Best Practices in Screening, Assessment and Intervention for Children with Autism Spectrum Disorders Susan L. Hepburn, Ph.D. University of Colorado at.

Best Practices in Screening, Best Practices in Screening, Assessment and Intervention Assessment and Intervention

for Children with for Children with Autism Spectrum DisordersAutism Spectrum Disorders

Susan L. Hepburn, Ph.D.Susan L. Hepburn, Ph.D.University of Colorado at Denver and University of Colorado at Denver and

Health SciencesHealth Sciences

Juneau, Fairbanks, and Anchorage, Juneau, Fairbanks, and Anchorage, Alaska Alaska

March 2008March 2008

The Autism SpectrumThe Autism Spectrum

Autism PDD-NOS Asperger Syndrom e

Pervasive D eve lopm enta l D isorders

Similarities = Difficulties in 3 areas:

Social functioningCommunication/languageRestricted activities and interests

Possible Differences Amongst Kids Possible Differences Amongst Kids with an ASDwith an ASD

Level of cognitive functioningLevel of cognitive functioning Presence/absence of spoken languagePresence/absence of spoken language Severity of symptomsSeverity of symptoms Specific behavioral expression of symptomsSpecific behavioral expression of symptoms Chronological ageChronological age Temperament or behavioral styleTemperament or behavioral style Vulnerability to other conditions, such as Vulnerability to other conditions, such as

attentional, anxiety or mood issuesattentional, anxiety or mood issues

Social StyleSocial Style

AloofAloof

PassivePassive

Active-But-OddActive-But-Odd

Aloof Responding

Passive Initiating

Active-But-Odd Reciprocity

Social Style and GoalsSocial Style and Goals

Children with different styles require Children with different styles require different educational approachesdifferent educational approaches

Developmental Aspects of Developmental Aspects of AutismAutism

Symptoms are Symptoms are qualitatively qualitatively different at different at different stages of different stages of developmentdevelopment

Developmental Model of Developmental Model of AutismAutism

Social/CommunicativeFunctioning

ModeratingFeatures

Outcomes

Associated Features

To elaborate....To elaborate.... Core featuresCore features: (1) Social-communicative : (1) Social-communicative

functioning and (2) ability to adapt functioning and (2) ability to adapt (or modify behavior in response to (or modify behavior in response to

changes in context in a fluid manner)changes in context in a fluid manner)

Moderating featuresModerating features: (1) cognitive ability, : (1) cognitive ability, (2) language ability, (3) behavioral style(2) language ability, (3) behavioral style

Associated featuresAssociated features: (1) attention, (2) : (1) attention, (2) anxiety, (3) mood, & (4) problem anxiety, (3) mood, & (4) problem behaviorsbehaviors

Best practice = Best practice = developmentally- developmentally- informed informed practicepractice

Screening

Assessment

Intervention

Always considering an individual child’s core symptoms of autism, moderating factors, and associated features

Focus of Today’s TalkFocus of Today’s Talk What do we know about autism across What do we know about autism across

development in childhood and development in childhood and adolescence? adolescence?

And what does our developmental And what does our developmental knowledge tell us about what we should knowledge tell us about what we should be doing?be doing? ScreeningScreening AssessmentAssessment InterventionIntervention

Studying Autism in InfancyStudying Autism in Infancy

Retrospective videotape analysisRetrospective videotape analysis See reviews by Charman (2000) and Rogers See reviews by Charman (2000) and Rogers

(2001); Werner et al (2000)(2001); Werner et al (2000)

Record reviewRecord review e.g., Johnson, Siddons, Frith, & Morton (1992)e.g., Johnson, Siddons, Frith, & Morton (1992)

Prospective sibling studiesProspective sibling studies e.g., Zweigenbaum et al (2005); Landa et al. e.g., Zweigenbaum et al (2005); Landa et al.

(2005); Rogers et al.(2005)(2005); Rogers et al.(2005)

Possible Symptoms in Possible Symptoms in Infancy Infancy

Deficits in dyadic – “person-to-Deficits in dyadic – “person-to-person” -social interactionperson” -social interaction Baby is out of sync with caregiversBaby is out of sync with caregivers Lack of social smileLack of social smile Delayed response to nameDelayed response to name

Unusual affectUnusual affect Lack of appropriate facial expressionsLack of appropriate facial expressions

Adrien et al, (1993); Baranek (1999); Rogers Adrien et al, (1993); Baranek (1999); Rogers (2005)(2005)

Possible Symptoms in Possible Symptoms in Infancy Infancy (cont.)(cont.)

Signs of central nervous system dysfunctionSigns of central nervous system dysfunction HypotoniaHypotonia Lack of appropriate facial expressionsLack of appropriate facial expressions Abnormalities in orientation to visual stimuliAbnormalities in orientation to visual stimuli Aversion to touchAversion to touch

Signs of poor frontal lobe developmentSigns of poor frontal lobe development Poor integration of verbal and nonverbal Poor integration of verbal and nonverbal

behaviorsbehaviors Poor attentionPoor attention

Adrien et al, (1993); Baranek (1999); Ozonoff et al (2007) Adrien et al, (1993); Baranek (1999); Ozonoff et al (2007)

In summary, the results of infant In summary, the results of infant studies suggest that abnormalities studies suggest that abnormalities

are:are: SubtleSubtle

More likely to involve the absence of rich social More likely to involve the absence of rich social behaviors and not the presence of unusual behaviorsbehaviors and not the presence of unusual behaviors

QualitativeQualitative

A matter of reduced frequency, not complete A matter of reduced frequency, not complete absence absence (Charman et al, 1997)(Charman et al, 1997)

Inconsistent: Presence of intact behavior sometimes Inconsistent: Presence of intact behavior sometimes does not mean everything is okay (Charman et al, does not mean everything is okay (Charman et al, 1998)1998)

Absolute Indicators for a Absolute Indicators for a Developmental Evaluation from Developmental Evaluation from

Birth to 3 YearsBirth to 3 Years No babbling by 12 monthsNo babbling by 12 months

No gesturing by 12 monthsNo gesturing by 12 months

No single words by 16 monthsNo single words by 16 months

No 2-word spontaneous phrases by 24 monthsNo 2-word spontaneous phrases by 24 months

Any loss of any language or social skills at Any loss of any language or social skills at any timeany time

American Academy of Pediatrics, 2005; Centers for Disease Control, 2006; Firstsigns.org)

Characteristics of Autism Characteristics of Autism at Young Agesat Young Ages

Toddlerhood: (18 – 36 Toddlerhood: (18 – 36 months) months)

Best Discriminators of Autism Best Discriminators of Autism between 18 months and 3 between 18 months and 3

years of ageyears of age Social and communicative impairmentsSocial and communicative impairments

Less likely look at othersLess likely look at others Less likely to show objectsLess likely to show objects Less likely to point to an objectLess likely to point to an object Less likely to orient to nameLess likely to orient to name Less likely to follow attentionLess likely to follow attention

**Overall: lack of social orienting **Overall: lack of social orienting

(Charman & Baird, 2002; Cox et al, 1999; Osterling & Dawson, 1994; Mundy et al, 1994; Stone, Hoffman, Lewis, & Ousley, 1994; Stone, Ousley & Coonrod, 2005)

Sometimes….Sometimes…. Parents of young children report Parents of young children report

general behavior problems, with few general behavior problems, with few reports of social difficulties reports of social difficulties (Charman (Charman & Baird, 2002)& Baird, 2002)

Parents of young children notice Parents of young children notice unusual responses to sensation unusual responses to sensation (Baranek, Foster, & Berkson, 1997)(Baranek, Foster, & Berkson, 1997)

Regression of communication skills Regression of communication skills occurs in approximately 15-30% of occurs in approximately 15-30% of cases cases (Filipek et al, 1989)(Filipek et al, 1989)

By 30 months, many children with By 30 months, many children with autism can…autism can…

Follow an adult’s attentionFollow an adult’s attention (i.e., “respond to joint (i.e., “respond to joint attention”; Mundy et al, 1994)attention”; Mundy et al, 1994)

Indicate a simple requestIndicate a simple request – without coordinated – without coordinated eye contact – usually requesting improves in eye contact – usually requesting improves in complexity by age 3 complexity by age 3 (DiLavore & Lord, 1995)(DiLavore & Lord, 1995)

Communicate to get access to objects, but not Communicate to get access to objects, but not to get an adult’s attentionto get an adult’s attention; ; Stone et al, 1997)Stone et al, 1997) However, requesting behavior in autism rarely includes However, requesting behavior in autism rarely includes

coordinated eye gaze, gesture, and/or vocalizations coordinated eye gaze, gesture, and/or vocalizations (Stone et al, 1997)(Stone et al, 1997)

