MAIN DIAGNOSTIC FEATURES OF AUTISTIC DISORDER Deficits in

MAIN DIAGNOSTIC FEATURES OF AUTISTIC DISORDER Deficits in

MAIN DIAGNOSTIC FEATURES OF AUTISTIC DISORDER Deficits in social attachments and behavior Deficits in verbal and nonverbal communication Presence of perseverative, stereotyped, repetitive, behaviors Social Interaction Differences Kids with autism smile! Social interaction may be desired but difficult Poor reciprocity in social interaction Relationship with care providers may be most strongly developed Peer relationships difficult

Autistic Types Unknown Aloof Passive Interactive but odd Dr. Lorna Wing Communication Differences Delayed/Different Communication Speech without communication vs. communication without speech

Echolalia Poor gesture use Instrumental hand leading Playlalia and lack of symbolic play Stereotyped Behavior Perseverative Interests or play Motor stereotopies in preschool and beyond Insistence on sameness/routine Need for prediction and control Preoccupation with parts of objects What is not addressed in the DSM-IV Sensory

Processing Temperament Motor Planning Imitation Anxiety and Avoidance Adaptive Skills Impact of intellectual functioning OTHER FEATURES OF AUTISM Incidence is cited at rate of between 1 in 2500 to 1 in 500 births. 4:1 boys to girls ratio Lifespan disorder No known etiology although known to be organic in nature. Commonly accompanied by mental retardation Heterogeneous disorder Treatment

Although current push towards identifying biological bases of the disorder, no treatment implications are on the horizon. The form of treatment with the greatest empirical validation is treatment based upon a behavioral model. Behavioral Model Treatment based on the systematic application of the principles of learning Consitently empirically demonstrated to be effective in improving the behavior of children with autism Developed via the methodology of applied behavior analysis Initial demonstrations were the first to show these children could learn in a systematic manner Components of Discrete Trial Training

Instruction > Response > Consequence Presenting Instructions and Questions: Child attending Easily discriminable Short and consistent Child responds or fails to respond Consequences: Types of consequences Manner of presenting consequences Results of Early Behavioral Intervention Initial demonstrations involved highly structured discrete trial format Proved to be very effective in establishing a wide range of behaviors in these children Provided basis for all behavioral treatments to follow Can lead to substantial improvement in many

children with autism Problem Areas Generalization Stimulus Response Lack of spontaneity Robotic responding Prompt dependency Slow progress Time consuming Difficult to implement Children and treatment provider may not like Naturalistic Strategies Developed in response to needed improvements Arose from a number of different laboratories Called incidental teaching, pivotal response training, milieu treatment, etc.

All share many of the same components Components of Pivotal Response Training Motivation Child Choice Reinforce Attempts Direct Reinforcement Intersperse Maintenance Tasks Frequent Task Variation Turn Taking Responsivity Tasks Involve Simultaneous Multiple Cues Results of Naturalistic Treatment Strategies Greater generalization More positive affect More positive home interactions More enjoyable for both children and

treatment provider Parental Affect Subject Means 5 Pivotal Response Training Individual Target Behavior Negative/Neutral Affect Positive Affect Overall Rating 4 3 2

1 0 A B C D E F G H

I J K L M Subject N O P

Q R S T U V W X Parent-Child Interaction Measures Pre Parent Training Post Parent Training

5 Positive 4 Interaction Scales Individual Target Behavior Pivotal Response Training 3 Neutral 2 1 Parent Training Conditions

Communication Style Stress Interest Happiness Stress Interest Happiness 0 Communication

Style Negative Developing Individualized Treatments Important child variables Important parent and family variables Important cultural variables Important treatment/behavior interactions Factors that Influence Treatment Efficacy Child Family Target Beh -Communication

-Stress level -Natural Reinf. -Motivation -Parenting Style -Social Skills -Play Skills -Support Level -Independent Skills -Nonverbal Ability -Depression

-Behavioral Excess -Behavioral Deficit Child Characteristics PRT DATA SET JODO CHLI ZATA NOFO JOCO ADMI ALKO

DAGL CANE DABO STWI CHDE ROBE YOTK PACH JOTO KYMA BESM

THBL AIAC KYBR JBBA SASI DYRE JECI KASU ROTO BOBA ELTU

ANCR JASA JOTA BEST RESPONDERS JODO CHLI ZATA NOFO JOCO ADMI ALKO

DAGL CANE DABO STWI CHDE ROBE YOTK PACH JOTO KYMA

KYBR JBBA BESM THBL AIAC SASI ROTO BOBA KASU ELTU

ANCR DYRE JECI JASA JOTA NON RESPONDERS JODO CHLI NOFO ZATA AIAC

ADMI ALKO DAGL CANE DABO STWI KYMA BESM JOCO YOTK

PACH JOTO JBBA KYBR KASU BOBA CHDE ROBE SASI ROTO THBL

ELTU ANCR DYRE JECI JASA JOTA Profile Behaviors Toy Play Approach Behavior Avoidance Behavior Verbal Self-Stimulatory Behavior Nonverbal Self-Stimulatory Behavior Best Responders Profile Toy Play

