Autistic Spectrum Disorders: Linking Assessment & Educational Planning California Association of School Psychologists Los Angeles, CA March 10, 2007 Bryna Siegel, Ph.D. Adj. Professor & Director, Autism Clinic University of Calif., San Francisco San Francisco, Calif Defining the Issues What Does Autistic Spectrum Imply? Seeing the Spectrum as a Collection of Autism-Specific Learning Weaknesses and Relative Strengths What is a Developmental-Behavioral Approach? Teaching/ Treating Developmentally AndTeaching/Treating Behaviorally AndGetting the Child to Want to Learn Autistic Spectrum Disorders are a SyndromeLike a Cold Its Multi-Factorial (Its Poly-Genetic) If Everybodys Autism is Different Everybodys Treatment Needs to be Different Syndromes: Autism and the Common Cold The Common Cold Runny Nose Stuffed Sinuses Hacking Cough Sneezing Sore Throat Feverish Headache The Autistic Spectrum Social Isolation Low Interest in Peers Echolalic Speech Non-conversational Perseveration Poor Toy Play Odd Motor Movements What Does This Mean For Epidemiology? (W hen is a sneeze a cold?) The Latest from the CDC :1,000= 1:160 # 1: Language concerns, #2: Social Earlier Studies 1:101 to 1:222 (2000) 1:303 to 1:94 (2002 ) 51%-88% w/ signs < 3 years old 4-5 years old Lets Just Treat Whats Wrong Importance (or Not) of Diagnosis Identifying Learning Processes Identification of What Needs to be Learned Figuring Out How to Teach so the Child becomes an Independent Learner Whats Inside the World of the Autistic Spectrum Child? Imagine the world of a blind child by closing your eyes. Imagine the world of a deaf child by putting hands tightly over your ears. How do you imagine autism? The Child with ASD Perceives Differently Sensory Threshold & Modulation Problems:Audition: Covers Ears Appears Deaf Tactile: Clothes Sensitivities Diminished Pain ResponseVisual: Gaze Avoidance Visual ScrutinyOlfactory: Pica Gags at Smells The Child with ASD Processes Differently Sensory threshold differences lead to misrepresentation of inputs Processing speed delays lead to loss of information What you get = what you can think (perceive plus process) Swiss cheese understanding The Child with ASD Stores Differently Constructive memory borrows from more fully represented data sources Retention is probably better where comprehension is better The Challenges: How do alterations in the way a child with autism perceives, processes, stores, and retrieves information create an altered world view? How can these alterations be regarded as a cluster of autistic learning disabilities (ALDs) so specific symptoms point to specific treatments? How Do We Start to Recognize ASDs? Early Screening with the PDDST-II Specific Qualities of an Early Childhood Screener Screening vs Diagnosis Diagnostic Best Practices PDDST-II PDDST-II Pervasive Developmental Disorders Screening Test-II (Siegel, 2004, Psych Corp/ Harcourt) Three Stages of Screening Primary Care Screener (PDDST-II/PCS) Developmental Clinic Screener (PDDST-II/ DCS) Autism Clinic Severity Screener (PDDST-II/ACSS) Who Can Use the PDDST-II? Stage I- PCS: Primary care providers such as pediatricians and family practitioner What Question Does It Answer? Should this child be referred from my primary care practice to a developmental specialist? Should I mention concerns about autism? Who Can Use the PDDST-II? Stage II-DCS: Any clinician or teacher involved in special education or DDS intake/ any trans-disciplinary team member/ SLPs/ OTs What Question Does It Answer? We know this child has some sort of developmental problem. Should we include autism-specific measures in our work-up? Who Can Use the PDDST-II? Stage III-ACSS: Specialty clinic where information is sought regarding likely longer-term severity What Question Does It Answer? The parents have been told the child has an ASD. They want to know how bad it is going to be. Can I give a data-based guess-timate? Administering the PDDST-II The PDDST-II detects concerns around 15 m. of age Each question is: Yes, Usually True or No, Usually Not True. If score cut score: Use Glossary, as needed to validate responses. If validated, refer for further assessment. Scoring the PDDST-II Allow parent to self-administer (5-10 minutes). Teacher can independent fill in own version. Teacher may