Manipulate another person’s hand like a toolManipulate another person’s hand like a tool to to send a messagesend a message (Stone et al, 1997) (Stone et al, 1997)

Characteristics of Autism Characteristics of Autism at Young Agesat Young Ages

Preschool Years: (3 – 5 years) Preschool Years: (3 – 5 years)

Discriminating Items on Screening Discriminating Items on Screening Tools for Preschool-aged Children (3 – Tools for Preschool-aged Children (3 –

5 years)5 years) Rarely performs simple actions with a dollRarely performs simple actions with a doll

Rarely engages in pretend play Rarely engages in pretend play

Rarely integrates gestures and/or eye gaze with Rarely integrates gestures and/or eye gaze with attempts to communicateattempts to communicate

May respond better to an adult’s bid for attention, May respond better to an adult’s bid for attention, but still has trouble with initiating joint attentionbut still has trouble with initiating joint attention Fewer shows and points to share attentionFewer shows and points to share attention

Imitation is not spontaneous, and/or is often of Imitation is not spontaneous, and/or is often of poor qualitypoor quality

Robins et al, 2002; Stone et al, 2005; Wetherby & Woods, 2004

Compared to Typical Compared to Typical Development…Development…

Remarkably, typically-developing children do Remarkably, typically-developing children do many of the behaviors lacking in 4-year olds many of the behaviors lacking in 4-year olds with autism by the end of their first or second with autism by the end of their first or second years of life years of life (Carpenter, Nagell, & Tomasello, 1998; Fenson et al, (Carpenter, Nagell, & Tomasello, 1998; Fenson et al, 1994)1994)

These behaviors are associated with word These behaviors are associated with word learning learning (Tomasello, 2001)(Tomasello, 2001)

And social understanding (And social understanding (Charman et al, 2000)Charman et al, 2000)

Autism Vs. Autism Vs. Developmental Developmental

Delay Delay Lack of social Lack of social

interestinterest Limited use of Limited use of

pointingpointing Poor nonverbal Poor nonverbal

communicationcommunication Poor imitation skillsPoor imitation skills Limited pretend playLimited pretend play

RELATIVE to overall RELATIVE to overall developmental leveldevelopmental level

Any impairment in Any impairment in social or social or communicative communicative behavior seems behavior seems consistent with the consistent with the child’s mental agechild’s mental age

Development is Development is evenly delayed; few evenly delayed; few splinter skillssplinter skills

(Lord & Pickles, 1996)(Lord & Pickles, 1996)

Characteristics of Autism Characteristics of Autism at School Ageat School Age

Elementary Years: (6 – 11 years) Elementary Years: (6 – 11 years) Middle School Years (11 – 14 Middle School Years (11 – 14

years)years)High School Years (14 – 18 years)High School Years (14 – 18 years)Transition/Young Adulthood (19 – Transition/Young Adulthood (19 –

22) 22)

Developmental Challenges Developmental Challenges During Elementary YearsDuring Elementary Years

Play gets more cooperativePlay gets more cooperative Social groups form (in and out)Social groups form (in and out) Planning and other executive function skills Planning and other executive function skills

become more importantbecome more important Social demands for conformity increaseSocial demands for conformity increase Social relationships are more complexSocial relationships are more complex Increased reliance on nonverbal cues and Increased reliance on nonverbal cues and

subtlety of social signalssubtlety of social signals May be more self-awareness of differences, May be more self-awareness of differences,

particularly around the 3particularly around the 3rdrd grade grade

Around Puberty….Around Puberty….

Some children become more anxiousSome children become more anxious Some become a bit overwhelmed by the Some become a bit overwhelmed by the

organizational demands of middle schoolorganizational demands of middle school Some show some problem behaviors that Some show some problem behaviors that

haven’t shown for a long timehaven’t shown for a long time Some have questions about social rules Some have questions about social rules

and boundaries and need some and boundaries and need some psychoeducationpsychoeducation

Important time to monitor for overall well-Important time to monitor for overall well-beingbeing

Quality of Life for Quality of Life for TeenagersTeenagers

Does he/she have a favorite activity or Does he/she have a favorite activity or passion and are there opportunities to passion and are there opportunities to enjoy this often?enjoy this often?

Are there chances to spend time with Are there chances to spend time with other kids of similar ages and interests?other kids of similar ages and interests?

Is there a chance to get exercise and have Is there a chance to get exercise and have time outside?time outside?

Are there expectations for taking Are there expectations for taking personal responsibility at home and at personal responsibility at home and at school?school?

Critical Issues of Late Critical Issues of Late Adolescence Adolescence (Ozonoff et al., (Ozonoff et al.,

2002)2002) Finding support people other than parentsFinding support people other than parents DisclosureDisclosure Sexual developmentSexual development Romantic relationshipsRomantic relationships Identity DevelopmentIdentity Development Depression and anxietyDepression and anxiety Seizures or other neurological symptoms Seizures or other neurological symptoms

(e.g., tics)(e.g., tics)

Implications for ScreeningImplications for Screening

Across childhood and Across childhood and adolescenceadolescence

Essential Elements of Essential Elements of ScreeningScreening

Developmental history (e.g., milestones, first Developmental history (e.g., milestones, first concerns)concerns)

Medical historyMedical history

Family historyFamily history

Cognitive/developmental assessmentCognitive/developmental assessment

Needs to include interview and observationNeeds to include interview and observation

Best Practice in ScreeningBest Practice in Screening If you hear concerns about nonverbal social-If you hear concerns about nonverbal social-

communication behavior linked with concerns about communication behavior linked with concerns about rigidity – refer for screeningrigidity – refer for screening

Gather both parent report and direct observation Gather both parent report and direct observation datadata

Integrate observations from a multidisciplinary Integrate observations from a multidisciplinary teamteam

Directly assess social reciprocityDirectly assess social reciprocity

(Charman & Baird, 2002; Filipek et al, 1999; Lord & Risi, 1999; (Charman & Baird, 2002; Filipek et al, 1999; Lord & Risi, 1999; Rogers, 2001; Sandler et al, 2001)Rogers, 2001; Sandler et al, 2001)

Best Practice (cont.)Best Practice (cont.) Obtain information from unstructured situationsObtain information from unstructured situations

Consider the child’s access to social experienceConsider the child’s access to social experience

Clinicians should seek training on semi-structured Clinicians should seek training on semi-structured interviews to expand their knowledge of autism at interviews to expand their knowledge of autism at different levels of development– even if they don’t different levels of development– even if they don’t use them all the timeuse them all the time

(Charman & Baird, 2002; Filipek et al, 1999; Lord & Risi, 1999; (Charman & Baird, 2002; Filipek et al, 1999; Lord & Risi, 1999; Rogers, 2001; Sandler et al, 2001)Rogers, 2001; Sandler et al, 2001)

Best Practice (cont.)Best Practice (cont.)

Include a medical and Include a medical and developmental historydevelopmental history

Provide various types of social Provide various types of social presses in interaction with childpresses in interaction with child

(Charman & Baird, 2002; Filipek et al, 1999; Lord & (Charman & Baird, 2002; Filipek et al, 1999; Lord &

Risi, 1999; Rogers, 2001; Sandler et al,Risi, 1999; Rogers, 2001; Sandler et al, 2001)2001)

Consider the known genetic risksConsider the known genetic risks 5% of families5% of families with a child on the autism with a child on the autism

spectrum will have anotherspectrum will have another

This translates to This translates to 5 in 1005 in 100, or , or 50 in 100050 in 1000 Typical rate is Typical rate is 1 in 10001 in 1000 Risk increases from 1 to 50 per 1000Risk increases from 1 to 50 per 1000Or….Or…. If you have a child with autism, you have a 19-If you have a child with autism, you have a 19-

out-of-20 chance that a future child will out-of-20 chance that a future child will notnot be be autistic autistic

Keep in mindKeep in mind... The risk of having a ... The risk of having a second child with second child with some featuressome features (but not (but not the whole picture) is thought to be higherthe whole picture) is thought to be higher(LeCouteur et al., 1996; Rutter et al, 1996; Szatmari, Jones, Zwaigenbaum, & MacLean, 1998)(LeCouteur et al., 1996; Rutter et al, 1996; Szatmari, Jones, Zwaigenbaum, & MacLean, 1998)

Challenges of Screening for Challenges of Screening for Autism in Young ChildrenAutism in Young Children

Autism can occur with other conditionsAutism can occur with other conditions Hard to know how good the Hard to know how good the

standardized tools are for early standardized tools are for early identificationidentification

Reliability of early diagnosis is still Reliability of early diagnosis is still being assessedbeing assessed

