Applied Behavior Analysis for Children with Autism

1. Applied Behavior Analysis for Children with Autism Jonathan Tarbox, PhD, BCBA, & Bill Roth, PhD, BCBA

2. Presentation Outline • Introduction to CARD • Brief introduction to ABA and autism • How to teach: Components of a comprehensive ABA program for children with autism • What to teach: CARD curriculum • Note: Don’t be afraid to raise your hand with a question at any time!

3. 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 • 15 locations in U.S.A. – newest office is Berkeley • 2 locations outside U.S.A.: New Zealand, and Australia • Consultation in Asia, Europe, Middle East, and South America

4. 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: money, feeling good for helping someone, approval from others, satisfaction of a good book, 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 think should be motivating to the child • Then we teach the child by teaching new skills in very small steps and rewarding the child with positive reinforcement when they make an effort at learning

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 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

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

8. Support for ABA as a Treatment for Autism • Surgeon General • NY State Department of Health • National Academy of Sciences • American Academy of Pediatrics • “The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups.

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. 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

11. Discrete Trial Training (DTT) • Breaks down learning opportunities into well-controlled, discrete teacher-student interactions Instruction → Correct Response → Reward OR Instruction → Incorrect Response → Correction

12. Discrete Trial Training (DTT) • Provides structure for the learning interaction • Provides a very large number of learning opportunities in a small amount of time • Is proven by hundreds of studies to be an effective teaching procedure

13. One Discrete Trial

14. Many Discrete Trials

15. Natural Environment Training • Naturalistic behavioral teaching procedures go by many names: • Incidental Teaching, Pivotal Response Teaching, • 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

16. Natural Environment Training • Much more natural approach than DTT • Less structured • Looks more like typical interactions • Great for teaching play and social skills • Great for establishing generalization of skills learned in DTT • Some children prefer NET over DTT • Proven by dozens of studies to be an effective teaching procedure

17. 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

18. Verbal Behavior • Most comprehensive ABA programs incorporate Skinner’s analysis of verbal behavior into their treatment • Some incorrectly say that “Verbal behavior is not ABA” or “We don’t do ABA, we do verbal behavior” • Verbal behavior is one area within ABA, it is not seperate

19. Challenging Behavior • Examples: aggression, self-injury, self-stimulatory 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

20. Challenging Behavior • First step is to do a “functional assessment” • This means assess what they child is getting from their challenging 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.

21. 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

22. Data Collection: Teaching If / Then Reasoning Baseline Teaching

23. Data Collection: Accidents During Toilet Training

24. Data Collection: Compliance with Instructions

25. Generalization • Comprehensive ABA programs must explicitly focus on generalization • Generalization does NOT occur automatically • Generalization is NOT an afterthought or side-effect • Generalization is THE central goal of intervention

26. 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

27. 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

28. Supervision • Good ABA programs provide approximately 2 hours of 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

29. Workshop Model • There aren’t enough ABA experts in the world to provide supervision • Another option is the “workshop” model • For families who do not live within an hour drive of an ABA clinic • A consultant travels out to family’s home and trains everyone • Then the family runs the program and manages the therapists • Consultant follows up with regular contacts

30. Overview of CARD Curriculum

31. The CARD Curriculum Academic Skills Executive Functions Cognition Social Skills Motor Skills Adaptive Skills Play Language

32. 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

33. CARD Curriculum • Every area of human functioning is addressed in the eight 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 • Lessons are arranged in the order in which they emerge in typical development

34. Language

35. 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

36. Language Language Curriculum • 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

37. Language Language Curriculum 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

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

39. Play

40. Play Curriculum Play Domains Sensorimotor Play Task Completion Play Play Stations Independent Play Early Social Games Read-to-Me Books & Nursery Rhymes Music and Movement Treasure Hunt Card and Board Games Locomotor Play Peer Play Block Constructions Structure Building Sand and Water Constructions Clay Constructions Arts and Crafts Constructive Play Interactive Play Functional Pretend Play Symbolic Play Imaginary Play Sociodramatic Play Pretend Play Audio and Video Play Computer Play Video Games Electronic Play

41. The CARD Curriculum Adaptive

42. Adaptive Curriculum Adaptive

43. The CARD Curriculum Motor Skills

44. Motor Motor Curriculum

45. The CARD Curriculum Social Skills

46. Social Skills Social Skills Curriculum Social Language Greetings and Salutations Social ID Questions Prosody Regulating Others Conversational Audience Physical Context of Conversation Listening to Conversation Initiating Conversation Joining Conversation Maintaining Conversation Repairing Conversation Transitioning Topics of Conversation Ending Conversation • Non-Vocal • Eye Contact • Non-Vocal Imitation • Body Language & Facial Expressions • Gestures to Regulate Social Interaction Absurdities Figures of Speech Humor and Jokes What’s Wrong? Social Interaction Apologizing Assertiveness Compliments Cooperation & Negotiation Gaining Attention Introductions Levels of Friendship Sharing & Turn-Taking Lending & Borrowing Group Related Skills Responding in Unison Group Discussion Social Rules Compliance Following Rules Community Rules Politeness & Manners Self Esteem Dealing with Conflict Positive Self-Statements Winning & Losing Constructive Criticism Social Context Responding to Social Cues Learning Through Observation

47. The CARD Curriculum Academic Skills

48. Academic Skills Curriculum Language Arts Colors Community Helpers Handwriting and Penmanship Writing Letters Spelling Print Concepts Literary Genres Decoding & Word Recognition: Phonics Sight Reading Comprehension: Oral Story Comprehension Reading Comprehension Phonological Awareness: Phoneme Isolation Phoneme Blending & Segmentation Phoneme Matching Phoneme Manipulation Word Discrimination & Segmentation Rhyming Syllables Academic Skills Math Shapes Money Patterning Calendar Addition Subtraction Statistics and Data Analysis Number Concepts: Numbers Counting & Quantities Quantitative Concepts Ordering Numbers & Groups Comparisons Number Patterns Time: Time of Day & Daily Activities Telling Time

49. The CARD Curriculum School Skills Executive Functions Cognition Social Skills Motor Skills Adaptive Skills Play Language

50. Conclusion • ABA is the only treatment for autism that has substantial science evidence for causing large improvements in children • ABA programs should be comprehensive: • 25 or more hours per week of one-to-one • Address all skills areas • Two years or more of treatment • Verbal behavior • Generalization • DTT • NET • Top-quality supervision