個行為一遍一遍地重復（比如每隔一段時間，前后搖晃5分鐘）？
Does it appear to you that the child enjoys performing this behavior and would continue even if no one was around?即使周圍沒人，孩子也會很高興地不間斷地表現這個行為？
When this behavior is occurring, does the child seem unaware of anything else going on around him or her? 這個行為發生時，孩子是否對周圍發生的事毫無察覺？
When a child is left in a room for long period of time, he/she engages in stimming (hand flapping, rocking, flipping objects in front of face), and then the function of the behavior is automatic reinforcement. Even when a child is in an automatic reinforcing behavior, we can be creative, and are able to redirect, introduce and engage him/her in other reinforcing behaviors. 當一個孩子自己在房間呆很長時間時，他／她有自我刺激的行為（擺手、搖晃、把東西在面前翻來倒去），那么這個行為的功能就是自動強化。孩子有自動強化的刺激行為時，我們要根據具體情況，來分散和轉移注意力，并引導孩子做其它更有趣的事。
3. Escape or Avoidance逃避任務:
Examples of questions to ask yourself: what functions does this appear to be? 每當孩子的一個行為發生時，要問自己：這個行為的功能是什么？
Does this behavior occur following a command to perform a difficult task?這個行為是否是在告知要進行困難的工作后發生的？
Does this behavior occur when any request is made of the child? 這個行為是否是在和孩子提要求時發生的？
Does the child seem to do this behavior to upset or annoy you when you are trying to get him or her to do what you ask? 每次在你試圖讓孩子按你的要求去做時，他／她似乎都會這樣做來惹你生氣嗎？
Does this behavior stop occurring shortly after (one to five minutes) you stop working or making demands of him or her? 在你停止強迫孩子做事后很短的時間內（一至五分鐘），這個行為就消失了嗎？
When children struggle with verbal communication, they are asked to say a word, they may start to cry or throw a tantrum at that point. 在孩子語言交流有很大困難，但又被要求用一個詞表達自己時，可能會大哭大鬧。
When parents ask the child to use sign language or say a word to ask for a preferred item，the parent says, “OK, say train please!” then the child cries or starts to stimming or other behavior other than follow instruction. The behavior is motivated by escape or avoidance—they are trying to get out of the task. 當父母要孩子用手語或一個詞來要一個想要的東西時，家長說：“好了，請說火車！”孩子立即哭鬧起來，或者開始自我刺激，或者其它行為，而不是按照要求去做。這個行為的動機是逃避——他們企圖避免按要求做。
When you were trying to get the child take a bath, he/she threw a tantrum. Then suddenly, you stopped trying to demand him/her to take a bath, he/she stopped crying. It is an indication that the function of crying is avoidance. 當你想給孩子洗澡時，他／她大哭大鬧。一旦你不要求了，他／她的哭聲突然停止。這就是說，“哭”的功能是逃避。
It is challenging to change behaviors that are motivated by escape or avoidance. There are two parts involved in the behavior intervention. The first is to block the individual from being able to escape the task. The second is offering reinforcement of engaging in the task or an easier form of the task. 改變以逃避為動機的行為是很有挑戰性的。這個行為干預有兩個重要的部分。第一個部分是阻止逃避的可能。第二個部分是提供做事的強化物（獎勵），或者把任務變得容易一些。
4. Access items得到東西:
Examples of questions to ask yourself: what functions does this appear to be? 每當孩子的一個行為發生時，要問自己：這個行為的功能是什么？
Does this behavior ever occur to get an object, activity, food, or game that the child has been told he/she can’t have?這個行為是否在被告知不能得到某一個物品、活動、食物或游戲時發生？
Does this behavior occur when you take away a favorite object, activity, or food? 這個行為是否在你拿走一個最喜歡的物品、游戲或食物時發生？
Does this behavior stop occurring shortly after you give the child the object, activity, or food he/she has requested? 這個行為是否在你給回孩子物品、游戲或食物不久后就停止？
