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Implementing a Continuum of Promising Interventions for Students with ASD: Implications for School-Based Practitioners

Overview

Brief Overview of ASD Role of the School Psychologist in the Education and Treatment of Children with ASD Diagnostic and Assessment Considerations Fostering Data-Based Decision-Making Promising vs. Questionable Interventions Working with Teams to Implement a Continuum of Services for Children with ASD

Richard J. Cowan, Ph.D., NCSP Kent State University

Autism Spectrum Disorders & Pervasive Developmental Disorders

Autistic Disorder

Autistic Disorder is characterized by...

Qualitative differences in communication

Functional communication Limited means of expressing wants, needs, emotions

Qualitative differences in social interactions Autistic Disorder PDD-NOS Asperger's Syndrome Rett's Disorder

Often isolated May appear non-responsive Unaware of nonverbal communication patterns in social interactions

Restricted, repetitive, and stereotyped patterns of behavior, interests, or activities

Childhood Disintegrative Disorder

Autistic Disorder

There is a high rate of incidence of mental retardation in individuals with Autistic Disorder Individuals with Autistic Disorder often demonstrate poor self-help skills Autistic Disorder is an early-onset disorder

Asperger's Syndrome

Individuals with Asperger's...

have impairments in the area of socialization, & exhibit restricted, repetitive, stereotyped patterns of behaviors and interests

Individuals with Asperger's tend not to show significant delays in...

Communication Cognitive development

1

Asperger's Syndrome

Fewer individuals with Asperger's experience mental retardation Many children with Asperger's have `lowaverage' intelligence According to the current classification system (i.e., the DSM-IV of the APA, 2000), this is separate from high functioning autism

PDD-NOS

Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) is diagnosed when someone does not meet the criteria for any of the other PDD disorders yet demonstrates severe impairment in social interaction, communication, and/or exhibits restricted, stereotyped behavior patterns

Do not forget to consider the individual child....

low Functioning high

Prevalence of ASD

1:150--Center for Disease Control (CDC) 4-5 times more likely in boys than girls Is there a rise in incidence?

Absolutely

Individual Diagnosed with Autistic Disorder

Do we know why there is a rise?

low

PDD-NOS

SEVERITY

Autistic Disorder

high

Asperger's

No...but we can speculate...

Roles

Student/Instructional Assistance Teams Pre-referral intervention Consultation Individualized, Class-wide, School-wide, District Level, Systems Level Multi-Factor Evaluations (MFE) or Evaluation Team Reports (ETR) Diagnosis and Assessment Considerations IFSP/IEP development and implementation Re-evaluation Others?

Overview

Brief Overview of ASD Role of the School Psychologist in the Education and Treatment of Children with ASD Diagnostic and Assessment Considerations Fostering Data-Based Decision-Making Promising vs. Questionable Interventions Working with Teams to Implement a Continuum of Services for Children with ASD

2

Diagnosis: Typical Pathway

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR, American Psychiatric Association, 2000) Generally, an ASD/PDD diagnosis comes from a psychologist (Ph.D.), psychiatrist (MD), or pediatrician (or other qualified physician, MD) Caution: Insurance Caps/Denial Many regional/national organizations (e.g., OCALI) suggests a multidisciplinary, team-based approach (i.e., medical and educational professionals working together)

Diagnostic Process, Methods, and Instruments

Process

Interviews (Developmental History) Observations (Social interactions, in particular) Norm-referenced tests and rating instruments Medical tests

Co-morbid conditions, not diagnostic

Method

Multidimensional Multiple sources, settings, instruments

Diagnostic Process, Methods, and Instruments

Common Diagnostic Instruments

Infancy/Toddler

Checklist for Autism in Toddlers (CHAT)

CHAT is available ONLINE for FREE!

Diagnostic Process, Methods, and Instruments

Diagnostic Assessment Method

(Adapted from Khouzman, El-Gabalawi, Pirwani, & Priest, 2004)

Social Abilities and Interactions

Social Skills Rating System (SSRS; AGS) Behavioral Assessment System for Children, Second Edition (BASC-2; AGS) Interviews and Observations Other considerations? Methods?

