Autism Spectrum Disorders and Applied Behavior Analysis. Elyse W. Bradford, BCBA Behavior Analyst Center for Autism

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1 Autism Spectrum Disorders and Applied Behavior Analysis Elyse W. Bradford, BCBA Behavior Analyst Center for Autism

2 Show of Hands How many Teachers In-home providers SLP OT Parents

3 Goals for Today Gain a basic grounding in what autism is, how it is diagnosed, and how it is treated Understand the basics of Applied Behavior Analysis (ABA) Learn how the principles of ABA can be applied to create desired behavior change

4 About Me Bachelor s University of Michigan, Ann Arbor Master s in Applied Behavior Analysis University of South Florida Behavior Analyst Hope Network s Center for Autism My current responsibilities include development and ongoing implementation of Early Intensive Behavioral Intervention program (EIBI). How did I get started in this field? My younger brother is diagnosed with Autism

5 The Center for Autism We emphasize Early diagnosis with comprehensive treatment planning Early Intensive Behavioral Intervention (EIBI) with Board Certified Behavior Analyst (BCBA) oversight Informal social supports (Puzzle Partners) Educational programming (Grand Rounds and Family Rounds)

6 Crucial Role of Early Diagnosis You are crucial to the screening process as an objective professional Early diagnosis and evidence based intervention are key to create favorable outcomes Mainstream education Career choice Independent living

7 Prevalence 1 in 88 1 in 54 boys 1 in 252 girls (Center for Disease Control, 2012) If an older sibling is diagnosed with Autism, the risk for a Younger brother is 1 in 4 Younger sister is 1 in 11

8 Milestones Failure to meet any of the following milestones: Babbling by 12 months Gesturing (point/wave) by 12 months Single words by 16 months Spontaneous phrases by 24 months Loss of language or social skills at any age (specifically months) (American Academy of Neurology)

9 American Association of Pediatrics Autism is Prevalent Listen to Parents Act Early Refer Monitor <http://www.medicalhomeinfo.org/downloads/pdfs/autismalarm.pdf>

10 American Association of Pediatrics

11 M-CHAT The Modified Checklist for Autism in Toddlers is an evidence-based tool for screening children from months of age Available for free online: https://www.mchat.org/ 23 questions that can be filled out by a parent in a couple of minutes Scored based on overall responses and also responses to key items There is also a screening interview that can improve the diagnostic accuracy somewhat

12 M-CHAT

13 Defining Autism DSM-IV A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3): (1) qualitative impairment in social interaction, as manifested by at least two of the following: (a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction (b) failure to develop peer relationships appropriate to developmental level (c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) (d) lack of social or emotional reciprocity (2) qualitative impairments in communication as manifested by at least one of the following: (a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) (b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others (c) stereotyped and repetitive use of language or idiosyncratic language (d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level (3) restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: (a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (b) apparently inflexible adherence to specific, nonfunctional routines or rituals (c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) (d) persistent preoccupation with parts of objects B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play. C. The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.

14 DSM-IV Summary Impairments in social interaction Non verbal behavior, failure to develop peer relationships, lack of social or emotional reciprocity Impairments in communication Delay in spoken language, marked impairment in the ability to initiate or sustain conversation with others, repetitive use of language, lack of make-believe play Restrictive patterns of behavior or interests/play Inflexibility, repetitive motor movements, persistent preoccupation with objects

15 The Autism Spectrum- DSM-IV Autism Spectrum Disorder/Pervasive Developmental Disorder Autism Asperger's PDD NOS Childhood Disintegrative Disorder Rett s

16 The Autism Spectrum- DSM-V Neurodevelopmental Disorder Autism Spectrum Disorder

17 DSM-V A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: 1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction, 2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures. 3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases). 2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes). 3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects). C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) D. Symptoms together limit and impair everyday functioning.

18 DSM-V : Summary Persistent deficits in (all 3): Social-emotional reciprocity Lack of social interactions abnormal social approach (emotions) Non-verbal communication Lack of gestures understanding body language Developing and maintaining relationships Absence of interest in people adjusting behavior to fit social context

19 DMS-V : Summary Cont. Presence of restrictive, repetitive behavior patterns (2 of 4) Stereotypies, echoalia idiosyncratic phrases Distress at small changes ritual patterns Restrictive, fixed interests Sensory: over or under responsive, unusual interest in environmental aspects

20 High Functioning Autism This term is generally taken to mean children or adults who have autistic disorder but have subsequently progressed to a point where they are broadly cognitively normal (i.e., test within the broad normal range on IQ testing) Studies generally show that there is no clear clinical distinction (other than history) between HFA and Asperger s Disorder

21 Diagnosing Autism No medical tests No blood tests Genetic tests and brain imaging are not diagnostic but are indicated with specific concerns Diagnosed through interview and observation clinical history with a structured diagnostic that utilizes developmentally appropriate play and conversational situations that press for signs of autism

22 ADI-R The Autism Diagnostic Interview Revised (ADI-R) is a structured clinical interview diagnostic for autism spectrum disorders Designed to work in conjunction with ADOS Common in research protocols

23 ADOS The Autism Diagnostic Observation Schedule is the most widely recognized structured play / conversation diagnostic tool consists of four modules to assess children starting at the non-verbal / preschool level and going up to adult functional levels Should be administered by specialized physician, neuropsychologist/ psychologist

24 ADOS

25 Other Components of Evaluation The initial diagnostic evaluation also serves to establish a baseline of related patient characteristics Cognitive (including linguistic) strengths and weaknesses Behavioral and emotional functioning Functional abilities (ADL/IADL) Medical co-morbidities Caregiver capability, perceptions, and stress level

26 What is ABA? Applied: meaningful to society/lives Behavior: anything an organism does that can be observed and measured Analysis: demonstrating a functional relationship between environmental events and behavior change

27 Brief History of ABA John Watson: stimulus-response behaviorism B.F. Skinner: The Behavior of Organisms (1938) Respondent behavior: elicits reflexive behaviors Operant behavior: evoked by stimulus changes that have followed behavior in the past Science and Human Behavior (1953): Radical Behaviorism 1950s-60s: Brought empirically based principles out of the rat-lab and into human life. 1968: Some Current Dimensions of Applied Behavior Analysis by Donald M. Baer, Montrose M. Wolf, and Todd Risley in the first Journal of Applied Behavior Analysis (JABA) publication.

