Bryna Siegel, Ph.D. Director, Autism Clinic Co-Director, Autism Neurodevelopment Center

1. What Is An ABA Placement? Seattle University School of Law Administrative Law Judge Training October 19, 2011 Bryna Siegel, Ph.D.Director, Autism Clinic Co-Director, Autism Neurodevelopment Center Bryna.Siegel@ucsf.edu Professor, Child & Adolescent Psychiatry University of California, San Francisco

2. Today’s Topics • What has applied behavior analysis contributed to the treatment of autism? • How and when do we use it? • Where does ABA ‘fit’ with developmental considerations for treatment? • How do we integrate approaches to ‘cover all bases’ in defining ‘appropriate placement’? bryna.siegel@ucsf.edu

3. Themes in ABA Literature on Autism Treatment • Efficacy of behavioral methods (ABA) • Individualization (ABA) • Intensity (ABA) • Natural environment as teaching milieu (PRT) • Parents/ home/ outside world’s role in acquisition & generalization (NET) bryna.siegel@ucsf.edu

4. A Brief History of ABA and Autism • Pavlov Skinner: Learning in animals worked in humans too • Lovaas at UCLA uses ABA for severe SIBs • Lovaas uses ABA to teach ‘positive’ behavior, not just to extinguish ‘negative’ behavior. • Lovaas’s curriculum content neither developmental or autism-specific, but… • Introduces intensity, data-based trials & high mastery levels; these are validated and reified. bryna.siegel@ucsf.edu

5. Applied Behavior Analysis (ABA) and the Culture of Autism Treatment • ABA has become most widely-available one-to-one treatment modality for ASDs • One-to-one complements heterogeneity of ASDs • Potential for highest intensity • ABA has become highly influential in classroom practices too: • Mandate for data-driven instructional practices • Need for functional behavioral analyses of behavior incompatible with instruction bryna.siegel@ucsf.edu

6. What Have We Learned About ABA and ASDs in the Last 20 Years? • ABA can be effective at home and in schools • Behavioral principles have been applied with different emphases: • Performing: Discrete trial training (DTT) • Requesting: Pivotal response training (PRT) • Adapting: Natural environment training (NET) • Remaining Challenges: • Motivation especially social motivation • Developmental appropriateness of curriculum • Generalization of objectives of learning bryna.siegel@ucsf.edu

7. Selecting the Right Tool for the Job Concept of the Autism Treatment Toolbox

8. ABA and the Autism Treatment Toolbox • What does autism treatment need to target? • What does ABA target most specifically? • What does ABA leave unaddressed? • How do you fill an autism treatment ‘toolbox’: • for a particular child, or • for a particular age group, or • for a particular sub-group of children with ASDs? What tools does ABA give us? bryna.siegel@ucsf.edu

9. An Example: ABA for Low Functioning Autism (LFA)? LFA: NV/ minimally verbal, PIQ < 50, verbal lower • Non-linear effect of # hrs of tx • More is not necessarily better if LFA • Hi intensity (≥ 25 hr./wk)~ low intensity (≤ 20 hr./wk) • Best ABA outcomes: • NVVerbal in 1st 3 m. of tx (per Lovaas)= non-responders • Low level of behavior incompatible w/ instruction bryna.siegel@ucsf.edu

10. Implementation of ABA Methods as a Function of Placement • When should treatment be given in a natural environment? • Home? Child care? • Can treatment be delivered in an inclusive setting? • Typically developing peers predominate? • Can treatment be delivered in an integrated setting? • Designed for typical and atypically developing children both? • Does treatment motivate child to self-initiate? bryna.siegel@ucsf.edu

11. The Importance of Integrating ABA Methods with Developmental Considerations (so it’s not dog training….) bryna.siegel@ucsf.edu

12. What Is the Developmental-Behavioral Approach? • Establish curriculum content based on developmental level/ ‘what comes next’. • Uses behavioral methodology to teach developmentally-based curriculum. • Enhancing motivation by differentially rewarding self-initiative in learning bryna.siegel@ucsf.edu

