Behavioral Approaches to Early Intervention with Autism

1. Behavioral Approaches to Early Intervention with Autism WAYNE W. FISHER Munroe-Meyer Institute at the University of Nebraska Medical Center

2. Autism and Childhood Schizophrenia • Once thought to be a form of schizophrenia • Differs from schizophrenia in terms of symptoms, age of onset, family history, etiology, and response to treatment

3. Definition of Autism • markedly abnormal or impaireddevelopment in: • social interaction • communication • and markedly restricted repertoire of activities and interests.

4. Definition of Autism (continued) • Definitions are cheap, but explanations are dear, and we must be careful not to confuse them. • David Palmer, 2004

5. Autism Spectrum Disorders • Neurological disorders characterized by "severe and pervasive impairment in several areas of development • Autistic Disorder • Asperger's Disorder • Childhood Disintegrative Disorder (CDD) • Rett's Disorder • PDD-Not Otherwise Specified (PDD-NOS)

6. Prevalence of Autism • Typically diagnosed within first three years • 2 to 6 in 1,000 individuals (Centers for Disease Control and Prevention, 2001) • Four times more prevalent in boys than girls

7. NIH Research Dollars Devoted to Autism • When compared with other serious childhood conditions, autism is much more common, but fewer dollars per case are spent on autism.

8. Prevalence of Autism and Other Conditions (Number of Cases per 10,000 Children) 70 60 50 40 30 20 10 0 Autism Juvenile Diabetes Muscular Dystrophy Leukemia Cystic Fibrosis

9. NIH Research Dollars for Autism and Other Conditions (Number of Dollars per Case) $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $- Autism Juvenile Diabetes Muscular Dystrophy Leukemia Cystic Fibrosis

11. Demographics of Autism • Knows no racial, ethnic, or social boundaries • Family income, lifestyle, and educational levels do not affect the chance of autism's occurrence • Diagnosis of autism is growing at a rate of 10-17% per year (U.S. Department of Education, 2002)

12. Assessment and Diagnosis of Autism • No medical tests for diagnosing autism • Accurate diagnosis is based on observation of the individual's communication, behavior, and developmental levels. • Autism Diagnostic Interview-R (ADI-R) • Home and/or school observation • Video analysis of behavioral observation

13. Identifying the Genetic Bases of Autism Spectrum Disorders • Etiologic workups identify specific genetic causes for autism in about 20% of cases. • At the Munroe-Meyer Institute, Dr. Schaefer and colleagues (2006) developed a 3-Tiered Approach that identifies genetic causes in 40% of cases.

14. Early Screening for Autism (NICHD) • Does not babble or coo by 12 months • Does not gesture (point, wave, grasp) by 12 months • Does not say single words by 16 months • Does not say two-word phrases on his or her own by 24 months • Has any loss of any language or social skill at any age

15. Early Screening for Autism (CHAT) • Does not display pretend play (e.g., pretending to drink from a toy cup) • Does not point at objects to indicate interest • Does not show interest in other children • Does not enjoy peek-a-boo hide-and-seek or other social games • Does not bring and show objects to parents

16. Associated Disorders • Mental Retardation 70% 15% • Seizure Disorder 35% 10% • Self-Injury, Aggression 50% • Tourette Disorder • Bipolar Disorder Autism ASD

17. Associated Etiologic Diagnoses • Fragile-X syndrome • Tuberous Sclerosis • Williams syndrome • Landau-Kleffner syndrome • Congenital Rubella • Smith-Magenis syndrome • Neurofibromatosis

18. Genetics and Twin Studies • Autism runs in families • Heritability for autism is about 90% • Monozygotic twin concordance, 60%-100% • Dizygotic twin concordance, 10% • Associated with abnormalities on chromosomes 7q, 2q, and 15q

19. Applied Behavior Analysis (ABA) • What is ABA? • How is it different from other approaches? • How is it done?

20. Baer, Wolf, & Risley (1968) APPLIED—strives to produce rapid and clear benefit to problems of social importance; BEHAVIORAL—usesobjective and accurate measurement of the behavior of interest; ANALYSIS—uses controlled (single-case) methods to understand the environmental variable(s) that influence an individual’s behavior.

21. Historical Roots of Behavior Analysis • 1911 Thorndike-Law of effect • 1924 Watson-Behaviorism • 1927 Pavlov-Conditioned Reflexes • 1938-Skinner Behavior of Organisms • 1950’s-Behavioral applications reported in scientific journals • 1968-Journal of Applied Behavior Analysis

22. How Effective is ABA for Autism? • About 50% of Children with autism and mild mental retardation who received early intervention with ABA attain normal IQs and are educated in regular classrooms with minimal assistance.

23. Outcomes of ABA for Autism 35 30 25 20 Increases in IQ Scores r = .79 15 p < .02 10 5 0 0 5 10 15 20 25 30 35 40 45 Hours per Week of Treatment

24. How Effective is ABA for Autism? • Early Intervention of Autism using ABA has been recommended by: • New York State Dept. of Health • U.S. Surgeon General • National Research Council • Association for Science in Autism Treatment

25. Why is ABA Effective? • ABA developed from and remains closely linked to basic research on the principles of learning and behavior. • A central principle of ABA is called “Selection by Consequences.” • In a given environment, behaviors that produce favorable outcomes are selected (or continue to occur) and those that produce unfavorable consequences are extinguished.

26. Why is ABA Effective? (continued) • ABA has developed a wide variety of procedures for identifying the antecedents and consequences that influence behavior. • We rearrange the antecedents and consequences in the environment so that appropriate behavior is selected (or re-occurs) and problem behavior is extinguished.