It is still difficult to predict prognosisIt is still difficult to predict prognosis(Charman & Baird, 2002)(Charman & Baird, 2002)

Remember how different the picture Remember how different the picture can look in young children (Dixon et can look in young children (Dixon et

al., 2005)al., 2005)

Majority of toddlers with autism do Majority of toddlers with autism do NOT display the following DSM-IV NOT display the following DSM-IV symptoms:symptoms: Impaired conversationImpaired conversation Adherence to routineAdherence to routine Stereotyped languageStereotyped language Restricted interestsRestricted interests Preoccupations with parts of objectsPreoccupations with parts of objects

Screening Instruments for Young Screening Instruments for Young ChildrenChildren

Within the general population:Within the general population: Checklist for Autism in Toddlers Checklist for Autism in Toddlers (CHAT; (CHAT;

Baird et al, 2000; Baron-Cohen et al, 2000)Baird et al, 2000; Baron-Cohen et al, 2000)

Within a clinically-referred population:Within a clinically-referred population: Modified CHAT Modified CHAT (M-CHAT; Robin et al, 2001)(M-CHAT; Robin et al, 2001) Screening for Autism in Toddlers Screening for Autism in Toddlers (STAT; (STAT;

Stone, Coonrod, & Ousley, 2000Stone, Coonrod, & Ousley, 2000 Pervasive Developmental Disorders Pervasive Developmental Disorders

Screening TestScreening Test (PDDST; Siegel, 1999) (PDDST; Siegel, 1999)

New Screening Tools for Young New Screening Tools for Young ChildrenChildren

STAT – scoring system for children between 12-24 STAT – scoring system for children between 12-24 months months (Stone et al., 2005)(Stone et al., 2005)

First year Inventory (FYI) First year Inventory (FYI) (Watson et al. 2005)(Watson et al. 2005)—screening —screening 12 month olds in general population for risk of ASD12 month olds in general population for risk of ASD

Language impairments in ASD Language impairments in ASD (Zwaigenbaum et al. 2005); (Zwaigenbaum et al. 2005); less vocalization overall and more atypical less vocalization overall and more atypical vocalizationsvocalizations

AOSI AOSI (Bryson et al, 2007):(Bryson et al, 2007): development of instrument to development of instrument to measure autistic behaviors in very young children measure autistic behaviors in very young children (beginning at 6 months)(beginning at 6 months)

Why screen after age 5?Why screen after age 5? Some bright children, particularly those who are not high in Some bright children, particularly those who are not high in

activity level, may not be identified in the preschool yearsactivity level, may not be identified in the preschool years

The impact of having high-functioning autism can hit harder after The impact of having high-functioning autism can hit harder after preschool – and more kids need helppreschool – and more kids need help

Due to increase in organizational demandsDue to increase in organizational demands Due to increase in abstract (not rote) material in 2Due to increase in abstract (not rote) material in 2ndnd-3-3rdrd grade grade Due to decreased opportunities to learnDue to decreased opportunities to learn

Some severely-impaired, developmentally delayed children are Some severely-impaired, developmentally delayed children are misdiagnosed with autism in preschool years, and SES factors may misdiagnosed with autism in preschool years, and SES factors may influence early identification process (Desposito, 2002)influence early identification process (Desposito, 2002)

A formal identification of an ASD can help to guide interventions A formal identification of an ASD can help to guide interventions and promote understanding of why the student behaves as he doesand promote understanding of why the student behaves as he does

and communicate other times a needs-based approach, without a and communicate other times a needs-based approach, without a formal label, can be effective formal label, can be effective

Screening Tools for School-Aged Screening Tools for School-Aged ChildrenChildren

Social Communication QuestionnaireSocial Communication Questionnaire (SCQ; Lord et al., 2003): parent (SCQ; Lord et al., 2003): parent interview, very short version of ADI-R; interview, very short version of ADI-R; yes/no responses, best for children 5 and yes/no responses, best for children 5 and older, score of 15 is “at risk”older, score of 15 is “at risk”

Autism Behavior ChecklistAutism Behavior Checklist (Krug, 1989): (Krug, 1989): Teacher or parent checklist, symptoms Teacher or parent checklist, symptoms consistent with classic as opposed to atypical consistent with classic as opposed to atypical presentation, may over-identify kids with MR as presentation, may over-identify kids with MR as having autism…having autism…

Screening for high-functioning Screening for high-functioning or atypical autismor atypical autism

Asperger Syndrome School Asperger Syndrome School QuestionnaireQuestionnaire (ASSQ; Ehlers, et al., 1989); (ASSQ; Ehlers, et al., 1989); normed on several thousand school-aged normed on several thousand school-aged children in Europe, being piloted in US through children in Europe, being piloted in US through CADDRE projectCADDRE project

Children’s Communication ChecklistChildren’s Communication Checklist (Bishop (Bishop et al, 2003); teacher or parent checklist or et al, 2003); teacher or parent checklist or interview that captures information on child’s interview that captures information on child’s use of pragmatics (social communication)use of pragmatics (social communication)

Sample Questions from the Sample Questions from the ASSQASSQ

““can be with other children, but only on his/her can be with other children, but only on his/her terms”terms”

““has clumsy or awkward movements or gestures”has clumsy or awkward movements or gestures”

““uses language freely, but fails to make uses language freely, but fails to make adjustments for his listener”adjustments for his listener”

““has a literal understanding of language”has a literal understanding of language”

““has difficulties completing daily routine activities”has difficulties completing daily routine activities”

Implications for Implications for AssessmentAssessment

Across childhood and Across childhood and adolescenceadolescence

The Family’s Experience with The Family’s Experience with Diagnosis:Diagnosis:

Is it a ….Is it a …. Hearing problem? Hearing problem? Language delay? Language delay? Global developmental Global developmental

delay?delay? Is it a general behavior Is it a general behavior

problem?problem? Seizure disorder?Seizure disorder? Genetic disorderGenetic disorder Metabolic or gastro-Metabolic or gastro-

intestinal disorder?intestinal disorder? Auto-immune disorder?Auto-immune disorder?

Go to the audiologistGo to the audiologist Go to Child FindGo to Child Find Go to the speech Go to the speech

pathologistpathologist Go to a psychologistGo to a psychologist Go to your Go to your

pediatricianpediatrician Go to a neurologistGo to a neurologist Go to a genetics clinicGo to a genetics clinic Go to a GI doctorGo to a GI doctor Go to a nutritionistGo to a nutritionist Go to a DAN doctorGo to a DAN doctor

Areas of AssessmentAreas of Assessment

Developmental/cognition/academicsDevelopmental/cognition/academics Strengths, preferences, learning styleStrengths, preferences, learning style Play and social interactionPlay and social interaction Communication, language, speechCommunication, language, speech Adaptive behaviorAdaptive behavior Fine/gross motorFine/gross motor Family functioning and resourcesFamily functioning and resources

Developmental/Cognitive Developmental/Cognitive AssessmentsAssessments

Consider standardized measures that assess Consider standardized measures that assess both verbal and nonverbal functioningboth verbal and nonverbal functioning

Preschool:Preschool: Mullen Scales of Early Learning or Mullen Scales of Early Learning or Bayley Scales of Infant DevelopmentBayley Scales of Infant Development

Kindergarten +:Kindergarten +: Differential Abilities Scale, Differential Abilities Scale, Stanford-Binet-V, K-ABC, WISC-IVStanford-Binet-V, K-ABC, WISC-IV

Sometimes, examine nonverbal cognitive Sometimes, examine nonverbal cognitive functioning more deeply functioning more deeply (e.g., Leiter-R, Merrill-(e.g., Leiter-R, Merrill-Palmer, Ravens Matrices, C-TONI)Palmer, Ravens Matrices, C-TONI)

Communication SkillsCommunication Skills

Range of Range of communicative communicative functionsfunctions Behavioral regulationBehavioral regulation Coordinating joint Coordinating joint

attentionattention

Ability to synthesize Ability to synthesize formsforms GesturesGestures Eye gazeEye gaze

Spontaneity of useSpontaneity of use

Social directedness Social directedness of communicationof communication

Profile of receptive Profile of receptive and expressive and expressive abilitiesabilities

Language SkillsLanguage Skills Receptive abilityReceptive ability

Expressive abilityExpressive ability

Pragmatic skillsPragmatic skills

Functional/spontaneous use of language Functional/spontaneous use of language on a daily basis (e.g., frequency and on a daily basis (e.g., frequency and complexity)complexity)

Symbolic playSymbolic play

Speech SkillsSpeech Skills Oral-motor integrityOral-motor integrity

Range of vocalizationsRange of vocalizations

Spontaneity of vocalizationsSpontaneity of vocalizations

Ability to imitate sounds or produce on cueAbility to imitate sounds or produce on cue

Volume, prosody, etc.Volume, prosody, etc.

