8/12/2012
1
Part II Treatment Options
Martha S. Burns, Ph.D.
September, 2012
Right now the research evidence points to value of ABA approaches and promising new areas for intervention: ◦ perceptual training and the mirror neuron system in
young children Interactive play
Imitation
◦ mentalizing and other prefrontal lobe functions as the children mature TOM
Working memory
Maestro S et al Psychopathology 38(1): 26-31, January 2005
87.5% display symptoms in first year of life ◦ Withdrawn
◦ Displaying poor social initiative
◦ Lack of emotional modulation
8/12/2012
2
Zwaigenbaum et al International Journal of Developmental Neuroscience, 23(2-3), April-May, 2005
Marked passivity and decreased activity at 6 months
Followed by extreme distress reactions
Tendency to fixate on particular objects in the environment
Decreased expression of positive affect by 12 months
Johns Hopkins University Study Prospective, longitudinal design in which 125 infants
at high and low risk for autism were tested from age 14 to 36 months.
Comprehensive standardized assessments included measures of social, communication, and play behavior
Low-risk controls (n=18) and siblings of children with autism, grouped on the basis of outcome diagnostic classification at 30 or 36 months: ◦ autism spectrum disorders (early diagnosis, n=16; later
diagnosis,n=14), ◦ broader autism phenotype (n=19), and non–broader autism
phenotype (n=58).
Results: Social, communication, and play behavior in the early-diagnosis group differed from that in all other groups by 14 months of age.
By 24 months, the later-diagnosis group differed from the non–autism spectrum disorder groups in social and communication behavior, but not from the early-diagnosis group.
Examination of growth trajectories suggests that autism may involve developmental arrest, slowing, or even regression.
8/12/2012
3
Compared with the later-diagnosis group at 14 months of age, the early-diagnosis group produced significantly less frequent ◦ shared positive affect (P=.002),
◦ Initiation of behavior regulatory bids (P=.001),
◦ and initiation of joint attention bids (P=.009),
◦ as well as a smaller inventory of gestures and consonants (all P=.001) (Table 2).
By 24 months, these ASD groups exhibited similar frequency and diversity of social, communication, and play behaviors. Landa, et al., 2007 Figure. Developmental change of the 5 groups from 14 to 24
months of age on the Communication and Symbolic Behavior Scales
Developmental Profile
(CSBS DP) for frequency of shared positive affect (A), frequency of initiation of joint
attention bids (B), inventory of gestures
8/12/2012
4
Published April 28, Journal of Pediatrics
5 minute checklist for pediatricians
10,479 babies screened at one year checkups
24 questions
Accurately predicted problems in 75% of children (184)
False alarms for 25% ◦ Lack of shared attention (babies should try to pull
your attention to their world
Lack of shared enjoyment – may smile at mom but not engage if other people play peek-a-boo
Repetitive behaviors like spinning a car wheel rather than play with the car
Language problems seen with any of the above
Possible mechanisms of recovery include: ◦ normalizing input by forcing attention outward or
enriching the environment;
◦ promoting the reinforcement value of social stimuli;
◦ preventing interfering behaviors;
◦ mass practice of weak skills;
◦ reducing stress and stabilizing arousal.
Improving nutrition and sleep quality is non-specifically beneficial.
8/12/2012
5
The presence of seizures, mental retardation and genetic syndromes are unfavorable signs,
whereas head growth does not predict outcome.
◦ Residual vulnerabilities affect higher-order communication and attention.
