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Autistic Disorders: Single case and group interventions

Autistic Disorders: Single case and group interventions. Paul Probst, Department of Psychology University of Hamburg, Germany probst@uni-hamburg.de

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Autistic Disorders: Single case and group interventions

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  1. Autistic Disorders: Single case and group interventions Paul Probst, Department of Psychology University of Hamburg, Germanyprobst@uni-hamburg.de Lectures at the Department of Psychology of the Sun Yat-Sen-University in Guangzhou (Kanton), the School of Psychology in Zhou Hai and the East China University in Shanghai Collaborators: Marlis Rossbach (Ph.D.), Tobias Leppert (Ph.D.) and a group of Psychology-Diploma (graduate ) students Scientists Exchange Program Between Germany & People‘s Republic of China (Supported by German Academic Exchange Agency, Bonn and Ministry of Education, China)

  2. Pervasive Developmental Disorders: Assessment and Interventions • Common historical roots between Chinese and German Psychology? • Assessment Methods • Intervention Methods • Metaanalysis • Group trainings • Single case studies • Conclusions • Theoretical validity • Internal validity • External validity

  3. COMMON HISTORICAL ROOTS • Ernst MEUMAN, 1862-1915 • Psychologist and Philosopher • 1911-1915: Chair of the first Philophical and Psychological Institute in Hamburg, Germany • 1911: founded the Psychological Laboratory in Hamburg • Main field: Educational Psychology (transfer between theory to practice) • William STERN (1916-1933): Successor: Focus on interdependence between basic and applied psychology and philosophy (ethical issues). „Intelligent Quotient“ (critical view)

  4. COMMON HISTORICAL ROOTS AND IDEAS • Ernst MEUMAN: Student of Wilhelm WUNDT, (University of Leipzig (Lipsy), Germany: Founder of first Psychological Laboratory in 1879) • Tsai YANPAI: First Psy. Lab. in Beijing, 1917 (Qicheng Jing, 2000, Wang, 1993) • Central ideas in Meuman‘s program • Better understanding of the „child‘s nature“ by „Experimental Pedagogy“ (educational measurement, devel. p.) • Close association between basic and applied research • Close association between research and teaching • Parallels to „Institutions of Psychology in China“ (2000) and current international psychology („Practitioner Scientist Model“)

  5. Pervasive Developmental Disorders: Assessment Methods • International Classification Systems: • ICD-10 (WHO Multiaxial version for child disorders (similar to DSM-4) • Interviews and Questionnaires (with parents and significant others) • Autism Diagnostic Interview-Revised (ADI-R) / Questionnaire • Checklist for Autism in Toddlers (CHAT) • Child Behavior Checklist (CBCL, Parent Form, Teacher Form) • Parent Stress Index (Abidin) • Behavioral Observational instruments • Autism Observational Schedule-Generic (ADOS-G) • Adolescent and Adult Psychoeducational Profile (AAPEP) • Cognitive and Language Development • Wechsler Intelligence Test for Children (WISC) • Progressive Matrices Test • Peabody Picture Vocabulary Test • Diverse Language Development Tests (Morphology, Syntax, Semantics, Pragmatics) • Chinese-Language Assessment Methods (ZHANG, Houcan, 2000)

  6. Pervasive Developmental Disorders: Assessment • Infantile Autism: International Classification of Diseases (ICD-10-Rev)(ICD- 10, F84): • Deficits in Social Interaction • Gaze behavior, less play with children, less mutual emotion, less shared attention • Deficits in Communication & Language • 50 percent: no expressive language, monotonous speech, deficits in conversation • Deficits in Interests and Behavior • Stereotyped behavior, rituals, less pretend play • Early Beginning: 24-36 mo. • Comorbidity and above-chance associated symptoms: • Mental Retardation (F7) (about 70%), • Epilepsy (15-25%) • Behavioral symptoms like self-injuring behavior, aggression • Hyperactive behavior: inattention, hyperactivity, impulsivity

