11/15/2013

Evidence-Based Intervention for the

Young Child with Autism:
Making the Strategies Work for You

Elizabeth McMahon Griffith, PhD

University of Colorado School of Medicine &
Children's Hospital Colorado

Objectives

o Review 3 different models of intervention

o Extract "Key Strategies"
o Discuss implementing Key Strategies
o Family-centered practice
o Identifying target skills
o Building relationships
o Careful teaching
o Explore Specific Content Areas

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Examples of Models of Intervention:

Early Start Denver Model
LEAP
DIR®/FloortimeTM

Early Start Denver Model ESDM)

Rogers & Dawson, 2010
Dawson, Rogers, et. al., 2010

* Comprehensive manualized early intervention approach,

with a fidelity measure
* Structured, hands-on strategies for working with
toddlers with ASD to promote developmental acceleration
& reduce severity of the symptoms of autism
* Specific teaching of developmentally sequenced skills
embedded in social relationships and play following child-
motivation
* Includes both a Curriculum & Specific Teaching Practices
* Foundations in Theory and Empirical Interventions

Using ESDM

, With whom?
* Children with ASD
* 1-5 years chronological age
* 9-48 months developmental maturity

* Where?
* 1:1 or small group
* Home or Center based
* Classrooms

* Delivered by whom?
* Early childhood professionals (multiple disciplines)
* Paraprofessionals
* Parents

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Some Key Elements of ESDM

* Developmental Framework
* Relationship Based
* Parents at the Helm
* Science of Learning
* Interdisciplinary/Generalist approach
* Multiple Environments
* Learning Opportunities All Day Long

Learning Experiences and Alternative Program for

Preschooler & Their Parents (LEAP)
Strain & Cardiac°, 1994
Sttain & Bowl, 2011

* Comprehensive manualized inclusion model with a fidelity

measure
* Integrated preschool that includes peer-mediated
instruction, and behavioral skill training programs for
parents for working with preschoolers with ASD to promote
developmental acceleration & reduce severity of the
symptoms of autism
* Naturally occurring incidental teaching in classrooms
* Foundations in Theory and Empirical Interventions

Using LEAP

* With whom?
* Children with and without ASD
* 3-5 years of age (preschool)

* Where?
* Integrated high - quality preschool classrooms

* Delivered by whom?
* ECE Teachers
* Paraprofessionals
* Early childhood professionals (transdisciplinary)
* Parents/Primary Caregivers
* Peers/Siblings

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Some Key Elements of LEAP

* Embed strategies within high quality preschool programs

* Children are included from "Day 1" with support
* Teach typical peers to facilitate social and communicative behaviors
* Planned, systematic, individualized intervention
* Learning objectives are taught to generalization
* Skill training for families
* Data systems and decision making
* Uses "science-based intervention approaches" (peer-mediated,
errorless learning, time-delay, incidental teaching, pivotal response
training, PECS, PBS)

Developmental, Individual Difference,

Relationship-based Model
DIR®/FloortimenGL. 8 Wieder 2005
Pajareya et. al.. 2011 ,

* Comprehensive framework to construct program tailored to

child's unique challenges and strengths
* Philosophy of joining child and then bringing child into
shared world to develop emotional and developmental
functioning and processing
* Home-based developmentally appropriate practices
* Foundations in Theory

Using DI Re

* With whom?
* Children with ASD
Infancy into school age

* Where?
* Home
• Clinic
* Delivered by whom?
* Parents
* Clinicians
* Early childhood professionals (multiple disciplines)

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Key Elements of DIRO

* Developmental - 6 Developmental Milestones (shared

attention & regulation, engagement & relating, purposeful communication,
complex communication g, problem solving, creating emotional ideas, emotional
ideas Sr logical thinking)

* Individual Difference - in sensory, planning and

sequencing, and actions and ideas
* Relationship-Based - learning to be in relationship
with others
• Floortim e TM as a specific technique

Key Strategies:

Family-Centered Practice
Identifying target skills
Building relationships & Routines
Careful teaching

Family-Centered Practice

* "Family strengthening and competency-enhancing"

* Shared responsibility/partnership
* Supporting family relationships/strengthening families
* Individualized, flexible, responsive support
In congruence with family values and beliefs
* Build on strengths & assets/resources
* Family choices, concerns, priorities
* Preparing parents for a lifetime of decision-making
and advocacy
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Determining the needs

of the child

Objectives

Data

Monitoring Progress

Determining the needs

of the child

Family Concerns

>Research in Early Autism

>Knowledge of Development

>Curricula & Tests

Family Concerns

* Meaningful Outcomes
* General concerns/worries/needs Interview
* What is important to family?
* Need context, meaningful activities & environments
* Don't forget strengths
* Routines-Based Interview
* Everyday activities
* Child's engagement, independence, social relationships