Adaptive Behavior Adaptive Behavior AssessmentAssessment

Scales of Independent Behavior - Scales of Independent Behavior - Revised (SIB-R; Bruininks et al., 1996)Revised (SIB-R; Bruininks et al., 1996)

Vineland Adaptive Behavior Scales Vineland Adaptive Behavior Scales (Sparrow et al. 1984; teacher and parent (Sparrow et al. 1984; teacher and parent forms; supplementary norms for autism)forms; supplementary norms for autism)

AAMD Adaptive Behavior Scales AAMD Adaptive Behavior Scales (Lambert et al., 1993)(Lambert et al., 1993)

Could the child have autism?Could the child have autism?First Step: Parent InterviewFirst Step: Parent Interview

Presenting problems and concernsPresenting problems and concerns Medical and developmental HistoryMedical and developmental History Social and family history; family functioning Social and family history; family functioning

and resourcesand resources Current interventions and therapiesCurrent interventions and therapies

Autism Diagnostic Interview Revised (Lord et Autism Diagnostic Interview Revised (Lord et al., 1994)al., 1994) social relatedness, communication, ritualistic social relatedness, communication, ritualistic

behaviors; “gold standard”, requires trainingbehaviors; “gold standard”, requires training

Parent/Caregiver Questionnaires Parent/Caregiver Questionnaires about Social and Communicative about Social and Communicative

DevelopmentDevelopment Social Communication Questionnaire: Social Communication Questionnaire:

ages 4+ ages 4+ (SCQ; Berument et al, 1999)(SCQ; Berument et al, 1999)

Childhood Routines Questionnaire Childhood Routines Questionnaire (Evans et al, 1997)(Evans et al, 1997)

MacArthur Communication Development MacArthur Communication Development Inventory: best for young children or less Inventory: best for young children or less verbal childrenverbal children(CDI; Fenson et al, 1993; 1994)(CDI; Fenson et al, 1993; 1994)

Social Responsivity ScaleSocial Responsivity Scale (SRS; Constantino, (SRS; Constantino, 2001)2001)

Direct Observation of Direct Observation of Social and Communicative BehaviorsSocial and Communicative Behaviors

Autism Diagnostic Observation Schedule Autism Diagnostic Observation Schedule (Lord et al, 1999) is a commonly used (Lord et al, 1999) is a commonly used assessment tool that provides assessment tool that provides opportunities to observe subtle social opportunities to observe subtle social and communicative behaviorsand communicative behaviors

Developmentally sensitiveDevelopmentally sensitive Can inform interventionsCan inform interventions Can be used across the lifespanCan be used across the lifespan

Challenges Using the ADOSChallenges Using the ADOS

Requires clinical experience with Requires clinical experience with autism spectrum disordersautism spectrum disorders

Requires a lot of practice to Requires a lot of practice to administer and scoreadminister and score

Requires that you sit back and not Requires that you sit back and not over-scaffold or do your job too wellover-scaffold or do your job too well

Best PracticeBest Practice Seek trainingSeek training through the University of Chicago through the University of Chicago

or certified trainer and follow the recommended or certified trainer and follow the recommended training protocoltraining protocol

Maintain a core groupMaintain a core group of staff to administer of staff to administer and co-score assessments and co-score assessments

Practice regularlyPractice regularly

Use in combinationUse in combination with other measures - with other measures - Especially parent report Especially parent report

Know the limitsKnow the limits and the strengths of the tool and the strengths of the tool

Know how to talkKnow how to talk to the parents about the to the parents about the resultsresults

Implications for Implications for InterventionIntervention

For Young ChildrenFor Young Children

Cascade Theory Cascade Theory (Rogers, Pennington, Loveland)(Rogers, Pennington, Loveland)

Maybe there are several early deficits that Maybe there are several early deficits that conspire to pull the child away from active conspire to pull the child away from active involvement with the social worldinvolvement with the social world

And maybe this restricts their access to And maybe this restricts their access to social learning, so that they miss out on social learning, so that they miss out on learning opportunitieslearning opportunities

And maybe that’s why some kids get worse And maybe that’s why some kids get worse and worse, and others get better and betterand worse, and others get better and better

The key to outcome for children The key to outcome for children with autism might be…with autism might be…

Active engagement in the social worldActive engagement in the social world Active involvement with peers and adultsActive involvement with peers and adults Lots of practice with difficult social and Lots of practice with difficult social and

communicative interactionscommunicative interactions Consistent exposure to new situationsConsistent exposure to new situations Persistence, even when it’s hardPersistence, even when it’s hard Setting small goals and ensuring successSetting small goals and ensuring success

Which is best delivered Which is best delivered through…through…

Early intervention in an integrated, Early intervention in an integrated, multifaceted intervention programmultifaceted intervention program

Developmentally-focused approachDevelopmentally-focused approach Delivered in many different formatsDelivered in many different formats

1:1 and highly structured1:1 and highly structured Natural routines and daily activitiesNatural routines and daily activities

For a review: see National Council on For a review: see National Council on Research, 2001Research, 2001

Goals for Intervention with Young Goals for Intervention with Young ChildrenChildren

Increase active engagement in social and Increase active engagement in social and communicative interactionscommunicative interactions

Teach in multiple real-life settingsTeach in multiple real-life settings Increase the opportunities for sharing Increase the opportunities for sharing

attention and affect with the child with autismattention and affect with the child with autism Use routines and predictable, physical activities Use routines and predictable, physical activities Alternate following child’s lead with leading the Alternate following child’s lead with leading the

childchild Actively teach Actively teach followingfollowing and and initiatinginitiating joint joint

attentionattention, as well as , as well as imitation skillsimitation skills

Teaching Joint Attention Teaching Joint Attention (cont.)(cont.)

Set up motivating activities that encourage Set up motivating activities that encourage attention and interestattention and interest

Prompt the shared attention response and Prompt the shared attention response and reinforce with continued activation of the toy (or reinforce with continued activation of the toy (or another natural consequence)another natural consequence)

Practice, practice, practice – Kasari et al. (2004) Practice, practice, practice – Kasari et al. (2004) are doing 10-minutes per day for 5 days a week are doing 10-minutes per day for 5 days a week and showing strong skill development in and showing strong skill development in preschool children within 7 weekspreschool children within 7 weeks

Imitation Imitation

Imitation is the basis for cultural Imitation is the basis for cultural learning learning

Imitation ability is strongly influenced Imitation ability is strongly influenced by one’s ability to generalizeby one’s ability to generalize

Imitation leads to language learning in Imitation leads to language learning in typically developing children, as well typically developing children, as well as social-emotional understandingas social-emotional understanding

Implications for Implications for InterventionIntervention

For School-aged childrenFor School-aged children

Overview of InterventionsOverview of Interventions

Supporting the “Master Planner of the Brain”Supporting the “Master Planner of the Brain”

Educational modificationsEducational modifications

Minimizing interfering behaviors in the classroomMinimizing interfering behaviors in the classroom

Improving social competenceImproving social competence Naturalistic or Peer-MediatedNaturalistic or Peer-Mediated Narrative or Cognitive-BehavioralNarrative or Cognitive-Behavioral Direct Instruction Direct Instruction

I. Supporting the “Master Planner” I. Supporting the “Master Planner” of the Brainof the Brain

Helping with Helping with attentionattention,, organizationorganization, ,

inhibitioninhibition, , initiationinitiation, and , and

sustaining attentionsustaining attention

3 Kinds of Attention 3 Kinds of Attention ProblemsProblems

Shifting attentionShifting attention From own agenda to From own agenda to

another’s agendaanother’s agenda

From favorite topic to From favorite topic to less preferred topicless preferred topic

From internal world to From internal world to external worldexternal world

From self to otherFrom self to other

Sustaining Sustaining attentionattention Short attention spanShort attention span Tendency not to finish Tendency not to finish

what has been startedwhat has been started Easily distractibleEasily distractible

Missing the forest Missing the forest for the treesfor the trees Overly focused on Overly focused on

detailsdetails Missing the “big Missing the “big

picture”picture”

Helping Children Shift Helping Children Shift AttentionAttention

Visual cues to focus attentionVisual cues to focus attention

Advanced warning of shift in attentionAdvanced warning of shift in attention

Clear endpoints for activitiesClear endpoints for activities

Routine for shifting attentionRoutine for shifting attention

Practice attending to nonverbal cuesPractice attending to nonverbal cues

Helping Children Sustain Helping Children Sustain AttentionAttention

Clear indication of how long attention should Clear indication of how long attention should be sustainedbe sustained

Provide frequent breaksProvide frequent breaks

Reinforce/reward appropriate attendingReinforce/reward appropriate attending

Give them a task to do – need some kind of Give them a task to do – need some kind of active involvement in activityactive involvement in activity

Reduce distractors in the environmentReduce distractors in the environment

Give directions 1 step at a timeGive directions 1 step at a time

Sustaining attention (cont.)Sustaining attention (cont.)

