Autism Spectrum Disorders: Strategies for the School-Based SLP

transcript

Melanie W. Hudson, M.A., CCC-SLP

National Director

EBS Healthcare

Understanding Asperger’s Syndrome and the SLP’s Role in Assessment and Intervention

Defining Autism

• DSM- IV-TR, 2000• Behavior Disorder• Brain disorder with genetic basis• Social interaction• Verbal/non-verbal communication• Restricted range of interests and activities

Prevalence of Autism

• 1970s: 2-5 per 1000• 2000: 1/500 (DSM-IV-TR, 2000)• 2003: 34-60 per 1000 (Fombonne)• 2007: 1/150 births (CDC)• 2008: 1/91 (Kogan, Strickland, et.al)• 2009: 1/91 (Bloomberg, et.al)

(Prelock, 2010)

The Concept of Autism:

• Richard Grinker: Anthropological Explanation

• Leo Kanner: Differential Diagnosis with Schizophrenia

• Hans Asperger: Genetic and Biological Factors

• Lorna Wing: Spectrum Concept

1. Autism Disorder2. Asperger’s Disorder3. PDD - NOS

Autism Spectrum Disorder

Autism

4. Rett’s Disorder

5. Childhood Disintegrative Disorder

Asperger’s Disorder

• Qualitative impairment in social interaction in at least 2 of the following:– Marked impairment in the use of multiple nonverbal

behaviors such as eye contact, facial expression, body postures, and gestures to regulate social interaction;

– Failure to develop peer relationships appropriate to developmental level;

– Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people;

– Lack of social or emotional reciprocity

Asperger’s Disorder (cont’d)

• Restricted repetitive and stereotyped patterns of behavior, interests, and activities as manifested by at least 1 of the following:– Encompassing preoccupation with one or more

stereotyped and restricted patterns of interest that is abnormal either in intensity or focus;

– Apparently inflexible adherence to specific, nonfunctional routines or rituals;

– Stereotyped and repetitive motor mannerisms;– Persistent preoccupation with parts of objects

(Diehl, S., 2008)

Early Diagnosis is Critical

• Early identification of children who are “at risk” for ASD facilitates early intervention

• Early intervention is essential for better outcomes

(Diehl, 2008)

Autism impacts:

• Social Interaction• Communication• Behavior

SLP Role in Assessment and Intervention

• Prioritize goals for achieving social communication

• Honor and adapt to a family’s individual needs and cultural context

• Recognize evidence-based practice• Understand the communication demands of the

classroom

(ASHA, 2006c)

Assessment Tools:

• Structured parent interviews• Extensive observations of the child in a

variety of settings – with one preferably made in the home environment

• Observations by more than one evaluator, either separately or jointly conducted

• Observations made at different times

Assessment for ASD Child with Higher Skills

• More traditional tools do not get at underlying pragmatic challenges

• Narrative assessment allows for observation of breakdown in personal story-telling ability, use of internal responses and solutions to problems

• Also consider: Test of Language Competence, The Word Test, Test of Problem-Solving, and pragmatic subtests of CASL

• ADOS is “gold standard” for assessment; requires face-to-face training (videotaped training is available); based on DSM criteria

(Prelock, 2010, live chat on ASHA Web site)

Other Tools

• “The Pragmatic Protocol”, Prutting and Kirchner– Developed in 1982 to provide an overall

communication index for school-age children, adolescents and adults

– Consists of 30 pragmatic aspects of language – Considers role of each participant in structuring the

interaction and evaluate results accordingly

Pragmatic Protocol

• How Does it Work?– Observation of individuals engaged in

spontaneous, unstructured conversation with positive neutral partner

– 15 minutes of videotaped interaction– Each aspect is judged as appropriate,

inappropriate or not observed– Consider sociolinguistic background of the

individual being observed

Communication Acts

• Verbal Aspects:– Speech Acts– Topic Maintenance– Turn-taking– Lexical selection– Stylistic Variations

Communication Acts:

• Non-verbal Aspects:–Kenesics–Proxemics

Communication Acts

• Paralinguistic Aspects:–Intelligibility of speech–Prosodics

Conversational Effectiveness Profile-Revised(Kowalski, T., 2010)

• Documents relative strengths and weaknesses in social-pragmatic communication inherent in Asperger’s