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Research on Early Autism

* Social orientation, sharing attention, affect and

attunement
* Imitation
* Joint attention & other nonverbals
* Language
* Functional/Symbolic Play
* Learning rate

Knowledge of Development

* Autism is a developmental disorder

* Developmental processes are at work
* All developmental areas are affected and must
be targeted
* Work to "fill-in" gaps in development
* Individualized

Curricula & Tests

V Receptive & Expressive language

V Fine & Gross motor
v Cognition
V Personal independence

V Preverbal Communication like Joint attention

Social interaction
V Imitation
V Play
V General Learning Skills (motivation, attentional focus)

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How to know if child is learning

1. Determine IFSP/IEP goals

2. Build "Working" Objectives
3. Break into Teaching Steps
4. Take Data
5. Monitor Progress Regularly
6. Alter Teaching to Ensure Learning

Build Working Objectives

* Family identified outcomes

* Target functional, adaptive actions in context

* Across developmental areas/domains

* Set for short-term mastery

* Measurable learning objective:

* Antecedent event
* Behavior
* Criterion for mastery
* Generalized across people, materials, & settings

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Writing Objectives

A: What is the antecedent or stimulus that is to cue

the behavior? May include a setting statement.

B: What is the observable behavior?

C: What is the measurable criterion for evaluating

mastery?

How will the skill be Generalized?

A
Antecedent to cue the behavior

What cues the behavior in the natural environment

for typically developing children?

*Another person's behavior

*Environmental cue
*Internal cue
*Preceding behavior in a sequence

Observable Behavior

What behavior do we want the child to exhibit?

What is the "action"?
*Observable behavior ("point to")
o Not abstract ("knowledge of")

*Specific & Measurable

*May be multiple behaviors

*Don't have to specify all instances

Ex. in nouns to request

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Criterion for mastery

What indicates that the skill is truly mastered?

* Measureable
quantity (beware % statements)
Accuracy
Fluency/Latency
Duration
1. opportunity

*Level of independence/support
*Generalization across
* Settings/Environments, Materials, People, Time

Example Objective:
Imitation

A: When adult models simple gestures inside sensory social

routines (songs, finger plays, active social games), during
circle time or in individual or small group learning,

B: child will imitate 3 different gestures in each of m

familiar routines,

C (&G): 80% of opportunities, across 3 consecutive days,

with S or more adults, at home, school, and clinic.

Example Objective:
Eating

A: xxxx

B: Child will participate in breakfast, in lunch and in

restaurants by chewing food and swallowing it.

C (&G): We will know she can do this when she eats .1 cup of
food in this manner once at each (breakfast, lunch,
restaurants) in i week.

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Teaching Steps

* How will the skill develop?

How will we teach it?

* Steps to learning
* Increasing independence
* Refining behavior
* Broadening the range/frequency of the behavior or antecedents
* Increasing generalization

, . . .

ExampIe::Teaching Steps
Objective: When adult models simple gestures inside sensory social
routines (songs, finger plays, active social games), during circle time or in
individual or small group learning, child will imitate 3 different gestures in
each of 10 familiar routines, 80% of opportunities, across 3 consecutive
days, with 201 more adults, at home, school, and clinlc

I. Observes adult's actions during sensory social routines

2. Does not resist adult assistance for 2 gestures in 2 routines

3. Imitates 2 gestures in 2 routines independently

4. Imitates 2 gesture in 6 routines Independently

5. Imitates 3 gestures in 8 routines Independently

6. Imitates 3 different gestures in 10 routines,80% opportunities,

3 days, 2+ adults, 3 settings

Take Data

* Yes, it is important
* Write it down and track over time
* Different Methods
* Doesn't have to be trial-by-trial
* Time intervals
* Per activity

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Monitor Progress Regularly

Assess
progress on
objectives

Re-assess Write new

skills objectives

Teach

Building Relationships
with Caregivers

Building Relationships 8(
Routines with Children

Hanft, Rush, & Shelden, 2004

Rogers & Dawson, 2010

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Building Relationships
with Caregivers

:Why?
• Determining Caregiver Needs
Setting Expectations
■ Coaching

VVhy Build Relationships

with Caregivers?