also want to administer Supplemental Items (Pgs ) from Manual for further description. Score items by reviewing Glossary (if needed) and tallying total/ Refer a positive case for further assessment. Components of the PDDST-II Kit Separate scoring forms for Stage I, Stage II, Stage III PDDST-II Manual: Explains psychometrics Supplemental Items add to description (& Se, but Spif added to screening algorithms, would Sp) Provides Glossary with Qualities, Thresholds, and Probes for each item at each stage. Supplemental Items for more full clinical description How the PDDST-II Glossary Works: Qualities: What does this behavior look like compared to what is expected Threshold: Is this behavior so marked as to be qualitatively or quantitatively abnormal? Probe: Specific questions the clinician can ask to elicited targeted information about item. The PDDST-II: Comparison to Other Screeners CHAT: Norms: Identifies autismand other severe DD; needs interview follow-up. CARS: Norms: Children > 5, most screening < 5; score w/ MR and NV. GARS: Norms: Self-diagnosed sample, low specificity, over-includes other DD. Working to Develop Evidence- Based Practice How Do You Judge A Treatments Efficacy? Tiers of Evidence Making Treatment Decisions: The Difficult Issues Determining the Validity of Treatment Approaches from the Studies Backing It Weighing Qualitatively Different Kinds of Evidence Weighing Evidence from Different Theoretical Perspectives Making Autism Treatment Decisions: Tiers of Evidence BEST: EMPIRICAL STUDIES OF GROUPS Matched groups Representative samples Sufficient sample sizes Pre- and post-testing Longitudinal outcome data Assessment of responder characteristics Making Autism Treatment Decisions: Tiers of Evidence NEXT BEST: THEORY on the Brain, Behavior, Social Policy Child Development Theory and Research On Typical Development On Learning Disabilities & Mental Retardation Behavioral Theory and Research Social Policy Guided Treatment Decisions Making Autism Treatment Decisions: Tiers of Evidence NEXT BEST: CLINICAL EXPERIENCE Autism-Specific Expertise Experience with More than One Method Developmental Disability Expertise Special Education Expertise Child Development Expertise Issues in Recognizing Quality National Research Council: Effective Interventions for Autism: I Program Design Intensity: # Hours/ Week? # Interactions? # Correct Responses? An Early Start (ideally before 30 months) Direct Instruction/ Highly Structured Teacher-Therapist Training/ Supervision Parent Training/ Involvement National Research Council: Effective Interventions for Autism: II Curriculum Content Developmental Appropriateness Opportunities for Functional Use Language Emphasis Smell Tests: Treatment Validity, Fidelity & Consistency Face Validity: Does this treatment make sense? Fidelity: True to the model that had good results? Consistency of Implementation: Is this treatment what it once was? The Big Dilemma in Designing Autism Treatment If no two children have the same exact needs, how can they benefit from the exact same treatment? If each child gets a different treatment how do we learn whats best? Understanding Responder Characteristics What is A Responder Characteristic? Specific Autistic Learning Disabilities Developmental Level Language Level Maladaptive Behaviors Upon What Do We Base Practice? We need to treat, even if we dont have all the empirical studies. We need to have Best Practice guidelines based on evidence, theory, and experience. We need to know if what we do helps as much as we hope it does. The ALD/ALS Approach: A New Heuristic ALD ALD = Autistic Learning Disabilities ALS ALS = Autistic Learning Styles The Concepts of ASDs and ALSs can be used to classify autistic alterations in Perception, Cognition, Information- Processing, Motivation and Expression Mapping DSM Criteria for Autism onto Autistic Learning Disability Profile Qualitative Impairments in Social Interaction Qualitative Impairments in Communication Restricted, Repetitive & Stereotyped Patterns of Behavior, Interests, or Activities Social Autistic Learning Disabilities Communicative Autistic Learning Disabilities Non-Social Autistic Learning Disabilities How Social Deficits Affect Learning Lack of socio-emotional reciprocity= Lack of desire to please others