13. Why It’s Important to Include a ‘Developmental’ Perspective • The brain matures in a fixed sequence, supporting behavior emerging from increasingly complex and integrated neural capacities. • Behavioral development has a fixed sequence tied to that neural development. • Children may learn at different rates & ways, but the ordered sequence for a solid foundation. bryna.siegel@ucsf.edu

14. Why is it Important to Include a Behavioral Perspective? • Empirical efficacy of behavioral methods • Flexibility for individualization • Ability to control intensity • Natural environment as teaching milieu (PRT) • Parents/ home/ outside world’s role in acquisition & generalization (NET) bryna.siegel@ucsf.edu

15. An Example of Curriculum that is Developmental andBehavioral • Based on where the child is developmentally (e.g. 18 month receptive language—teach the next set of skills—moving from MLU=1 to MLU=2). • Calibrate growth trajectory based on learning history and assessment observations and results; re-calibrate trajectory annually before drafting IEP goals. • Do teach using validated behavioral principles. bryna.siegel@ucsf.edu

16. Another Example of Curriculum that is Developmental andBehavioral • Purely Behavioral/ Not Developmental: Learning ‘stand-up/ sit down’ before ‘mama and dada.’ • Changing the content to be developmental: Teaching ‘horizontally’, not ‘vertically’: 10 barnyard animals versus 10 faces of mommy • Integrating Developmental and Behavioral: Keeping the ABA teaching method and pairing it with a developmental curriculum. bryna.siegel@ucsf.edu

17. How Have These Considerations Been Reified in National Standards? • National Research Council of Nat. Acad. Of Sciences (2001) • Part C of IDEIA (2004) • Div. of Early Childhood/ Council on Exceptional Children (2005) • Nat. Assn. for Ed. of Young Children (2009) bryna.siegel@ucsf.edu

18. ‘Active Ingredients’: Intensity Candidates include: • Use of 1:1 ? • # Hours/ Week? • # Trials? • % Accurate Responses? • Level of prompting needed for response? bryna.siegel@ucsf.edu

19. ‘Active Ingredients’: Developmentally-Appropriate • Appropriate for Chronological Age? • Appropriate for Developmental ‘Age’? • Developmentally-sequenced? • Comports with developmental ‘morphology’? (e.g., Language: # of single words before phrases) bryna.siegel@ucsf.edu

20. ‘Active Ingredients’: Addresses Social Deficits • Establishes theory of mind • Establishes joint attention • Establishes instrumental attention-seeking • Establishes expressive attention-sharing • Promotes imitative learning bryna.siegel@ucsf.edu

21. The Role of Diagnostic and Psycho-Educational Assessment in Formulating a Developmental-Behavioral Plan bryna.siegel@ucsf.edu

22. The Importance of Convergent Validity in Differential Diagnosis Informant: Parent Structure (Structured) Criterion Based Informant: Child Data Collection: Observe Structure (Unstructured) Play-Based AUTISM DIAGNOSIS Data Collection: Interview Setting: (Natural) Home Setting: School/Clinic bryna.siegel@ucsf.edu

23. Let’s Just Treat What’s Wrong • Importance (or Not) of Diagnosis • Identifying Learning Processes • Identification of What Needs to be Learned • Figuring Out How to Teach so the Child becomes an Independent Learner bryna.siegel@ucsf.edu

24. Accounting for Responder Characteristics in an Educational Plan What is A ‘Responder Characteristic?’ • Specific ‘Autistic Learning Disabilities’ • Developmental Level • Language Level • Maladaptive Behaviors bryna.siegel@ucsf.edu

25. (Behavioral) Goals Should Be Predicated on Developmental Trajectory • Diagnosis can change • Degree of cognitive impairment can change • Language competencies can change • Changes affect treatment plans • Changes affect prognostic expectations • Re-examining goals in light of developmental trajectory bryna.siegel@ucsf.edu

26. The Autistic Learning Disabilities / Autistic Learning Styles Approach Siegel B (2010). ‘Reconceptualizing Autistic Spectrum Disorders as Autism-Specific Learning Disabilities and Learning Styles’ in T Millon, Krueger, & Simonsen (Eds) Contemporary Directions in Psychopathology, New York: Guilford Publications

