Using ABA for the Treatment of Autism: The CARD Program

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1 Using ABA for the Treatment of Autism: The CARD Program Autism Symposium Aruba 2010 Adel C. Najdowski, PhD, BCBA Center for Autism & Related Disorders, Inc.

2 Presentation Outline Brief Introduction to CARD Brief introduction to ABA Components of a comprehensive ABA program for children with autism Description of SKILLS CARD s method for increasing access to the components of a comprehensive ABA program

3 Introduction to CARD Founded in Los Angeles in 1990 by Dr. Doreen Granpeesheh Mission: give top-quality ABA-based services to children around the world 18 locations in U.S.A. 2 locations outside U.S.A.: New Zealand and Australia

4 What is ABA? Applied Behavior Analysis ABA is the use of scientific principles of learning and motivation to teach effectively The main concept is that the consequences of what we do affect what we learn and what we will do in the future Positive reinforcement: behaviors that produce a good outcome are more likely to occur in the future People are motivated by what they get out of what they do Examples: money, feeling good for helping someone, approval from others, etc.

5 Positive Reinforcement The ABA approach to autism is to identify what motivates each individual child Every child is different Teaching must use what is motivating to the child, not what we wish was motivating to the child Then we teach the child new skills in very small steps by rewarding the child with positive reinforcement when they try to learn

6 Accountability and Effectiveness ABA assumes that if a child is not learning, it is NOT the child s fault, it is our fault We never blame the child if learning does not happen We believe it s our responsibility to figure out how to teach whatever the child needs to learn We must change the way we are teaching Continue to try different ways of teaching until we find one that works

7 Evidence for the Effectiveness of ABA Lovaas (1987): Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children Experimental Group: N=19 40 hours/wk 47% Achieved ABA normal functioning 3 yrs 10 hours/wk 10 hours/wk 2% Achieved ABA normal Non-ABA functioning 3 yrs 3 yrs Control Group 1: N=20 Control Group 2: N=20

8 Outcome Research on ABA for Autism Lovaas (1987) Smith (2000) Sallows (2005) Howard (2005) Cohen (2006) Eikeseth (2007) Remington (2007) Perry (2008)

9 Outcome Research on ABA for Autism Conclusions of outcome research Every published study demonstrated very large treatment effects Replicated across research groups, across university vs. community settings, and across continents Intensity matters: at least 30 hours per week of one-to-one intervention for more than a year produces best outcomes Duration matters: two or more years of intervention

10 Acceptability of ABA The following bodies now recommend ABA as a treatment for autism American Academy of Pediatrics The New York State Department of Health The National Academy of Sciences Surgeon General 30 years of research demonstrated the efficacy of Applied Behavioral methods in reducing inappropriate behavior and in increasing communication, learning and appropriate social behavior Surgeon General, 1999

11 Comprehensive ABA Programs Earliest versions of ABA programs focused mostly on discrete trial teaching (DTT) Comprehensive ABA programs include a variety of components DTT Natural Environment Training (NET) Fluency-Based Instruction (FBI) Verbal Behavior Challenging behavior Data collection Programming for generalization

12 Discrete Trial Teaching (DTT) Breaks down learning opportunities into wellcontrolled, discrete teacher-student interactions Instruction Correct Response Reinforcer OR Instruction Incorrect Response Correction

13 Natural Environment Training Naturalistic behavioral teaching procedures go by many names: Incidental Teaching, Modified Incidental Teaching, Natural Language Paradigm, Pivotal Response Training, Mileu Training, Mand-model Basic approach: Teach in the natural environment Set up situations where the child will be motivated (e.g., tempt the child with preferred items) Wait for child to initiate Prompt the correct behavior Reinforce correct and attempted responses Reinforcers are related to the task

14 Fluency-Based Instruction (FBI) Being able to respond accurately and rapidly (fluently) results in better retention and generalization Retention: the child remembers better Endurance: child has sustained performance Stability: child can persevere despite distractions Application: child generalizes more readily Adduction: child can create new skills by joining the component skills that the child is fluent in

15 Verbal Behavior B.F. Skinner, Verbal Behavior (1957): Applied principles of ABA to language Separates language into categories by function Reminds us to teach all functions of words Teaching one function does not necessarily lead to learning other functions of the same word More on this later

16 Challenging Behavior Examples: aggression, self-injury, stereotypy, tantrums ABA assumes that children are getting something they want from challenging behavior Attention Escape Toys or food Sensory stimulation

17 Challenging Behavior First step is to do a functional assessment This means assess what the child is getting from their challenging behavior The next step is to not give it to them any more when they engage in the behavior ( extinction ) AND teach the child a more appropriate behavior that will get them what they want Example: asking for a break, playing with a toy, asking for attention, etc.