Low response to social reinforcers Lacks concern re: effect on others Lack of awareness of others= Motive to please self is foremost Instrumental learning style Lack of social imitation= Low incidental learning via copying others No drive to follow group norms How Non-Verbal Communication Deficits Affect Learning Low comprehension of facial cues such as: Smiles of Encouragement Gaze toward topic of conversation Ignores gestures that should be the first language such as: Warnings or Displeasure Tone of voice to mark meaning How Verbal Communication Deficits Affect Learning Receptive language Signal:noise problem for verbal signal -H: Noisy social-linguistic field -H: Limitations to pure memory buffer Language processing with poor parsing Expressive language Without theory of mind, no drive to share ideas Oral-motor apraxia synergistic w/ low expressive drive How Play and Exploration Deficits Affect Learning Lack of imagination in play= No consolidation of experience via play linking action and language No symbolic actions to link to language to abstract thinking Stereotyped and repetitive interests= Averse to novelty/ low curiosity Limited learning through exploration Repetitive interests = mental down time What Is the Developmental- Behavioral Approach? APPLYING THE ALD/ ALS MODEL Determine ALD/ALS Profile (ALD-I) Establish curriculum content based on developmental level/ what comes next. Uses behavioral methodology to teach developmentally-based curriculum. Enhancing motivation by differentially rewarding self-initiative in learning Step I: Develop An ALD-Specific Treatment Plan 1) Whats the child missing (ALDs)? 2)What compensatory strategies (ALSs) can provide needed inputs and information? 3)How do you match ALDs and ALSs to available treatments? The Autism Learning Disabilities Inventory (ALD-I, Siegel, 2003) MECHANICS Questionnaire 3 Point Frequency Scale Parent or Teacher Completed 7 Scales Social Scales Awareness Reciprocity Imitation Communication Scales Receptive Para-linguistics Expressive Paralinguistics Receptive Oral Language Spoken Oral Language World of Objects Sensory Processing Repetitions/ Novelty Response Play ALD-I Social ALDS Awareness and Social Motive Acts as if in own little world. Foremost motivation is usually to please self. More readily learns things that result in meeting own needs. Fails to notice certain things that others this age usually notice. ALD-I Social ALDS Imitation and Affiliative Drive Apparent lack of concern about the effect of his behavior on others. Uninterested in trying to do new things just to earn approval of others. Does not seem to be motivated to copy actions or attitudes of others. Does not readily learn by being shown by others; must figure it out on own. Low level of interest in peers ALD-I Communication ALDs Receptive Gesture & Body Language Doesnt look to where something is pointed out. Doesnt look back after seeing something to see if youve seen it, too. Stops an action when receiving a stern look. + Knows that a nod of the head yes means that what s/hes doing is OK. + ALD-I Communication ALDs Expressive Gesture & Body Language Doesnt points with index finger at things he wants. or that are interesting, but not wanted. Doesnt smiles when someone smiles at him. Doesnt looks happy if others act happy. Cant clearly read guilt on childs face. Cant tell when child feels proud of actions. ALD-I Communication ALDs Use of Spoken Language Echoes some of your speech to show you hes with the conversation. Uses echolalic (exact, repeated speech) to re-enact play from videos. Uses odd, not-quite-right, but understandable phrasing in speech. ALD-I ALDs- World of Objects Sensory Processing Seems not to hear (not just ignores) some sounds/ speech. Seem over-sensitive to some sounds, as too loud. Very positive response to movement Very negative about tactile irritations Puts non-food items in mouth, as if to learn Picky about textures in mouth (& what is chewed or swallowed. ALD-I ALDs- World of Objects Repetitions/ Novelty Prefers old familiar toys to new toys. Initially fearful of something he now loves, e.g., vacuum, carousel. Once something is done one way, its always done the same way. Has odd little ritualslike only drinking from one cup, for no reason. Very focused in play with one thing, showing good concentration. Step II: Include a Developmental Perspective 1)Evolution has worked out the most efficient sequence for skill acquisition. 