School-aged Students

Autism Diagnostic Interview-Revised (ADI-R) Autism Diagnostic Observation Schedule (ADOS) Childhood Autism Rating Scale (CARS) Gilliam Asperger's Disorder Scale (GADS) Gilliam Autism Rating Scale (GARS) Interviews and Observations

Social-Emotional/Behavioral

SSRS, BASC-2, Achenbach Scales (TRF; ASEBA) Interviews and Observations

Diagnostic Process, Methods, and Instruments

Diagnostic Assessment Method

(Adapted from Khouzman, El-Gabalawi, Pirwani, & Priest, 2004)

Diagnostic Process, Methods, and Instruments

Diagnostic Assessment Method

Neuropsychological Processing

Halstead-Reitan Neuropsychological Battery Luria-Nebraska Neuropsychological Battery Wisconsin Card Sorting Test

Sorting by shape, number of stimuli, and color Purpose: an applied observation of task-shifting ability

IQ/Cognitive Scales

Stanford-Binet: Fifth Edition (SB-5) Wechsler Scales: WAIS-III, WISC-IV, WPPSI-III WJ-III-COG; DAS; Kaufman Scales Psychoeducational Profile, Third Edition (PEP-III) Nonverbal: Lieter International Performance Scale, Comprehensive Test of Nonverbal Intelligence (CTONI), Wechsler Scale Others?

Stroop Test

Reading words in different colors Purpose: measures ability to discriminate, filter distracters

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Diagnostic Process, Methods, and Instruments

Diagnostic Assessment Method

(Adapted from Khouzman, El-Gabalawi, Pirwani, & Priest, 2004)

Diagnostic Process, Methods, and Instruments

Diagnostic Assessment Method

(Adapted from Khouzman, El-Gabalawi, Pirwani, & Priest, 2004)

Communication

Pragmatic Language Questionnaire (from: CELF-4) BASC-2 Interviews and Observations

Interviews are less reliable than observations! Gather as much informal and authentic assessment data as possible (How might this be accomplished?)

Scales/Subscales from SSRS, Vineland, etc.

Stereotypical Behavior Aberrant Behavior Checklist (ABC) Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) Interviews and Observations Movement and Sensory Fine/Gross Motor, Other? CAUTION! Vineland, Other? Adaptive Functioning Vineland, Other? What about INDIVIDUAL strengths and needs?

Diagnosis: Educational Team

Following from the Individuals with Disabilities Education Improvement Act (IDEA, 2004) Educational Team

Academic and Behavioral Assessment Autism category Other categories: LD, ED/BD, OHI, others?

Beyond Diagnosis: Individualized Assessment

First, eligibility determination (per IDEA), then... Impact on educational progress (IDEA)

Behavioral Social-Emotional Communication (quality, topography) Cognitive Adaptive Academic Achievement Consider academic, social, behavioral functioning across settings, at the individual level...

What is unique about educational assessment? It is characterized by...

Informal/Local/Authentic Assessment

IEP Considerations

Don't forget the process: Eligibility determination goals and objectives of IEP accommodations LRE placement ongoing evaluation recycle (as needed) Each child with autism is unique; each child will require an individualized assessment and education plan

Overview

Brief Overview of ASD Role of the School Psychologist in the Education and Treatment of Children with ASD Diagnostic and Assessment Considerations Fostering Data-Based Decision-Making Promising vs. Questionable Interventions Working with Teams to Implement a Continuum of Services for Children with ASD

4

Types of Measurement Techniques

Permanent products Direct Observation of Behavior

Event recording Duration recording Latency recording Interval recording

Partial interval Whole interval Momentary time sampling

Permanent Product

Use it when

You can see evidence that the behavior happened You are interested in how many times the behavior occurs

Keep in mind

Each time the behavior happens, it should result in the same end-product Only the target behavior should be able to have produced the evidence

Not good to use if

(Alberto & Troutman, 2006)

The behavior does not result in a product You are interested in how long the behavior occurs

Using Permanent Product Measurement

Determine what constitutes an acceptable outcome of the behavior--use the conditions established in the behavioral definition Evaluate the outcome of the behavior Make note of how many of the products were produced acceptably according to the definition of the behavior

Event Recording

Use it when

You want to know how many times a behavior happens

Keep in mind

The behavior must have a definite beginning and ending

Not good to use if

The behavior occurs too quickly to count each time it happens accurately You are concerned with how long the behavior occurs instead of how many times it happens

Duration Recording

Use it when

You want to know the length of time a behaivor occurs

Latency Recording

Use it when

You want to know how much time passes between an opportunity to perform a behavior and the initiation of the behavior

