Four key take home treatment strategies.

There was a great deal of information in the area of behavior and emotional/social treatment plans for children with autism. From the information that I learned, the following 4 strategies will make a positive impact on children with ASD.

1. From the verbal behavior treatment plan, one of the first goals for early or very low communicators would be to determine the items or objects that are reinforcing for the child
(beginning with 4-5) and work on getting the child to request these items using words, word approximations, signs or symbols. The rational for this treatment is that motivation needs to be established for the child and if there is motivation present there is a significantly increased chance that the communication attempt will be made (Sundberg and Partington, 1998)).

2. The use of 1-1 intensive treatment sessions for short periods of time (5-10 minutes), similar to discrete trial training, is a helpful strategy to incorporate when a child is very self directed initially and has difficulty completing simple imitation skills and following very simple 1 word directions. I would plan on moving these skills to a more natural teaching routine as soon as success is noted with the child being able to follow a task that is directed by an adult and is not strictly self-directed. The rationale is that for a child that does not demonstrate any ability to imitate of follow simple directions, the skills need to be taught before further learning can take place.

3. A key strategy from the floortime model is to allow the child to take the lead and attach meaning to their actions. One way that this can be helpful is in the development of imitation skills. When children have difficulty in verbally imitating sounds, if you follow the child’s lead and imitate what they are doing, they will often repeat the action again and both a turn taking routine and imitation of each other is developed.

4. A strategy from the Relationship Development Intervention program for children with autism that I would incorporate is to develop storng episodic memories through the use of videotaping. I would use videotapes of special events such as picnics or family get together and play these for the child while describing the routine, structure and events surrounding the event. Additionally from the RDI model I would treat initially individually, and then move to dyad and small groups. The rational for that is that typical children learn to be competent with adults before desiring to be with peers.

To see a very short RDI treatment video on 'emotion sharing with mommy', click on the link below:

http://www.youtube.com/watch?v=pp1LHVkocc4&feature=PlayList&p=95E4F2E6C25EEAD0&playnext=1&playnext_from=PL&index=3

What is valued and under-considered in current practice for children with ASD?

In all fields of treatment, both in schools, hospitals and rehabilitation centers, the target is the use of therapy techniques that are research –based. Evidence-based practice includes the use of therapy, treatments, and techniques that have been proven to be successful and to promote improvement with a certain population. Unfortunately, in the area of Speech and Language Pathology, there are few studies that are directly related to our field for the programs that I have covered in this blog. Generally, in the area of autism, the most research has been completed on ABA programs and success has been seen, albeit slowly, depending on the level of deficit. Therefore, I feel that ABA programs are the most valued, especially by parents and those whose training is in the area of Applied Behavior Analysis. There is a study from the University of Wisconsin that compares the research in several programs for students with autism and how the techniques apply to the field of Speech Pathology.

I am including the link to the student research study below:

http://minds.wisconsin.edu/handle/1793/23126

From the extensive and very interesting research that has been read for this course, I feel that any program that is developed for children with autism needs to include the core deficits of that particular child or individual. Therefore, each program should look different for each child. Both behavior and social/emotional based programming is needed in most cases for individuals with ASD, as their core deficits fall in these areas. Additionally, the inclusion of strategies to help with issues of environmental complexity and to help meet the sensory needs of each child will also need to be incorporated in a comprehensive program for those with ASD. Programming should also continue to be adapted as the child’s needs change.
One example is the need for ABA treatment procedures for a child that has many behavior issues and no beginning communication. The ABA programming will help to develop the beginning prerequisite skills, communication, specifically the ability to request wants and needs, and following directions. Along with that the child may be receiving sensory strategies to help them to modulation themselves and strategies to improve joint attention (following a point, following a person’s gaze). As these skills develop, play, initiation with adults and peers, teaching executive function skills that we have learned are important, categorization, as well as teaching deficit areas in academic skills and socialization will be added throughout the years to help the individual with autism continue to succeed and be better prepared for the transition to adolescence and adulthood.

The link below is a song that I just discovered on youtube that captures the essence of why we need to use whatever methods will help the increasing number of children with autism be successful in life:

http://www.youtube.com/watch?v=1hiQYurSJCQ&feature=related

ABA/Emotional programs and their relationship to the SLP

The involvement of Speech-Language Pathologists in behavior or emotional/social based programs will vary according to the program in which they work.