Does this behavior seem to occur when the child has been told that he/she can’t do something he or she wanted to do?這個行為是否在被告知不可以做孩子想做的事時發生？
When you take away the iPad, the child starts to cry, then the function of crying is to access the iPad. To check the function of the crying behavior is to access items, you can give the iPad back to the child and see if he/she stops crying. 當你拿走iPad時，孩子哭了起來，那么，哭的功能就是得到iPad。如果要證明哭的功能是要得到物品，你可以把iPad給回孩子，然后觀察他／她是否不哭了。
If the function of the behavior is to access an item, the intervention is relatively simple. Sign language, picture selection and approximation (partial sound) of the word can be taught to the child to access the item. 如果一個行為的功能是得到物品，所需的行為干預會相對容易。可以教會孩子使用手語、選圖和類似那個詞的聲音來得到那個東西。
Review of the 4 functions行為四功能的綜述:
When a behavior function is identified as to gain attention, we can teach the child how to get the attention in a socially acceptable way. For a child who is none verbal, walking to a person and tapping to the arm or shoulder, pointing to a picture of mommy or a preferred teacher can be used to obtain the needed attention. Caregivers need to observe any hint of such socially appropriate behavior and reinforce it by providing immediate access to the attention. To reinforce a behavior of an ASD child, it is very important to give him/her immediate attention without a period of waiting. For reinforcers, the more immediate they are the more effective they will be. 如果一個行為的功能是得到關注，我們可以教會孩子如何通過合適的社交途徑來得到別人的注意。對于一個不會講話的孩子，走到那個人跟前，輕輕地拍胳膊或肩膀，手指著媽媽或一個喜歡的老師的照片，都是合適的得到所需關注的行為。保育人員需要觀察孩子任何這類合適的社交行為的跡象，并通過提供即時的關注而進行強化。要強化一個自閉癥孩子的行為，即時的關注非常重要，真的是刻不容緩。對于強化物，越是即時就越有效果。
It is definitely trickier to intervene with automatic or self-stimulating behaviors. It is important to encourage the child’s stimming behavior for a certain period of time to satisfy the need, then redirect and engage the child into a highly preferred activity. For example, Tracy worked with a child who was constantly focusing on hand flapping and paid no attention to the environment. It was almostimpossible to teach him anything in the beginning. Tracy flapped her hands with the child to catch his attention, and laugh together with him to gain his trust. Then she set a timer. As soon as the timer went off she presented him a very desirable food and gave him a lot of verbal praise while eating. After stabilizing the transition from hand flapping to food, Tracy added trampoline jumping as the following activity, and eventually faded away the food. Over time, the hand flapping behavior was reduced to 10 minutes every hour. 對自動或自我刺激的行為進行干預一定要謹慎。在一定時間范圍內，鼓勵并滿足孩子自我刺激的需要十分重要。在這個基礎上再分散和轉移注意力，并引導孩子做非常喜歡的事。舉例說明， Tracy曾經教過一個只對擺手感興趣的孩子，他對周圍環境全然不知。剛開始幾乎無法教他任何東西。Tracy和孩子一起擺手并得到了他的關注，和他一起大笑并取得了他的信任。過了一段時間后，她開始使用計時器。計時器一響，她就給孩子非常喜歡吃的食物。他一邊吃一邊使勁表揚他。在從擺手到食物的轉換過程穩定后，Tracy又引入蹦床的游戲，并慢慢減少食物，直到完全不需要食物就可以從擺手轉換到蹦床游戲。經過一點時間的訓練，擺手的時間減少到了每小時10分鐘。