Consider seating the child towards the Consider seating the child towards the front of the classroom near good peer front of the classroom near good peer modelsmodels

Be aware that too much auditory Be aware that too much auditory information without visuals is difficult to information without visuals is difficult to attend to for most of these kidsattend to for most of these kids

Give specific listening assignments (e.g., Give specific listening assignments (e.g., list of words to check off when heard)list of words to check off when heard)

Helping Children to Focus Helping Children to Focus on the Whole as the Sum of on the Whole as the Sum of

the Partsthe Parts Provide verbal and visual cues Provide verbal and visual cues

concerning the “big picture”concerning the “big picture”

Highlight the most important Highlight the most important conceptsconcepts

Explicitly link main ideas and Explicitly link main ideas and supporting ideassupporting ideas

Structured TeachingStructured Teaching

Structured teaching examples were downloaded from the Wisconsin Structured teaching examples were downloaded from the Wisconsin Department of Special Education website: Department of Special Education website: www.specialed.us/autism/early/ear11.htmwww.specialed.us/autism/early/ear11.htm

Stokes, S. (2005). Effective Programming for Young Children with Stokes, S. (2005). Effective Programming for Young Children with Autism (Ages 3-5)Autism (Ages 3-5). . “Written by Susan Stokes under a contract with “Written by Susan Stokes under a contract with

CESA 7 and funded by a discretionary grant from the Wisconsin CESA 7 and funded by a discretionary grant from the Wisconsin Department of Public Instruction.” Department of Public Instruction.”   

Allow a headstart on Allow a headstart on transitionstransitions

Student may need more time to Student may need more time to organize self for next activityorganize self for next activity

For some students, chaos of other For some students, chaos of other children making a transition is children making a transition is overwhelming – see if student can start overwhelming – see if student can start earlier or later than other studentsearlier or later than other students

Whenever possible, reduce transitionsWhenever possible, reduce transitions Use buddy system for room changesUse buddy system for room changes

II. Educational ModificationsII. Educational Modifications

Contributions by: Contributions by:

Sally Ozonoff, Sue Thompson, Jennifer StellaSally Ozonoff, Sue Thompson, Jennifer Stella

How to teach new How to teach new concepts concepts

(Klin & Volkmar, 2001)(Klin & Volkmar, 2001) ExplicitlyExplicitly

Rote/rule-governedRote/rule-governed

Verbally (if Aspergers’)Verbally (if Aspergers’) Visually (if High-functioning Autism)Visually (if High-functioning Autism)

Parts-to-wholesParts-to-wholes

SequentiallySequentially

If the child processes If the child processes slowly:slowly:

Avoid timed testsAvoid timed tests

Encourage completion – provide visual Encourage completion – provide visual cues for starting and stopping and require cues for starting and stopping and require only enough work that child can finish with only enough work that child can finish with other students and experience closureother students and experience closure

Require completion of part of assignmentRequire completion of part of assignment

If the child struggles with If the child struggles with handwriting…handwriting…

Consider oral tests or projects instead of Consider oral tests or projects instead of paperspapers

Encourage typing assignmentsEncourage typing assignments Reduce amount of copying that must be doneReduce amount of copying that must be done Make sure worksheets have enough response Make sure worksheets have enough response

space for large writingspace for large writing Use multiple choice instead of fill in the blankUse multiple choice instead of fill in the blank Emphasize quality, not quantityEmphasize quality, not quantity See if child can purchase school books and See if child can purchase school books and

highlight (instead of taking notes)highlight (instead of taking notes)

If the student has visual-If the student has visual-spatial weaknesses that spatial weaknesses that make math difficult…make math difficult…

May need visual cues to align numbers in May need visual cues to align numbers in math problems, use decimal points,dollar math problems, use decimal points,dollar signs, etc.signs, etc.

Provide a step-by-step approach to solving Provide a step-by-step approach to solving problemsproblems

Encourage “talking through” word problemsEncourage “talking through” word problems Try to reduce amount of repetitive writingTry to reduce amount of repetitive writing Give an example of a completed assignmentGive an example of a completed assignment

Monitor for reading Monitor for reading comprehensioncomprehension

Some students will become expert Some students will become expert “decoders” without truly understanding “decoders” without truly understanding what they are readingwhat they are reading

Actively teach how to identify main ideas, Actively teach how to identify main ideas, supporting points, character perspectives, supporting points, character perspectives, etc. Can be done in a rule-based approach.etc. Can be done in a rule-based approach.

Provide the student with the text the night Provide the student with the text the night before so that he/she can preview itbefore so that he/she can preview it

Be ready for “parallel Be ready for “parallel activities”activities”

If an activity is appropriate for the If an activity is appropriate for the other students, but is likely to be other students, but is likely to be frustrating for the student with HFA, frustrating for the student with HFA, consider designing a parallel activity consider designing a parallel activity that teaches the same concepts but that teaches the same concepts but in a different way. Allow students to in a different way. Allow students to choose which activity to do.choose which activity to do.

Use Computer-Based Use Computer-Based InstructionInstruction

Practice skills with educational softwarePractice skills with educational software Fast ForWord for phonological processing and Fast ForWord for phonological processing and

other important literacy and language skillsother important literacy and language skills Interactive CD-ROMs for narrative structure, Interactive CD-ROMs for narrative structure,

science, math, special interestsscience, math, special interests

Practice writing via emailPractice writing via email

Practice research via internetPractice research via internet

Be careful about Be careful about overwhelming the student overwhelming the student

with homeworkwith homework Families often report that homework is a Families often report that homework is a

significant stressorsignificant stressor

When giving homework, be sure to give complete When giving homework, be sure to give complete instructionsinstructions

Whenever possible, provide study hall towards Whenever possible, provide study hall towards the end of the day with a tutor available to the end of the day with a tutor available to complete homeworkcomplete homework

Whenever possible, set a homework routineWhenever possible, set a homework routine

Use an assignment Use an assignment notebooknotebook

Teacher takes the lead in monitoring Teacher takes the lead in monitoring its useits use

Student will need to be prompted to Student will need to be prompted to add/delete assignmentsadd/delete assignments

Use existing systems that look Use existing systems that look “normal” – Daytimer, etc.“normal” – Daytimer, etc.

Break assignments down Break assignments down into stepsinto steps

Use clearly numbered sequences to Use clearly numbered sequences to illustrate progressionillustrate progression

Webs or flowcharts might be usefulWebs or flowcharts might be useful

Actively involve student in monitoring Actively involve student in monitoring completion of assignmentscompletion of assignments

For large assignments…For large assignments…

Show student Show student how to break how to break large tasks into large tasks into steps and check-steps and check-off when each off when each step is completed step is completed – observe – observe completed steps, completed steps, student may not student may not report wellreport well

Have regular Have regular meetings with meetings with student to monitor student to monitor progressprogress

Send written Send written description of large description of large assignments (with assignments (with due dates and due dates and steps) to parentssteps) to parents

III. Minimizing Problem BehaviorsIII. Minimizing Problem Behaviors

that interfere in classroom that interfere in classroom activitiesactivities

Commonly reported Commonly reported challenging behaviors in challenging behaviors in

the classroomthe classroom Interrupting and Interrupting and

other impulsive other impulsive verbal behaviorsverbal behaviors

Resistance to Resistance to changes in changes in routineroutine

Insistence that Insistence that certain rules be certain rules be followedfollowed

Concrete styleConcrete style Poor handwritingPoor handwriting

Difficulty Difficulty accepting mistakesaccepting mistakes

Little patience Little patience Driven qualityDriven quality Social vulnerabilitySocial vulnerability DistractibilityDistractibility Perseverations or Perseverations or

obsessionsobsessions

Consider the message the Consider the message the behavior is sendingbehavior is sending

Is confused, needs help but has difficulty Is confused, needs help but has difficulty communicating under pressurecommunicating under pressure

Feels negative affect (e.g., anxiety, worry, Feels negative affect (e.g., anxiety, worry, sad, mad) and doesn’t know how to sad, mad) and doesn’t know how to manage it physiologically and behaviorallymanage it physiologically and behaviorally

Wants to escapeWants to escape Craves predictabilityCraves predictability Wants to interact, doesn’t know howWants to interact, doesn’t know how Thinks he can’t do something well, so Thinks he can’t do something well, so

doesn’t trydoesn’t try

Avoid Contingencies and Avoid Contingencies and Instead….Instead….