• Comprised of 6 domains (social interaction, social communication, academic communication, perspective-taking, social-emotional)

• Diagnostician rates each area on 3-point scale (appropriate, somewhat appropriate, extremely inappropriate)

• May be used in a variety of settings

Understanding the Influence of Language and Cognition in ASD

Language Impairments in ASD

• Difficulty with pragmatic aspects of language may be present across the spectrum:– Conversational discourse– Understanding and telling stories– Nonverbal aspects of communication, including

prosody, facial expression, body language

Language Profiles and Cognitive Mechanisms: The Links

• Theory of Mind: Ability to interpret mental states in people and relate to their behavior, (put yourself in someone else’s shoes)

• Executive Functions: Skill set for planning, guiding problem-solving, and regulation of behavior

• Impairments in both found among range of children with ASD

(Tager-Flusberg, 2010)

Theory of Mind and Language

• Necessary to interpret others’ mental states to communicate effectively

• Joint attention skills at the root of Theory of Mind• Significantly impaired in ASD population

Findings Related to Theory of Mind

• After accounting for age, IQ, and general language level:– Theory of Mind was a significant predictor of

child’s ability to maintain discourse topic – Theory of Mind was significant predictor of

socialization scores on the Vineland– Theory of Mind was a significant predictor of

severity of autism symptoms

Findings Related to Executive Functions

• Related to language and other co-morbid symptoms (ex. ADHD)

• More significant impairments in children with ADHD symptoms

Clinical Implications: Assessment

• Language-Theory of Mind-Executive Functions: Mutually influencing cognitive functions, impaired to a different degree in each child

• Influences academic performance and peer relations

• Effective assessment will evaluate ALL aspects• Child can perform well on test but still have

everyday problems

EF and Social Adaptation Measures

• Standardized Assessment: NEPSY-2 (Korkman et al., 2007) for ages 3-16

• BRIEF: Parent report measure, 86 items, for ages 2-18

• Social Maturity Scale- Teacher rating, 7 items, correlates with Theory of Mind (Peterson et al., 2007)

Clinical Implications: Treatment

• Organizational Skills• Reading Comprehension• Asking and Responding to Questions• Following Directions• Conversational Skills• Peer Relationships

Service Delivery Models

Service Delivery Models:

A Continuum

SLP Role in Intervention

• Prioritize the goals for achieving social communication

• Honor and adapt to a family’s individual needs and cultural context

• Recognize evidence-based practice• Understand the communication demands

of the classroom

(ASHA, 2006c)

SLP Role in Intervention

• Partner with families• Collaborate with teams• Engage in professional development• Advance the knowledge base• Advocate to promote communication and

independence

(ASHA, 2006c)

Interventions with varying levels of evidence (National Standards Project, 2009)

Established

•Joint Attention Training•Modeling•Naturalistic Teaching•Pivotal Response•Peer Training

Emerging•AAC•Developmental-Relationship Based•Language Training•Sign•PECS

Unestablished

•Academic•Auditory Integration•Sensory Integration•Facilitated Communication•Gluten and casein-free diet

Continuum of Interventions: Social Pragmatic Developmental (Prelock, 2010)

Emphasize initiation and spontaneity

Follow child’s lead

Teach within the natural environment

Example: Floor Time

Contemporary Behavioral Approaches

• Give children choices• Share control of teaching opportunities• Use preferred activities and materials

(Prelock, 2010)

Service Delivery is Dynamic Process

• Change intervention models based on:– Individual progress– Changing communication demands– Response to treatment

(Prelock, 2010)

Planning Intervention

• Consider each of the following:– Functional, spontaneous communication– Social instruction in various settings throughout the day– New skill acquisition that then includes generalization and

maintenance (a skill remains a “trick” until it is performed across settings, people and materials)

– Play skills that include peer and peer interaction– Functional assessment and positive behavior support to address

problem behaviors– Functional academic skills

(Diehl, 2008)

Positive Behavior Support

• Teaching the child an appropriate way to communicate results in reducing challenging behavior and increases communication skills

• Created because of dissatisfaction with traditional methods for addressing severe behavior problems

• Directly targets the relationship between challenging behavior and communication

• Focuses on intervention in natural contexts• Shifts focus from restricting behavior with narrowly defined settings

and expectations • Increases quality and quantity of meaningful and positive

interchanges

(Diehl, 2008)

• Review of single-subject intervention in more than 100 studies demonstrated its effectiveness in reducing challenging behavior (Carr,1999)

• Average behavior reduction for single-subject studies for children with autism was 94.6% (Horner, 2000)

(Diehl, 2008)

Functional Assessment

Features

Intervention Plan Focus

Visual Strategies and Supports

• Things that are seen that enhance the communication process (ex. body language, calendars, maps, etc.)