2) Research in developmental psychology maps that sequence. 3) Children learn at different rates and in different ways, but the sequence of skills- building needs to be developmentally- ordered to provide a solid foundation. Separating Curriculum From Method A Brief History of ABA/DTT: How many autistic children learned stand-up/ sit down before mama and dada. The concept of teaching horizontally, not vertically: 10 barnyard animals versus 10 faces of mommy Lets not throw the baby out with the bath water: Keeping the ABA principles; pairing them with a developmental curriculum. EnterA Curriculum that is Developmental and Behavioral Based on where the child is developmentally (e.g. 18 month receptive language)teach the next set of skills. Calibrate growth trajectory based on learning history; re-calibrate annually. Do teach using validated behavioral principles. Dont teach from a cookbook dog-training manual. Step III: Make the Curriculum Motivating Ask: What Does He Want to Learn? NOT What Do I Want to Teach? Strategies for Enhancing Motivation Develop Response to Social Praise (to expand possible LREs) Develop An Interest in Affiliation/ Modeling Develop An Interest in Learning Materials/ Objectives (Thin Edge of Wedge) Using Predictability via Routines & Schedule Make Comprehensible through Visuals Reward Strategies: Develop a Reward Hierarchy Primary Reinforcement (e.g., in DTT) Establishes learning contract Can schedule rewards according to task difficulty, novelty and childs persistence Intrinsic Reinforcement (e.g., in PRT) Materials as reward Context as reward Successful problem-solving leads to internalized drive Modifying Time Outs for ASDs Functions of Time-Out: Use of an accompanied time out Isolation as cool down not as deterrent Criteria for when and how long to time out Calming down is a behavior to be shaped Modifying Negative Reinforcement and Over-Correction for ASDs Negative Reinforcement: Why should Ignoring work if you dont mind being ignored? Over-Correction: Changing the intrinsic reward valence by controlling access through over-exposure (Examples: Light-switches, doors) An ALD/ALS Specific Approach to Motivation Two Tiered Reinforcement First Tier: Part reward for Necessary, but not sufficient behavior Second Tier: Full reward for attaining goal ( Examples: Potty-training, seat belts) Social ALDs: Working to Increase Interaction and Social Understanding Prerequisite, Developmental Considerations in Peer Play Receptiveness (to Play): Peers and their activities must present a replicable model Play content must hold intrinsic interest Expressive (Engagement in Play): Childs play is supported by language level/ internal capacity to represent Teach play the way others the same age do it Strategies for Peer Integration Preschoolers: Play pre-teaching (1:1) with adult Play pre-teaching w/ 1 peer Putting the included child at the center Pre-verbal parallel play (group) School Aged: Reverse mainstreaming (1:1) Integrated peer play groups (group) PALS threesomes Strategies for Facilitating Interaction Para-Professional Aides Shadow Aides: Being Jiminy Cricket Fading: One-to-two Aides obscured Aide Behavioral vs Social Skills vs Academic Aides Peers as Facilitators (More naturalistic play) Teen Tutors Junior Babysitters/ Bossy 9-year-old girls Ideal Play Partners: Altruistic, initiators, good theory of mind Communicative ALDs: Working on Initial Communication What Is VIA (Visual Interaction Augmentation)? VIA is a visually augmentative communication program like PECS VIA is based on teaching communication in context VIA is based on teaching language development in a step-by-step sequence laid out by principles of psycho-linguistics VIA: Rationale Emphasizes teaching integrated para- linguistics as foundational to linguistics Developmentally focused on increasing spontaneity over MLU or speech clarity Focused on increasing inter-subjectivity by sharing of desired object of communication Underpinnings of VIA: Developmental Psycholinguistics Para-linguistics Concepts Implications for Design of VIA Pragmatics: Communication regulation via