Applied Behavior Analysis for the Treatment of Autism Jonathan Tarbox, PhD, BCBA-D ATEDM, March 20 th, 2009 Center for Autism & Related Disorders, Inc.
Presentation Outline Introduction to CARD Research on effectiveness of ABA Recovery from autism How to teach: Description of a comprehensive ABA program What to teach: CARD SKILLS Other treatments Collaboration between ABA and medical
Introduction to CARD Founded in Los Angeles in 1990 by Dr. Doreen Granpeesheh Mission: give top-quality ABA to the maximum number of children around the world 16 locations in U.S.A. 2 locations outside U.S.A.: New Zealand, and Australia Consultation on every continent (including several sites in Canada)
Introduction to CARD Our services are comprehensive: If there is something that an individual with autism needs to learn how to do, it s our job to teach it effectively I m Jonathan Tarbox and I m the director of research and development My job is to do research on treatments that make a difference in the lives of people with autism
Early Intensive Behavioral Intervention (EIBI) Our research review will primarily focus on large-scale, long-term studies of ABA for young children with autism Hundreds of smaller scale, shorter-term studies have been done on ABA for teaching particular skills for older children ABA is NOT just for little kids but we are going to focus on early intervention for today s presentation
General Effectiveness Compared 40 hrs/week ABA to 10 hrs/week ABA and to 10 hrs/week daycare 40 hour ABA group achieved far greater gains 9 out of 19 children (47%) achieved average IQ and educational placement by the finish McEachin (1993): gains maintained for 8/9
General Effectiveness 4 years of EIBI produced large gains Average IQ: 11/23 = 48% Typical school placement: 8/23 = 34% VABS Communication: 9/21 = 42% VABS Social: 9/21 = 42% ADI-R: 8/23 = 34% Important note: Parent-directed group still had professional therapists
General Effectiveness 3 years of EIBI Average IQ: 12/21 = 57% Typical school placement: 6/21 = 28% VABS composite: 8/21 = 38%
General Effectiveness 2 years of intensive center-based ABA compared to 2 years of ecclectic classroom services Average IQ: 7/13 = 54% Average score on Aechenbach CBC: 4/13 = 31%
General Effectiveness Replication in Europe 25 hrs/week for 2 years Gains in language, intelligence, daily living, positive social behavior No increase in parent stress
Scoring in non-asd range on ADOS after treatment: 4/19 = 21%
General Effectiveness First ever large-scale community-based evaluation Whole province of Ontario, Canada Free ABA for all young children with autism 332 children 71% made significant gains 11% achieved functioning in the average range Poor quality control, lots of different provides, still had large good effects
Weekly Intensity More than 25 hours is what works best, period Original Lovaas (1987) study: 10 hours/week group did not improve very much Eldevick (2006) did 12 hours/week for two years: improvements but not good enough Reed (2006) statistically compared 12 hours/week to 30 hours/week: 30 was better
Total Duration of Treatment Two or more years is what works best, period Howard (2005) did 14 months, worked well but not as well as longer. Follow-up data not published yet but shows greater gains at later times Eikeseth (2002) did 12 months, good but not good enough Reed (2006) 30 hours/week for 9 months, good but not good enough
Support from Outside ABA Research just described has lead to many independent institutions endorsing ABA for the treatment of autism US Surgeon General New York State Department of Health National Academy of Sciences American Academy of Pediatrics Insurance legislation in several US states
Recovery Recovery from autism is a controversial topic The consensus in the medical community is that children do not recover from autism When giving the diagnosis, pediatricians often say something like start saving your money and start looking into institutions
Outline of Recovery Discussion State our position on recovery from autism Describe a definition of recovery Define how to measure recovery in research and practice Review research relevant to recovery Discuss clinical and ethical implications
Our Position on Recovery Recovery from autism exists Early intensive behavioral intervention (EIBI) causes recovery in some proportion of clients EIBI is more than 25 hours per week for more than a year, starting under 5 years old
Defining Recovery from Autism By definition, a disorder requires the presence of functional impairment or clinically significant impairment In children who once had autism but recover after ABA treatment, there is no longer impairment in their ability to live their daily lives Recovery from autism = no functional impairment produced by delays in language, socialization, and stereotypy
Measuring Recovery How we measure recovery in research and practice: Child cannot qualify for a diagnosis on the autism spectrum, according to the DSM-IV Scores in the average range on tests of intelligence, language, social skills, and adaptive functioning Success in regular education, without any special supports
Recovery We have seen our definition of recovery happen many times Some children who receive early intensive ABA treatment recover from autism
What About Biology? Whatever was wrong biologically / physiologically is presumably remaining But functional impairment has been removed If a person is functioning just fine in their daily lives, where s the disorder?