• Compliment the learning style of the child with ASD

• Not transient such as oral or picture language• Much evidence to support

(Diehl, 2008)

Types of Visual Strategies and Supports

• Schedules• Calendars• Choice Boards• Environmental Organizers (labels on

shelves, bins, etc.)• Visual sorting tasks (ex. categorization)• Word Wall

(Diehl, 2008)

Word Wall

• Acts as a reference and scaffold for written work; reinforces theme vocabulary

• High-frequency words and most commonly misspelled words on permanent wall for child to see

• Theme or unit words should be available for more interactive activities (ex. key rings)

(Diehl, 2008)

Priming (Pre-Teaching)Diehl, 2008

• Previewing classroom assignments before being presented in class

• Parents or special educators can implement• Use on daily basis• Done as pull-out session the day before or at home

the night before• Familiarize student with material in relaxed, non-

threatening manner• High reinforcement for learning• Evidence-supported

(Wilde, L.D., Koegel, L.K., & Koegel, R.L., 1992)

Priming

Benefits of Priming

Decrease in problem behavior

May provide necessary

motivation to complete task

May heighten student

confidence

Enables enhanced performance on similar activities

Priming

Collaboration team determines who

will be participating

Establish timely and efficient communication method for exchanges

between not primed and when it is

Feedback forms designed, making sure assignments are clear, primed vs. unprimed,

documentation of communication between team

members

If child resists, begin with short

sessions and gradually build up

Begin with limited response

requirements on part of child and build up

Examples of Priming

• Semantic Webbing

• Reading checklist

• SQ3R

Reading Checklist (Diehl, 2008)

Assignment (Ex. Read pages 15-22)

Things to look for?

Where do snow leopards live?

What do they eat?

Word to find in dictionary

Habitat; mammal;

• Survey: Chapter Headings, bold-faced headings, pictures, captions; Guess what text is about

• Question: Read search questions or comprehension questions at end of chapter

• Read: Read to answer questions• Recite: Try to answer questions from memory• Review: Verify and support answers by

rereading

Social Stories (Carol Gray)

• To bridge or scaffold social understanding gap• Effective in enhancing perspective-taking• Allow parents and professionals to better

understand child’s perspective• May be used to address broad range of situations• Evidence-supported

Available from: http://www.thegraycenter.org/Social_Stories.html

Teaching Social Stories(Gray,C.)

• Introduce story in quiet place• Review daily before targeted situation• Keep data on student responses during story

and targeted situation• Revise or add to story as needed• Revise the review schedule as student shows it

can be faded. Decrease verbal support• Keep stories available to student

(Diehl, 2008)

Comic Strip Conversations

• A conversation between 2 or more people using simple drawings

• Use dry erase boards, chalk boards, paper• Depicts ideas such as everyone talking at once,

listening as part of a group, interrupting, LOUD or quiet words, who is saying what, who is listening, thoughts

• Beginning evidence-supported

(Diehl, 2008)

Comic Strip Conversations

Where are you?

Who else is here?

What are you doing?

What happened?

What did others do?

What did you say?

What did others say?

What did you think when you

said that?

What did others think when you

said that?

Video Modeling(Charlop-Christy, 2004)

• Watching a video of adults or children modeling particular target behaviors

• Helps focus child’s attention on relevant stimuli in video

• With practice and rehearsing, child begins to retain and display targeted language and behavior

• Fosters generalization of behaviors• Established evidence-supported

(Diehl, 2008)

Steps for Video Modeling

• Select and define the targeted behavior (ex. asking a question during class)

• Complete a task analysis to itemize the steps• Observe target script for typically-developing children• Present each step slowly with exaggerated acting• Provide at least 2 observations before assessing learning• Create short scripts allowing for reciprocal communication

exchange• Gather input from parents, teachers and child to guide

development of the video model(Courtesy, M. Mount, 2009)

