Naturalistic Interventions for Children with Autism KSHA, 2015 G. Robert Buckendorf, PhD Hello Clinic, LLC G. Robert Buckendorf, PhD Hello Clinic, LLC.

Naturalistic Interventions for Children with Autism

KSHA, 2015

•G. Robert Buckendorf, PhDG. Robert Buckendorf, PhDHello Clinic, LLCHello Clinic, LLC

•Assistant Clinical Professor, Oregon Assistant Clinical Professor, Oregon Health Science UniversityHealth Science University

•bob.buckendorf@gmail.com

In next slide, look for:

eye gaze

gesture

body orientation

language

kind of play

responsiveness to play partner including sharing and showing

Why Does Accurate Diagnosis Matter

Explains symptoms/ guilt relief

Course of disorder and co-occurring conditions

Correct interventions

Communication among professionals and families

Autism DSM-5Diagnostic and Statistical Manual-5

Two major clusters of symptoms, not three

Qualifiers added including with or without intellectual disability and with or without language disorder; severity (requiring support, requiring substantial support, requiring very substantial support)

Autism- diagnostic Autism- diagnostic criteria; DSM-IVcriteria; DSM-IV

•Persistent deficits in social communication Persistent deficits in social communication and social interaction across contexts, and social interaction across contexts, including deficits in (need all three):including deficits in (need all three):

•social-emotional reciprocitysocial-emotional reciprocity

•nonverbal communicative behaviors nonverbal communicative behaviors used for social interactionused for social interaction

•developing and maintaining relationshipsdeveloping and maintaining relationships

Social-Emotional Reciprocity

Abnormal social approach; failure in the back and forth of conversation

Reduced sharing of interests, emotions, or affect

Failure to initiate or respond to social interactions

Nonverbal Communicative Behaviors Used for

Communication

Poorly integrated verbal and nonverbal communication

Abnormalities in eye contact and body language

Total lack or reduced facial expressions and nonverbal communication

Difficulty in developing, maintaining, and understanding

relationships

Adjusting behavior to suit various social contexts

Sharing imaginative play or in making friends

Absence of interest in peers

Restricted, repetitive patterns of behavior, interests or activities including (need 2)

Stereotyped or repetitive speech, motor movements, or use of objects (simple motor stereotypies, lining up of toys or flipping objects, echolalia, idiosyncratic phrases)

Excessive adherence to routines, insistence on sameness, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change (extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greetings rituals, need to take same route or eats same food every day)

Highly restricted, fixated interests that are abnormal in intensity or focus (strong attachment to or preoccupations with unusual objects, excessively circumscribed or perseverative interests)

Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of environment (apparent indifference to pain or temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement

Alternative Diagnoses

Intellectual disability (Mental Retardation)

Language disorder

Reactive attachment disorder (History of pathogenic care)

Anxiety disorders

Mood disorders

Attention deficit disorder

Effective Interventions- National Research Council, 2001(NRC)

Start early and intensive (every day, all day)

Always work on engaging the child- looking, vocalizing, showing, modeling, arranging

Activities that are developmentally appropriate; target functional and spontaneous language

Goal driven and track changes (i.e., initiate and respond to joint attention, coordinate gesture and vocalization)

Types of Treatment McCoy,

2013

Family support

Educational-behavioral interventions (target core symptoms)

Treatment for associated medical problems

Medications to target behaviors

Complimentary and alternative medicine

Treatment

Goals:

Minimize the core features and associated deficits

Maximize functional independence and quality of life

Alleviate family distress

What do we teach?

Mastery of skills that follow a developmental sequence

Functional perspective- skills that allow the child to participate more fully in community settings; real world skills; adolescents

Focus on skills needed in future settings- preacademics

Challenging Behaviors: General Approaches

Behavior is communication

Challenging behavior may reflect a common medical problem

Medications are never used alone; it should be part of a comprehensive, multidisciplinary treatment approach

Evidence Based Practice

Team is composed of

Parents- priorities, concerns, knowledge of child; listen to clinician experts

Clinician- expertise and clinical judgment, knowledge, practice based evidence; be willing to change and learn; challenge assumptions

Research findings- what is effective

Purpose of InterventionEliminate underlying cause of disorder (hearing aids, soft palate surgery or appliance

Teach compensatory strategies (pictures or sign to communicate if unable to speak; control rate if stutters)

Modify the disorder by teahing specific behaviors (language, stuttering, engagement, eye gaze

Core Communication Deficits- NRC

Joint attention (“Keys of the Kingdom”)- Coordinating attention between people and an object- point to share, difficulty attending to a social partner, gaze shift, sharing affect with another, follow gaze or point, showing. Lack of initiating JA discriminated ASD from all other disorders.