  7. Other Pervasive Developmental Disorders: AssessmentICD-10 • Asperger-Syndrome • Deficits in Social Interaction • Deficits in Interests and Behavior • No important delay in language and cognitive development (however deviant speech: intonation, rhythm: prosodic features of language) • Atypical Autism • Onset after 36 months OR • Not all three key symptoms completely present • Rett-Syndrom • Normal development during the first 5 months • Loss of goal-directed hand movement skills • Disturbance of cognitive, language and motoric abilities • Disintegrative Childhood Disorder • Loss of already aquired language skills after second year • Disturbance of social, cognitive, and motivational abilities

  8. Pervasive Developmental Disorders: Prevalence • Infantile Autism: 0.5 per 1000 • Autism spectrum: 1 per 1000 or more • Estimation of prevalence by Chinese Parent Organization: Stars and Rain, founded by the parent Ms. Tian Huiping in 1993: 1.2 per 1000(400 000 to 500 000 autistic children out of 380 Mio children) (Li Heng, 2002 http://www.guduzh.org.cn/english/index.htm)

  9. Autistic child: Christoph, 12 yrs.

  10. Autistic child: Maksim, 6 yrs.

  11. Pervasive Developmental Disorders: Assessment • Autism Diagnostic Interview (ADI-R): about 110 Items • General development of child; worries of parents • Communication and Language • Social Development and Play • Interests and Behavior • Example from Part"Interest and Behavior" (Item 75: "Compulsions and Rituals"):"Are there things which apparently have to be done by your child in some fixed serial order or in some specified manner (...), as for example, touching special objects or putting of objects in specified orde, before he / she will be able to start with a new activity?" • Coding: Rating: 0, 1, 2, 3.3= one ore more activities which HAVE do be done in specified manner,- if interrupted extremely anxious and upset, - family life severely impaired

  12. Pervasive Developmental Disorders: Assessment • Checklist for Autism in Toddlers(CHAT) • Parent Questionnaire: • "Has your child ever used his/ her index finger to show you something or to ask for somewhat"? • Examiner Observations • Try to get the attention of the child. Then point to something in the room which is attractive and interesting and say: " Oh look, there is a teddy!" • Autism Diagnostic Observation Schedule- Generic (ADOS-G) • Language and Communication • Reciprocal Social Interaction • Play and Phantasy • Stereotyped Behavior and Restricted Behavior • Other Deviant Behaviors • 4Modules: • Module-1 = Non-speaking Children • Module-2 = Children and Adults: Phrases and sentences with 3 or more words • Module-3 = Children and Youth, fluently speaking • Module-4 = Youth and Adults, fluently speaking

  13. Pervasive Developmental Disorders: Assessment-ADOS-G Child's reaction on the attempt to produce "Shared Attention" (Toy: remote-controlled dog) Coding on 4-point rating scale: 0-3

  14. Pervasive Developmental Disorders: Assessment: ADOS-G • Module 1 • Module 2

  15. Pervasive Developmental Disorders: Assessment: ADOS-G Module 3 Module 4

  16. Pervasive Developmental Disorders: AssessmentAdolescent and Adult Psychoeducational Profile (AAPEP) • AAPEP: Assessment of developmental level of persons with autism and mental retardation: 3 Scales • Direct observation: semi-standardized • in the home environment • Questionnaire for significant others in the areas of school and work • Six dimensions of development • Vocational skills • Independence • Leisure skills • Professional skills • Functional communication • Interpersonal Behavior

  17. Pervasive Developmental Disorders: AssessmentAdolescent and Adult Psychoeducational Profile (AAPEP): Examples • Vocational/ professionall skills • Leisure skills

  18. Pervasive Developmental Disorders: Assessment: Coloured and Progressive Matrices: Adapted to non-speaking persons

  19. Pervasive Developmental Disorders: Assessment: Peabody Picture Vocabulary Test: Adapted

  20. Aspects of program development and Evaluation (Rossi et al., 2004, "Evaluation" ) Pervasive Developmental Disorders: Interventions • Assessment of social needs for intervention • Program theory evaluation • Program elements based on scientific evidence? • Process evaluation • Are participants satisfied with the program services • Outcome (impact) evaluation • Positive („desired“) outcomes? • Unintended side effects? • Efficiency evaluation: cost benefit analysis