If the SLP is trained in a specific program, such as verbal behavior, they may be running mand (request) sessions in a 1-1 format, or even running intensive teaching session, which involves many more skills than just manding or teaching a child with ASD to request. In other programs, the SLP may have a very large caseload and may only be providing support to the team carrying out the program. Support may consist of helping to plan carryover of skills to the natural environment (NET) or to help to determine what syllable shape a child may be using if there is suspicion of verbal apraxia. The SLP has the most knowledge in knowing how syllable shapes develop and what the next level of production can be as a child masters an easier production (such as with the Kaufman cards that are used frequently in shaping word production with this population and others). This same type of involvement can be seen in the CLM and discrete trial sessions. SLP involvement is seen less frequently in DTT programs in the location in which I practice.

In emotional/social based programs such as RDI and Floortime, there is specific training that is required in order to teach parents to carry out the program. There are no programs in my vicinity that utilize these programs. However, SLP’s receive specific training in the area of pragmatic language, and we use many techniques that we incorporate from programs such as theirs into our therapy sessions, as well as when we treat in an integrated classroom. Some of the programs that we have spoken about is the I LAUGH program by Michele Garcia-Winner. The Hanen Centre is also centre that focuses on training SLP’s to provide family, parent and teacher trainings and have programs specifically for autism. They have several books such as “More than Words’ and Talkability” that contain many great strategies for increasing conversation and non verbal language, which is crucial in the development of social skills for individuals with autism.

http://www.hanen.org/web/Home/tabid/36/Default.aspx

http://www.socialthinking.com/

Comparison of 3 ABA -based therapy approaches with those that are more socially and emotionally based

There are several basic differences between ABA based programs and social/emotionally based programs that were discussed previously in this blog. The basis of Applied Behavior Analysis programs, such as discrete trial teaching , verbal behavior and the competent learner model, focus on teaching specific skills, such as communication and academic skills using objective and measurable terms. Tasks are often broken into small discrete steps so that mastery and progress can be easily measured. Data collection is a key component of ABA based programs, so that it is easy to determine whether a child is improving. ABA programs also help to provide a replacement behavior, such as communication skills, in order to aid in reducing the problem behaviors that often occur in children with autism. Generalization is a part of ABA teaching and training, and planned structured activities are used to generalize mastered skills to a natural environment. There are specific assessments in ABA programs to help determine the starting point for a child, and baselines for behaviors are also used to measure progress or the reduction of behaviors. Therapy is carried out by trained therapists and often managed by behavior specialists. ABA programs have research that demonstrates the effectiveness of their programs, due to the extensive amount of data collection that occurs.

Programs such as Floortime and RDI have the emotional and social development of the child as their primary focus. Therapy is focused on play and imaginative skills, or on the emotional relationship development of the child. Therapy is also often child centered and parents, who lead the therapy sessions, are taught to follow the child’s lead. The measured of progress is more subjective, although there are specific levels in each of the programs that a child needs to work through. Academic skills and basic communication are not the focus of these programs, although basic turn taking in interactions is stressed. Behavior is not targeted. Since social relationships are an integral part of the autism spectrum disorder, these programs are felt to be addressing the ‘crux’ of the problem, and improvement in these areas will help the individual with autism function in his environment and develop friendships and peer relationships. Although these programs are parent led, parents are supported by specially trained clinicians. Due to the child-led focus, it is sometimes easier to keep and maintain the attention of the child for longer periods of time. Research to support these programs is less extensive than that of ABA programs.

Floor Time and RDI

Floor Time and RDI

Floortime
Drs. Stanley Greenspan and Serena Wieder developed, DIR, which stands for the Developmental, Individual Differences, Relationship-Based Model. It is an in-depth, interdisciplinary approach that has the emotional development of the child as its primary focus. It takes into account the child's feelings, relationships with caregivers, developmental level and individual differences in a child's ability to process and respond to sensory information
The goal of treatment is to help the child develop emotional milestones that were missed in his early development and that are critical to learning.