Use of symbols- words, gestures, functional use of objects, symbolic play.

Communicative Communicative IntentIntent

•Child becomes intentional and interactive; Child becomes intentional and interactive; purposeful, about 6 mos.purposeful, about 6 mos.

•Begins with caregivers reading non-Begins with caregivers reading non-purposeful behaviors as purposeful (smile, purposeful behaviors as purposeful (smile, coo, cries for distress, follows gaze, coo, cries for distress, follows gaze, vocalizes)vocalizes)

•The child tells you what they want in a The child tells you what they want in a variety of ways; eventually request for variety of ways; eventually request for information, comments, acknowledgement, information, comments, acknowledgement, greeting, attention gettinggreeting, attention getting

Initiation

Child must initiate or take the lead

Set up environment so child initiates; at the beginning it will be a glance or reach toward

Respond quickly to that initiation, no matter how subtle.

The key is quick response to the child’s initiations

ReciprocityReciprocity

• Joint EngagementJoint Engagement

•Shared attentionShared attention

•Turn take (paying attention to each other)Turn take (paying attention to each other)

•Circles of communicationCircles of communication

•Not object focused but other focusedNot object focused but other focused

Applied Behavioral Analysis Amy Donaldson, 2013

Measurable tasks to determine if interventions are effective

A- Antecedent (stimulus) “what is this?”

B- Behavior (what person does in response to behavior (“it’s a car”)

C- Consequence (reinforcer which shapes the behavior “great job”)

Behavior has to be measurable

Intervention Domains

Communication

Social interaction

Play

Motor

Cognition

Adaptive behaviors

ESDM Treatment ModelTeaching strategies that target

reciprocal turns driven by affect, use of real-life materials and activities, teaching caregivers to be responsive and sensitive to child cues, and focus on both verbal and gestural communication. Uses developmental curriculum that focuses on language, social skills, cognition, play, fine and gross motor skills, and personal independence at four levels.

Strategies from ABACapturing attention

Antecedent-Behavior-Consequence

Prompt desired behaviors

Manage consequences

Fade prompts

Shape behaviors

Chaining behaviors

Functional Assessment

Strategies from PRTMotivation through: Child Choice and follow

turn taking; lead and follow

Reinforcing all attempts and reinforcer with direct relationship to behavior

Interspersing maintenance tasks

Response to multiple cues by vary antecedents, set up stimuli with multiple cues

teach children to give same behavior with a variety of antecedents

Specific ESDM Strategies

Adults optimize child’s affect

Adults use positive affect

Turn-taking and engagement throughout

Adults respond sensitively to child’s cues

Multiple and varied communicative opportunities occur

Elaboration of activities- multiple materials and many activities from many domains

Parent-Training Program (2010)Ingersol and Dvortcsak

Follow your child’s lead

Imitate your child

Be animated

Model and expand language

Playful obstruction

Turn taking and modeling and expanding play

Communicative Temptations

Responsive Teaching (McDonald Responsive Teaching (McDonald & Mahoney) & Mahoney)

responsiveteaching.orgresponsiveteaching.org•Parent mediated; uses strategies that help Parent mediated; uses strategies that help children use pivotal behaviors (cognition, children use pivotal behaviors (cognition, communication, social emotional functioning, communication, social emotional functioning, motivation-interest and enjoyment); teach motivation-interest and enjoyment); teach parents to be proactively responsive to their parents to be proactively responsive to their children and shift lead to child; parents can children and shift lead to child; parents can be effective.be effective.

