Building Capacity for Serving Infants and Toddlers Suspected of Having Autism Spectrum Disorder (ASD)

1. Building Capacity for Serving Infants and Toddlers Suspected of Having Autism Spectrum Disorder (ASD) Adrienne Frank, MS, OTR Beth Pruitt, MEd,CCC-SLP Child Development Resources

2. Participant Goals • Learn about a grant-funded project • Review promising approaches and related research for serving young children with ASD • Understand key interventions appropriate for infants and toddlers • Identify ways that EI providers can build capacity for serving ASD

3. Building Capacity Project • A one-year grant project at CDR • Funded by the Williamsburg Community Health Foundation • Goal: To investigate proven, successful approaches, obtain resources, and develop a revised plan for serving infants and toddlers with ASD

4. Project AccomplishmentsVisits to Programs • TEACCH in Chapel Hill, NC • Virginia Institute of Autism in Charlottesville • The Step-by-Step program in Suffolk

5. Conference Attendance • DIR Model – Greenspan • SCERTS Model • Sensory Integration • Biomedical Approaches • Applied Behavioral Analysis (ABA) • Pivotal Response Training (PRT)

6. Workshops Sponsored by CDR • Quarterly staff development • Pivotal Response Training – 2 days • Dr. Accardo • Screening Young Children Suspected of ASD • Explaining ASD Resources and Services to Families • Partnering with Physicians Related to Diagnosis and Services

7. Other Grant Funded Activities • Families participated in training • Purchased materials and equipment • Obtained screening/assessment instruments • Partnered with the College of William & Mary for consultation, staff development, student research tasks, and respite care for children

8. Other Activities continued • Collected data and compared approaches • Clarified values for CDR’s approach for serving infants and toddlers with ASD • Developed considerations for IFSP development

9. CDR Values Statements for Serving Infants and Toddlers Suspected of Having ASD • Outcomes, interventions, and services must be individualized and based on family’s identified needs and stated in the IFSP • Intervention takes place in the natural environment, functional for child and family • Frequency and intensity based on child and family’s concerns and preferences • All children suspected of having ASD should be screened with appropriate instruments and assessed and followed by the MDT team

10. Values continued • All children suspected of ASD should be seen by a neurologist or developmental pediatrician • Intervention should be positive, social and communicative, especially with primary caregivers • Skills should be developed and practiced across daily routines and settings for generalization and maintenance • Developmentally appropriate play is linked to cognitive, linguistic, and social skills

11. Values continued • Family and primary caregivers learn intervention as part of the daily routine, using activities beyond the times when professionals are available • Professional development must be continuous and intensive and there must be a transfer of knowledge across professional disciplines

12. Screening for ASD A number of screening instruments exist, “none are sufficiently sensitive and specific to warrant universal usage, … many await validation… many over identify or miss children with mild variations of ASD.” Pasquale Accardo, M.D. (e.g., ABC, ASQ, CHAT, M-CHAT, PDDST, STAT, SCQ)

13. Multiple Screening Instruments - Most sensitive items • Does your child ever bring objects over to you to show you something? (M-CHAT) • Child looks to where mother is pointing (Johnson 04) • Show interest in non-sibling peers (Klin, Volkar, & Sparrow, 92) • No babbling by 12 mos (Choueiri & Bridgemohan, 05)

14. What to look for… • What is the child’s language history? • Milestones (e.g., words, phrases) • Deviance (e.g., echoed speech) • Regression (i.e., decrease in language at 12-24 months) • What is the family history? • Autism, PDD, depression, schizophrenia

15. What to look for… • Presence or history of… • Poor eye contact • Lack of emotional expression • Toe walking • Flapping • Picky eating • Large head circumference (1.5 SD above mean) • Posteriorly rotated ears (> 10 degrees) Pasquale Accardo, M.D.