topic selection, topic initiation, and topic maintenance. VIA Teach reciprocity in communication non- verbally before/ alongside oral communication/ semantics as in typical neurodevelopment. Para-linguistics Concepts Implications for Design of VIA Non-Verbal Communication: "Body language", micro-expressions, physical proximity and contact to modify communication. VIA Pair with visually augmented communication to classically condition meaning. Para-linguistics Concepts Implications for Design of VIA Motherese: Style of talking characterized by accentuated inflection, repetitions, and simplification. May include: recasts (repetition of key semantics to along with "new" info.) VIA Pair with visual augmentation (gesturally and orally) to make communicative signal enhanced and multi-sensory as in typical neurodevelopment. Concepts Related to Intent-I Implications for Design of VIA Proto-imperative Communication: Use of a gesture to issue a command or request. Proto-declarative Communication: Use of gesture to call attention to an event. VIA Teach imperative before declarative intent. Teach prerequiste paralinguistics alongside. Concepts Related to Intent-II Implications for Design of VIA Turnabouts : Elements requesting a response VIA Teach by creating set-ups. Turn-taking: Contingent, alternating vocalizations VIA Play around mastered communicative intents Concepts Related to Acquisition Implications for Design of VIA Semantic Bootstrapping Hypothesis: Idea that children learn syntax from semantics. VIA No SD speak such as Good touching nose! Using inflection to mark novel, semantic and syntax of utterance such as Good! You touched your NOSE! OR Good! YOU touched YOUR nose! Concepts Related to Acquisition Implications for Design of VIA Fast-mapping: Deriving the meaning of words from context; 'mutual exclusivity bias (e.g. new words go with novel objects. VIA Use specific and multiple icons with same nominal class to form semantic prototype as in typical neurodevelopment (e.g., red dog, big dog, fuzzy dog, Clifford the Dog). Concepts Related to Acquisition Implications for Design of VIA Pivot grammar: Early language characterized by repetitive formulation, e.g. "no___", "more___", "all gone____". VIA Teach language developmentally, i.e. MLU=1 MLU=2 MLU=3 MLU=4 etc. Not Juice (icon) I want (juice icon) please. Mechanics of Setting Up A VIA Program VIA Procedures Photographic (or 3-D) icons only Photos of exactly what the child has in mind Icons with words labels to promote auditory recognition Icons located when and where the child has the object or action in mind Orally: Speak motherese Gesturally: Motherese para-linguistics Developing Icons Simple photos of specific examples of high value items to show child you see what he has in mind Consider 3-D icons (e.g., goldfish crackers glued shut in a clear box) if non-verbal MA < about 9 months. Shape Non-Verbal Communication Step 1: Follow speakers point to icon Step 2: Gaze shift from icon to speakers eyes Step 3: Attend (briefly) to speakers facial affect Selecting Things to Request Develop hierarchy of reinforcers Introduce photos of high reinforcement icons first Set up pivotal requests (i.e., to get something wanted) Put away high value objects to create communicative press Train with single photo and brief exposure to requested item VIA: Prompting Requests Full prompting fully faded prompt to help child hand over icon to listener. Listener adds gaze directs between child & icon held close beside listeners face Add gesture (e.g., shoulder shrug=What?)/ point to icon Add exaggerated facial expression to mark Q/ Yes/ No Motherese inflection and pitch VIA: Choice-Making High contrast choices (Speak N Say v broccoli) After simple choice-making established, sequence icons (e.g., bring open door icon, plus ball icon from toy chest) Model/ link pivotal grammar & natural grammar vs VIA: Icons in Context Icons located in natural environment where child sees them in his minds eye (e.g., sippy cup on fridge) Icons create an opportunity to communicate After mastery in natural environment, consider portable belt loop/ key ring of small icons-to-go Communicative ALDs: Working on Spoken Language ALSs: How the Child with ASDs Can Compensate for Verbal Deficits Promote sight-reading first