Tics, depression and phobias are frequent residual co-morbidities after recovery
Getting started ◦ Language & early imitative routines
Functional Communication (PECs)
Gestalt Processing
Visualization
Until controlled research is available – continue to use tried and true interventions ◦ ABA to control behavior and establish task
orientation – especially with severe symptoms ◦ Naturalistic “play approaches” like DIR (Floortime)
Right now the research evidence points to promising new areas for intervention: ◦ perceptual training and the mirror neuron system
in young children Interactive play – DIR is a good formalized approach
Imitation – RDI is a good formalized approach
Interest in and attention to speech vs. nonspeech stimuli
Interest in and attention to faces
Interest in and attention to body parts
Tolerance of holding, rocking, and stroking
8/12/2012
6
Henry OT
Sensory Integration activities for young children
Until controlled research is available – continue to use tried and true interventions ◦ ABA to control behavior and establish task
orientation – especially with severe symptoms ◦ Naturalistic “play approaches” like DIR (Floortime)
Right now the research evidence points to promising new areas for intervention: ◦ perceptual training and the mirror neuron system
in young children Interactive play – DIR is a good formalized approach
Imitation – RDI is a good formalized approach
Interest in and attention to speech vs. nonspeech stimuli
Interest in and attention to faces
Interest in and attention to body parts
Tolerance of holding, rocking, and stroking
Sensory Integration activities for young children ◦ Engaging the baby
Respect the baby’s sensory preferences – then incorporate what he likes into activities
Interact a few inches away
Match your loudness and animation to his preferences
Rub, deep touch, tickle, to see what she likes and tolerates
8/12/2012
7
If the tot prefers movement to interaction ◦ Follow the baby and join in his activity –
remember that imitation builds mirror neurons
◦ Try swings or lifting
◦ Try to encourage behaviors that initiate (to engage mirror mechanism) Return to the activity
Order of activity events
Interaction
◦ Block stereotypic/repetitive behaviors with interceptive actions
Language & early imitative routines for Mirror
Mechanism ◦ Peek-a-boo
◦ Nursery rhymes and songs with gestures ◦ Music to words
◦ Animal sounds to words
Functional Communication (PECs) Visualization
Movement tools ◦ Bouncing, swinging, pushing, pulling, slides – always face
child and stress imitation of facial expression and movement sequences
Muscle tools ◦ Tug of war, weighted toys, mini-trampolines and inflatable
jumpers
Touch tools ◦ Hand fidgets (Henry, 2001), putty or play dough,
temperature (cool and warm water)
Ear Tools – music and animal sounds Eye Tools – adjust the lighting, facial puzzles Mouth Tools – chew tubes, mouth fidgets (Henry,
2001) “Talk Tools”
Movement tools – slow rhythmic movements before tactile activities
Muscle tools – smash, pull and squeeze materials
Touch tools – vibrating toys, weighted blankets, play with varied textures, dress up,
Ear tools – use calming music
Eye tools – “What’s inside”
Mouth tools – mouth fidgets and bubbles
8/12/2012
8
Movement tools – start predictable and move to novel; piggy back rides; wrap tot in blanket and pull on the floor; up-over-around tunnels
Muscle tools – push a swing, pull a rope to make the swing move
Touch tools – allow a “blankey” and start movement snuggled in a blanket or bean bag chair
Ear tools – pair movement with songs Eye tools – hide and seek (well test) Mouth tools – only during therapy
Language
Visualization
Go to PECS if there is no language
8/12/2012
9
Use visual strategies to help with concepts of time, order and schedule
Monkey see (“look at me”) – Monkey do (“follow me”) ◦ See especially new research on imitative routines in
primates
M. Carpenter In S. J. Rogers, J. Williams, Eds. (Guilford, New York, 2006), pp. 48–70 In humans, imitation is not only a way of
acquiring new behaviors, but also is a way of connecting with others and aligning oneself with them—of communicating one’s likeness and affinity to others
Social function of imitation is apparent from a very early age, when human children copy others closely
even in problem-solving tasks when copying the particular actions the demonstrator used often is not necessary to achieve the instrumental goal
8/12/2012
10
Annika Paukner Stephen J. Suomi, Elisabetta Visalberghi, Pier F. Ferrari
Science 14 August 2009: Vol. 325. no. 5942, pp. 880 - 883
Session 1 and 2 Give the child a ball or a favorite toy
Do not ask the child to do anything with the toy ◦ Let the child play with the toy or ball anyway she
wants ◦ Imitate what the child does – if he lines up trucks
– you do the same – if she chews the ball you do the same
◦ After a short period where you imitate and the child seems interested in your imitations – give the child a token for each time the child attends to your imitation
◦ The child can turn in the tokens at the end of the session for a reinforcer
Session 3-4 After a few sessions where the child has begun to attend to adult imitations ◦ Imitate the child first then add a new action or new
toy (DIR – bridging) If the child lined up trucks, you line up trucks but then
move one truck along a line or make a truck sound
If the child imitates your added action, give him a token, if not continue to imitate the child but give her a new toy
Sessions 5-6 ◦ During imitative play – try to encourage imitative
routines: movements (like Patty Cake) or gestures (like so big) or animal behaviors or rhythm marching bands
Sessions 7-8 ◦ Begin to stress imitation of facial expressions
during – peek-a-boo may help get this started
Sessions 9+ combine imitative routines using tokens as rewards for attention and imitation
8/12/2012
11
Facial expression ◦ Use photos imitating the expression and asking the
child to do so as well
◦ Look at animal and insect photos and try to imitate their expressions (eg. fish face, beaver face, monkey grin, etc.)
