Just a year ago, Alexandra Ramirez’s 2-year-old patient refused to sit at a table and could not vocalize his wants or needs to the adults around him.
He would get upset and cry whenever he needed something, and his family was left frantically wondering exactly what he wanted. The challenges seemed endless, until his family found the University of Miami’s Intensive Behavioral Intervention Services (IBIS) Clinic—which serves children exhibiting developmental delays and those diagnosed with an autism spectrum disorder—and began therapy.
Today, the toddler is able to point or tap on a picture board to communicate what he wants, and is starting to use a form of sign language to say the word “more” when he wants extra food or to play a game again. He hugs Ramirez often and grins when she agrees to keep jumping if he says “more.” His expression in response to his therapist, although fleeting, is a critical step.
“He used to get so frustrated and shake his head, but now he can point to the toys he wants. And he is starting to use some words,” said Ramirez.
Although the toddler’s progress is slow, and he must practice these skills daily, the young boy’s therapy team is thrilled to see him grasping these important social cues. He is just one of about 15 to 20 students each year who spends three hours Monday through Thursday at the IBIS Clinic. And now, one of the clinic’s directors is looking for novel ways that technology can extend their services even more to those on the spectrum.
Started in 2015, the IBIS Clinic provides applied behavior analysis (ABA) therapy to children in the South Florida area who are ages 18 months to 3 years old. From the start, each child has their own individual therapist, who is also a graduate student in the master’s in behavior analysis program. Each therapist is then paired with a more experienced graduate student, as well as a faculty member from the Department of Psychology in the College of Arts and Sciences. Together, the therapy team designs a custom learning plan for each child based on their strengths and weaknesses. Then, each day during therapy, a faculty member and second-year student watch the session through a tablet—at least during the COVID-19 pandemic—and provide feedback and guidance to the therapist through a wireless earpiece (typically they work together in person).
According to the U.S. Centers for Disease Control, 1 in 54 children are diagnosed on the autism spectrum, and boys are four times more likely to be diagnosed than girls. Research indicates that the earlier children on the autism spectrum start therapy, the better they can adapt to societal norms like those expected in school. That is why the IBIS clinic works with toddlers at this pivotal time (before they turn 3 years old), said psychology professor Anibal Gutierrez, co-director of the clinic as well as associate director of the University of Miami-Nova Southeastern University Center for Autism and Related Disabilities (UM-NSU CARD). The clinic is a collaboration between faculty and staff members who are experts in ABA therapy, which utilizes evidence-based practices and lots of repetition to help young children gain the skills they need to thrive.
The results are often astonishing. By focusing on the building blocks of social communication—joint attention, play, imitation, and language—the therapists literally chart children’s progress each day, said Elaine Espanola-Aguirre, a board-certified behavior analyst and one of the four co-directors of the IBIS Clinic, as well as the practicum coordinator for the master’s in applied behavioral analysis program. One of the clinic's main goals is to prepare these children to acclimate to a school setting.
“We also want them to find their voice. Because while these children are communicating, it’s not always in a way that we can understand,” she added.
While some children may come in completely nonverbal and unable to identify their family members in photos, after a year they often leave the clinic chatting or saying a few words. Others are unable to make eye contact at the start of their therapy and later are able to interact with their therapist or another child without much prompting.
“Each child has a different result, but we always see a difference in all of our kids,” Espanola-Aguirre pointed out. “We all love being here each day because we all know we have the ability to directly impact a child’s life.”
Although the IBIS Clinic’s results are encouraging, Gutierrez also recognizes its limitations. To really provide effective therapy, young children on the spectrum need so much one-on-one time that often there are not enough therapists or clinics to meet the demand. While children enrolled in the small IBIS Clinic get 12 hours of therapy each week, they could use a great deal more, he said. Therefore, Gutierrez is working on two interdisciplinary teams to develop virtual reality and augmented reality applications that could supplement a patient’s time in the clinic.
One University Laboratory for Integrative Knowledge (U-LINK) team that includes Gutierrez, psychology professor Yanerys Leon, interactive media associate professor Kim Grinfeder, and electrical and computer engineering professors Hammam Alsafrjalani and Mohamed Abdel-Mottaleb, is working to develop applications for adolescents and adults on the spectrum to learn skills for independence, like how to build a hamburger, wash their hands, do their own laundry, and acclimate to an office space. Meanwhile, Gutierrez is also working on other virtual reality applications for toddlers on the spectrum to learn how to identify shapes, colors, animals, letters, and numbers.
“For most people, learning happens so quickly, we don’t even realize it, but for people on the autism spectrum, it can be days or weeks to learn something—often, they need a lot more practice,” explained Gutierrez, a board-certified behavior analyst who has been working with those on the spectrum for more than 20 years. “These repetitive tasks lend themselves to technology helping out.”
Once the applications are fully developed, Gutierrez hopes to test some of them in the IBIS Clinic, as well as through UM-NSU CARD’s network to find people with ASD of all ages—and to see if the technology is useful for therapy. The pandemic has slowed their progress, but Gutierrez hopes to start this summer.
“Some kids go to therapy for a few hours and that’s it, but this could be like homework and the goggles could guide them,” he said. “For example, children with autism need a lot of physical prompting, so could the goggles point them in the right direction?”
As artificial intelligence advances, these applications could also learn the preferences of each child, like the therapists at the IBIS Clinic do to motivate the children, said Grinfeder, chair of the Department of Interactive Media and director of the University’s Extended Reality (XR) Initiative, who is working with Gutierrez to brainstorm more applications where technology could amplify therapy. For example, in the clinic, Ramirez knows her patient loves Baby Shark. So, she often provides him with breaks between lessons with a Baby Shark book or puzzle. In the future, the applications could learn that a child likes a certain song or character and offer it each time the child is successful with a task.
“Children and adults on the autism spectrum often need training, experience, and coaching,” Gutierrez said. “So, we are thinking about how we could use technology to help give them greater independence.”