Catch the Student Being GoodCatch the Student Being Good Always be on the look out to praise Always be on the look out to praise

or reinforce good attention, effort, or reinforce good attention, effort, participation, waiting, tolerance, participation, waiting, tolerance, acceptance of change, coping, etc.acceptance of change, coping, etc.

Link rewards to effort and Link rewards to effort and participation but provide participation but provide intermittently and not with a intermittently and not with a formalized contract ahead of timeformalized contract ahead of time

Set Clear LimitsSet Clear Limits

Anticipate challenging situationsAnticipate challenging situations Share written rules/guidelines with Share written rules/guidelines with

student for specific situationsstudent for specific situations Be explicit, rule-governed, clear, Be explicit, rule-governed, clear,

consistentconsistent Pick and choose battlesPick and choose battles

Use clear and specific Use clear and specific language to shape behaviorlanguage to shape behavior

Avoid phrases like “behave yourself” – not Avoid phrases like “behave yourself” – not specific enoughspecific enough

Tell the student exactly what is expected and Tell the student exactly what is expected and for how long: “You need to be sitting quietly for how long: “You need to be sitting quietly and reading your science book until 11:15.”and reading your science book until 11:15.”

Emphasize words that indicate when – Emphasize words that indicate when – “now”, “later”, etc. and gently redirect if “now”, “later”, etc. and gently redirect if student acts before it is timestudent acts before it is time

Encourage Choice-makingEncourage Choice-making

Autonomy is often very important for Autonomy is often very important for these students; use it to prevent these students; use it to prevent problems and reinforce effortproblems and reinforce effort

Help student identify how choices Help student identify how choices are perceived by other peopleare perceived by other people

Use Visual RemindersUse Visual Reminders

Use post-it notes or index cards on Use post-it notes or index cards on the child’s desk to remind him/her of the child’s desk to remind him/her of appropriate behavior (e.g., “raise appropriate behavior (e.g., “raise your hand”)your hand”)

Instead of verbally reminding child, Instead of verbally reminding child, simply touch the card to send the simply touch the card to send the messagemessage

Use the Buddy SystemUse the Buddy System

Encourage the child to watch what Encourage the child to watch what another student does and model that another student does and model that behaviorbehavior

Rotate buddiesRotate buddies Whenever possible, use same-gender Whenever possible, use same-gender

buddiesbuddies

Minimize down timeMinimize down time

Give the child 2-3 functional Give the child 2-3 functional activities to engage in when he/she activities to engage in when he/she has completed work and is waiting has completed work and is waiting for the next activityfor the next activity

Provide clear rules about behavior Provide clear rules about behavior during “down time” or independent during “down time” or independent work.work.

Use a “ticket out” systemUse a “ticket out” system

Provide a limited number of tickets out of Provide a limited number of tickets out of the classroom per daythe classroom per day

Provide written guidelines to the student Provide written guidelines to the student for where to go, how long, etc.for where to go, how long, etc.

Determine a safe place to go and/or Determine a safe place to go and/or supervisionsupervision

Teach the student when to use the ticketsTeach the student when to use the tickets Reinforce appropriate useReinforce appropriate use

Plan for alternative Plan for alternative activitiesactivities

For example, if cafeteria is too noisy For example, if cafeteria is too noisy and upsetting, create a plan for and upsetting, create a plan for eating and going elsewhereeating and going elsewhere

It may not be useful for some It may not be useful for some students to participate in all classes, students to participate in all classes, assemblies, field trips etc.– make assemblies, field trips etc.– make these decisions with parentsthese decisions with parents

When problem behaviors When problem behaviors occuroccur

Label the misbehavior in a calm, Label the misbehavior in a calm, neutral mannerneutral manner

Whenever possible, allow natural Whenever possible, allow natural consequences to ariseconsequences to arise

Do not process/discuss problem Do not process/discuss problem behavior in the momentbehavior in the moment

Wait for a calm time to discuss what Wait for a calm time to discuss what the student could have done the student could have done differentlydifferently

Encourage self-reflectionEncourage self-reflection

Help student to identify situations that are Help student to identify situations that are particularly challenging for themparticularly challenging for them

Help student to create a list of options for Help student to create a list of options for responding to these situations in the futureresponding to these situations in the future

Use self-reflection to strengthen self-esteemUse self-reflection to strengthen self-esteem Demonstrate differences between student’s Demonstrate differences between student’s

perspective and others’ perspectiveperspective and others’ perspective

IV. Improving social competenceIV. Improving social competence

A. Naturalistic TeachingA. Naturalistic Teaching

Narrating situations (Tony Attwood calls Narrating situations (Tony Attwood calls this “being an anthropologist”)this “being an anthropologist”)

Setting up play/social situations that you Setting up play/social situations that you can subtly observe and teach throughcan subtly observe and teach through Bring good models into your house/classroom Bring good models into your house/classroom

and structure play activities to encourage active and structure play activities to encourage active participationparticipation

Prime or prepare student with ASDPrime or prepare student with ASD Choose shared activities that emphasize Choose shared activities that emphasize

strengths and are cooperative, not competitivestrengths and are cooperative, not competitive

Peer Mediated Interventions:Peer Mediated Interventions:

Improving Social Relationships Improving Social Relationships Among Children with Autism Among Children with Autism

in Inclusive Settingsin Inclusive Settings

Audrey Blakeley-Smith, Ph.D.Audrey Blakeley-Smith, Ph.D.

JFK PartnersJFK PartnersUniversity of Colorado at Denver and Health Sciences CenterUniversity of Colorado at Denver and Health Sciences Center

[email protected]@uchsc.edu

Research on Inclusion for Research on Inclusion for Students with ASDStudents with ASD

Changes in problem behavior Changes in problem behavior (stereotypies, self-injury) (stereotypies, self-injury) (Lee & (Lee & Odom, 1996; McGee, Paradis & Feldman, Odom, 1996; McGee, Paradis & Feldman, 1993)1993)

Changes in academic performance Changes in academic performance (Saint-Laurent & Lessard, 1991; Saint-(Saint-Laurent & Lessard, 1991; Saint-Laurent, Fournier & Lessard, 1993)Laurent, Fournier & Lessard, 1993)

Social Inclusion: Social Inclusion: What Does the Research What Does the Research

Say?Say?

Students in integrated settings Students in integrated settings spend more time engaged in spend more time engaged in interactions than students in interactions than students in segregated settingssegregated settings (Center & Curry, (Center & Curry, 1993)1993)

But What Does this Mean…But What Does this Mean…

Interactions between students with Interactions between students with special needs and their peers, are often special needs and their peers, are often one-sided and didacticone-sided and didactic

78% of student interactions were 78% of student interactions were instructionalinstructional

<5% of student interactions were social<5% of student interactions were social

(Farrell, 1997; Hilton & Liberty, 1992)(Farrell, 1997; Hilton & Liberty, 1992)

Social Inclusion:Social Inclusion:What Do the Peers Say?What Do the Peers Say?

Typical peers often report that Typical peers often report that they have insufficient knowledge they have insufficient knowledge and inadequate communication and inadequate communication strategiesstrategies (York & Tundidor, 1995)(York & Tundidor, 1995)

Most peers prefer to interact with Most peers prefer to interact with each other rather than children each other rather than children with HFA with HFA (Chamberline, Kasari, (Chamberline, Kasari, Rotheram-Fuller, 2007)Rotheram-Fuller, 2007)

Social Inclusion:Social Inclusion:What do Children with ASD What do Children with ASD

say?say? Children with HFA tend to view Children with HFA tend to view

themselves as more socially involved themselves as more socially involved than their peers reportthan their peers report (Chamberlin, (Chamberlin, Kasari,& Rotheram-Fuller, 2007)Kasari,& Rotheram-Fuller, 2007)

Children with HFA report greater Children with HFA report greater loneliness than their typical peersloneliness than their typical peers (Bauminger & Kasari, 2000)(Bauminger & Kasari, 2000)

Peer Mediated Peer Mediated InterventionsInterventions

Choose Peers Who Are… Choose Peers Who Are…

A part of the child’s social worldA part of the child’s social world

InterestedInterested

Attentive to adult instructionAttentive to adult instruction

Responsive to adult praiseResponsive to adult praise

Preparing PeersPreparing Peers

Learn about their interests and motivationsLearn about their interests and motivations

Discuss goals of groupDiscuss goals of group

Teach how to prompt/helpTeach how to prompt/help

Role play prompting/helpingRole play prompting/helping

Systematically fade reinforcementSystematically fade reinforcement

Does sharing the autism Does sharing the autism diagnosis with peers help?diagnosis with peers help?