Bodily movement ◦ Have young children act like an animal and guess
the animal - Elephant walk, bird flight, monkey scratch, etc.
There are no visual perceptual programs designed to improve perception of facial expression or biological movement ◦ Beware of visual therapies that stress eye
tracking, eg. through optometrists – there is no evidence of any value in ASD
The most thoroughly researched approach for building auditory perceptual skills is Fast ForWord Language.
Earobics may be helpful but at this time there is no specific research with autism spectrum
Give picture to adult to get item desired
Select desired picture then give to adult
Select picture, generate phrase, give to adult
Seek PECs book, select picture, generate phrase and/or sentence, give to adult
8/12/2012
12
PECS – Picture Exchange Communication
AAC – Augmentative & Alternative Communication (including voice-output)
Sign Language – SEE / ASL
8/12/2012
13
Red plus Green tree
The big dog jumps
article adjective
noun verb
8/12/2012
14
Try auditory processing computer-based interventions ◦ Listening programs ◦ Fast ForWord Basics to Language ◦ Reading Assistant
Visual processing programs ◦ Mind Reading – Interactive Guide to Emotions
http://www.jkp.com/mindreading/demo/content/dswmedia/loader.htm
Begin organized movement interventions – smart moves
Emphasize mirror neuron activities ◦ RDI ◦ Imitative visual motor routines
Executive function tasks especially stressing working memory
The Interactive Guide to Emotions - Version 1.3
Simon Baron-Cohen
http://www.jkp.com/mindreading/demo/index.php
http://www.jkp.com/mindreading/demo/
Brain HQ (from Posit Science)
Demo
8/12/2012
15
Techniques to empower parents to develop mirror neuron building interactions with their children
http://www.rdiconnect.com/
4130 Bellaire Boulevard Suite 210
Houston, Texas 77025
Toll-Free: 866.378.6405
Phone: 713.838.1362
Fax: 713.838.1447
Demo
www.socialthinking.com
Taking perspective – she was a pioneer in working on TOM with adolescent ASD
Humor – she believes that children with ASD need to learn to laugh at themselves
Social Skills – unlike the social scripts she advocates developing a view of the other, how they think and what they might think of you
8/12/2012
16
1. Improving the awareness of self and others,
including physical appearance, likes, dislikes and
problem solving;
2. Allowing clients to assess their own
communication skills;
3. Taking the client through eight levels of body
language;
4.'Talkabout the way we talk' improving
paralinguistic skills;
5. Taking the client through the processes needed to
improve conversational and listening skills;
6. Awareness and use of assertiveness skills.
Practical and user-friendly, this comprehensive
workbook is an essential resource for therapists
running social skills groups.
Talkabout
Visual Thinking Strategies For Individuals With
Autism Spectrum Disorders
In this groundbreaking book, Arwood, Kaulitz and
Brown explore and explain how persons at
different levels of sensory and cognitive
functioning need visual information presented
differently to facilitate their individual thinking and
learning. This information helps us all (parents
and professionals) to shift our perspective away
from using visuals that make sense to us, to
creating visuals that are designed to facilitate a
student's understanding. This book clearly demonstrates the `science' behind the art!"