* Family-Centered Practice

* Family implemented intervention

* Families are lifetime caregivers
* Embed in natural environment
* Families have more teaching opportunities
* Participation in community
* Strengthens caregivers confidence and competence

Determining Caregiver Needs

* Goals for themselves

* Cultural differences
* Barriers
* Meaningful activities and environments
* Learning style
* Coping strategies
* Motivation

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Setting Expectations

* Explicit — Have the conversation

* Partnership
* Set-up of sessions/visits
* Talk about previous week
* Talk about your suggestion/topic
* Model (tell what going to do, dolt, tell what did and
explain the consequences)
* Caregiver guided practice
(multiple activities) (video review?)
* Discuss when can use in daily life and when will use in
upcoming week (what, when, where, how often)

* Goals:
* Support learner to recognize what already doing that
promotes child learning

* Assist learner in creating new learning opportunities

throughout child's day, across settings

Hanft, Rush, 3, Shelden, 2004, p. 31

Components of Coaching

* Initiation/Joint Planning
* Observation
* Action/Practice
* Reflection
* Evaluation/Feedback

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Building Relationships
with Children

Why?
* Becoming a Play Partner
* Building Frames for Teaching
* Joint Activity Routines
* Daily Routines

Why are Relationships so important?

* Development is an interpersonal process

* Quality of relationships mediate development

* Positive affect
* Reciprocity
* Adult sensitivity
* Responsivity

* Naturalistic Teaching approaches

Becoming a Play Partner

* Set up the environment

* Provide a variety of age - appropriate objects

* Child becomes interested in something "Find the

smile" — Approach & Motivation
* You may need to:
* offer particular toys as options
* provide an "object spectacle"
* start a physical activity
* offer food

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Next steps

* Join the child

* Eliminate the competition
* Take center stage, "step into the spotlight"
* face-to-face with child
* eye level
* materials between you and child
* monitor child cues (watch & listen)
* Watch and comment
* watch with interest
* approving sounds/gestures
* simple narrative and sound effects

Next steps

* Touching the materials

* No demands
* Giving materials
* Be helpful
* Package so that needs help
* Move materials closer
* Hold to be helpful

Becoming an Active Play Partner

Follow-into the play

* Imitate Child
* No demands & No conflict
* Parallel play
* Interactive - Quick turn to add

* Elaborate play
* Add a small aspect
* Introduce something novel

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Becoming an Active Play Partner

Increase your presence

* Increase control of materials

* materials in your possession
* "Take over the reinforcers"
* give freely

* Turn taking
* "My turn"
* imitative or spectacle
* brief
* child always takes the last turn

Frames for teaching:

Joint activity routines

* Follows child choice or interest

* Both partners actively engaged in the activity
"co-construction"
* Theme and variation
* Includes multiple developmental areas
* Multiple learning opportunities
* Age-appropriate length

Joint activity routines

Types

* Object-Based Routine
* Still social and communicative
* Sets up joint-attention (triadic attention)
* Sensory Social Routines
* Dyadic engagement
* Social-communicative cues, facial awareness,
communication, regulate arousal
* Hello & Goodbye
* Meal routines
* Self Care/Daily Living

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Stages of Joint activity routines

o Opening- Introduce & Develop Theme

* Child's choke of activity/Therapist's offer of activity & child's acceptancg
* Set up the activity to work on objectives

* Theme
* Sharing the activity
• HavIng a good time- Emotion sharing
• Working on objectives
• flows from child to therapist and therapist to child
* Elaboration orVarying
* Making it more interesting by varying the play
• Extends attention, promotes flexibility, develops creativity
* Other objectives or different aspects of same objectives

o Closing - > Transition

* Attention Is waning Or therapist decides Its time to shift
* "Finish?"
* Clean up
* Transition to another activity

Clean-up

* Clean-up
* Build up this routine like others
* Teaching opportunities within clean-up
* Temporal sequencing
* Regulation and "first-then" or "when-then"

Transitions

* Key Elements
* Independent
* Going to a new place for a specific purpose
* Change in space, type of activity
* In Groups
* Consistent Visual & Auditory signals
* Assigned staff roles
* Staggered

* Managing Resistance
* make more boring
o tempt to other activities

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Science of Learning

Common Teaching
Strategies

Addressing Unwanted
Behavior

Learning in a Group

Using the Science of Learning

* Systematic intentional intervention

* Tools of Applied Behavior Analysis (ABA)
* Data-based Decisions
* Positive Behavior approaches for unwanted behaviors

"Recommended instructional strategies are used with sufficient

fidelity, consistency, frequency, and intensity to ensure high
levels of behavior occurring frequently" (DEC, 2005)

Antecedent-Behavior-Consequence

A = What cues the behavior?