Video Modeling

• Considerations (Charlop-Christy & Kelso, 1997):– Consider a motivating theme in the conversation or play

being modeled– Camera is strategically located to present facial expression

or show hands carrying out a particular task– Pause the video to highlight target expressions– Prompt child’s attention as needed by saying something like “watch the T. V.” or “Look”

– Immediately following the video viewing, ask the child to do what they watched

– Debrief the child reviewing what was seen and heard, identifying any new language heard as well as noting prosody and emotional expression of the “models”

Video Modeling Considerations:

– Talk about possible variations of events so the child has opportunities for flexible learning and thinking

– Encourage and reinforce attempts to demonstrate the modeled behavior

– Rewind to review important parts

Self Management Strategies(Koegel, R.L., Koegel, L.K., & Parks, D.R.,1995)

• Promote independence and responsibility for behavior

• Improve social interactions• External control does not result in lasting change

(Diehl, 2008)

Steps to Self-Management

• Discriminate between appropriate and inappropriate behavior

• Evaluate behavior (ex. happy/sad face)• Monitor behavior over time (checking in at

various times of the day, etc.)• Self-reinforce behavior when expected behavior

met (ex. earning points)

(Diehl, 2008)

Choice Chart

Peer Mediated Intervention

• Peers used in variety of roles:– Tutoring– Buddy system– Prompters– Reinforcers

– Established evidence

(Diehl, 2008)

Peer Mediated Interventions

• Proximity: Placing typical peers who are socially competent with children with ASD, directing them to play with their peers without specific training– Biggest outcome here is that

children will be actively engaged with someone and they will stop or limit the stereotyped behaviors you often see

• Prompting and Reinforcing: Combination strategy where socially competent peers are trained to prompt a child with disabilities to play and then to reinforce the child’s responses

• Antecedent Prompting: Child with ASD is paired with a socially competent peer who is instructed to remain in proximity to the child with ASD; teacher provides periodic prompts to the child with ASD to engage in social interaction

(Simpson et al., 1997)

Four Steps to Support Peer Mediated Intervention:

1. Introduce the skill to a typical peer, describing and providing a rationale (describe the skill)

2. Demonstrate the skill for the typical peer (demonstration)

3. Rehearse skill with the interventionist

4. Typical peer practices/rehearses the skill with another child, then works with the child with ASD after interventionist is certain he is ready

Relationship Development Intervention

• Goal is to provide comprehensive program for developing relationship skills

• Based on developmental model that begins with basic relationship exercises

• Uses 10 skill areas that encompass the qualities of children who are successful in developing and maintaining friendships

• Uses 6 stages from novice to Partner• Developed by Steven Gutstein and later collaboration

with Rachelle Sheely• Evidence-supported

(Diehl, 2008)

Inclusion Strategies for ASD (Diehl, 2008)

• Classroom Organization– Use consistent routines– Delineate spaces (labeling)– Use abundance of visual supports– Prepare for transitions– Specify endings and new starts to activities

Inclusion Strategies (cont’d.)

• Before Teaching Supports– Establish signal words to get attention– Give assignments in written form– Use priming strategies– Pair strong interests as motivators (ex. put

dinosaur sticker on top of worksheet)

Inclusion strategies (cont’d.)

• During Teaching Supports– Use signal words for stressing important

information– Keep essential questions and concepts in the

forefront– Avoid lengthy verbal instructions– Use visual supports (daily schedules, choice

boards, etc.) – Provide models (work first math problem

together)

Watch for attention, stress, fatigue and provide alternate pleasurable assignments during that time

• Facilitating Independent Work– Provide visual instructions– Provide specific roles for collaborative work– Assign peer buddies– Avoid burning out one student– Use timer, or something to delineate time/amount

– Allow keyboard for writing assignments

• Student Organizers– Use daily planners and teach independent use– Laminate daily schedule to use with soluble markers– Color-code folders for each subject– Label sections in folder for homework, completed work, etc.– Keep “obsessive” stuff in one place with written instructions on

when to use it– “Post-its” help with things that pop up during the day– Keep 2 sets of texts, one each for home and school– Keep written rules consistent– Use technology whenever possible

Collaboration and ASD

“I believe that you don’t make major input with children with complex disabilities unless it is collaborative”

(Sylvia Diehl, 2010)

Learning Spanish (Diehl, 2010)

Attending class 1 hour per week for 6 weeks

Speaking Spanish with classmate who is also learning Spanish

Living in Spain and using language daily in variety of contexts

Contextualized Learning

Language needs to be infused throughout a child’s day in order for learning to occur.