Pathways for Learning I and II
An outstanding resource of VISUAL ORGANIZERS that helps children better recognize the predictable patterns within classroom language
experiences. This resource provides visual organizers for use with:
Vocabulary and Concept Development
Associations
Categories
Multiple Meaning Words Analogies
Compare/Contrast
Cause and Effect
Literature note taking and comprehension: Organizing Story Details, Main Ideas, Story Sequence and Chapter Summaries
Story Elements: Characterizations, Setting, Conflict, Theme Analysis,
Context and Significance Classroom Content: Lesson Preview/Review, Topic/Lesson Summary,
Outlining Notes, Unit/Chapter/Lesson Connections/Current Events, Historical People/Event Outlines, Geography Themes, Biography
Brain Cogs(2001) – Learning and Study Skills software for grades 4-8 ◦ FableVision – 44 Pleasant Street, Watertown, MA
02472, 617.926.1231, www.fablevision.com ◦ Teach strategies for remembering, organizing*,
prioritizing*, shifting*, and checking (*great for older NVLD, HFA, and Asperger’s children)
8/12/2012
17
Brain Fitness games for kids
http://www.lumosity.com/
New York Times Puzzle page ◦ Visual set puzzle for adolescents
◦ http://www.nytimes.com/ref/crosswords/setpuzzle.html
Barb Kirby, OASIS, www.aspergersyndrome.org, Co-author, the OASIS
guide to Asperger Syndrome.
Jennifer Abbott Bulka, M.A., SLP, www.talkingplayhouse.com
Understanding the main idea Explaining the main idea Synthesis of information – including part-
whole relationships and categorization Story formation Planning Problem solving Gestalt in conversations – the social
importance of gestalt processing
8/12/2012
18
Listen/read description of an item/activity – identify one word main idea (ex. Playing outside and making a man out of snow = snowman)
Tell story – identify one word/phrase for main idea
Give steps – identify task
Tell story – answer questions about the main idea
Tell story – generate main idea sentence
Tell story – generate summary
Describe the necessary steps for a task
8/12/2012
19
Part-whole relationships
Identify the parts for a given item
Identify the item when given list of parts
Categorization
Identify category for list of items
List items in a given category
Identify why an item does or does not go into a given category
Select topic/theme
Select main idea
Generate vocabulary
Generate sentence for each vocabulary word
Connect sentences to main idea
Cat Food
Fish Toys
Dog Vet
Story:
I want to have a pet. I could have a cat or a dog. I
could also have a fish. I will need to feed my pets.
Pets like to have toys, like a ball. If my pet gets sick I will take it to the Vet.
Simple story formulation activity
Who is this story
about? What is this story
about?
Describe what happened?
Describe when it happened?
Describe where it happened?
Describe how or why it happened?
Story Map
Copyright by Christine Brennan, MA CCC-SLP, 2006
www.brennanandburns.com
8/12/2012
20
Plan multiple activities to complete in sequence
Plan steps for each given activity
Review activities completed
Review steps completed
Refer back to main idea or purpose of plan
Use a visual schedule or visual choices
8/12/2012
21
The social importance of gestalt processing People communicate in stories Listen to a story and understand the main
idea / main topic Share a story of your own about the same
topic Staying on topic requires that the topic is
understood If the main idea is missed, reciprocal stories
or related comments and questions will be unrelated
8/12/2012
22
Speech production
Communication about items not present
Thinking about past / future events
Describing
Story telling
LIPS – Lindamood Phonemic Sequencing® Stimulates phonemic awareness Increase awareness of the mouth actions that
produce speech sounds Becomes the means of verifying sounds
within words Impacts speech comprehension, reading,
spelling, and speech production
Look at a picture or object, describe it when it is gone
Think of an item and describe it’s visual characteristics
Drawing /discussing people and items Recalling and describing other places Describing activities Touching (but not looking at) an item and
describing shape, color, size
8/12/2012
23
Use calendar, planner, schedule
Categorize activities by month, season
Teach time concepts
Teach “when” questions
Teach story telling about past events
Teach story telling about future events
Practice asking questions about other people’s past and future events
When ?