Keep in mind

The behavior must have a definite beginning and ending

Not good to use if

The behavior occurs too quickly to measure the duration of each occurrence You are concerned with how many times the behavior happens instead of how long it occurs

Keep in mind

The behavior must have a definite beginning and ending

Not good to use if

You are concerned with how many times the behavior happens or the total duration of the behavior instead of how long it takes to initiate the behavior

5

Interval Recording

Use it when

You want to estimate how many times a behavior happens You can not count each occurrence of behavior; instead the number of intervals that the behavior happened within a period of time is counted

Types of Interval Recording

Partial interval recording

Did the behavior happen at all during the interval?

Whole interval recording

Did the behavior happen for the entire interval?

Keep in mind

Good to use if the behavior happens quickly

Momentary time sampling

Was the behavior happening at the end of the interval?

Not good to use if

You want to know the actual number of times a behavior happens or how long a behavior occurs

What do you want to know?

Baseline Assessment of Skills and Curriculum Development

Where do you turn for curriculum? What data do you have on the student's strengths and needs? What can the student do? What are the student's emerging skills? Where do you begin DTT programming?

Number of Times

Amount of Time

Event Interval Recording

Duration Latency

Baseline Assessment of Skills and Curriculum Development

Conduct an individualized skills assessment to guide programming Useful Assessment Tools:

Interviews and Classroom Observations BRIGANCE Comprehensive Inventory of Basic Skills­ Revised (CIBS­R; Brigance Publishing) Assessment of Basic Language and Learning SkillsRevised (ABLLS-R; Partington & Sundberg, 2006) Assessment, Evaluation and Programming System ­ Second Edition (AEPS; Brookes Publishing)

Baseline Assessment of Skills and Curriculum Development

Assessment of Basic Language and Learning SkillsRevised (ABLLS-R; Partington & Sundberg, 2006) Assesses multiple domains, including language (communication), social, self-help, and range of behaviors (linked to range of interests) Allows for within-subject comparisons, over time Has immediate implications for intervention Built-in progress monitoring system

6

The ABLLS Assessment Domains

Cooperation/Reinforcement Visual Performance Receptive Language Imitation Vocal Imitation Requests Labeling

The ABLLS Assessment Domains (continued)

Intraverbals Spontaneous Vocalizations Syntax and Grammar Play/Leisure Social Group Instruction Classroom Routines

The ABLLS Assessment Domains (continued)

Generalized Responding Reading Math Writing Spelling Dressing, Eating, Grooming, Toileting Gross Motor, Fine Motor

B16 B15 B14 B13 B12 B11 B10 B9 B8 B7 B6 B5 B4 B3 B2 B1

B Visual Performance

DTT Case Study: Client Demographics

Jared

4 ½ year-old African-American male Diagnosed with autism at age two Significant language delays Cognitive functioning at intake: MH Moderate range Overall SS = 36 Lives in with parents and three siblings (older sister [6], younger sister [2], and younger brother [3]) In addition to social, communication, and play deficits, concerns for this client included physical aggression and noncompliance His family was considering residential placement

DTT Case Study: Initial ABLLS Results

Areas of assessment:

-Cooperation and Reinforcer Effectiveness: -Visual Performance: -Receptive Language: -Imitation: -Vocal Imitation: -Requests (manding): -Labeling (tacting): -Intraverbals (FFC: Feature, Function, Class): -Spontaneous Vocalization: 12/30 13/76 10/116 8/46 2/36 5/68 0/142 0/164 3/28

7

DTT Case Study: Outcome Assessment

ABLLS Core Area: Gain: Cooperation and Reinforcer Effectiveness: Visual Performance: Receptive Language Imitation: Vocal Imitation: Requests (manding): Labeling (tacting): Intraverbals (FFC: Feature, Function, Class): Spontaneous Vocalization: Overall IQ : Initial: 6-mo: % 12/30 13/76 10/116 8/46 2/36 5/68 0/142 0/164 3/28 23/30 46/76 60/116 35/46 17/36 31/68 9/142 7/164 11/28 92% 254% 600% 338% 750% 360% n/a n/a 267%

Overview

Brief Overview of ASD Role of the School Psychologist in the Education and Treatment of Children with ASD Diagnostic and Assessment Considerations Fostering Data-Based Decision-Making Promising vs. Questionable Interventions Working with Teams to Implement a Continuum of Services for Children with ASD