Negative attitudes frequently persist Negative attitudes frequently persist despite providing children with despite providing children with information about ASD information about ASD (Swaim & Morgan, (Swaim & Morgan, 2001)2001)

By the 5By the 5thth grade, students are no longer grade, students are no longer as receptive to explanatory information as receptive to explanatory information regarding ASD regarding ASD (Cambell, 2006)(Cambell, 2006)

Guidelines for Peer Guidelines for Peer PromptingPrompting

Teach peers to provide visual and gestural prompts as Teach peers to provide visual and gestural prompts as well as “sentence starters”, “help” cardswell as “sentence starters”, “help” cards

Encourage peers to help more in the beginning and Encourage peers to help more in the beginning and less at the end of a taskless at the end of a task

Teach peers to wait for a response from target childTeach peers to wait for a response from target child

Focus peers on prompts and praise, not criticism or Focus peers on prompts and praise, not criticism or correctioncorrection

Emphasize modelingEmphasize modeling

Teach Peers to Respond Teach Peers to Respond AppropriatelyAppropriately

Follow and redirectFollow and redirect PersistencePersistence PatiencePatience Change their expectancies regarding Change their expectancies regarding

the nature of the interactionthe nature of the interaction Change their attributions for the child’s Change their attributions for the child’s

behaviorbehavior

B.B. Cognitive-Behavioral Cognitive-Behavioral Approaches*Approaches*

Using narrative strategies (scripts, video Using narrative strategies (scripts, video examples, comic strips, social stories) to examples, comic strips, social stories) to clarify basic social conceptsclarify basic social concepts

Relying on a child’s cognitive strengths to Relying on a child’s cognitive strengths to compensate for lack of social insightcompensate for lack of social insight

*This section relies heavily on contributions from Audrey Blakeley-Smith: [email protected]

Social NarrativesSocial NarrativesPurpose:Purpose: To teach social rules and the reasons why To teach social rules and the reasons why

situations are handled in certain wayssituations are handled in certain ways Provide alternatives and/or coping Provide alternatives and/or coping

strategiesstrategies

How to:How to:

Review Carol Gray’s website or seeReview Carol Gray’s website or see Gray, Gray, 1993; Gray, 1994; Fullerton, Stratton, Coyne, & 1993; Gray, 1994; Fullerton, Stratton, Coyne, & Gray, 1996Gray, 1996

Differentiating situationsDifferentiating situations

Behavior in Behavior in library……library……

…….is the same as in .is the same as in the bank, dentist the bank, dentist office, etc.office, etc.

Behavior with little Behavior with little sister……sister……

……..not the same as ..not the same as behavior with behavior with friendsfriends

Behavior on the Behavior on the playground…playground…

……not the same as not the same as behavior in the carbehavior in the car

Comic Strip Comic Strip ConversationsConversations

Purpose:Purpose: Increase social understanding of Increase social understanding of

difficult situationsdifficult situations

Incorporates the use of color and Incorporates the use of color and simple drawings to improve the simple drawings to improve the student’s understanding of language student’s understanding of language and social interactions and social interactions (Gray, 1994; (Gray, 1994; Fullerton, Stratton, Coyne, & Gray, 1996)Fullerton, Stratton, Coyne, & Gray, 1996)

ConversatioConversation symbols n symbols

representinrepresenting:g:

Interrupt Listen

LOUD words

quiet words

Talk Think

Colors Representing Colors Representing Emotions:Emotions:

GreenGreen = good ideas, happy, friendly = good ideas, happy, friendly RedRed = bad ideas, teasing, angry, = bad ideas, teasing, angry,

unfriendlyunfriendly CCoommbbiinneedd ccoolloorrss = confusion = confusion

Setting symbols to indicate the Setting symbols to indicate the setting for the social situationsetting for the social situation

Comic Strip ConversationsComic Strip Conversations

How to:How to: Review –With the student, draw the difficult Review –With the student, draw the difficult

social situation;support the student in social situation;support the student in identifying thoughts and emotionsidentifying thoughts and emotions

Practice –Help the student identify more Practice –Help the student identify more appropriate ways to respond in similar social appropriate ways to respond in similar social situations in the future; draw these picturessituations in the future; draw these pictures

Using comic strip Using comic strip conversations to conversations to

understand social situationsunderstand social situations Who is challenging Who is challenging

me?me?

Where are we?Where are we?

What are the rules?What are the rules?

Who is on my side Who is on my side here?here?

What happened just What happened just before?before?

What happened just What happened just after?after?

What should I do What should I do next time?next time?

Social ScriptsSocial Scripts

How to:How to: Identify age-appropriate social Identify age-appropriate social

interactions, language and behaviorsinteractions, language and behaviors Develop a scriptDevelop a script Practice the script with the studentPractice the script with the student Alter the language/behaviors to reduce Alter the language/behaviors to reduce

rigidityrigidity Support the student to initiate and Support the student to initiate and

complete the script with a peer(s)complete the script with a peer(s)

Social ScriptsSocial Scripts

Scripted conversations and interactionsScripted conversations and interactions E.g.,: Scripts for entering/leaving E.g.,: Scripts for entering/leaving

classroom/activity, going to McDonalds etc.classroom/activity, going to McDonalds etc.

Scripts for classroom jobsScripts for classroom jobs E.g., paper distributor: make eye contact or E.g., paper distributor: make eye contact or

tap shoulder and make eye contact, “Here’s tap shoulder and make eye contact, “Here’s your paper ____”your paper ____”

VideoVideo

Purpose:Purpose: View videos to:View videos to:

Highlight salient social cuesHighlight salient social cues Highlight specific social communicative Highlight specific social communicative

behaviorsbehaviors

Create videos to teach:Create videos to teach: Imitation, play, community expectations, Imitation, play, community expectations,

replacements to challenging behaviors, replacements to challenging behaviors, language and conversation skillslanguage and conversation skills

How to View Videos/TVHow to View Videos/TV

Have the student observe and Have the student observe and interpret nonverbal messages in interpret nonverbal messages in the showthe show

Have the student make predictions Have the student make predictions about behaviors about behaviors

““Video Detective” Video Detective” (Smith Myles & (Smith Myles & Southwick, 1999; Attwood, 1998)Southwick, 1999; Attwood, 1998)

How to Create VideosHow to Create Videos Identify target social behaviors & situationsIdentify target social behaviors & situations

Videotape familiar peers in those situations Videotape familiar peers in those situations engaging in appropriate social behaviorengaging in appropriate social behavior

Make the social cues and target behavior Make the social cues and target behavior the most salient aspects of the videothe most salient aspects of the video

Have the child view the video and critique Have the child view the video and critique their own and others’ behaviorstheir own and others’ behaviors

From: Quill, K. A. (2000). From: Quill, K. A. (2000). Do-Watch-Listen-SayDo-Watch-Listen-Say

How to Use the Created VideoHow to Use the Created Video View the video regularly (daily)View the video regularly (daily)

Preview the video just prior to the relevant Preview the video just prior to the relevant situationsituation

Pair the video with other visual cues to use as Pair the video with other visual cues to use as instructional prompts in the actual situationinstructional prompts in the actual situation

Fade video viewing as the skills are mastered Fade video viewing as the skills are mastered in the actual settingin the actual setting

Modeling and RehearsalModeling and RehearsalPurpose:Purpose: To highlight the key behaviors that the child To highlight the key behaviors that the child

should attend to in developing a social sequenceshould attend to in developing a social sequence

How to:How to: Peer or adult demonstrates the appropriate Peer or adult demonstrates the appropriate

social skill for the child to imitatesocial skill for the child to imitate do in vivo, during role play, or set up do in vivo, during role play, or set up

situations for practicesituations for practice

Acting LessonsActing Lessons

Purpose:Purpose: Role-playing and acting may help the child Role-playing and acting may help the child

to express emotions verbally and to express emotions verbally and nonverbally nonverbally

The child may learn to interpret others’ The child may learn to interpret others’ emotions, feelings, and voices emotions, feelings, and voices

(Smith Myles & Southwick, 1999; Attwood, 1998)(Smith Myles & Southwick, 1999; Attwood, 1998)

C. Direct InstructionC. Direct Instruction

Adult-directed activitiesAdult-directed activities

““Lesson-like”Lesson-like”

Involves lots of practice and repetitionInvolves lots of practice and repetition

Reinforce effort and attention and scaffold enough Reinforce effort and attention and scaffold enough to ensure successto ensure success

Goal is to master basics – think of learning a Goal is to master basics – think of learning a foreign language!!foreign language!!