Pairing pictures with spoken words Slow speech to auditory processing time Pairing pictures with written words, turn on close-captioning Using motherese (voice & gesture) Talking about things the child visualizes Teaching Verbal Communication: Playing to Autistic Learning Styles The Language-Learning Brain Listens to: High Inflection/ Developmental Use of Natural Grammar (What the Research Says) Visual Augmentation: Picture Schedules/ Visual Schedules/ Activity Schedules Make it Easy to Succeed with Words Require only as much as needed for meaning Verbal Children: Strategies for Auditory Processing Difficulties Increasing Semantic Salience: Slowing Down Pairing Visual and Auditory Computer Assisted Instruction Address Signal:Noise Problems (Earobics, Fast Forward, Laureate Learning Seeing Language, TeachTown) Working with Echolalia Recognize as functional, Simplify MLU, Prompt w/o interfering with pragmatics Verbal Children: Strategies for Increasing Spontaneity Moving from Instrumental to Expressive Conversation while window of interest is open Creating Opportunities to Increase Press Pivotal Response Training Moving from Elicited to Spontaneous Scripted dramatic play, taking videos off-road Letting the Child Lead Working to Increase Meaningful Play and Exploration ALSs: How the Child with ASDs Can Compensate for Deficits in Exploration Play Modeling at Developmental Level Build In Repetition As Reinforcer, E.g., Lego. Child-led Play to Build in Intrinsic Reinforcement Choice-Making to Re-direct Away from Perseverative Playing Scripted Play to Provoke Playlalia Start With Narrow Interests As The Thin Edge Of The Wedge Expanding Social Play Video-modeling to develop: New play schema Pre-teaching for group instruction Child-centric play to develop: Self-efficacy through lead-following Expanded exploration Inclusion to develop: Spontaneity, motivation, expanded repertoire Expanding Play with Toys (Sensory and Concrete Levels) Titrating/ varying / expanding use w/ materials used perseveratively/ narrowly Pair functional use with classification Single themes playlalia (Adult and child with same toy)model parallel play Expanding Play with Toys (Representational & Symbolic Levels) Use of theme toy sets: FP, Playmobiles and elaborate beyond logical themes Going Off-Road with familiar scripts Promoting Play Private Speech Introducing symbolic play with as if play materials (symbolic referents) Summary: ALDs in the Context of Specific Treatment Strategies Area of Autistic Learning Disability: SOCIAL INTERACTION Habilitative Approaches Low Response to Social Reward Paired association w/ primary rewards Comprehension: routines & visual supports Associate lower value w/ higher value topics Reward instrumental behavior w/ social rewards Motivate via choice Infrequent Social Reference or Joint Attention Motherese para-linguistics Model attention-directing in instrumental contexts Model voice & face affect in instrumental contexts Low Drive for Peer Affiliation Peers must present a replicable model Activities with must hold intrinsic interest Pre-teaching: with adult with peer Reverse mainstreaming Scaffolding peers: increase salience & success Titrate scaffolders from more to less Limited Modeling or Imitation Shaping/ pairing with primary reward Start w/ modeling of salient activities Model within developmental reach Area of Autistic Learning Disability: COMMUNICATION Habilitative Approaches Poor Comprehension/ Limited Para-Linguistics Training paralinguistics through PRT Motherese gestural communication Motherese facial affect Slow Auditory Processing Speed, Poor Parsing Highly inflected speech Slowed, enunciated speech Repeat key words w/ visual support Preserve grammar (promote boot-strapping) Preference for Visual over Auditory Modalities Photo or 3-D icons, not M-J/PECS Picture schedules & visual schedules Play to procedural memory Sight-reading over phonics?