What About Biology? If you view autism as only a disordered body, then behavioral intervention cannot produce recovery But autism is NOT just a disordered body Autism is a combination of a disordered body and an impaired ability to function in life
Recovery Autism from Autism Impaired physiology Impaired everyday functioning Impaired physiology Non-impaired everyday functioning
Objections He s still not normal What is normal? Who wants to be normal? I can still tell he was the one that had autism Being able to tell who used to have autism is not the same as having autism now Having a quirky and unique personality is not a disorder or disability Being a bit different does not equal having a pervasive developmental disorder
Individuality Recovery from autism via ABA does NOT remove the individuality, dignity, or change the personality or unique perspectives of the child with autism Recovery via ABA does not make a child normal Recovery means a child has the skills to successfully do what he or she wants to do in life
Individuality: Examples Social skills: Before ABA, Jimmy did not know how to make friends, whether he wanted to or not After recovery: Jimmy now knows how to make friends, if he wants to, just like anyone else Language: Before ABA, Sally could not talk After recovery: Sally can now talk as much or little as she wants about whatever she wants Stereotypy: Before ABA, Sam spent all his time flapping his hands and other kids teased him After recovery: Sam now knows to flap his hands in his bedroom by himself if he doesn t want other kids to tease him
Parents Perspectives Parents of recovered kids frequently cite the following as evidence that their kids are doing great: Having a group of friends / best friends Good report cards Learning to drive a car Dating Going to college
What About the Science? Almost every treatment has someone who says it produces recovery Science is the only method for separating what works from what doesn t Opinion, experience, intuition, and faith are not enough by themselves Let s look at the science
State of the Science on Recovery Our full definition of recovery has rarely been directly evaluated in research Let s look at outcome studies of EIBI Let s look at the measures that moved into the average range after treatment First, let s look at studies with control groups
Group Outcome Studies Summary Summary of controlled studies We already discussed results from outcome studies that had control groups EVERY controlled study of ABA done for more than 25 hours per week and for more than 1 year results in some percentage of children achieving some scores in the average range Now let s look at studies that did not have control groups
Intensive ABA for 2 years Vineland ABC: 11/20 = 55% School placement: 7/20 = 35% CARS: 9/20 = 45%
35-35 hours per week of ABA IQ: 12/27 = 44% School placement: 3/27 = 11%
Over 25 hrs / week, More than 1 yr: Percentage of Participants in Average Range at End of Treatment Controlled Studies IQ VABS ABC Diagnostic Language (Expressive) Language (Receptive) School Placement Lovaas (1987) 47% 47% Sallows (2005) 48% 48% Howard (2005) 45% 69% 72% Cohen (2006) 57% 38% 43% 38% 29% Remington (2007) Zachor (2007) 20% Descriptive Studies Harris (2000) 44% 11% Perry (2008) 34% Weiss (1999) 55% 45% 35%
First published case study of recovery via ABA Catherine Maurice s two children with autism ABA began around 2 yrs old and lasted 2-3 yrs Both are now living independent lives with no special supports
Intensive ABA treatment for 3 years Gradual transition to typical education Achieved IQ and adaptive functioning in the average range Succeeding without support in regular education Teacher never new she previously had special needs
Case Studies 8 children with autism whose parents reported recovered from ABA All children made large gains in IQ 4/8 had IQ in the average range after ABA was done 7/8 still had delays in language
CARD Case Study: Anthony Age at intake: 2 years Independent diagnosis of autism With CARD for 3 years and 2 months Treatment: One-on-one therapy gradually decreased Was gradually transitioned into regular education classroom, with a one-to-one aid One-to-one aid gradually faded out
130 120 110 100 90 80 70 60 50 40 30 20 10 0 CARD Case Study: Anthony IQ Intake 1.6 Years 2.5 Years Standard Score
130 120 110 100 90 80 70 60 50 40 30 20 10 0 CARD Case Study: Anthony Language 1.6 Years 2.5 Years Intake Standard Score
130 120 110 100 90 80 70 60 50 40 30 20 10 0 CARD Case Study: Anthony Adaptive 1.6 Years 2.5 Years Intake Standard Score
CARD Case Study: Anthony Current status Passed Kindergarten entrance exam with a score in the 90 th percentile Completed Kindergarten in the 06/07 academic year with no special supports Completed 1 st grade in 07/08 successfully Teacher does not know he ever had Autism All report cards for school have been average-above average with no concerns He s not exceptional