Why Collaborate?

“ASHA recognizes that the provision of speech, language, and hearing services in educational settings is moving toward service-delivery models that integrate intervention with general education programming, often termed inclusion.”

(American Speech-Language-Hearing Association [ASHA], 1996)

Why Collaborate?

Federal Law tells us that we should focus on the services we provide rather than “a place” where the students go.

(IDEA, 2004 [118 Stat. 2649])

Why Collaborate?

Effective schools research indicates that collaboration within the school staff increases student achievement.

(Thompson, 2002)

Principles of Learning are Supported in a Collaborative Model

• Learning that is meaningful to the learner is acquired more readily and is retained longer

• Learning is influenced by the frequency with which the stimuli are encountered and the same or similar response is made

• In general, practice in varied contexts can both increase retention of learning and extend its range of utility

• Transfer is facilitated where the learning situation resembles the application situation, or where the learning is practiced in various “realistic” contexts

• Observing the actions of another person can lead to the acquisition of new learning or the facilitation or inhibition of prior learning

• Group discussion and decision can facilitate change

(Ehren and Ehren, 2004)

The Classroom is a Natural Setting

Services delivered in a classroom provide:• More opportunities to communicate• More variety of communication opportunities• More variety of communication partners• More resemblance to real life• Less disruption in a student’s day that is disruptive to

learning• Models for teachers • Seamless transfer (carryover) of skills

(adapted from Ehren and Ehren, 2004)

Advantages of Classroom-Based Intervention

• No time wasted in transition (some behavior problems are related to transition)

• Child stays in LRE• Teachers have more frequent opportunities for planned

teaching• Classroom offers many opportunities to interact with and learn

from peers

(Hadley & Schuele, 1998; Garfinkle & Schwartz, 2002; Brinton & Frijiki, 2004; Case-Smith & Holland, 2009)

Collaboration is not a Replacement for Isolated Intervention

• It is designed to assess and treat communication impairments within natural settings

• It can supplement or extend services offered in a traditional pull-out model

(ASHA Relevant Paper, 1990)

Why Use Pull-Out Model?

• Allows intensive 1:1 treatment• Useful for some intervention approaches• May be best environment to establish new behaviors

(ex. discrete trial training)• Should be purposeful, planned and short-term

(Case-Smith & Holland, 2009; Moore & Montgomery, 2008)

Myths About Service Delivery

• Individual therapy is always the best option• Communication problems should only be addressed

by the “expert”• SLPs need to protect their territory• People who advocate a collaborative model are

trying to get out of work

(Haynes, Moran & Pindzola, 2006)

Barriers to Collaboration

• Graduate students are taught medical model• New SLPs are inexperienced in collaboration• Parents expect medical/clinical model• Teachers/Administrators expect pull-out model• Team planning is time-consuming• Turf Conflicts• Teachers don’t want to/know how to collect data

To facilitate collaboration among the educators of preschool and school-age children in developing functional social communication skills within the classroom context

(Frassinelli, Superior, & Meyers, 1983)

SLPs in the Classroom

Always look at academic and social issues from a language perspective; trust teachers to know curriculum and standards; SLPs role is to facilitate interactions and learning.

Administrative Support

Administrators must be willing to:• Provide meeting time for collaboration by all team

members• Maintain sufficient number of support staff• Understand that collaboration is efficient use of

educational resources but not a method to reduce amount or expense of special services

• Understand that SLP caseloads may need to be reduced

(ASHA Relevant Paper, 1990)

Breaking Down Barriers

• Work with university programs to teach collaboration strategies; teach a “workload “ approach* to service delivery

• Learn about collaboration and try it gradually

• Explain benefits of collaboration to parents; have parents tell other parents their child’s success stories

• Explain to teachers that collaboration meets the student’s needs; we are there to meet their needs and not our own

Planning

“A meeting to infuse goals is more important than an individual session”