Floortime is a vital element of the DIR/Floortime model. It is a treatment methodology for interacting with children (and adults as well) that was developed by Greenspan around 1988. Floortime involves meeting a child at his current developmental level, and building upon his particular set of strengths. It trains parents and caregivers to work together with children using child-directed play, which is what Greenspan calls “floor-time’. His intention is to use play to improve attention and intimacy, promote two- way interaction and communication, encourage expression of feelings and ideas and develop logical thoughts. During floor time, a more child -based methodology is followed. Adults do not impose their thoughts or ideas on the child to engage in adult – directed activities. Parents are taught to view all activities as purposeful and use the child’s interests to expand upon through imitation, expansion and responding in a way that will elicit communication.
DIR/Floortime works on improving six basic developmental milestones that they feel children must master for healthy emotional and intellectual growth. They are:
1. Self-regulation and interest in the world
2. Intimacy or Engagement
3. Two-way Communication
4. Complex Communication
5. Emotional Ideas
6. Emotional and Logical Thinking

DIR/Floortime therapy is parent based but under the very strict control of a clinician trained in the program model. That person may prescribe a number of 20-minute Floortime sessions a day as part of a comprehensive treatment program. Therapy can also be provided through natural routines within the child’s daily routines.

It was difficult to find research that supported the actual DIT-Floortime Model of therapy specifically. According to information on the DIR- Floortime Website, a recent chart review of 200 children with complex developmental challenges found over 50% of children originally diagnosed with autistic spectrum disorders and treated intensively with DIR/Floortime approaches for four to six years have become warm, engaged and loving, no longer qualifying for the Autism diagnosis. These children became active learners with highly developed abilities in the areas of verbal skills, imagination, logical and abstract thinking, as well as pleasurable peer relationships. Many of them attended mainstream schools, and their teachers were often unaware of the child’s original diagnosis. Other children, because of greater neurological challenges, made slow and steady progress.

Progress is measured by observing how the child is relating, communicating and thinking. Improvements in these skills are felt to be far more important indicators of progress than a lessening of symptoms.

For more information on the DIR-Floortime model of treatment for children with autism, please follow the link below:

http://www.icdl.com/dirFloortime/research/index.shtml


RDI

RDI stands for Relationship Development Intervention. It is a parent-based clinical treatment for individuals with a diagnosis of an autism spectrum disorder as well as other relationship –based disorders. RDI is based on a model of Experience sharing developed by Steven Gutstein, Ph.D. this program is based on his extensive research of the development of emotional relationships by typical children. The primary goal of RDI therapy is to teach motivation for and the skills of experience sharing interaction, which Gutstein feel is at the core of autism.

There are 10 basic principles that underlie the model of DRI. They are as follows:
1. Carefully and Systematically Build Motivations
Create strong and positive episodic memories by the use of shared excitement, videotape review, memory books…
Teach functions before skills, which provides the motivation
2. Carefully Evaluate Developmental Readiness before Teaching Skills
3. Children Learn to Be Successful by Experiencing Competence. They Cannot Achieve Competence if They Develop a Dependency on Capable Partners.
4. Learn to be an Experience sharing Coach by Developing a Balance of Guiding and Pacing
5. Employ an Invitational Approach and use Indirect Prompts when Possible
6. Spotlight Important Information using your Face, Voice and Body to Ensure that Critical Information Stands Out.
7. Use Expandable Activities to Develop Experience Sharing and Avoid Activities.
8. Expect to Make Mistakes Lading to New Discoveries
9. Make Sure to Develop Experience Sharing Language
Examples: We can do it! Tray again! Did you see that?
10. Move from adults to dyads to groups
Typical children learn to be competent with adults before desiring to be with peers/ Move from 1 peer to dyads to groups systematically.

The research that supports RDI was completed by Steven Gutstein. The link for this research can be found on the RDI website link provided below. His research summary reports that 17 children aged 2 to 10 who received RDI therapy from their parents were compared to 14 children receiving other therapies. Both groups were administered the ADOS (Autism Diagnostic Observation Schedule) initially then 9 months later. Although both groups were similar at the initiation of the study, 70% of the RDI group had improved their ADOS scores, while none of the non-RDI group improved their classification.

For additional information on RDI please follow the following link:

http://www.rdiconnect.com/default.asp

Comparisons of RDI and Floortime

RDI and DIR-Floortime interventions are similar in that both are based on improving and increasing the emotional and relationship aspects of those children with autism, as they feel that this is the core deficit in autism. Both use trained clinicians to monitor the program and both programs use parents as the actual ‘teachers’ or executors of the actual program. The RDI program has an assessment that is completed prior to starting, which is called RDA or Relationship Development Assessment. This assessment is then used to monitor progress. Floortime works through levels that are set up within the program. Specific data collection for either of these programs was not mentioned. Additionally, peer reviewed research was not available for either program.