Initial: 36

Post: 74

Approaches to Intervention

Attitudes, values, and beliefs shape our approach to working with children who demonstrate disruptive behaviors Our approach to working with children is also influenced by what we know about various schools of thought about behavior explanations (e.g., psychodynamic vs. behavioral)

Approaches to Intervention

(continued)

Psychodynamic/Psychoanalytic

Relates back to childhood "couch therapy"

Medical/Biological

Prescriptions Over the counter agents

Behavioral/Educational

Arranging antecedents and consequences

Comprehensive Approach

How to Determine the Best Approach

Start with evidence-based interventions

Research shows the treatment made a statistically significant change in children's behavior--statistically significant vs. clinically significant Find evidence-based practices in professional journals or ask experts--but ask experts to tell you what the research shows about the effectiveness of the intervention.

Levels of Research/Evidence of Effectiveness

Questionable interventions

Although there is a clear lack of scientific evidence, these interventions continue to be promoted

Promising interventions

There exists some research to support the effectiveness of these interventions; however, we still need to approach them with caution and make sure they are applicable to this child in this situation

8

Questionable Interventions

Psychoanalysis Sensory Integration Therapy Auditory Integration Therapy Equestrian Therapy Dolphin Therapy Holding Therapy Options Therapy Rapid Prompting Refuted Intervention: Neurological Facilitated Communication Reprogramming

Herbert et al., 2002; National Research Council, 2001

Questionable Interventions

(cont'd)

Social Stories Sensory Diets Floor Time (Greenspan) Diets/Vitamins/Supplements Chelation Therapy

(removing toxins)

Recreational Therapies

Aquatic, Art, Music, etc.

Relationship Development Intervention (RDI)

Focuses on transition, relaxation and flow

Herbert et al., 2002; National Research Council, 2001

Promising Interventions

Applied Behavior Analysis (ABA)

Positive/Negative Reinforcement, Differential Reinforcement, Behavior Momentum, Token Economies, Discrete Trial Training (DTT)

Promising Interventions

Applied Behavior Analysis (ABA)

Positive Reinforcement Negative Reinforcement Differential Reinforcement

Planned Ignoring + Positive Reinforcement

Structured Teaching (e.g., TEACCH) Educational Interventions (e.g., PECS) Comprehensive Programs Medical Interventions

Token Economy Systems Discrete Trial Training Thousands of studies demonstrating efficacy of ABA-based interventions for individuals with disruptive behavior (Maurice, Green, & Luce, 1996, 2001)

ANTECEDENT OR TRIGGER Providing an Opportunity to Learn Practice

Promising Interventions

Educational Interventions

TEACCH (Teaching and Education of Autistic and related Communication handicapped Children) PECS (Picture Exchange Communication System)

BEHAVIOR A Response from the Student

Comprehensive Programs

Learning Experiences: An Alternative Program for Preschoolers and Parents (LEAP) Denver Health Sciences Program

CONSEQUENCES Reinforcing the Appropriate Response (or Approximation)

Medical Interventions

Think about the implications of medical interventions as a "ready to learn" process

9

Medical Interventions

Stimulants, SSRI's, and other classes of medication These are helpful for TREATING SYMPTOMS Each medicine targets a specific symptom/set of symptoms; however, there is no cure for autism! What is our role in medical intervention?

Making sure the child takes his/her medication to maximize performance in the classroom Monitoring the symptoms associated with the medication to help make decisions about the effectiveness of meds Making certain that you view medication as one component in a comprehensive approach to education

Recommended Practice

National Research Council (2001)

"Effective preschool programs for children with ASD include: Entry into intervention programs as soon as the diagnosis is suspected, Active engagement in intensive instructional programming for a minimum of the equivalent of a full school day, 5 days a week (at least 25 hours a week), with full year programming varied according to the child's chronological age and developmental level, Repeated, planned teaching opportunities generally organized around relatively brief periods of time for the youngest of children (e.g., 15-20 minute intervals), including sufficient amounts of adult attention in one-on-one and very small group instruction to meet individualized goals,

Recommended Practice

National Research Council (2001)

(continued)

Additional Recommendations National Research Council (2001)