  21. Pervasive Developmental Disorders: Interventions: Social needs assessment • Social need for parent and teacher programs? • Broad evidence from international research literature for elevated stress profiles in families and classrooms with autistic and hyperactive children. : • Specific symptom pattern which are disruptive in social group life (e. g. compulsive, ritualistic behaviors) • Parent and teacher ask for more professional support and education (e. g. Haeussler, 2000, Three-nation-study)

  22. Pervasive Developmental Disorders: Interventions: - Social needs assessment • * 85% of parents report: My child lives in his/her own world sometimes or frequently, 61% of these parents say that this child behavior is very stressful. * Similarly, impairment in verbal communication, tantrum behavior, self-injuring behaviors, and strange behaviors in the public put high stresses on parents as well. * All parents from the present study report permanent demands caused by dependent behaviors of their child. • Causes for stress reactions: (a) Specific child symptom pattern; (b) Fundamental attribution errors in former (and present!!) science: biased psychogenic theories blaming parents and other significant others for having caused autism tec.)

  23. Autistic child: Christoph, 12 yrs.

  24. Autistic child: Maksim, 6 yrs.

  25. Conceptual Framework: Program Theory Assessment • 1. Etiology and Nature: Autism and ADHD are caused by genetic and medical factors; • Autism: mostly permanent disability; • Autistic persons have specific needs: "Need for sameness" (Kanner, 1943), "visual learners", "need for visual structure" and "daily life routines" (Schopler, Schreibman; Howlin& Rutter); • 2. Evidence-based psychological interventions can influence course and shape of autism and ADHD positively. They include: • 3. Broad Spectrum Cognitive-Behavioral interventions • Consequential interventions: focus on consequences following behavior; • Antecedent interventions: focus on stimulus (environment) preceding behavior („Developmental perspective“); • Broad spectrum parent, teacher and community interventions („Social systems perspective“); • 4. Creating a trustful Expert –Mediator(= parent ... ) relationship. • 5. „Client-centered“ perspective (Carl Rogers).

  26. Antecedent and Consequential Interventions Antecendent = preceding interventions • S-O-R-C-K Modification of child‘s environment accor-ding to develop-mental level + needs Consequential interventions S= Stimulus/ Situation: social and physical environment; O= Organism (Individuum, Personality); R= Response (behavior, action);C= Consequence (e. g. encouragement, reward, reproach,reprimand, admonition, withdrawal of privileges), K= Contingency: reinforcement schedule: (e. g. continuous or intermittent)

  27. Evidence from metaanalysis: autism intervention studies S= significant Outcome in One-Group-Pre-Post-Study; D= Descriptive Statistics= positive; Numbers in cells: Post-Post-Effect sizes from 2-group-controlled studies

  28. Main Research Objectives: • Are psychoeducational group training programs effective in: • Parents of autistic (mostly mentally retarded children) • Special Education Teachers of autistic and mentally retarded students • (School councelors for serving students with attention deficit/ hyperactivity disorder (AD/HD), who councel and supervise classroom teachers in regular schools)

  29. Methods of Evaluation-1

  30. Methods of Evaluation-2

  31. Effect size • Effect size statistics characterizes the magnitude of a program effect in a standardized form that makes it comparable across measures that use different units or scales (Rossi). • Effect size-Post-Post: The standardized mean difference: the mean outcome difference between an experimental group and a control/ comparison group in standard deviation units: • ES-Post-Post= (M-Post-Experimental minus M-Post-Control)/ pooled standard deviation (sd-post-post-pooled) • ES-Post-Post-corrected-for-Pre-Pre-difference:[ES-Post-Post= (M-Post-Experimental minus M-Post-Control)/ pooled standard deviation-post (sd-post-post)] minus [(M-Pre-Experimental minus M-Pre-Control)/ pooled standard deviation-pre (sd-post-post • ES-Pre-Post= (M-Pre minus M-Post)/standard deviations of individual differences (s-diff): ES-Pre-Post= M-diff/s-diff