16. Intervention Continuum Didactic Naturalistic Developmental Flexible Prescriptive Facilitative Directive Activity - based Skill - based

17. Didactic Approaches • Based on behavioral theory • Repetitive drill and practice trials • Prescriptive antecedent/behavior/consequence ABC sequence or stimulus-response-reinforcement • Adult directed – leads to passive communication style • Reinforcement of desired behavior in controlled setting – lacks of generalization to new setting

18. Naturalistic Approaches • Applies behavioral principles in natural settings • Moderately adult directed - adult makes decisions in the moment, requires skill • Emphasis on using functional, pragmatic social interactions rather than ABC sequences • Goal of spontaneous, child initiated interactions • Intrinsic rather than tangible/edible reinforcement • Focus on maintenance / generalization

19. Developmental Approaches • Intervention goals based on typical communication development • Functional communication rather than speech • Child directed for motivation, functionality • Teach through routines -multiple opportunities, increasing desire to communicate • Success relies on the talent of interventionist • Limited research

20. Approaches

21. Simpson (2005) Practice Categories • Scientifically based practices • ABA including discrete trial • Pivotal Response Training (PRT) • Promising practices • TEACCH • Limited supporting research • DIR • SCERTS (not in book) • Biomedical approaches

22. Developmental Approach e.g., SCERTS • Based on developmental research with priority goals of social communication and emotional regulation • Considers health including biological and/or nutrition, sensory, arousal levels, and environmental stressors • Considers child’s functional needs and family priorities • Teaching is flexible – “teachable moments” • Activity based in multiple, natural environments and contexts with families as intervention agents and learning with typically developing peers • Incorporates positive behavior support methods, multimodal communication, visual, etc.

23. Applied Behavior Analysis (ABA)E.g., Discrete Trial Training (Lovaas) A scientific approach to improving socially important behaviors • ABC / SRR sequences • Direct measurement, single-subject study • Functional assessment task analysis • Setting event and establishing operation • Stimulus control • Generalization / maintenance • Shaping, fading, prompting, chaining • Reinforcement contingencies

24. ABA Based ApproachPivotal Response Training (PRT) • Pivotal areas:Motivation, responsivity to multiple cues, self-management, self-initiations, empathy • Use pivotal response techniques: Obtain and keep child attention, maintenance tasks (interspersing, variation), shared control (child choice and directed), responsivity to multiple cues (decrease overselectivity), reinforcement contingent, reinforce attempts for motivation, direct and natural reinforcers

25. Goals of Pivotal Response Training • Increase child’s motivation • Increase responsiveness • Increase engagement of the learning environment • Increase functional behavior /replace repetitive or challenging behaviors

26. Examples of Environmental Arrangement • Interesting materials • Inadequate portions • Out of reach • Choice making • Assistance • Unexpected situations

27. Plan for Generalization • Careful selection of targeted environments, situations for intervention • Interventions occur within natural environments relevant/typical to the child • Not contrived situations • Across settings, stimuli, people • Opportunities to use skill

28. Writing IFSP Goals for ASD Types of Goal Content • Developmental milestones based on the area of delay • Developmental milestones related to items significant to children with ASD • Intervention goals from ASD approach • Change/ decrease in behavior that is atypical or affects interactions

29. Objectives Examples • Area of delay – e.g., Child will use 10 words • ASD area – e.g., Child will point to item named in 8/10 trials. • ASD approach – e.g., Child will match 5 objects to picture (photo, color drawing, line drawing). • Behavior– e.g., Child will exhibit hand flapping less than 5 times during a structured task with an adult.

30. Criteria for Measurement Quantity • Amount – e.g., 3-5 words • Trials – e.g., 3 out of 5 times Generalization • People – mother, babysitter, visitor • Places – home, neighbor’s, play group • Situations – quiet, noisy, unfamiliar

31. Examples of Goal Areas • Joint attention • Communication – frequency, form, function • Social interactions – imitation, with peers • Generalization across settings, situations • Play behavior - symbolic, pretend, imaginative • Improve regulatory/sensory capacity

32. The National Research Council (2000) says children with ASD should receive… • Early identification and intervention • Active engagement and intensive programming (at least 25 hours) • Repeated and planned teaching opportunities • One-to-one or small group / low adult to child ratio • Family involvement • Continuing assessment

33. CDR’s Revised Plan will help to: • Identify and diagnose children suspected of having ASD • Develop IFSPs that reflect values of practice • Refer children to appropriate diagnostic evaluations • Continuously seek out new intervention approaches/ strategies • Make materials and resources available to families • Help children to transition to appropriate services