28 ABA & Language B.F. Skinner s Verbal Behavior (1957) Formal and functional properties of language Language as a learned behavior controlled by environmental variables Speaker Behavior: Mand, Tact, Intraverbal Listener Behavior: Echoic, textual, transcriptive, and coping-a text relations

29 Ivar Lovaas ABA & Autism First long-term study on the effectiveness of Applied Behavior Analysis in 1987 Found that intensive ABA for 40 hours per week for 2 years yielded effective outcomes 47% of this group achieved normal IQ and placement in a typical 1 st grade classroom after 2 years Compared to 2% of control groups

30 ABA & Autism Further studies on the effectiveness of ABA McEachin et al 1993 Sallows and Graupner 2005 Howard et al 2005 Cohen et al 2006 Eldevik et al 2006

31 ABA programs Early Intervention Discrete Trial Training (DTT) Presentation of Sd, delivery of reinforcer Verbal Behavior (VB) Communication training based on Skinner s verbal operants Naturalistic Teaching Incidental Teaching/ Pivotal Response Training/ Natural Environment Training

32 VB- MAPP Mand Echoic Vocal Tact Listener VP/MTS Play Imitation LRFFC Intraverbal Group Linguistics Social Math Uses typical language development as a curriculum guide Build skills equally across categories Identifies barriers to treatment Designed to be used by various types of clinicians Targeted for use in schools for IEP goals

33

34

35 One Success Story A 7yo boy in our early intensive behavioral intervention clinic Identified by school at 3yo 2 years academic interventions, 1 year of other clinical interventions After that, tested IQ of 54 (would likely require lifelong support) In EIBI for a 8-12 hours a week for 14 months IQ 14 months later: 84 (likely to achieve independent living, employment) He is due for another evaluation this winter Now in mainstream1st grade with an aide Starting to understand how to make friends Reads bedtime stories to his sister Attended day camp last summer Our next challenge is to make this kind of outcome occur more predictably

36 Jack The problem with this that and please Deficit: Spontaneous mands Baseline: 6 generalized mands

37 Jack

38 Jack What do you see? December 2011 dog tree November 2013 Giggle. That dog is eating a tree.

39 Skill Acquisition Beginning programming Eye Contact Responds to name Listener Responding Compliance Imitation Object Play Mands Spontaneous Persistent

40 Environmental Variables that Control Behavior Discriminative Stimulus (Sd): a stimulus that is present when a behavior is reinforced Stimulus Control: a behavior is likely to occur in the presence of a Sd Reinforcement: a behavior occurs in the present of an Sd and occurs more in the future Motivating Operations: increases the reinforcer effectiveness

41 Teaching Procedures Used in Acquisition Prompting: increase the likelihood of the person engaging in the correct behavior Fading: gradual removal of prompts (behavior still occurs) Shaping: reinforcing successive approximations Chaining: teach a person to engage in a chain of behaviors (the completion of one signals the start of another)

42 Consequences Stimulus Added (POSITIVE) Stimulus Removed (NEGATIVE ) Behavior occurs MORE often (REINFORCEMENT) Positive Reinforcement Negative Reinforcement Behavior occurs LESS often (PUNISHMENT) Positive Punishment Negative Punishment

43 A-B-C All behaviors can be broken down into the A-B-C Model Antecedent Behavior Consequence

44 Escape Doing Homework Throw Pencil Removed to hallway Non-Preferred Behavior Preferred

45 Attention Mom talking to Sister Hit Sister Mom yells Non-preferred No Attention Behavior Preferred Attention

46 Tangible No Candy Scream at Store Get Candy Non-Preferred Behavior Preferred

47 Automatic No Sensory Input Bang Head Sensory Input Non-Preferred No Feel Good Experience Behavior Preferred Feel Good Experience

48 Example of ABC Data Sheet TIME/ ACTIVITY Alone play ANTECEDENT BEHAVIOR W/ TOPOGRAPHY Playing alone near sister CONSEQUENCE Hit Sister in the head Parents say, Stop it! I FREQUENCY/ DURATION Alone play Parents changing sister Hit Mom in face Mom sends to room I Playing with sister Dad says, Hi! to sister Hit Sister is the head Dad yells and sends to room II ABC Analysis BEHAVIOR Physical Aggression: Hitting or kicking others FREQUENCY OR DURATION ESCAPE ATTENTION ACCESS AUTOMATIC 0 IIII 0 0

49 Behavior Intervention Plan Operational definition of behavior As specific as possible Physical aggression: Episodes of engaging in hitting others with the hand and leaving a red mark. Determine likely function Withhold the previous reinforcer to problem behavior* Replacement behavior Same function as problem behavior Reduce the likelihood for the behavior to occur Give what the problem behavior gets on a schedule Generalization/Maintainace

50 Break Card

51 Overall Treatment Goal Decrease negative behaviors, and increase positive behaviors Increase functional repertoire Positive Behaviors Negative Behaviors

52 Our Center The Center for Autism is online at: We have a number of presentations located there and at our education page: We are on Facebook: Look out for #cfarounds and #familyrounds on Twitter

53 Questions or Comments? THANK YOU!

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