18 Data Collection Good ABA programs take lots of data on the child s progress Frequency of challenging behavior Rate or percent correct of a skill being learned Data are graphed after every teaching session Frequency of challenging behavior should be decreasing The rate or percent correct of the skill being learned should be increasing over time

19 Data Collection: Tantrums Before Intervention During ABA Intervention

20 Data Collection: Learning a New Skill Example instruction: What s your name?

21 Planning for Generalization Best way Teach skills in many different environments Teach with many different teachers Teach during many different times of day Do NOT do the same thing the same way all of the time When skills are learned in DTT, make sure to practice them in natural settings Parents must practice all new skills as often as possible

22 Therapist Training ABA therapy is difficult to do It s much more structured than feels natural It takes a LOT of training to learn how to do it correctly 40 hours of initial classroom training Another hours of hands-on training with children

23 Supervision Good ABA programs provide approximately 2-4 hours of supervision for every child, every two weeks Supervisors must be experts in ABA, with several years of experience They observe therapists directly working with the child They give therapists immediate feedback on good and bad performance

24 Workshop Model There aren t enough ABA experts to provide supervision in many areas Another option is the workshop model A consultant flies to the location and trains everyone Then the family and therapists implement treatment with follow-up training from the consultant on a scheduled basis The consultant directs the child s treatment plan from a distance

25 A Comprehensive Curriculum What needs to be taught in ABA programs for kids with autism? Autism is defined by global deficits If we want to catch kids up to typical development, we need to teach EVERYTHING that they are delayed in! That is what the CARD curriculum was designed for

26 Overview of CARD Curricula Academic Skills Executive Functions Cognition Social Skills Language Play Adaptive Motor

27 The CARD Curricula Every area of human functioning is addressed in one of several content areas Each content area in the curriculum is broken down into dozens of teaching lessons Each lesson is broken down into many specific instructions along with the correct child behavior (over 3,000)

28 The CARD Curricula Language

29 Language Curriculum Language Each lesson Goes beyond teaching the meaning of words Because we cannot assume that once the child has learned the meaning of a word that she will use it in all possible situations We need to make sure a child can use a word in all of its functions

30 Language Curriculum Language Example We teach the child to hand us an apple when we say Give me apple (receptive) We teach the child to respond apple when shown apple & asked What is it? (expressive) This does not mean the child will now be able to respond apple in other situations or ask for apples when he/she wants them

31 Language Curriculum Language Function Instruction or Setting Behavior Consequence (Reinforcer) Matching Put with same apple is matched with apple Praise Listening Touch apple Selects apple Praise (Receptive) Vocal Imitation Someone says apple Praise (Echoic) apple Request (Mand) Hungry and no apple present apple Child gets an apple Labeling (Tact) Apple is present apple Praise Conversation (Intraverbal) What is your favorite fruit? apple Praise

32 The CARD Curricula Play

33 The CARD Curricula Adaptive

34 The CARD Curricula Motor Skills

35 The CARD Curricula Social Skills

36 The CARD Curricula Cognition

37 Cognition Curriculum Cognition: The ability to recognize the mental states of self (metacognition) and others (social cognition) Cognition Typical Social Cognitive Development 9 months: Joint Attention / Social Referencing 15 months: Pretense 18 months: Desire / Intention 2 years: Senses 3 years: Emotion / Thinking 4 years: Knowing / Beliefs / Deception 5 years: Sarcasm

38 Classic Test of a Theory of Mind : Sally-Anne or False-Belief Task Cognition Where will Sally look for her ball? Where does she think her ball is?

39 The CARD Curricula Executive Functions

40 Executive Functions Curriculum What is Executive Function? Process that underlies goal directed behavior Goal Directed Behavior Involves Visualizing situation Identifying desired objective Determining plan to meet objective Sustaining attention Inhibiting distractions Problem solving Monitoring progress to goal Staying organized Executive Functions

41 The CARD Curricula Academic Skills

42 Math Shapes Money Patterning Calendar Addition Subtraction Charts and Graphs Number Concepts: Quantitative Concepts Listening Comprehension: Counting & Quantities Retelling Stories Numbers Ordering Numbers & Groups Story Prediction Quantitative Comparisons Reading Comprehension Ordinal Numbers Phonological Awareness: Sequencing Numerals and Ordering Groups Minimal Pairs Skip Counting Words and Syllables Rhyming Time: Phoneme Isolation Time of Day & Daily Activities Telling Time Language Arts Colors Academic Skills Curriculum Letters Community Helpers Handwriting and Penmanship Independent Writing Spelling Print Concepts Decoding & Word Recognition: Phonics Single Letter / Sound Correspondence Sight Words Decoding Phonics Initial Consonants Phonics Final Consonants Phonics Short Vowels Phonics Consonant Blends and Digraphs Answering and Asking Questions Phoneme Blending & Segmentation Phoneme Matching Phoneme Manipulation Syllables Academic Skills

43 The CARD Curricula School Skills Executive Functions Cognition Social Skills Language Play Adaptive Motor

44 SKILLS: Shaping Knowledge Through Individualized Life Learning Systems

45 What is SKILLS? elearning Trains how to do ABA (the techniques) SKILLS Index Every child is different what do I teach my child? Assesses child s known and unknown skills through questions directly tied to CARD I Curricula CARD I Curricula Provides what to teach

46 SKILLS demo

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