Individual WorkIndividual Work

Include parents whenever possibleInclude parents whenever possible

Incorporate homeworkIncorporate homework

Use a notebook systemUse a notebook system

Clearly define goals and review progress Clearly define goals and review progress regularly in sessions with child and parentregularly in sessions with child and parent

Individual Work (cont.)Individual Work (cont.)

Use: children’s books, art, music, Use: children’s books, art, music, games, physical activities, games, physical activities, worksheets, puzzles, videotape, worksheets, puzzles, videotape, roleplays, snack timeroleplays, snack time

Remember: if you use this approach Remember: if you use this approach alone -- you won’t get much alone -- you won’t get much

carry-over of skillscarry-over of skills

DyadsDyads

Same focus of individual work, but with Same focus of individual work, but with another child attending alsoanother child attending also

Choose a peer from the school or Choose a peer from the school or neighborhoodneighborhood

Parents still attend and homework is often Parents still attend and homework is often focused on fostering interaction between focused on fostering interaction between the two kidsthe two kids

Small Social Skills GroupsSmall Social Skills Groups

4-6 children4-6 children

1-2 adults1-2 adults

Target to Peer Target to Peer ratio of 2:1 or 1:1ratio of 2:1 or 1:1

Stable vs. variable Stable vs. variable peerspeers

Adult InteractionAdult Interaction

Model and narrate appropriate social Model and narrate appropriate social behavior in a very obvious waybehavior in a very obvious way

Use humor and lighthearted approachUse humor and lighthearted approach

Provide frequent praise and Provide frequent praise and reinforcement for effort and attentionreinforcement for effort and attention

Choose a Focus for the Choose a Focus for the GroupGroup

Cooperative PlayCooperative Play

Problem-SolvingProblem-Solving

Emotional Emotional UnderstandingUnderstanding

Social Social UnderstandingUnderstanding

Pragmatic LanguagePragmatic Language

Emotional RegulationEmotional Regulation

Basic Social Basic Social InteractionInteraction

Leisure Skills Leisure Skills

Determine Setting/LogisticsDetermine Setting/Logistics

Where?Where?

How Often?How Often?

How long?How long?

Rules?Rules?

Materials?Materials?

Planning a SessionPlanning a Session

Emphasize routineEmphasize routine

Provide visual structureProvide visual structure

Apply the “70/30 Rule of Repetition”Apply the “70/30 Rule of Repetition”

Incorporate special interestsIncorporate special interests

Planning Planning (cont).(cont).

Alternate tasks by difficulty, activity levelAlternate tasks by difficulty, activity level

Teach using multiple modalitiesTeach using multiple modalities

Start each session with a snackStart each session with a snack

End each session with R+End each session with R+

Maintain close contact with familiesMaintain close contact with families

Teaching ActivitiesTeaching Activities

Use existing social skills curricula Use existing social skills curricula (see reference list)(see reference list)

Use actual situations to fuel lessons Use actual situations to fuel lessons within a predictable frameworkwithin a predictable framework

Know the child’s peer group and be Know the child’s peer group and be developmentally informeddevelopmentally informed

Dealing with Teasing and Dealing with Teasing and Bullies Bullies (Ozonoff, 2002)(Ozonoff, 2002)

Establish peer buddies and foster Establish peer buddies and foster good peer relationsgood peer relations

Teaching classes on tolerance, Teaching classes on tolerance, diversity, learning stylesdiversity, learning styles

Assertiveness trainingAssertiveness training Asking for help, finding safe places, Asking for help, finding safe places,

walking away, using humorwalking away, using humor

Resources for Resources for Teasing/Bullying Teasing/Bullying

Bully-proofing your child: A parent’s Bully-proofing your child: A parent’s guideguide by Garrity, Mitchell, & Porter by Garrity, Mitchell, & Porter (2000).(2000).

Bully-proofing your school: A Bully-proofing your school: A comprehensive approach for elementary comprehensive approach for elementary schoolsschools. Garrity et al. (2000).. Garrity et al. (2000).

For children: For children: Bullies are a pain in the Bullies are a pain in the brainbrain by Trevor Romain by Trevor Romain

Talking to a Child About Talking to a Child About Having AutismHaving Autism

Often best to wait until they have questions; Often best to wait until they have questions; often comes up at around age 10 or sooften comes up at around age 10 or so

Many good books available to help to educate Many good books available to help to educate kids about their condition; see kids about their condition; see www.futurehorizons.orgwww.futurehorizons.org

Be matter of fact and calm and positiveBe matter of fact and calm and positive

Discuss it as a way to describe a person’s Discuss it as a way to describe a person’s strengths and challenges, not as a way of strengths and challenges, not as a way of capturing the whole personcapturing the whole person

Have the conversation several timesHave the conversation several times

In ConclusionIn Conclusion

Need to think developmentally when Need to think developmentally when planning screening, assessment, or planning screening, assessment, or interventionintervention

There are many good resources for There are many good resources for intervention for kids of different intervention for kids of different ages and functioning levelsages and functioning levels

Thanks to…Thanks to…

Families who participate in our Families who participate in our research and clinical activities at JFK research and clinical activities at JFK Partners of the University of Colorado Partners of the University of Colorado at Denver and Health Sciencesat Denver and Health Sciences

The Nebraska Autism Spectrum The Nebraska Autism Spectrum Disorders Network Disorders Network Laura Maddox, State ASD CoordinatorLaura Maddox, State ASD Coordinator

This work has been funded This work has been funded by:by:

National Institute of Child Health and Development National Institute of Child Health and Development (U19 HD035468)(U19 HD035468)

National Institute of Communication Disorders and National Institute of Communication Disorders and Deafness (R21 DC005574-03)Deafness (R21 DC005574-03)

Association of University Centers on Developmental Association of University Centers on Developmental DisabilitiesDisabilities

University Centers of Excellence University Centers of Excellence Cure Autism NowCure Autism Now March of DimesMarch of Dimes Organization for Autism ResearchOrganization for Autism Research Autism SpeaksAutism Speaks Doug Flutie FoundationDoug Flutie Foundation

Research Team at JFK Partners and Research Team at JFK Partners and the the

University of Colorado at Denver University of Colorado at Denver and Health Sciences Centerand Health Sciences Center

Director:Director: Susan Hepburn, Ph.D.Susan Hepburn, Ph.D.

MentorsMentors::Sally RogersSally RogersBruce PenningtonBruce PenningtonCorry RobinsonCorry RobinsonLinda CrnicLinda Crnic

Collaborating scientistsCollaborating scientists::Deborah Fidler, Ph.D.Deborah Fidler, Ph.D.Judy Reaven, Ph.D.Judy Reaven, Ph.D.Audrey Blakeley-Smith, Audrey Blakeley-Smith,

Ph.D.Ph.D.Amy Philofsky, Ph.D.Amy Philofsky, Ph.D.Ann Reynolds, M.D.Ann Reynolds, M.D.Daniel McIntosh, Ph.D.Daniel McIntosh, Ph.D.Eric Moody, Ph.D.Eric Moody, Ph.D.Don Rojas, Ph.D.Don Rojas, Ph.D.Hilary Coon, Ph.D.Hilary Coon, Ph.D.Kathy Culhane-Shelburne, Kathy Culhane-Shelburne,

Ph.D.Ph.D.

www.jfkpartners.org

With Appreciation to Many With Appreciation to Many Students and Research Students and Research

Assistants Over the YearsAssistants Over the Years Katy RidgeKaty Ridge Galit Mankin, M.S.W.Galit Mankin, M.S.W. Athena Hayes, M.S.Athena Hayes, M.S. Angela John, M.S.Angela John, M.S. Benjamin Yerys, Ph.D.Benjamin Yerys, Ph.D. Erin FlaniganErin Flanigan Helga SimonsHelga Simons Mark Guiberson, Mark Guiberson,

Ph.D.Ph.D. Elizabeth Eno, M.S.Elizabeth Eno, M.S. Susan Murray, CCC-Susan Murray, CCC-

SLPSLP Kym GilchristKym Gilchrist

Nancy Lee, Ph.D.Nancy Lee, Ph.D. Terry Hall, CCC-SLPTerry Hall, CCC-SLP Renee Charlifue-Smith, Renee Charlifue-Smith,

CCC-SLPCCC-SLP Alison Herndon, MPHAlison Herndon, MPH Kristina Kaparich, MPHKristina Kaparich, MPH Marissa Sellinger, M.S.Marissa Sellinger, M.S. Lila Kimel, M.S.Lila Kimel, M.S. Shana Nichols, Ph.D.Shana Nichols, Ph.D. Tracy Stackhouse, OTRTracy Stackhouse, OTR Megan Martins, Ph.D.Megan Martins, Ph.D. Mim AriMim Ari Norbert NguiyaNorbert Nguiya