Recovery Retrospective Chart Review Recently asked our senior clinicians to identify each child whom they observed to recover over the last 18 years Produced 204 names We then dug through all their files to look for data 38 files had at least pre and post IQ scores
Recovery Chart Review IQ
Recovery Chart Review Vineland ABC Scores
Recovery Retrospective Chart Review Mean Intake IQ: 83.6 Range of IQ at intake: 50-133 Mean Discharge IQ: 108 Mean increase in IQ: 24 Mean adaptive scores at intake: 68 Range of adaptive at intake: 57-82 Mean of adaptive at discharge: 88 Mean increase in adaptive: 21
Recovery Retrospective Chart Review NOT a representative clinical sample Simply a description of the characteristics of children who achieved the best possible outcome: recovery Controlled research is needed that addresses the same questions but with better experimental methodology
More Anecdotes Conversation with recovered teenager Succeeding in high school, now in 10 th grade Advice for future kids with autism Inclusion classroom in DC Recovery DVD Clients/siblings in clinic CARD employee in R + D department
Clinical Implications It is now considered normal in top-quality ABA programs to recover some percentage of your clients If an ABA program is doing more than 25 hours per week for more than a year, starting under 5 years old, and they are NOT recovering at least some of their children, something is wrong
Ethical Implications Professionals who know about recovery have an ethical obligation to tell others about it ABA audience member Imagine if a doctor knew of a treatment for cancer that produced recovery for a third or half of his patients but he did not tell patients or other doctors about it
Unanswered Questions We don t know what percent will recover probably between 20 and 50% of children who get top-quality ABA programs, for more than 25 hours per week, for more than a year, starting under 5 years old Recovery rates differ between studies We can t yet predict which kids will recover We don t know why some kids recover and some don t
Future Research We need to improve the effectiveness of ABA to increase recovery rates We have a treatment that produces recovery the primary question driving future research should be: How can we make ABA more effective so we can recover more?
Kids Who Don t Recover Our goal with young children is recovery However, many families cannot get enough hours AND, even given the best program, most children will not recover. All children with autism can learn All children who receive good quality ABA intervention can increase their independence, learn some important skills, and can decrease their challenging behaviors All children with autism have a right to the most effective treatment
Eclectic versus ABA Most public school special education treatment for autism is eclectic It s a mix of everything Little bit of ABA, little bit of TEACCH, little bit of Floortime, etc. The rationale is that every kid is different so we will do everything in hopes that we will hit the thing that is right for each kid Existing research is clear: there is no evidence that eclectic treatment works
Eclectic versus ABA Howard (2005): intensive ABA worked much better than public eclectic Eikeseth (2007): same finding in Norway Zachor (2007): same finding in Israel ABA does address the unique learning styles of each child because it s based on principles of learning and motivation that apply to all people and each program is customized to each child
Eikeseth (2007) IQ Communication Socialization Daily living Eclectic versus ABA
We ve talked about the research Now let s go into more depth about what a top-quality ABA program looks like
What is ABA? Applied Behavior Analysis ABA is the use of scientific principles of learning and motivation to teach effectively The core 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: feeling good after helping someone else, money, approval from others, satisfaction of reading a good book, etc.
Positive Reinforcement The ABA approach to autism is to identify what motivates each individual child Every child is different therefore positive reinforcement is different for every child We teach the child by teaching new skills in very small steps and rewarding the child with positive reinforcement when they try to learn
Positive Reinforcement When teaching, we must use what is motivating to the child, not what we wish was motivating to the child or what should be Reinforcement frees you from ideology Most arguments about education center on ideology, not on reality of what works ABA is based on doing what works If a particular thing works to motivate, then use it. If it doesn t, then use something else.