For escape or avoidance behavior, it is a two-part process. We need to break tasks down into smaller components. If an escape or avoidance behavior works for the child, he/she will continue the behavior. The challenge for parents is to make the behavior not effective. For example, if a child can escape from his/her math homework whenever he/she cries,he/she will cry whenever asked to do the homework. The first step to stop the behavior is to tell the child that he/she will need to do the homework no matter how long he/she cries—crying will not get him/her out of the homework. Since it is a highly aversive activity for the child, we will need to be creative and use reinforcers to meet the child where he/she is. It is very important to know the learning history of a child including all the difficult tasks such as math time, bath time, etc. We need to use the information to set the child up for success in the future. If we know that math is challenging for the child, we need to adjust our expectations accordingly. For example, instead of forcing the child to do 20 math problems at once, we may ask him/her to come to the tale to do just one math problem, and then immediately reinforce it with highly preferred activity. If a child is unwilling to take a bath, the first step may be just putting a washcloth on the child’s forehead. In the field of behavior analysis, this process is called shaping, which means we breakdown the task into small steps, and each time we apply lots and lots of reinforcement, and each time we get closer to the end goal of the task. 逃避行為的干預需要兩個步驟。我們必須將任務分解成一些小的部分。如果逃避行為能夠達到目的，這個行為就會持續下去。父母的挑戰是使這個行為無效。比如，如果哭鬧后可以不做作業，那么，每次叫他／她做作業時孩子就都會哭鬧。第一步是告訴孩子無論他／她哭多久，作業最終還是要做的——他／她逃避不了作業這個任務。由于做作業是孩子非常不喜歡的事，我們需要有靈活性，并且用強化物來幫助孩子做他／她力所能及的作業量。了解一個孩子的學習歷程非常重要，包括所有對于孩子來說非常困難的學習科目和日常生活的任務，比如：數學、洗澡、等等。我們要用這個知識來幫助孩子不斷成長。如果我們知道數學對一個孩子很困難，我們要根據情況調整期望值。例如，我們不去強迫孩子一次做20道題， 而是要他／她到桌子前來只做一道題，然后立即通過讓他／她做非常喜歡的事來強化這個行為。如果一個孩子不喜歡洗澡，第一步也許只是把濕毛巾放在前額上。在行為分析領域，這個過程稱為行為“塑造”，意思是，我們把任務分割成小的步驟，每一次小的進步，都給予大量的行為強化（獎勵），因此每一次我們就離目標更近一步了。
Questions and Answers問題解答
Q1: What can be used to as appropriate reinforcement? I think candy is a no while preferred activities are better. 合適的行為強化物有哪些？我認為糖果不好，但游戲很好。
A1: Candy is not good to be used as reinforcement in long term since a lot of ASD children are obese due to food as reinforcer. The categories of reinforcers are primary reinforcers and secondary reinforcers. Food is considered as primary reinforcers. Primary reinforcers are items that do not need learning curve. A food that taste good to an individual does not require learning history to want more of the food. In the beginning stages of behavior analysis, food is incorporated into early practice because most of the time, food is the only reinforcement option available. Food will become a problem if it is not faded away. In the hand flapping case, the child was able to transition from hand flapping to jumping on a trampoline, which actually engaged him in physical activity. ABA intervention uses ABLLS (assessment of basic language and learning skills). One of the first tasks that a child is taught to learn is a task of having a reinforcing toy, learning how to play with a toy, and learning how to find that toy is reinforcing. The way is to pair a toy with food or stimming to give the child a range of choices to choose from that are considered reinforcers. 糖果不可以長期用于自閉癥孩子的行為強化，因為很多自閉癥孩子由于過度使用食物作為行為強化物而有肥胖的問題。行為強化物有原始和次級兩大類。食物是原始強化物。原始強化物是指不需要學習過程的強化物。美味食品一旦品嘗后，不需要任何學習歷程，孩子就會還要吃。行為分析學的行為干預過程的初級階段，食物往往被用做行為強化物，因為大部分時候，實在是別無選擇。如果食物不漸漸被其它強化物所取代，就會有問題。在前面的擺手案例里，那個孩子最后可以不需要食物就從擺手轉換到蹦床游戲，反而使他增加了體能活動。應用行為分析學的行為干預步驟，會以ABLLS作為參考。孩子首先要學會的技能之一是能夠玩行為強化玩具，要學會玩這個玩具，并且發現這個玩具有強化功能（越玩越有趣）。方法是把這個玩具和食物或自我刺激對應起來，讓孩子選擇強化物。