Sylvia Diehl

Team-Teaching/Co-Teaching

• Requires a significant amount of respect and trust between teachers

• Avoid the same teacher always taking the lead instructional role

• Take turns “leading” the lessons and instructional units• Requires long-range planning• Requires commitment of classroom teacher to always be

present

(adapted from Green, 2008)

Benefits of Thematic Units

• Increase in student achievement• Helps student to connect learning both within the

topic and across other subjects (generalization)• Enables student to understand big concepts of

curriculum and apply them in many ways• Promotes depth of learning

(Thompson, 2002; Marzano, 2001)

Interventions with Case Studies

• Social interaction• Communication• Behavior

• 8 years old• Talks constantly about video games• Academically on grade level• Other children play with him in short spurts

until they tire of his bossy behavior• Needs personal assistant to move from

one activity to another• Disruptive when routine changes

Hunter

• 17-years old• In regular HS academic program with

SpEd support• Other students tolerate but do not seek

him out• Pleasant appearance and no behavior

issues except during fire drill

“The absence of evidence is not evidence of absence” (Paula Kluth, 2010)

References

• American Speech-Language-Hearing Association. (2006c). Roles and responsibilities of speech-language pathologists in diagnosis, assessment, and treatment of autism spectrum disorders across the life span: Position statement. Available from http://www.asha.org/policy.

• American Speech-Language-Hearing Association. (2006b). Knowledge and skills needed by speech-language pathologists for diagnosis, assessment, and treatment for autism spectrum disorders across the life span. Available from http://www.asha.org/policy.

• American Speech-Language-Hearing Association. (2006a). Guidelines for speech-language pathologists in diagnosis, assessment, and treatment of autism spectrum disorders across the life span. Available from http://www.asha.org/policy.

• American Speech-Language-Hearing Association. (1990). A Model for Collaborative Service delivery for Students With Language-Learning Disorders in the Public Schools [Relevant Paper]. Available from www.asha.org/docs/html/RP1991-00123.html

References

• American Speech-Language-Hearing Association. (1996). Inclusive practices for children and youths with communication disorders [Position Statement]. Retrieved March 1, 2010 from http://www.asha.org/docs/html/PS1996-00223.html

• Bondy, A., & Frost, L. (1998). Picture Exchange Communication System. Topics in Language Disorders, 19, 373–390.

• Diehl, S. (2008). Working with children with autism: Resource manual. ASHA Autism online web event, March 2010.

• Ehren, T. & Ehren, B. (2004). Therapy Services in the Classroom: Creating Students Success. ASHA Telephone Seminar, September 14, 2004.

• Green, Charlette. (2008). SLPs Collaborating in General Education: Practicing Seamless Education. Presentation to North Carolina Public Schools.

• Individuals with Disabilities Education Act. (2004). Public Law 108-446. Retrieved March 1, 2010, from http://www.copyright.gov/legislation/pll08-446.pdf

• Kowalski, T. (2010) Social-pragmatic success for asperger syndrome and other related disorders. Orlando, FL: Professional Communication Services.

• Marzano, R.J., Pickering, D.J., & Pollock, J.E. (2001). Classroom instruction that works. Alexandria, VA: Association for Supervision and Curriculum Development.

References

• Montgomery, J. (1990). Effective Collaboration and Consultation Services for Speech and Language Hearing Handicapped Children. Short Course at California Speech Language Hearing Association Annual Conference, Monterey, CA.

• Moore-Brown, B. (1989). The Speech/Language Specialist-Critical Support for Teaching Literacy. Presentation at the California State Federation/Council for Exceptional Children Annual Conference, Costa Mesa, CA.

• Paul, R. (2010). Communication Intervention Programs. ASHA Autism Online Web event.• Prelock, P. (2010). Assessment and Intervention in Autism Spectrum Disorders: The role

of the SLP. ASHA Autism online web event• Sancibrian, C. (2010). Navigating the service delivery continuum. ASHA Autism Online

web event.• Tager-Flusberg, H. (2010). Language and Cognition in Autism Spectrum Disorders. ASHA

Autism Online web event.• Thompson, M., & Thomason, J. (2002). Leadership, achievement, and accountability.

Boone, NC: Learning Concepts.• Wiig, E.. (1992) Language intevention with school-age children: Models and procedures

that work. Chicago, IL: Riverside Publishing Co.