  32. Methods of Evaluation: Autism Parent Training Curriculum: practical instruction: Visual Structure • Daily Schedule(for Christoph, 12 yrs.) • What to do next? • Lunch • Sleeping break • Leisure activities with educator Holger • Guided work with educator • Independent work on table

  33. Methods of Evaluation: Autism Parent Training Curriculum: practical instruction Visual structure in the classroom: No kicking other children !!! Visual structure in the bath-room: How to brush my teeth

  34. Example: Autism Parent Training Curriculum: Practical instruction: parent discussion on dressing/ undressing problems in children: how to implement visual structure

  35. Autism-Parent-Training: Parental Evaluation of Training QuestionnairePercentage (%) of moderate or strong agreements to the statements on 4-point unipolar rating-scale

  36. Autism-Parent-Training: Parent homework: Implementation of visual structure • Visual structure in the kitchen: Susanne's (16 yrs.) working schedule for setting the table: • First to find plate • then cup • then glass • then knive, fork and spoon

  37. Autism-Teacher-Training: Child Behavior Symptom Scale (Teacher Rating: 48 Item-Questionnaire) Pre-Post-Effect size d= 0.66

  38. Autism-Teacher-Training: Child Behavior Symptom Scale (Teacher Rating): Most improved symptoms

  39. Autism-Teacher-Training: Implementation of "Structured Teaching Strategies" • Implementation: 9 of 10 (90%) teachers implemented at least one “structured teaching” strategy in the classroom. On the average, the teachers implemented 2 (out of 5 trained) strategies. • Example: a 10-year old boy with mild mental retardation, severe language deficits, disruptive hyperactive and noisy behaviours got the opportunity to separate from the group for some time by sitting on a working place in a small room close to the classroom. After a few weeks the boy tolerated the group situation in the classroom better than before.

  40. ADHD-Teacher-Training: AD/ HS Symptom-Score (DSM-IV)Teacher Rating: Number of symptoms (Max.= 18) ES-Follow-Up-Follow-Up= 1.14

  41. ADHD-Teacher-Training: : Child Behavior Checklist (CBCL):Teachers‘s Report Form (TRF): “How happy or satisfied is he/she?“ 4= average, 5= somewhat less, 6= clearly less

  42. Autism Intervention Methods: Single Case Study • Computer-assisted training of purchasing skills: A single case study of a 15-year-old boy with early infantile autism • Abstract. The aim of the present exploratory single case study is to examine the effectiveness of a computer-assisted training of purchasing skills in a 15-year-old boy with early infantile autism. The purchasing behavior was systematically observed under baseline, training, and post-training conditions. The systematic observation of the training process included variables of trainee's learning and tutor's teaching behavior. The video-based behavioral observations are analyzed by the partial time sampling and the event sampling method..

  43. Autism Intervention Methods: Single Case Study Take (buy) it Now! • Anthony, • WISC: • Verbal-IQ= 57, • Non-Verbal-IQ= 48, • Total-IQ= 57

  44. Autism Intervention Methods: Single Case Study A. goes shopping: Left column: Count your money; Right column: Select products, fill in prizes; Add by pocket calculator, Middle column: compare both numbers : Enough money? If YES, go to the cashier - Example for training task: „You have 10 Euro, select 5 or more products ......

  45. Autism Intervention Methods: Single Case Study

  46. Autism Intervention Methods: Single Case Study - Event sampling method: successful shopping trials

  47. Autism Intervention Methods: Single Case Study • The results indicate that the purchasing skills of the autistic adolescent could be improved significantly by the training. • There are restraints of internal and external validity. • The findings give evidence to the assumption that daily living skills such as shopping behavior in autistic persons can be improved significantly by computer-based interventions.

  48. Conclusions

  49. Conclusions • Overall Conclusions • Given some methodological constraints, the investigated parent and teacher training approaches have revealed some substantial degree of educational & clinical validity • The findings are consistent with the results of a large body of international studies • The findings suggest cross-cultural validity in terms of culture-specific adaptability of training concepts and interventions

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