B = What behavior do we want the child to exhibit?

What is the "action"?

C = What follows the behavior that makes it more or

less likely to happen again? As natural as possible.

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Common Teaching Strategies

* Prompting & Prompt Fading

* Shaping
* Chaining
* Reinforcement principles
* Time Delay
* Maintenance of skills
* Peer Modeling

Addressing Unwanted Behaviors:

Preventative & Positive
* Why is it occurring?
* FBA: A-B-Cs to determine function
* In context

* Is the child getting enough reward for being engaged,

attentive, participating, attempting difficult skills?

* Antecedent Based Intervention

* Replacement Behaviors
* Alter Consequences

Learning in a Croup

* Goals of group learning

* When to teach
* Environmental supports
* Scheduling

* Must have: adequate staff support, teaming time,

preparation time, implementing high quality
programs to fidelity

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Goals of Group Learning

* Independence
* Communicate intentionally with adults and peers
* Engage in purposeful play and appropriate toy use
* Interact spontaneously with peers & adults
* Expand developmental skills in all areas
* Acquire skills for next learning environment

When to teach

* Embed objectives into regular activities

* Small group learning
* Individualized learning 1:1

* Note: have child's activity-related objectives posted in the

appropriate area of the classroom
* Daily data and data tracking across time are a necessity

Group Activities
* Short
* Appropriate to skill level and interests
a Visual supports
* Lively pace
* Individualized learning interactions
* Active and successful participation
* Rewarded for active participation
* Planned for each child's objectives
* Activity Lead is Primary
a Delivers teaching
* Rewards
* Other staff as silent support

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Environmental Supports

* Supports child-initiated & child-directed play/learning

* Clearly defined interest areas:
* Highlights most important aspect of activity/task
* Clearly reflects/states goals for area/activity
* Clean and organized
* Visual cues
* Supports independent transitions

Scheduling

* Overall Group Schedule

* Consistent and predictable
* Balance of developmental areas, classroom areas, activity
levels, degree of structure, size of learning group, outdoor
* Staff Schedules
* Role in each activity with "script"
* Individual Child Plan
* Includes individualized instruction time & specialized therapies
* Balanced for child needs
* Activity-related objectives
* "Down time" - supporting appropriate use

LEAP Peer-Facilitative Strategies

* Describe
* Demonstrate
* Demonstrate Incorrect
* Child practice with adult
* Practice with target child
* Awards 8c prizes
* Posters to remind throughout classroom

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Specific Key Content Areas

Imitation

* Natural opportunities throughout activities

* Mark actions with language

* Imitation opportunities
* Object imitation
* Gestural imitation
* Oral-Facial imitation
Vocal imitation

* Caution to fade prompts

Play

* Deepen & Broaden play

* Teaching through imitation

* Developmentally appropriate
* Toys
* Types of play

* Quickly move to spontaneous independent play

* Sensorimotor
* Functional
* Symbolic
* Increase story lines & Role Play

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Developing Communication

* Relationship Based
* Coordinated Attention

* Communication interwoven throughout activities

* "Why" of Communication

* "How" of Communication
* Developmental Stages
* Nonverbal & Verbal
* Receptive & Expressive

Nonverbal Communication

* Coordinated Attention

* Joint attention

* Natural gestures

* Conventional gestures

* Variety of communicative functions

* Expressive & Receptive

Nonverbal Communication

* Natural gestures
* WAIT & Shape
* Think developmentally
* Look for coordination of eyes and gestures
* Demonstrate so also add receptive

* Conventional gestures
* Demonstrate
* Set-up and prompt
* Joint Attention
• Giving
v Showing
• Painting

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Verbal Communication

* Foundational skills
* "Why?"
* Intentional control of speech production system
* Imitation of others' speech
* Word meanings
* Combining verbal and nonverbal communication

* Increase vocalizations
* Increase frequency/amount
* Increase variety/range

Verbal Communication

* Words
* Give meaning to vocals
* Model words (specific)
• Shape & fade to Spontaneous
* Broaden type and pragmatics

* Phrases
* Model 2 - words (do not model one at a time)
* "One-up rule" for spontaneous (not echoed)

Receptive Language

* Understanding?
. Following nonverbal cues
* Ignoring verbal language

* Teach importance
* Instruction at appropriate MLU
• Cue to respond
Follow through
* Require a response
• Verbal precedes nonverbal in instructions
* Reinforce

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