Before / After
Today / Yesterday & Tomorrow
8/12/2012
24
8/12/2012
25
Category
Appearance
Size
Location
Function
Association
Generate a topic
Generate related items
Talk about event(s) in story
Draw a picture about the story – show all related items as identified
8/12/2012
26
Voice output
Signed Exact English vs. ASL
Idiomatic signs
Sign + verbal
+ AAC
Key signs to teach: more, all done, help, drink, cookie, eat/food, play, open
Teach signs for each child’s most motivating items
Auditory Processing
Social Thinking – part 1 Also see Michelle Garcia Winner’s
www.socialthinking.com
Motor Planning
Abstract Language
Executive Functioning
Theory of Mind
Speech-sound discrimination
Auditory memory
Sequencing
Language processing
Conversation processing
Speed of processing
8/12/2012
27
Discrimination of speech sounds letters and letter sounds
Minimal word pairs
Sentences with minimal word pairs
Fast ForWord Language / Literacy
Digit span, word span, sentence recall
Story recall
Visual recall
Work on building auditory memory starting at current level of child
Sequencing / Temporal vocabulary: first, next, last, when, then, after, before, during, will,
did,
Auditory directions with sequence order
Auditory description of event(s) with steps
Listening to speech sounds, synthesizing into word
Recall (auditory presentation) words, sentences, information in order or in reverse order
Listen to partial sequence and complete
Comprehension of various language structures
Comprehension of stories
Comprehension of questions
Discrimination of similar sentences
8/12/2012
28
Processing and comprehending:
statements made by others
questions asked by others
stories shared by others
comments made by others
Fast ForWord Language / Literacy
Eye contact
Developing reciprocity
Developing empathy
Basic social skills ◦ Responding to others
◦ Making comments
◦ Asking questions
◦ Turn-taking
8/12/2012
29
This is you.
What do you think about?
What do you like to talk about?
Conceptual reciprocity
This is a dog.
What do dogs think about?
Require eye contact following a motivating request
Don’t request eye contact during listening activities
Practice eye contact during conversational activities
Focus on facial interpretation during conversation activities instead of focusing on eyes
8/12/2012
30
My eyes show what am thinking about
(Look at item in room, like your watch)
What am I thinking about – the time
(Look at child)
Ask again - What am I thinking about?
Practice using eyes to determine what each other is looking at
Practice “Guess what I did…”
Formulate stories about personal events
Share opinions and preferences
Practice sharing and asking about preferences
Practice sharing and asking about events and opinions
8/12/2012
31
Responding to others Answering questions, making comments
Making comments Commenting on play, actions, statements, feelings,
opinions, sharing stories
Asking questions About preferences, activities, people, events
Turn-taking (game related and task related)
Conversational reciprocity
Ask people about the things they want to talk about
Ask people about the things they like
Share what you think about
Ask questions about the things you like
Share opinions and ask others about their opinions
This is Christine.
What does she think about?
What might she talk about?
8/12/2012
32
Smart Moves ◦ Demo
Interactive Metronome
8/12/2012
33
Inferences
Reading between the lines
Expressions
Interpreting behavior of others
Meaning from context
Ambiguous language
What, who, where am I? I am a red fruit that grows on a tree? What
am I? apple Open wide and relax. I’ll take a look at that
sore tooth. Who am I? dentist My latest book is a children’s story. It will
be published next month. Who am I? author
First I grab a tray. Then I get in either the hot or cold food line. Where am I? cafeteria
There are so many exhibits to see. Let’s find out where the dinosaur skeletons are. Where am I? museum
Inferences about where
Inferences about when
Inferences about reasons
Inferences about feelings
Predictions
Inferences from reading
Nonverbal language
Inferences from pantomime
Speaking style
Using what you know to guess what you don’t know
Deductive reasoning tasks / activities
Clue, Guess Who, Battleship, Breaking the Code
Understanding sarcasm
Using sarcasm
8/12/2012
34
Idioms
What they mean
What they don’t mean
Guessing what they mean
Using idioms correctly
Interpreting unknown idioms in context
Making observations about others behaviors Explaining the behavior of others
Actions
Statements (questions and comments)
Body language / gestures
Tone of voice
Facial expressions and eye contact
Lying
Hypothesizing why someone might be doing a given behavior
IDEAS for: Abstract Language Interpreting behavior of others
• Make observations about characters on TV show or movie
• Explain the behavior of the characters • Describe their Actions
• What did they say or ask
• Describe their body language / gestures
• Describe their tone of voice
• Describe their facial expressions and eye contact
• Why did the character do those things
• What was he / she feeling
• What did he / she want
Vocabulary meaning in context
Interpreting idioms in context
Interpreting sarcasm in context
Interpreting inferences in context
Reading activities
Picture activities
Conversational activities
8/12/2012
35
Interpreting ambiguous vocabulary (i.e. homonyms)
Interpreting ambiguous sentences (i.e. “A grandmother of five hits a hole in one!”)