Q2: What do you do if kids no longer react to positive reinforcement, but negative ones (warning, punishment)?如果正相強化物無效了怎么辦？能用負面的警告、懲罰嗎？
A2: We don’t call something reinforcement unless it increases behavior. For example, a parent says， “Good job！” that initially increases a behavior; after a while, it stops working, then we would no longer call it reinforcement because it does not have any effect on behavior. Periodically, we have to go back to the starting point and we have to figure out again what are positive reinforcers for the particular individual. A couple of months into a program, behavior analyst needs to evaluate the reinforcers and frequently change and swap those out. The reality is that people will get used to certain things and don’t find them exciting anymore, which is a good indication that it is time to change to a different reinforcer. The ideas of reinforcers can be easily found online by Google.只有增加行為的事物才是行為強化物，否則就不是。比如，一個家長說“做得好！”剛開始有行為強化作用；過了一陣子，就沒用了；那么，我們就不能叫它強化物，因為它對行為沒有影響。時不時的，我們必須回到起點，重溫哪些是這個孩子的正相行為強化物。每兩個月左右，行為分析師都需要重新評估孩子的行為強化物，并經常調換。實際情況是，每個人都會對事物逐漸習慣，當失去新鮮感時，就要及時更換行為強化物。網上有很多行為強化物的建議，可以根據孩子的情況選擇。
Q3: What are the effective positive reinforcement techniques for autistic teenagers, i.e., hands flapping in public, pinching mom’s arms, repeating the same questions or sentences all the time, staying up late and refusing to see psychologists? 對于十幾歲的自閉癥孩子，有什么有效的正相強化方法？孩子會在公共場合不停地擺手、掐媽媽的胳膊、重復不斷地問同一個問題或說同樣的話、晚上不睡覺而且拒絕看心理醫生。
A3: The “hand flapping in public” can be due toautomatically reinforcing and it feels good; or can be due to feeling uncomfortable in public and doing so can help him avoid feeling uncomfortable. There may be certain stimuli in the environment that the individual finds uncomfortable, thus he need to find a way to control that before he goes to public. Knowing the child will pinch mom while walking, then he needs to put his hands in his pockets. “Repeating the same questions or sentences all the time” and “hand flapping in public” are very common automatic reinforcement behaviors in ASD children, which is calledPerseveration. Perseveration is very difficult to treat. However, it just requires a lot of redirection and a lot of reinforcement. “在公共場合不停地擺手”可能是一種自動強化行為，孩子從中有快感；也可能是孩子不喜歡這種環境，這樣做會逃脫不舒服的感受。如果環境中有令孩子焦慮的事物，在去之前，我們首先要幫助他找到控制的方法。如果知道孩子會邊走邊掐媽媽的胳膊，他就需要把手放在口袋里。“在公共場合不停地擺手”和“重復不斷地問同一個問題或說同樣的話”是自閉癥孩子常有的自動強化行為，被稱作“言行持續癥”。“言行持續癥”是個很具挑戰的病癥，但是，通過堅持不懈的轉移注意力和堅持不懈的行為強化，會有顯著的改善。
Q4: How to use reinforcer to help a child be more focused when there is an elevator in sight, and he is obsessed with elevator? Whenever in malls, he just looks for elevators, nothing can gain his attention. 如何運用強化物來轉移孩子對電梯的癡迷？每次在商城，孩子只是在找電梯，對其它事物都沒有興趣。