Accountability and Effectiveness ABA assumes that if a child is not learning, it is NOT the child s fault, it is our fault We must change the way we are teaching We must continue to try different ways of teaching until we find one that works ABA is the best method for finding what works 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
Accountability and Effectiveness Common reactions to failed educational procedures: He has a lot of issues He s just really challenged Nothing motivates him He just isn t into learning ABA perspective: If a child is not motivated, then WE have failed at motivating him/her
Comprehensive ABA Programs Earliest versions of ABA programs focused mostly on discrete trial training (DTT) Comprehensive ABA programs now include a variety of behavioral teaching strategies DTT Natural Environment Training (NET) Verbal Behavior Challenging behavior Data collection Programming for generalization
Discrete Trial Training (DTT) Breaks down learning opportunities into wellcontrolled, discrete teacher-student interactions Instruction Correct Response Reward OR Instruction Incorrect Response Correction
RD1 One Discrete Trial
Slide 65 RD1 R + D, 6/15/2008
RD2 Many Discrete Trials
Slide 66 RD2 R + D, 6/15/2008
DTT Myths DTT is only for teaching simple skills Not true, you and I use DTT when doing math tutoring DTT has to be done at a table Not true, you can do it wherever the child is comfortable DTT is robotic and sounds like you are in the military Not true, you can do it as naturally as you want, as long as the child can attend to it
DTT: Reading Comprehension
DTT Rationale When something is very hard to learn, what you need is lots of practice under carefully controlled conditions Musicians practicing scales Basketball players practicing free-throws Martial artists practicing kicks and punches over and over Baseball players practicing batting Rescuers practicing rescues over and over Ballet dancers practicing moves repeatedly
DTT Rationale Some criticize DTT because it s too repetitive and appears rote it s not natural But you have to be GOOD at something before you can do it naturally and improvise Ray Charles said, to prepare for improvising, he practiced scales Reason: so that remembering how to play was so easy, he could focus on what to play
DTT Strengths Easy to train therapists in Ensures lots of learning opportunities Results in rapid learning of skills Proven by 100s of experiments to work Potential disadvantage May not produce generalization of learned skills automatically May not produce, natural, fluid responding
Natural Environment Training Naturalistic behavioral teaching procedures go by many names: Incidental Teaching, Pivotal Response Training, etc. Basic approach: Teach in the natural environment Set up situations where the child will be motivated (e.g., toy out of reach) Wait for child to initiate Prompt the correct behavior Reinforce it Mix learning opportunities of many different skills in many different settings no rote repetition
Natural Environment Training Examples: Place toy out of reach to teach requesting Teaching names of vehicles while playing with cars and trucks Teach names of kitchen utensils while cooking food in the kitchen
Natural Environment Training Video example: Practicing adjective-noun combinations while painting Child has already learned the skill in DTT Now it s time for generalization training in NET, while doing something he likes (painting) Teacher will pretend she doesn t understand what he wants until he uses the adjective-noun combination
Natural Environment Training Practicing adjective-noun combinations while painting
Verbal Behavior B.F. Skinner, Verbal Behavior (1957): Applied principles of behavior analysis 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 Example: if we teach a child how to say red, he may not actually be able to say red when he wants something that is red
Verbal Behavior Misconceptions Verbal behavior is NOT separate from ABA, it is part of ABA Some say We don t do ABA we do verbal behavior This demonstrates a fundamental misunderstanding of what ABA and verbal behavior are This should be a red flag this person does not understand ABA or verbal behavior very well Verbal behavior should be included in ABA programs, as one part of the whole
Challenging Behavior Examples: aggression, self-injury, selfstimulatory behavior, tantrums ABA assumes that children are getting something they want from challenging behavior Attention Escape Toys or food Sensory stimulation Autism is NOT the cause of bad behavior
Challenging Behavior First step is to do a functional assessment This means assess what the child is getting by doing the behavior The next step is to not give it to them any more when they have 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.