27. Why is ABA Effective? (continued) • Specific procedures include • Shaping • Chaining • Prompting • Fading • Extinction • Reinforcement • Generalization strategies, etc.

28. Why is ABA Effective with Autism? • Comprehensive: Teaches all skills (e.g., sitting, attending, imitating, direction following, language, social skills, self-help skills). • Goal and Data Driven: The focus on objective measurement and analysis of behavior provides ongoing feedback on progress and setbacks.

29. Example of Individual Goals for Billy • Decease self-injurious behavior • Increase eye contact • Increase spontaneous requesting • Increase labeling skills • Increase use of yes and no • Increase imitation skills • Increase matching skills • Increase letter identification • Increase self-feeding skills

30. Teaching Imitation Using Discrete Trials • Starts with simple responses (e.g., clapping). • Sessions consisting of 10 trials; each trial starts with the therapist saying “Do this” and then modeling the target response. • Any approximation of clapping, results in delivery of a preferred reinforcer (e.g., toy). • Otherwise, the therapist guides the child’s hands to complete the response and then begins the next trial.

31. Teaching Imitation Using Discrete Trials (continued) • Once the first response is mastered, the same procedure would be used to teach a second response (e.g., waving). • After two responses are mastered in individual sessions, they would alternately be presented in the same session (e.g., “Do this” [clapping]; “Do this” [waving]). • Over time, additional responses are added until the child immediately imitates any new action the therapist does following the prompt, “Do this.”

32. Generalization of Skills • Skills taught during discrete trials are then generalized to natural settings. • e.g., Clapping when another child answers correctly during group instruction or at a recital or school assembly. • e.g., Waving to another person when entering or leaving a room.

33. 100 Baseline Differential Reinforcement + Feedback 90 80 70 60 PERCENTAGE CORRECT (TOTAL) 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 SESSIONS Billy: Imitating a Model

34. Why is ABA Effective with Autism? (continued) • Empirical Emphasis: Treatments are based on principles and procedures supported by research. • Intensity Level: 25 to 40 hours per week for 3 years.

35. Early Behavioral Intervention for Autism • Lovaas, 1987; McEachin et al., 1993; Smith et al., 2000 • Year 1--reduce aberrant behavior, teach attending, imitation, instruction following, speaking in short phrases, play skills, and self-help skills

36. Early Behavioral Intervention for Autism (continued) • Year 2--extend expressive vocabulary, more abstract concepts, extend treatment to group and community settings • Year 3--pre-academic and academic skills, appropriate emotional expression, observational learning, and interactions and friendships with normally developing peers

37. Cost-Benefit Analysis of Early, Intensive ABA for Autism • Average lifetime cost for a person with autism is over $4 million • Average cost of Early, Intensive ABA is $150,000 over about 3 years • Average lifetime savings from ABA Treatment is between $1.6 and $2.7 million

38. Assessing Children with Autism • Periodic assessment for diagnosis and management • Ongoing assessment for intervention

39. Periodic Assessment for Diagnosis and Management • Identify the child’s overall strengths and limitations • Determine the appropriate diagnosis or diagnoses • Set the global goals for treatment

40. Components of a Diagnostic Assessment • Genetic/Etiologic workup • Assessment of behavior/symptoms • Formal audiologic evaluation • Cognitive testing • Assessment of adaptive behavior • Speech/Language evaluation

41. Ongoing Assessment for Intervention • Identify the specific behaviors to be increased • Identify the specific behaviors to be decreased • Identify effective reinforcers

42. Assessment of Skills to Increase • Attending Skills • Compliance • Following Simple Instructions • Motor Imitation • Vocal Imitation • Matching • Play Skills • Social Skills • Self-Help Skills

43. Skill Assessment Areas • Imitating Behavioral Chains • Following Multi-Step Instructions • Categorization • Verbal Behavior-Listener Skills • Verbal Behavior-Speaker Skills • Pre-academic and Academic Skills

44. Matching Skills Progression • Identity matching with objects • Identity matching with pictures • Matching pictures to objects • Matching objects to pictures • Matching shapes, colors, letters, numbers • Matching on 2 dimensions (color-shape) • Matching by categories (e.g., animals, vehicles) • Matching objects with their spoken names • Matching pictures with their spoken names

45. Social Skills Progression • Shaking hands • Making eye contact during greetings • Imitating a smile • Smiling reciprocally • Appropriately getting someone’s attention • Appropriately exchanging toys with a peer • Playing a simple interactive game (roll ball) • Showing appropriate affection (e.g., hugs) • Taking turns during a simple game • Making polite statements (e.g., “Bless you. “Your welcome.”) • Initiating a conversation (e.g., “Did you watch the Huskers game?”)

46. Preference Assessments • Children with developmental disabilities sometimes are not able to tell you what things they like or tell you when they want one thing instead of another. • Researchers have developed preference assessments to identify what things people with disabilities like.

47. Steps of Preference Assessments Step 1: Interview the parent with the RAISD to list the kinds of things that the child likes Step 2: Get the actual items the parent nominated as highly preferred Step 3: Allow the child to select items from the group Step 4: Rank the items from high to low based on what the child chose

48. Types of Preference Assessments • Single-item type – Present each item from the group one at a time • Choice type – Present all items 2 at a time and let the child choose between the 2. • Group type – Present all items together and let the child select items from the group

49. Single-item Preference Assessments • Developed by Pace et al. (1985) • 16 stimuli • Each stimulus presented individually 10 times for 5 seconds each • The SI method identified highly preferred stimuli for all participants in the study • However, subsequent research has shown that the SI method may also yield a high number of false positives

50. 100 90 80 70 60 Percentage of trials chosen 50 40 30 20 10 0 Toy Telephone Barney Doll Action Figures Radio Ball Items