Approach Avoidant Beh. Verbal Stim. Nonverbal Stim 0 20 40 60 80 100 Mean Percent Interval Occurrence Non Responders Profile

Toy Play Approach Avoidant Beh. Verbal Stim. Nonverbal Stim 0 20 40 60 80 100 Mean Percent Interval Occurrence

Language Data - Responders Mean Percent Interval Occurrence 100 Approximations 90 Cued Echo 80 Cued Non-Echo 70 Spont. Speech

Verbal Stim. 60 50 40 30 20 10 0 Baseline 3 months 6 months Responders Toy Play Representationa

100 Mean Percent Interval Occurrence 80 60 l Symbolic 40 20 0 BL 3 months

6 months 100 Social Skills 80 60 Maintaining 40 Initiating 20 0 BL

3 months 6 months Mean Percent Interval Occurrence Language Data Non-Responders 100 90 80 70 60 50 40 30 20 10

0 Approximations Cued Echo Cued Non-Echo Spont. Speech Verbal Stim. Baseline 5 weeks Non-Responders 100 Toy Play Mean Percent Interval Occurrence

80 60 Representational 40 Symbolic 20 0 Baseline week 5 100 Social Skills

80 60 Maintaining 40 Initiating 20 0 Baseline week 5 What about other treatments? 6 children: 5 boys, 1 girl

Age range: 24-47 mo. 6 children matching original nonresponder profile except for one area: 3 matching profile EXCEPT had lower avoidance 3 matching profile EXCEPT had higher toy play Experimental Conditions Baseline Varying length of baseline Child had free access to a variety of toys Opportunities to respond once per minute No contingencies PRT 3 weeks Specific aims imitation of sounds/words; eye contact, appropriate play DTT

3 weeks Specific aims imitation of sounds/words; eye contact, imitation of actions (with objects); receptive commands High Toy Contact Children Discrete Trial Tasks Mastered 12 10 8 Joey 6 Lisa Kevin 4 2

0 1 6 11 16 21 Treatment Hour 26 31 36

Low Avoidance Children Discrete Trial Tasks Mastered 12 10 8 George 6 Chris Nathan 4 2 0 1 6

11 16 21 Treatment Hour 26 31 36 Conclusions Change of either of two elements of the original (Sherer & Schreibman, 2005) profile led to changes in PRT treatment

outcome. Children responded at a level in between the original responders and nonresponders PRT profile was not predictive of treatment outcome with DTT suggesting specificity of PRT profile Family Characteristics Parental Stress Parents experience significant stress in areas related to child with autism

Long-term care Limits on family opportunity Koegel, Schreibman, Loos, DirlichWilhelm, Dunlap, Robbins & Plienis (1992) Parental Stress Cont Different types of training have a differential effect on stress of parents Naturalistic strategies reduce stress more than highly structured techniques Parental stress is correlated with progress of child in family-oriented programs

Parents under high degree of parent domain stress (PSI) may not benefit from parent training. Parent Support Parents enrolled in parent training programs report that social support would be likely to reduce stress. Gallagher, Beckman & Cross, 1983 Moes, Koegel, Schreibman & Loos, 1993 Parent Support/Information Group Purpose:

Does participation in a parent group reduce stress in parents of children recently diagnosed with Autistic Spectrum Disorders? Do parents enrolled in a parent group learn the training techniques better than parents not enrolled in a parent group? Percent Technique Used Changes in Technique Use Parent Group 100 80 60

No Parent Group 40 Range 20 0 Pre Tx Post Tx Group Parent 21 19

17 15 13 11 9 7 Parent Group No Parent Group 5 3

100 90 80 70 60 50 40 30 20 10 0 1 Percent Correct Indivdual Skill Mastery: Post Treatment

Change Scores for Language Use Number of Words/Gestures 150 Understood Produced Gestures 100 50 0 Met Criteria Did Not Meet Criteria Individualizing Placement Type

Which children will benefit most from early inclusion programming? Peer Social Avoidance Attempts %of Avoidance Opportunities 50 40 HPAs LPAs TPs 30 20 10 0

Intake 6 months Language Use 30 %of Intervals 25 20 HPAs LPAs TPs 15 10 5

0 Intake 6 months Conclusions Autism is a complex disorder One treatment methodology, placement type or parent program will not be optimally effective for all children or families. Continued individualization of intervention necessary.

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