A Comparison of 3 ABA Different Models

Discrete Trial Training is considered a more traditional ABA model, while Verbal Behavior and the CLM model are more contemporary type approaches. Discrete Trial Training , such as the one pioneered by Dr. Ivaar Lovaas stresses compliance training, imitation skills, and building receptive language for young, non-vocal early learners. The VB model, on the other hand, looks first at what the child wants and then teaches the child how to request (in VB terms, how to mand). Initially that may involve only the child reaching for the item to indicate interest. The child quickly learns that if he uses “verbal behavior” or reaching in this case, to indicate interest in something, he gets the item. Many VB consultants also recommend the use of sign language for most non vocal early learners while Lovaas consultants rarely recommend signing as a first step. In VB programs, early skills, such as manding, are usually taught away from a table and in the natural environment. Both Lovaas and VB programs are based on the principles of ABA so there are many similarities as well as a few key differences. (Pa Verbal Behavior Project Family Handbook, 2006).

A side-by-side comparison of the CLM and VB programs find many similarities and few differences. There are no large scale inter-group design comparison treatment studies to support either program, although they are both based on researched principles of effective instruction including ABA, Direct instruction and the Analysis of Verbal Behavior. Significant training is provided for staff in both of these programs to assure that they are carried out effectively. In the area of instruction, Verbal Behavior uses intensive teaching in 1;1 or dyads, where CLM begins in 1:1 and systematically moves to 1:2 , 1:3, 1:4 etc. both VB and CLM use natural environment teaching(NET) while verbal behavior also stresses errorless teaching procedures . There is a greater emphasis for non-vocal learners to establish an augmentative communication system with additional vocal training procedures in place.

In an article by Delprato (2001), researchers examined a series of 10 controlled studies in which traditional operant behavioral procedures were compared with more recently developed normalized interventions for teaching language to young children with autism. The main characteristics of the older treatments programs included highly structured direct teaching sessions of discrete trials, teacher initiation, artificial reinforcers, and response shaping. The programs that were considered a more normalized or contemporary use of ABA components consist of loosely structured sessions of indirect teaching with daily routines, child initiation, more natural reinforcers, and a liberal criteria for presentation of reinforcers. Two types of more contemporary ABA approaches considered were incidental teaching and pivotal response training. The conclusion was that in all eight studies, normalized language training was more effective than discrete-trial training. In addition, in the studies that assessed parental affect, normalized treatment yielded more positive affect than discrete-trial training.


CLM handout, Components of VB and CLM Projects, Side by Side Description, unknown source, February, 2009.

Delprato, Dennis. "Comparisons of Discrete-Trial and Normalized Behavioral Language Intervention for Young Children with Autism." Journal of Autism and Developmental Disorders 31.3 (2001): 315-325.

Three behavioral Theories

Applied Behavior Analysis was first originated by B.F Skinner. Applied Behavior Analysis is defined by Cooper, Heron, and Howard, (1987), as “The science in which procedures derived from the principles of behavior are systematically applied to improve socially significant behavior to a meaningful degree and to demonstrate experimentally that the procedures employed were responsible for the improvement in behavior.” In this model, behavior is defined in objective and measurable terms. All behavior is analyzed through a 3-part system, known as the ABC”s of behavior. Note the diagram below:

A B C
Antecedent Behavior Consequence
before after


An antecedent is what happens before the behavior occurred. The behavior is the exact description of what the behavior looked like using measurable terms. The consequence is what happened directly after the behavior occurred.

Reinforcement, data collection and very meticulous prompt delivery and fading are important in a successful ABA program. Differences lie in the way reinforcement is used and will be discussed in further program descriptions.

Although ABA has been around for many years, its use as a teaching method for teaching children with ASD is more recent. The purpose of ABA in programming for ASD is to reduce some of the disruptive behaviors in individuals with autism, and to teach communication, social skills, play and self -help skills. (Bureau of Autism Services, 2007) For the purposes of the topic, we will consider the use of ABA in a variety of teaching programs, specifically, Discrete Trial Training, Verbal Behavior and The Competent Learner Model.