Action monitoring (emotional regulation)
Self knowledge (emotional awareness)
Person perception
Mentalizing
Outcome monitoring
Self-monitoring: control of initiated actions and cognitive processes and awareness of errors
Increase awareness of self Increase general monitoring Make errors a game / make errors ok Practice reviewing actions Practice awareness and control of initiating
actions and processes Announcing what you will do next, explaing
actions step-by-step Giving clear directions / have child model
steps and actions for adult
8/12/2012
36
Children with ASD, especially Asperger’s may appear to over or under react to different situations
Reviewing the concept of “Putting things in Perspective” can be helpful
Make hierarchy of problems Discuss severity of problems Discuss how to express opinions as they
relate to perspective
Who I am?
Moods (positive and negative)
Beliefs ◦ Opinions
◦ Opinions of others
Desires (things, events, actions, people…)
Sensations (pleasant and unpleasant)
Personality – How am I different from other people
Begin developing flexibility early
Greenspan emphasis on “bridging”
Video
Say “day” Say “night”
8/12/2012
37
Emotion vocabulary
Emotions and causes
Feeling are ok, even if we don’t like them
Asking for help
Practice ID own emotional state
Practice expressing own emotional state
Problem solving as related to emotional difficulties
Do social stories or choices for behavior for different feelings
Example:
When I feel angry I can
Ask for help
Take a break
Go for a walk
Understanding motivation / nonverbal cues
8/12/2012
38
Forming impressions of other people Using observations of behavior to make
inferences Understanding motivation and how it affect
people Practice drawing inferences about the
personality and the emotional states of others
Explain the nonverbal cues used to drawing inferences about others
Practice interpreting nonverbal cues
The process of making sense of mental states in yourself and in others
Emotion vocabulary Identifying your emotional state Recognizing emotion states of others Hypothesizing why a person is behaving a
given way Role playing how to respond to other
people’s emotions Practice expressing your own emotional
state Practice explaining why you feel a given way
Anticipating consequences of various actions (what might happen if…)
Explaining connections between an action and a consequence (what happened and why?)
What did you do and what was the result? Making good choices Making good plans Evaluating past choices and past plans Predicting problems / consequences
Predicting problems / consequences Evaluating Risk Decision Making
8/12/2012
39
Theory about the nature of the mind Refers to the ability to understand that
others have beliefs, desires and intentions that are different from one's own
Includes two facets: ◦ 1 - understanding that others have minds of their
own with different ideas, thoughts, wants, needs, emotions, and intentions
◦ 2 - being able to form hypotheses about others’ ideas, thoughts, wants, needs, emotions, and intentions
Deficits in social and emotional reciprocity probably stem from a problem in their development of Theory of Mind
1 - Sally puts her ball in the
box and then leaves the room.
2 - While Sally is away, Anne
puts the ball in the bag
3 - Sally returns for her
ball. Where will she look?
Individuals with deficits in theory of mind have difficulty with the following: ◦ Discriminating what others know versus what they
know ◦ Disrimination of themselves from other ◦ Taking the perspecive of others ◦ Interpreting actions of others ◦ Thinking about/considering differences of opinion ◦ Emapathy/sympathy ◦ Conversation skills ◦ Learning social rules
8/12/2012
40
Practice false-belief tasks
Discuss others people’s ideas, thoughts, wants, needs, emotions, and intentions
Practice forming hypotheses about others’ ideas, thoughts, wants, needs, emotions, and intentions
Play games in which one person knows something the other doesn’t
Children with ASD often have difficulty with social and emotional reciprocity
This is a result of poor theory of mind
They may lack the ability to express their emotions as well as the ability to interpret and react to the emotions of others
This combination of deficits may make an individual with ASD seem cold and detached
8/12/2012
41
Asking questions ◦ Good generic questions
◦ Questions for different groups of people (i.e. teacher, family, peers, new people)
◦ Listen and ask a related question ◦ Introducing questions (i.e. I like dogs. Do you have
a dog?)
◦ Asking about previous knowledge
What do you know about a person then generate a related question (i.e. Christine went to Washington, ask “How was your trip to Washington?)
Generating
Questions