•Reciprocity- joint activity and routines; shared Reciprocity- joint activity and routines; shared powerpower

•Contingency- timingContingency- timing

•Shared control- moderate directionShared control- moderate direction

•Affect- warmth, enjoymentAffect- warmth, enjoyment

•Match- developmental, interests of childMatch- developmental, interests of child

Specific Specific strategiesstrategies

•ReciprocityReciprocity– Engagement; be physically available, play frequently Engagement; be physically available, play frequently

together; together; expect my child to interact expect my child to interact (versus (versus learned helplessness)learned helplessness)

– Balance; Balance; ““Take one turn and waitTake one turn and wait””, play with sounds , play with sounds back and forth, communicate less so my child has to back and forth, communicate less so my child has to communicate more; child learns to interact with communicate more; child learns to interact with ““someonesomeone”” instead of using the parent as a tool or ignoring them; instead of using the parent as a tool or ignoring them; ““eyeseyes”” are very important so work at eye level are very important so work at eye level

•ContingencyContingency

–Awareness; take my childAwareness; take my child’’s perspective, be s perspective, be sensitive to my childsensitive to my child’’s states state

–Timing; Timing; ““respond quickly to my childrespond quickly to my child’’s s cries and little behaviorscries and little behaviors””, discipline , discipline promptly and comfortpromptly and comfort

– Intent; respond to unintentional behaviors Intent; respond to unintentional behaviors as if they were meaningful, accept incorrect as if they were meaningful, accept incorrect articulations and just respond to intentarticulations and just respond to intent

–Frequency; respond throughout the day and Frequency; respond throughout the day and with multiple caregiverswith multiple caregivers

•AffectAffect

– Animation; wait with anticipation, respond to Animation; wait with anticipation, respond to child in playful ways, be more interesting than my child in playful ways, be more interesting than my childchild’’s distractions, use nonverbal gestures and s distractions, use nonverbal gestures and intonationintonation

– Enjoyment; playful partner, interact for fun, turn Enjoyment; playful partner, interact for fun, turn routines into games, repeat activities my child routines into games, repeat activities my child enjoysenjoys

– Warmth; be physical and gentle, respond with Warmth; be physical and gentle, respond with affection to childaffection to child’’s cries, comfort childs cries, comfort child

– Acceptance; value what child is doing, treat my Acceptance; value what child is doing, treat my childchild’’s fears as meaningful , accept what my child s fears as meaningful , accept what my child does, talk about funny and novel things my child does, talk about funny and novel things my child is doingis doing

•Shared ControlShared Control

–Moderate direction; communicate without Moderate direction; communicate without asking directions, imitate childasking directions, imitate child’’s actions, s actions, give my child frequent opportunities to give my child frequent opportunities to make choicesmake choices

–Facilitation; expand to show child the next Facilitation; expand to show child the next developmental step, expand their actions developmental step, expand their actions or utterances, wait silently for a more or utterances, wait silently for a more mature response, change the environmentmature response, change the environment

Ingersoll & Dvortsak

Always- follow lead, imitate child, model and expand language, be animated

Mostly- arrange environment, playfully obstruct, control access

Sometimes- prompt to increase complexity of child’s response

Importance of Teaching Parents Ingersoll & Dvortsak, 2003)

Parents can learn to effectively intervene

Parents spend the most time with their children; provide intervention throughout the day

Reduces parent stress and increases their feelings of competence (Koegel et al, 1982)

Family Goals

Consistently respond to his behaviors quickly- teaches him that he does something and then something happens.

Help him continually be engaged with you. When playing with or working with him, stop in the middle and wait to let him lead you.

Identify specific places where activities occur. Then the child can request purposefully by going to that area, then taking parent there, then using an object symbol to talk about the activity.

Begin to build object-symbol vocabulary of tangle object-symbols that relate to child’s basic needs.

website for objects is objectsymbol.com

Parent-Training Program (2010)Ingersol and Dvortcsak

Follow your child’s lead

Imitate your child

Be animated

Model and expand language

Playful obstruction

Turn taking and modeling and expanding play

Communicative Temptations

the old days

change

kisses

the lie

I am special

Other References

Educating Children with Autism. (2001). National Research Council.

Management of Children with Autism Spectrum Disorders, Pediatrics. Oct., 2007.

Rogers, S. & Dawson, G. (2010) Early Start Denver Model for Young Children. Guilford Press: New York.

Websites

firstsigns.org (videos, diagnosis, treatment)

autismspeaks.org (parent advocates, research, 100 day kit, autism and medication; safe use kit)

www.helpautismnow.com/international.html