Sufficient individual attention every day so that Individual Family Service Plan (IFSP) and Individualized Education Program (IEP) objectives may be addressed with adequate intensity Successful interactions with typically-developing children Instruction in the areas of functional spontaneous communication, social interaction, play skills, and cognitive skills taught in a manner to facilitate generalization, proactive and effective approaches to challenging behavior, and functional academic skills

Inclusion of a family component, including parent training, Low student/teacher ratios (no more than two young children with ASD per adult in the classroom), and Mechanisms for ongoing program evaluation and assessment of individualized children's progress, with results translated into adjustments in programming" (p. 175)

http://www.nationalacademies.org/nrc/ http://www4.nationalacademies.org/news.nsf/isbn/0309075777?OpenDocument

Overview

Brief Overview of ASD Role of the School Psychologist in the Education and Treatment of Children with ASD Diagnostic and Assessment Considerations Fostering Data-Based Decision-Making Promising vs. Questionable Interventions Working with Teams to Implement a Continuum of Services for Children with ASD

Things to Consider....

Who (staff, other) What (activities) Where (location) When (time) DATA (What data? & Who is responsible?) Preference Assessment and REWARDS! NRC: 15-minute intervals

10

Promising Interventions

Discrete Trial Training

Not just Lovaas (analog) discrete trial training There exists a range of evidence-based approaches to DTT (Analog ­ Naturalistic) Naturalistic approaches to DTT have proven equally effective as analog approached

In addition, generalization and spontaneity are enhanced, as compared to analog approaches alone

Discrete Trial Training

Analog Approach to Intervention

Lovaas-based DTT

Naturalistic Teaching

Natural Language Paradigm & Pivotal Response Training Incidental Teaching Milieu Teaching Mand-Model Procedure Time-Delay Procedure Behavior Chain Interruption Strategy Script Fading

Lovaas (Analog) Method

Antecedent

Present stimulus item (selected by clinician, repeated until criterion is met, analog context) Interaction: Clinician presents stimulus, waits for child to respond

Strengths of Lovaas

Based on ABA framework Well-developed procedures Promising approach to intervention Backed by clinical research Provides a format for 1:1 instruction

Response (Behavior)

Correct responses or successive approximations are rewarded

Consequences

Edible rewards paired with social rewards

Limitations of Lovaas

Adult directed; Not child-centered Not responsive to interests of the child Highly repetitive (boring?) Clinical setting (analog conditions) Does not lend to application in real world settings (e.g., classroom, home, daycare) Relies heavily on primary reinforcers (e.g., food); limited application of natural reinforcers (e.g., a chance to play with the toy)

Naturalistic Approaches

Antecedent

Present stimulus item (selected by the child, naturally varies, takes place in criterion setting) Interaction: Clinician and child play with the target stimulus in an applied context

Response (Behavior)

Looser shaping contingencies (e.g., continuing to look at the object is reinforced)

Consequences

Natural reinforcers are implemented (e.g., provide access to the target stimulus, contingent on desired response; social reward also included)

11

Advantages of Naturalistic Approach

Child choice in teaching interactions Task variation Reinforcing attempts and smaller units Natural reinforcers Can build on momentum in natural setting All of these factors can be linked to motivation

Disadvantages of Naturalistic Approach

May be difficult to get to all core curricular areas in applied setting May not work in all classrooms, all the time May require individualized application Related Strategy: Interspersed Model of Discrete Trial Training

Comparing Analog to Naturalistic Approach to DTT Koegel et al., 1999

Lovaas

Antecedent Present stimulus item (selected by clinician, repeated until criterion is met, analog context) Interaction: Clinician presents stimulus, waits for child to respond Response (Behavior) Correct responses or successive approximations are rewarded Consequences Edible rewards paired with social rewards

ANTECEDENT OR TRIGGER Providing an Opportunity to Learn Practice

Pivotal Trials

Antecedent Present stimulus item (selected by the child, naturally varies, takes place in criterion setting) Interaction: Clinician and child play with the target stimulus in an applied context Response (Behavior) Looser shaping contingencies (e.g., continuing to look at the object is reinforced) Consequences Natural reinforcers are implemented (e.g., provide access to the target stimulus, contingent on desired response; social reward also included)

BEHAVIOR A Response from the Student

CONSEQUENCES Reinforcing the Appropriate Response (or Approximation)

Wrap-up and Questions

Summary of Discussion Questions from Participants Contact Information:

Richard Cowan [email protected]

12

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