Discrete Trial Teaching is the primary instructional method in ABA. It involves breaking down a skill into much smaller parts, teaching each of these smaller parts at a time, allowing repeated practice, providing prompting for initial success then fading prompts systematically and utilizing reinforcement procedures to increase motivation. Skills are taught in a 1-1 format. Once a skill is mastered, generalization of that skill is incorporated into the program along with the acquisition of new skills.

To learn more about ABA and the early discrete trial method, watch this 9 minute video on you tube:
http://www.youtube.com/watch?v=2afb4i7LMJc

Verbal Behavior programming is also guided by the principles of Applied Behavior Analysis (ABA) and is considered a more contemporary behavior approach. . In addition to using ABA principles, a Verbal Behavior (VB) practitioner also incorporates B.F. Skinner’s Analysis of Verbal Behavior. More recently, Sundberg and Partington have outlined and studied the verbal behavior approach.

Verbal Behavior is defined as behavior that is mediated by the behavior of another person. This means it is what we do in most of our interactions with other people. Verbal behavior is communication. (Sundberg and Partington, 1998). It focuses attention on the functional analysis of language: looking at the conditions under which a person will use language. Rather than the communicative functions referred to by a speech-language pathologist, Verbal Behavior uses terms such as mands (requests), tacts ( labels) or intraverbals (answering questions and responding to another). All functions of a word are taught. Verbal behavior includes many different modalities, including speaking, using gestures, use of sign language, use of picture systems, and the use of various augmentative communication devices. Although all these modalities can be used with verbal behavior, the preferred alternative modality to speaking is signing, which is topographically similar to speaking. Verbal behavior instruction follows strict behavior principles and uses intensive data collection to record progress.

Verbal behavior involves teaching many skills within intensive teaching sessions using errorless teaching and fast paced instruction. In order to reduce problem behavior and enhance generalizations, tasks are presented one after another from many skill areas. Task complexity varies between easy tasks (allows for more reinforcement) with tasks that are more difficult and require more effort. The goal of this program is functional communication. The expectation is that the child will be able to request, comment, and respond to questions (using a word for a variety of language functions) in natural activities and routines. Manding or requesting is taught first, by paring yourself with fun and strong reinforcers that the child likes. An important and more recent aspect of Verbal Behavior is to teach a mastered skill in the natural environment, or Natural Environment Teaching (NET) to generalize the skills with others and in other environments.

The decision on what tasks to work on is determined by a criterion referenced assessment known as the ABLLS (The assessment of behavior and Language skills (Sundberg and Partington ) or a shortened version known as the BLAF ( The Behavioral Language Assessment Form ( Sundberg and Partington).This assessment is also helpful for demonstrating progress in the areas that are being addressed.

The Competent Learner Model is also based on behavioral and direct instruction principles. The target population is for children with complicated learning profiles, including children with autism. This program, developed by Vic Tucci, includes staff training and curriculum. The curriculum includes learner assessments, effective teaching strategies and a scope and sequence. Initially the student is assessed using the Competent Learner Repertoire Assessment and an Individual Placement test. There are seven repertoires and they include the following:
Participator –participates in a variety of instructional settings and persists with a task , even if novel or difficult.
Problem Solver- Learns to behave in a way that will lead to a solution
Listener- follows directions or listens to advice in given situations
Observer-Will produce factual information ( label), matches and imitates others actions
Talker- Speaks conventionally and answers questions on topic in an acceptable manner.
Reader- Reads material fluently and answers questions about the material.
Writer –Produces written material to convey clear ideas.
The seven repertoires form a core to all learning to all functional activities. The program provides very defined lessons which provide specific descriptions for teacher and learner behaviors, materials and criteria for mastery. There are specific training components or competencies that teachers and staff that work with this program must complete in order to administer it properly.
For a review of the CLM model, use the link below:

mms://pattanwc1.pattan.net/files/windows/2008/july/clm.wmv

Carbone, Vincent. "Teaching Communication Skills to Students with Autism Using Skinner's Analysis of Verbal Behavior." National Autism conference. Penn State University, State College, PA. 5 Aug. 2004.

Lee, David. "The ABC's of Applied Behavior Analysis-A Primer." Penn State University. videocassette. 2003.

Milchick, Sherry. "Advanced Applied Behavior Analysis." Berks County Intermediate Unit. Berks County Intermediate Unit. 10 May 2007.

Reese, Jeanne, and Mikus, Mary. "All About Autism." Berks County Intermediate Unit. Unknown.