/ Closed-captions? Theory of Mind/ Perspective-Taking VIA: show the child what he has in mind Create communicative press in context Use developmental guidelines to demo comprehension when understood Area of Autistic Learning Disability: ORGANIZING INFORMATION Habilitative Approaches Lack of Representation Capacity (Imagination) Teach play schemes at developmental level Video playlalia to initiate representation off- road w/ novel scripts, familiar characters Lead to higher level from childs initiative Model/ support play language Preference for Repetition over Novelty Over-correction for perseveration Choice: New use of preferred object v non-use Limit access to most perseverated activities Pair functional use w/ classification Sensory Modulation Difficulties Use valued high sensory as intrinsic reward Shape goal of time-out as self-regulation Teaching in stimulation controlled places Consider signal : noise (e.g., CAI) Lots of Little Strategies. How Do You Pull It All Together? Selecting Main Features of Curriculum for A Classroom Approaches to Autism Treatment One-to-One Treatments Adult-Led Child-Led Discrete Trial Training (Lovaas Therapy) Pivotal Response Training Incidental Teaching Floor-Time/ DIR Relationship Development Interaction (RDI) Hanen Group-Based Treatments Special Education General Education TEACCH Communication Classes Non- Categorical special day classes Inclusion/ Mainstreaming Resource Specialist Program (RSP) Support ADULT-LED/ Behavioral: Strengths Pairs primary and social reinforcers to increase value of social reinforcers Develops cause and effect responding Develops attention with use of salient reinforcers Teaches schema for imitative learning Bringing vocalization under imitative control as prerequisite for speech learning PRT: Develops self-initiative through choice ADULT-LED/ Behavioral: Quality Assurance Considerations Separate curriculum from method Teach in developmental sequence (e.g., Vocabulary: horizontally, not vertically) Teach age-appropriate functional and pre-academic skills Provide choice/ self-initiative (e.g.,activity schedules) The Developmental-Behavioral Approach Developmental DT v DT (c.f.:Lovaas) Teach linguistic prototypes, not verbal SDs Periodic data, not trial-by-trial data Build in more child choice Dynamically inter-leaf adult-led and child- initiated trials by consistently reinforcing (any) lead-taking by child The ALD/ALS Profile That Fits Adult-led/ Behavioral Interventions No Instruction Contract Yet No Response to Social Reinforcers No Imitative Learning Maladaptive Behaviors Are Instrumentally Successful GROUP-ORIENTED: TEACCH/ Structured Teaching Strengths Culture of autism (like culture of deafness) Task-choosing as intrinsic reinforcer Supports move to self-initiated learning High visual cueing, lower language press Defined work spaces to decrease sensory over-responding Stepping stone to inclusive classrooms GROUP-ORIENTED: TEACCH/ Structured Teaching Quality Assurance Considerations Use photos not icons: promotes thinking in pictures/ increases motivation Use work stations for maintenance skills Have children put away not throw away completed task, to increase sensory-motor involvement Use activity schedules & visual token boards at work stations Supervise work stations sufficiently (one- to-two) The ALD/ALS Profile That Fits Group-Oriented/Structured Teaching Imperative to function adaptively as part of group Prefers routines to makes sense of daily events Prefers visual over linguistic organizing structures Reinforced by predictability CHILD-CENTRIC: F loor-time/ RDI Strengths Child engagement sustained by self-choice of activity; i.e, intrinsically reinforcing Very slow-to-warm, very anxious or very avoidant child is gradually desensitized to over-arousing aspects of social contact Gradual change in learning contingencies circumscribes sensory over-responding. No battle for instructional control CHILD-CENTRIC: Floor-time/ RDI Quality Assurance Considerations Outcomes: Is there initiative/ spontaneity (child) or just better scaffolding (adult)? Does increased engagement in play drive language/ problem-solving/exploration? Are improvements in joint attention reflected in language/pragmatic gains? Is there really a relation between sensory issues and learning (cognitively? socially?) The ALD/ALS Profile That Fits Child-Centric Teaching Sensory over-responding impairs engagement with learning experiences that are otherwise accessible. Responds well to desensitization to novelty which is hard to tolerate Low motivation, needs intrinsic rewarding INCLUSIVE: Strengths Child is exposed to a (meaningfully) adapted core