A4: ASD child does not naturally pay attention to the most relevant stimuli in the room because it is not reinforcing. The strategies can be moving his chair to face away from the elevator, blocking his view to the elevator and providing lots of reinforcement when he is focusing on something other than the elevator. In general, visual and auditoria distractors are frequently present in the environment. We need to try to block them as much as possible. When a child is easily distracted by visual distractors, we need to seat the child in a place with minimum visual distractions. When a child is easily distracted by noise while reading, we can provide headphones to block the noise. 自閉癥的孩子不會自然地關注身邊最相關的社交信息，因為他們會覺得無聊、無強化性。可以采取的措施有，讓椅子面對與電梯相反的方向，擋住視線，不讓他看到電梯，并提供很多他感興趣的事，當他關注其它事情時用強化物進行獎勵。總之，環境中有很多視覺和聽覺的干擾，我們要盡力屏蔽。當孩子很容易受到視覺干擾時，我們得讓孩子坐在視覺干擾最少的地方。如果孩子讀書時容易被噪音干擾，我們可以用耳機幫助屏蔽噪音。
Q5: Is there an efficient way to look for local ABA/BCBA? How to find out if he/she is a good match to my child at a particular period of time? 如何尋找當地的行為分析師？如何知道他／她適合我的孩子？
A5: The best way to look for a local ABA/BCBA is to go on the board website最好的方法是在這個網頁上找: http://info.bacb.com/o.php?page=100155
To find out if a behavior analyst is right for your child, it has to go through trial and error. It is very important he/sheis a right match for your child. Parents have to be comfortable with the intervention style that the behavior analyst is recommending in order to follow through.Interview and trial processes are very important. If after a period of time a behavior analyst is not right, parents need to fire him/her, and find someone else who is a better fit. All parents are encouraged to do so. However, we need to be careful about the reason that the parents don’t feel right, and ask: is it because the behavior analyst is asking the parents to do something they don’t like to do (for example, to ride out tantrums of a child), or the personality of the behavior analyst is not a good match? The website also provides information regarding RBTs (registered behavior technicians). The person who works with an ASD child hasto at least have RBT credential and under supervision of a BCBA. 要知道一個行為分析師是否適合你的孩子，沒有捷徑，只能是通過試用。適合孩子非常重要。父母也要喜歡行為分析師的干預方案和本人個性，否則無法堅持。面試和試用都很重要。如果過了一段時間，父母覺得這個行為分析師不合適，就應該解雇他／她，找更合適的人。鼓勵所有的家長都這樣做。但是，家長要清楚自己不喜歡這個行為分析師的原因，并問自己：是給的任務太難做到了（如讓孩子哭個夠）？還是這個行為分析師的性格不合適？這個網頁還有RBT的信息。教自閉癥孩子的老師，至少要是在BCBA行為分析師指導下的RBT。
Q6: How do you teach a child about “joint attention” from the beginning step? What will be the next step? 如何培養孩子的“分享式注意力”？步驟是什么？
A6: “Joint attention” is a difficult area to study, and there are a lot of researches in this area. The child is initially taught how to play with the therapist. It begins with lots and lots of prompting and lots and lots of reinforcement. Then it follows the generalization training. The child should be able to engage in the same play behavior with other people including parents and other children. Teaching an ASD child how to play often requires tons of prompting in the beginning and then the prompts are faded over time. “分享式注意力”是一個非常不容易理解的領域，目前這方面有很多研究。孩子首先要學會和治療師玩。剛開始的時候需要很多對興趣的激發，并給予大量的獎勵強化。然后要進行概念化訓練。孩子應該逐漸可以和其他人（包括父母和其他孩子）玩同樣的玩具游戲。教自閉癥孩子學會玩游戲，剛開始需要很多的激勵，然后逐漸減少物質刺激，直到不需要。
Q7: What do you suggest parents do to prevent vocal stimming (grinding teeth, singing songs, talking nonsense) especially in public? 如何防止孩子在公共場所進行聲音刺激行為（磨牙、唱歌、胡言亂語）？