27. Autistic Learning Styles Defined: • Autistic learning styles are intact functions automatically being deployed to compensate for impaired systems • By looking for autistic learning styles, we discover what works and can make more use of those intact systems (improving on success) bryna.siegel@ucsf.edu

28. What’s an Autistic Learning Style?ALD + Intact Abilities = ALS Defined by Matrix of Ability and Disability: What the child can’t do (ALD) plus what the child can do = autistic learning style (ALS) What the Child Does Well Shows Us: How to ‘deconstruct’ ‘symptoms’ into what works & what doesn’t (e.g., Echolalia) Compensatory strategies that are autism-specific (e.g., VAC vs ASL) Processing modality ‘substitution’ (e.g., Hearing for blind vs visual memory for ASD) bryna.siegel@ucsf.edu

29. Matrix of Ability and DisabilityExamples:Auditory Processing& Visual Memory bryna.siegel@ucsf.edu

30. Autistic Learning Styles (ALSs)Related to Memory Verbal Intelligence-Related • Good Auditory Memory without ‘Parsing’ (Memorizes songs, videos or books without understanding full meaning) Performance Intelligence-Related • Good Procedural Memory (Prefers Routines) (Anticipates exact sequence of events leading to desired outcomes) bryna.siegel@ucsf.edu

31. Autistic Learning Styles (ALSs)Related to Motivation Verbal Intelligence-Related • Better use of language when requesting than commenting Performance Intelligence-Related • Good visual-motor-spatial ability without need for semantic supports (Does puzzles backward or upside down, draws from ‘photographic’ memory) bryna.siegel@ucsf.edu

32. The ALS/ALD Approach: A New Heuristic ALS=‘Autistic Learning Styles’ ALD=‘Autistic Learning Disabilities’ The ALS/ ALD heuristic can be used to classify autistic alterations in Perception, Cognition, Information-Processing, Motivation & Expression bryna.siegel@ucsf.edu

33. Autistic Learning Disabilities:How Social Deficits Affect Learning Lack of socio-emotional reciprocity= Lack of desire to please others Low response to social reinforcers Lacks concern re: effect on others Lack of awareness of others= Motive to please self is foremost Instrumental learning style Lack of social imitation= Low “incidental” learning via copying others No drive to follow group norms Why Should I Care? bryna.siegel@ucsf.edu

34. Autistic Learning Disabilities:How Non-Verbal Communication Deficits Affect Learning Low comprehension of facial/ vocal cues: • Smiles, frown, more subtle facial affect • Tone of voice to mark affective/ semantic meaning Ignores gestures that are the ‘first’ language: • Gaze toward topic of conversation • Point to initiate joint attention to topic Does not signal comprehension, intentions feelings bryna.siegel@ucsf.edu

35. Autistic Learning Disabilities:How Verbal CommunicationDeficits Affect Learning Receptive Language • Signal : noise problem for verbal ‘signal’ • Language processing with poor ‘parsing’ • Overly literal/ concrete, limited generalization Expressive Language • Without ‘theory of mind’, no drive to ‘share’ ideas • Without instrumental motive, no drive to express • Oral-motor apraxia synergistic w/ low expressive drive bryna.siegel@ucsf.edu

36. Autistic Learning Disabilities:How Play and Exploration Deficits Affect Learning Lack of imagination in play= • No consolidation of experience via play linking action and language • No symbolic actions to link to language to abstract thinking Stereotyped and repetitive interests= • Averse to novelty/ low curiosity • Limited learning through exploration • Repetitive interests = mental ‘down time’ bryna.siegel@ucsf.edu

37. ‘Active Ingredients’ of ABA Methodology & the ALD/ALS Model

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41. ABA Approaches in the Context of Group vs Individual Treatments Approaches

42. Approaches to Autism Treatment bryna.siegel@ucsf.edu

43. Autistic Learning Disabilities and the Methods that Address Them Or When to Use ABA and When to Reach for a Different Tool

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47. In Conclusion • ABA is a powerful tool in the autism treatment toolbox • It’s not the only tool • Integration of ABA methods with developmental curriculum is the highest standard for evidence-based treatment bryna.siegel@ucsf.edu