curriculum. Goal for peer models will stimulate age- appropriate functioning. Goal for children to decrease inappropriate behavior if segregated from others who behave similarly. Child more likely to attend neighborhood school/ develop natural friendships INCLUSIVE: Quality Assurance Considerations Prerequisite imitation for peer modeling? Developmentally relevant inclusion? Functional analyses of disruptive behavior where inclusion may be the antecedent Some maladaptive behavior is hard-wired not modeled Smooth transitions? One-to-one teaching special day class integration full inclusion (one-to-one) full inclusion (one- to-two) obscured aide The ALD/ALS Profile That Fits Inclusive Education Able/ interested to learn new things from model. Motivated by some social contingencies. Incidental learner. Developmentally within reach of instruction. Treatment Approaches Cross-Tabulated by ALDs to Be Addressed Area of Autistic Learning Disability One-to-One Adult-Led (ABA-DTT/ PRT) One-to-One Child- Initiative (Floor-Time/ RDI) Special Education (TEACCH/ Other Special Day Class) General Education (Full or Partial Inclusion) Social Interaction Primary Likely Benefits Low Response to Social Reward Yes (via paired association) Yes (via child choice of content No (completed order as reward) No (response assumed) Infrequent Social Reference or Joint Attention No (attention directed to stimulus materials) Yes (major focus) No (attention directed to routine or materials) Yes (once imitation present) Low Drive for Peer Affiliation No (object or teacher models) No (adult as model for affiliation) No (inclusion w/ comparable peers) Yes (IF peers are interesting models) Limited Modeling or Imitation Yes (via forward/ backward chaining) No (adult as model for affiliation No (routine as model) Yes (IF salient peer models) Area of Autistic Learning Disability One-to-One Adult-Led (ABA-DTT/ PRT) One-to-One Child- Initiative (Floor-Time/ RDI) Special Education (TEACCH/ Other Special Day Class) General Education (Full or Partial Inclusion) CommunicationPrimary Likely Benefits Poor Comprehension/ Limited Para- Linguistics Partial (Rotely- taught/ non-generative) Yes (In context of social regulation) Partial (Routine as Replacement) No (assumed mastered) Slow Auditory Processing Speed, Poor Parsing Partial (Telegraphic Speech) No (Often Assumes R > E) No (Emphasis on visual) No (assumed mastered) Preference for Visual over Auditory Modalities Yes (Use of Visuals & Procedures) Yes (Pairs words with activity) Yes (Visually sequenced environment) No (assumed mastered) Theory of Mind/ Perspective-Taking No (Reliance of Direct Learning) Yes (Anticipation / Prediction of Others Actions) No (work is individual) Yes (via group participation) Area of Autistic Learning Disability One-to-One Adult-Led (ABA-DTT/ PRT) One-to-One Child- Initiative (Floor-Time/ RDI) Special Education (TEACCH/ Other Special Day Class) General Education (Full or Partial Inclusion) Organizing Information Primary Likely Benefits Lack of Representation Capacity (Imagination) Partial (Rotely- taught/ non-generative) Yes (innovation as main focus) No (more emphasis on classification) Partial (if child imitates devel. level) Preference for Repetition over Novelty Yes (adult- direction) Yes (innovation as main focus) Yes (delimited tasks) Partial (varied curriculum if child can follow it) Sensory Modulation Difficulties Yes (de- sensitization) Yes (gradual building of reciprocity) Yes (controlled physical environment) No (environment design for those w/o difficulty) Defining Eclectic Eclectic is having a toolbox with a variety of tools Eclectic is not letting everyone choose what they like best Eclectic treatment is knowing what tool to use for which jobbased on the best available evidence. Bibliography Siegel, B (2007-in press). Parenting the Child with Autism, New York: Guilford Press. Siegel, B (2003). Helping Children with Autism Learn: Treatment Approaches for Parents and Professionals, New York: Oxford University Press. Siegel, B (1996). The World of the Autistic Child: Understanding and Treating Autistic Spectrum Disorders, New York: Oxford University Press. Siegel, B. and Silverstein, S. (1994). What About Me? Siblings of Developmentally Disabled Children New York: Perseus Press