A7: It is a good and tough question. These behaviors are self-simulative and automatically reinforcing. We want to be thoughtful about them when we think about different interventions. If a child can keep their mouth occupied then the grinding teeth, singing songs, talking nonsense behaviors can be reduced. For example, we can teach a child how to chew gum or even Laffy Taffy (a very chewy candy), which will give him/her sensory stimulation that he/she is looking for. Meanwhile, we can encourage his/herbehaviors in a car, but as soon as in public we can ask him/her to stop by saying: “Now it is time to chew this.” 這是一個非常好而且有難度的問題。這些是自我刺激和自動強化的行為。在考慮不同的行為干預方案時，一定要慎重。如果一個孩子的嘴不停地忙活，那么這些行為就會減少。比如，我們可以教孩子嚼口香糖，甚至Laffy Taffy糖， 這會滿足孩子感官刺激的需要。同時，孩子在車里的時候要鼓勵或允許這些行為，但是，一旦到了公共場所，我們可以通過說：“現在是嚼這塊糖的時候了。” 進行行為轉換。
Q8: Preschooler started to be scared of sleeping alone at night. Is there any way to handle it since he couldn’t explain what scared him or should I co-sleep? 學齡前兒童開始害怕晚上自己睡覺。有什么辦法嗎？他說不清害怕什么。家長應該和他一起睡嗎？
A8: It is a tough question. It has a lot of culture factors involved. Some families encourage co-sleeping for a number of years, and other families have strong feelings about not having their children in their bed. The expectations and plans need to be consistent every night, which include trying to sooth the child, and then teachingthe child how to sooth him/her self so that he/she can fall asleep on his/her own. Tracy has three children. She decided to train her 3rd child who was frequently waking up at night. Instead of taking the baby to her bed, she would frequently go to the baby’s room, start singing, and in the mean time, rub her back for 5 minutes, lay her back down in crib, rub her back again for 5 minutes, and stand by her crib, then gradually move out of the room. Occasionally, if the baby started crying very loud, she would go back in and rub the baby’s back again. It is not perfect plan but there are three more people sleeping in the house. It is the best she can do. After about one and half months, the baby finally was able to sleep through the night without waking up. 這是一個不容易回答的問題。與文化因素有關，有的家庭鼓勵和孩子同睡很多年，而有的家庭堅決不讓孩子睡在父母床上。不論是哪種情況，父母對孩子的期望和實施計劃必須每晚都一致。做法包括：安慰孩子，然后教孩子學會安慰自己，自己睡著。Tracy有三個孩子。她決定訓練晚上經常醒來的老三自己睡覺。寶寶醒來時，她沒有把孩子抱到自己的床上，而是經常去寶寶的房間，抱起寶寶并開始唱歌，同時給她按摩后背5分鐘，然后讓她躺在嬰兒床里，又按摩后背5分鐘，接著站在小床邊，唱著歌慢慢蹭到門外。有時候，如果寶寶大哭起來，她會又走回去，再次給寶寶按摩后背。這不是完美的方案（沒有保持一致），但家里還有三個人在睡覺，算是盡力了。大約一個半月之后，寶寶終于可以自己睡過夜了。
Q9: How to deal with inappropriate behaviors seeking attention or negative enforcement in social settings? For example, my son likes touching peer’s hairs or disrupting class music and other inappropriate behaviors, and laughing about repeat comments like “no touching friends hair” or “no opening doors” etc. 如何應對孩子在社交場合通過不合適的行為來引起注意的行為？比如，我兒子喜歡摸同學的頭發，干擾課堂音樂，嘲笑并重復別人的話“不要摸朋友的頭發”或“別開門”等。