Data Collection Good ABA programs take lots of data on the child s progress Frequency of challenging behavior Percent correct on skill teaching Data are graphed after every teaching session The percent correct should be increasing over time if the child is learning
Real Sample Data: Learning a New Skill Vocal imitation: Using chaining to teach the child to echo the word Victoria During baseline, the child cannot do it During chaining, the accuracy increases consistently and systematically 100 90 80 70 60 50 40 30 10 20-10 0 BL Chaining Maintenance "Victoria"
Real Sample Data: Tantrums Provided choice so that work was more fun Making work more fun decreased motivation to escape Tantrums decreased when choice was used and increased when choice was not used 50 BL Choice BL Choice % Challenging Behavior 40 30 20 10 0 1 6 11 16 21 Sessions
Generalization Generalization is when a child learns a skill and can then apply it across other settings in his/her life Comprehensive ABA programs must explicitly focus on generalization Generalization does NOT occur automatically Generalization is NOT an afterthought or side-effect
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 why 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
Sample Generalization Data Teaching conditionality: Teaching a child to understand if/then statements Teach many different statements then test others that haven t been taught 100 90 80 Baseline Teaching Generalization! Percent Correct 70 60 50 40 30 20 10 0 Training Generalization
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 20-30 hours of initial classroom training Another 30 hours of hands-on training with children Regular continuing education on advanced topics (e.g., once per month)
Supervision Good ABA programs provide approximately 2 hours of direct supervision for every child, every two weeks Supervisors must be experts in ABA, with several years of experience Every therapist that works with the child is directly observed working with the child Every therapist is given specific and immediate feedback on good and bad performance Supervisors spend another 4-8 hours per month per child on program development, etc. One full-time supervisor should not have more than 10-15 cases
Workshop Model There aren t enough ABA experts in the world (or Montreal) to provide supervision Another option is the workshop model A consultant flies here and trains everyone Consultant designs program for child Family and therapists implement program Consultant does ongoing supervision via email, telephone, videoconference Dubai, Hawaii, Hong Kong, Italy, Alberta, etc.
ABA for Older Children Many think ABA is only for young children This is FALSE ABA is the ONLY procedure proven to teach people with autism effectively, at all ages Hundreds of studies have evaluated ABA for individuals with autism of ALL ages and for teaching skills in all areas
ABA for Older Children: Our Review We recently reviewed every study published in the last 20 years in the following four journals: Journal of Applied Behavior Analysis, Behavioral Interventions, Research in Developmental Disabilities, and Behavior Modification 170 experiments showing effective ABA treatment for some aspect of autism with individuals aged 8-12 Every area addressed: Challenging behavior, daily living skills, socialization, academics, and vocational And that s just four journals and just the last 20 years
So far, we ve discussed HOW to teach. Now let s talk about WHAT to teach Overview of CARD Curriculum
The CARD Curriculum Academic Skills Executive Functions Cognition Social Skills Language Play Adaptive Skills Motor Skills
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
CARD Curriculum 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 programs Each program is broken down into many (up to 20 or more) specific instructions along with the correct child behavior
Language
Language Curriculum Language 31 Lessons by Emerging Age and Function: 0-12 mos. Body Parts Echoics Following Instructions Gestures Sound Discrimination 1-2 yrs. Actions Basic Mands Categories Choices Functions Negation Objects People & Relationships Prepositions Yes / No 2-3 yrs. Adverbs Attributes Features Gender Manding for Information Opposites Pronouns Wh- Discrimination Locations Plurals 3-4 yrs. Describe Sequences Statement - Statement 4-5 yrs. Same / Different 5-6 yrs. Ask & Tell Discrimination Statement Question Syntax 6-7 yrs. What Goes With
Language Curriculum Language Each lesson Teaches concepts, using Verbal Behavior as the basis 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
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 comment on apples when he/she sees them or ask for apples when he/she wants them
Language Curriculum Language Function Instruction or Setting Behavior Consequence (Reinforcer) Matching Put with same apple is matched with apple Praise Receptive Touch apple Selects apple Praise Vocal Imitation (echoic) Someone says apple apple Praise Request (mand) Hungry and doesn t have apple apple Child gets an apple Labeling (tact) Apple is present apple Praise Conversation (intraverbal) What is your favorite fruit? apple Praise
Language Curriculum Language Ensuring spontaneity It s important to establish language that the child initiates, so he/she does not only wait for the teacher to tell him what to do Spontaneous commenting or naming is an important goal We often use gestural prompts to teach this, in order to avoid teaching child to only respond to teacher s vocal prompt Video
Language Curriculum Language
Play
Domains Play Curriculum Sensorimotor Play Task Independent Completion Play Play Play Stations Play Block Constructions Constructive Structure Building Play and and Water Constructions Clay Constructions Arts and Crafts Early Social Games Read-to-Me Books & Nursery Rhymes Music Interactive and Movement Treasure Play Hunt Card and Board Games Locomotor Play Peer Play Audio and Video Play Electronic Computer Play Video Games Functional Pretend Pretend Play Symbolic Play Play Imaginary Play Sociodramatic Play
The CARD Curriculum Adaptive
Adaptive Curriculum Personal Feeding Toileting Undressing Unfastening Dressing Preventing Spread of Germs Bathing Fastening Teeth Care Hair Care Nail Care Health Care Domestic Pet Care Setting & Clearing Table Telephone Skills Tidying Meal Preparation Cleaning Gardening Laundry School Backpack Prep Making a Bed Adaptive Community Shopping Restaurant Readiness Safety Safety Awareness Safety Equipment
The CARD Curriculum Motor Skills
Motor Curriculum Motor Oral Oral Motor Visual Ocular Motility Binocular Vision Skills Visual Perception Fine Hand Skills Coloring Finger Skills Drawing Pre-Handwriting Cutting with Scissors Gross Sitting Crawling / Creeping Riding Foot-Propelled Vehicles Standing Rolling Over Rolling / Throwing / Dribbling Walking Stairs and Climbing Riding a Tricycle / Bicycle Running Balance Beam Swinging a Bat / Racquet / Paddle Jumping Kicking Physical Education Readiness Hopping Catching
The CARD Curriculum Social Skills
Social Skills Curriculum Social Skills Social Language Greetings and Salutations Non-Vocal Social ID Questions Eye Contact Prosody Non-Vocal Non-Vocal Imitation Absurdities Regulating Others Body Language & Facial Expressions Figures Gestures of Speech Social Conversational Audience to Regulate Social Interaction Absurdities Physical Context Social of Conversation Interaction Humor and Jokes Language Listening to Conversation Apologizing What s Wrong? Initiating Conversation Assertiveness Joining Conversation Compliments Group Related Group Skills Maintaining Cooperation Conversation & Negotiation Social Social Responding Related in Unison Repairing Gaining Conversation Attention Group Discussion Skills Transitioning Interaction Topics Introductions of Conversation Skills Ending Levels Conversation of Friendship Sharing & Turn-Taking Social Rules Self Lending Esteem& Borrowing Compliance Dealing with Conflict Social Following Rules Self Positive Esteem Self-Statements Community Rules Social Context Winning & Losing Politeness & Manners Responding to Social Constructive Cues Criticism Learning Context Through Observation
The CARD Curriculum Academic Skills
Colors Academic Skills Community Curriculum Helpers Academic Math Shapes Money Patterning Calendar Addition Subtraction Language Arts Handwriting and Penmanship Writing Letters Spelling Print Concepts Literary Genres Decoding & Word Recognition: Phonics Sight Reading Statistics and Data Analysis Comprehension: Number Concepts: Oral Story Comprehension Numbers Reading Comprehension Counting & Quantities Phonological Awareness: Phoneme Isolation Quantitative Concepts Phoneme Blending & Segmentation Ordering Numbers & Phoneme Groups Matching Comparisons Phoneme Manipulation Number Word Patterns Discrimination & Segmentation Time: Rhyming Time of Day & Daily Activities Syllables Telling Time Skills
The CARD Curriculum Cognition
Cognition Cognition Teaches children to talk about their own minds and understand other peoples perspectives Why do we care about social cognition? Because good social skills depend on being able to understand others Children with autism often have difficulty with social cognition, even after they have achieved age-appropriate verbal behavior
CARD Cognitive Curriculum Overview Physical States Detecting Sarcasm Intentions Emotions Cause & Effect Deception Senses Beliefs Thinking Knowing Sensory Perspective Taking Desires Preferences
Desires Teaches children to detect what other people want and to think about it in terms of their own behavior Cognition
The CARD Curriculum Executive Functions
Executive Functions What is executive function? Brain mechanisms that control goal-directed behavior Goal Directed Behavior Involves Visualizing situation Identifying desired objective Determining plan to meet objective Monitoring progress to goal Inhibiting distractions Executive Functions All of these are skills that can all be taught, just like any other skill
Executive Functions Planning Self-Organization Task / Social: Goal Setting Planning Previewing Using a Planner Organizing Materials Task Initiation Monitoring Progress Inhibition Waiting Physical Inhibition / Motor Vocal Pencil / Paper EF Flexibility/ Set-Shifting Flexibility Shades of Gray Nonsocial Set-Shifting Social Set-Shifting Social Cognitive Set-Shifting Attention Stimulus Orienting Disengagement Joint Attention Determining Saliency Paraphrasing Attention Summarizing Sustained Attention Divided Attention Alternating Attention Metacognition Self-Awareness Metamemory Emotion Control Self-Management Meta- Cognition Problem- Problem- Solving Simple Solving Nonsocial Social Memory Visual Memory Auditory Memory Associative Memory Memory Working Memory Episodic Memory