A9: It is a very good question and appropriate. First, we need to make sure the child receives as little attention as feasible for the negative attention seeking behaviors. Sometimes it can be very difficult. Some kids learn very quickly how to push the buttons and how to aggregate people in a way to provoke them and get large response. The teacher has to involve the class to selectively give attention to the behaviors that you want more of, and try to give less and less attention to those type of negative behaviors. Responding in a very neutral and calm tone and then providing appropriate and logical consequences for inappropriate social behavior is a really good place to start. Then, we need to make sure the child will have opportunities to gain attentions through positive social skills. 這是一個很好的問題，也很適合在這里分享。首先，我們要保證對尋求負面關注的孩子的行為給予盡可能少的關注。有時候這是一件非常難做到的事。有的孩子非常聰明，很快就學會了如何惹別人發怒，得以大鬧一場。老師要教會班級的同學如何選擇性地關注想要的行為，盡力逐漸減少對負面行為的關注。在孩子有搗亂行為時，如果能用平靜的語氣和他／她說話，同時提供合適的和自然的行為后果，就是一個好的開始。之后，我們必須保證孩子能有機會通過正面社交行為得到關注。
Q10: There are many different intervention methods out there, for example, DTT, VB, ESDM, RDI, etc. Does certain method work better with certain functioning level?行為干預的方法很多，比如DTT、VB、ESDM、RDI等等。不同程度的自閉癥孩子適合某個不同的方法嗎？
A10: There are a ton of intervention methods out there. Tracy has extended experience with DTT and VB. Her friend’s child was involved in RDI. What she can tell you is that as part of ABA, DTT and VB have the largest amount of research that demonstrates their efficacy. Parents can research other methods. However, ABA is the only one that is covered by insurance, which is considered as the gold standard. 行為干預的方法確實很多。Tracy在DTT和VB方面經驗豐富。她的朋友的孩子用過RDI。她可以確切說明的是，由于DTT和VB是ABA的一部分，有大量的研究證明其有效性。家長可以探索和嘗試其它方法。但是，ABA是唯一保險付費的方法，被認為是金標準。
Q11: How to help kids with delayed echolalia? 如何幫助延遲“仿說”的孩子？
A11: Echolalia is a common behavior among ASD children some time in their lives, especially during language acquisition years of childhood. Tracy has no experience with “delayed” echolalia. The strategy she can come up with is to block the behavior through occupying their mouths. It is also very important to have the child thoroughly checked for neuropsychological conditions to see if there are any medical causes such as auditoria processing issues. “仿說”是自閉癥孩子中常見的行為，特別是孩子在學習語言的童年期。Tracy對“延遲仿說”沒有經驗。如果不想孩子說，最好的方法是讓他們的嘴巴忙著嚼東西。同時，帶孩子去神經心理醫生那里做全面的檢查也是很必要的，有的仿說可能是“聽覺處理障礙”引起的。
https://www.iidc.indiana.edu/pages/Functional-Categories-of-Delayed-Echolalia
Q12: My 4 years old will sometimes start talking about books he read or show he watched out of nowhere. What can be done to reduce that behavior?我四歲的孩子有時會在，毫無關聯的情況下，講起他讀過的書或者看過的表演。如何減少這種行為？
A12: It depends on how it interferes with social situations. If it is not interfering with learning or functioning, it is best to be left alone. If it is interfering, you need to find competing reinforcer. During normal language development, it is common that while a child is falling asleep, he/she can tell a complete story about his/her day, which sounds not very sensible, but it is a normal part of language development. Thus, we need to be thoughtful and careful about the behavior, and make sure it is a socially significant problem. 這要看干擾社交的程度。如果不干擾學習和正常生活，最好不要當回事。如果有干擾，你要找有競爭性的強化物。在正常的語言發育過程中，常常看到，孩子快睡著時，他／她會講他／她一天的故事。聽起來詞不達意，但確實是語言發育中正常的現象。因此，我們必須謹慎小心，只有被專家診斷出是一個社交問題后再進行干預。
Some links一些鏈接:
http://www.specialconnections.ku.edu/~specconn/page/behavior/fba/pdf/completedabcchart.pdf
http://www.specialconnections.ku.edu/~specconn/page/behavior/fba/pdf/blankabcchart.pdf