The CARD Curriculum School Skills Executive Functions Cognition Social Skills Language Play Adaptive Skills Motor Skills
CARD Curriculum The CARD curriculum is the most comprehensive curriculum for teaching children with autism on the planet There are somewhere around 3,000 steps in it, covering every single skill a human child needs to know, up to age 7
We ve discussed ABA Now let s discuss the relationship of ABA to medical treatments The contemporary perspective is called the biobehavioral or neurobehavioral model
The Biobehavioral Model All humans have a biology and have behavior, and those two systems always interact, in everything we do Autism is a disorder that is diagnosed on the basis of behavior But everyone agrees that there are biological variables which are disordered
The Biobehavioral Model If the correct biological variable was identified for a particular child, and it was treated successfully, then the child s behavior should start to improve At this time, there aren t any biomedical treatments which have been proven to work in scientific research With every child, careful monitoring and assessment must be done at all times Demand careful data on ANY treatment your child is doing (including ABA)
Collaboration Collaboration is the MOST IMPORTANT THING!!! If the ABA provider and doctor do not know what each other are doing, they will not know which treatment caused a change in behavior Careful data collection is important Data sharing is critical Ideally, the ABA provider and doctor should meet in-person or at least via email
Crossland et al. (2003) Risperidone during a functional analysis Same behavior has different causes when on and off risperidone
Another participant Crossland et al. (2003)
Dicesare (2005) Ritalin during a functional analysis: reduced behavior but hid the cause
HBOT Hyperbaric Oxygen Therapy (HBOT) has become a very popular treatment in the last 5 or 10 years Involves sitting in a chamber with richer oxygen at higher pressure It s a proven treatment for decompression sickness and non-healing wounds Until recently, there was no research on HBOT for autism Thousands of families have reported that it works
HBOT We did two experiments One was a double blind, placebo-controlled studie with 38 children The other was a multiple baseline with 17 children We measured everything: language, play, stereotypy, desctructive behavior, executive function, socialization, etc. Both experiments found no effects at all
Treatment Evaluation All treatments must be evaluated carefully, especially if there is no science behind them But even proven treatments must be tested very carefully recall the frequent data collection in ABA, and ABA is already proven Do not trust degrees or reputations, look for results If a treatment does not work, stop doing it
Tips for Parents Now let s discuss some practical tips you can build into your everyday life to help your child learn more
Tips for Parents: Generalization The single best thing you can do is work on generalizing the skills your child learns in his/her ABA program At every meeting with your child s supervisor, ask for a list of skills your child learned in the last two weeks Practice these skills with your child EVERY DAY Example: If your child learns to label the color red, every time you see something red say, Look, what color is it? or Look at that, it s a red car, etc., and of course reinforce attempts at correct responding
Tips for Parents: Incidental Teaching Communication is the most important thing your child can learn Every time you know your child wants something, that s an opportunity to work on improving his/her requesting skills Use incidental teaching
Tips for Parents: Incidental Teaching Incidental teaching process: Your child wants something Don t give it immediately Wait for child to try to communicate If he does, then give it to him If he doesn t, then prompt If he responds to the prompt, give him what he wants If he doesn t respond to the prompt, prompt again If he already knows how to ask for it, then expand on it (e.g., use an adjective, say please, etc.)
Tips for Parents: Challenging Behavior You have the power to decrease your child s challenging behavior Single most important tip: When you child is having bad behavior DO NOT GIVE HIM ANYTHING HE WANTS Wait until bad behavior has been gone for at least a few minutes Always give lots of what he wants BEFORE he has bad behavior
Tips for Parents: Have High Expectations Ask for proof that your child s treatment is working Ask what the plan is for evaluating the effectiveness of the treatment Ask to see the data If improvement is not occurring, ask what the clinician plans to do about it
Tips for Parents: Try What the ABA Provider Asks Your child s treatment depends on you doing what is recommended If you want your child to succeed, you must put your all into it Don t make a fight with your child s clinician Try what they recommend and do it consistently If it doesn t work, then suggest a change or ask to try it your way
Conclusion Start ABA as young as possible Do it for more than 25 hours per week and for two years or more ABA is not just for young children Evaluate ANY treatment your child is getting very closely Demand evidence Stay involved work on generalization Never give up!!!