start orientation young children with autism spectrum disorders

Amy Matthews, Ph.D. & Jamie Owen- DeSchryver, Ph.D.

Grand Valley State University

START Orientation Young Children with Autism Spectrum

Disorders

Orientation to START and Early Childhood (EC)

Training

Evidence-Based Practices for Young Children with

ASD

Critical Components of Effective Programs

Foundations of ASD

Identification and Diagnosis

Next Steps

Agenda for Today

Early childhood programming is not a foreign concept

You know some basic information about autism spectrum disorders

You have experience working as a team

You are interested in young children with ASD

Assumptions

Who is here?Why Are we here?

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

2000

4000

6000

8000

10000

12000

14000

16000

18000

Michigan Students with an ASD EligibilityN

um

ber

of

stu

den

ts

1,208

17,415

5,682

If 1 in 68 children have an autism spectrum disorder…

The average elementary building will have 4-5 children with ASD

The average middle school building will have 8-9 students

The average high school will have about 14-15 students

Latest CDC Report

*Center-based programs

Autism is no longer a low incidence disorder

Latest CDC Report

We need to change our approach to educating

young children with ASD

START Primary Components

Team-based Intensive Training

START Early Childhood Intensive Training

START K-12 Intensive Training

START Building Your Future Training

Intensive yearlong training with multidisciplinary school based teams in

the areas of teaming and problem solving, effective educational

programming for students with Autism Spectrum Disorders, and systems

change.

START Intensive Training

Making Professional Development EffectiveLang & Fox (2003)

Traditional professional development (training without follow up to support implementation) yields a 5-10% implementation of strategies success rate

With follow up, that number can rise to 75-90%

Overview of Intensive Training

Location All trainings will run from 8:30-3:30 Breaks in am and pm Lunch will be provided CEUs will be offered Binders for each participant and

flashdrive for each sub team We will always leave with an action plan

Logistics

Snow Days

START Training is canceled if… “insert decision here”

Sub team leaders provide a contact phone number at home or cell to start the phone tree

Get home/cell numbers from your team members

ACTION PLANYou will complete a team action plan at

each meeting

During this training we will talk about how to teach…

oEarly Learners

oEmerging Learners

oTransitioning Learners

Everyone is at a Different Stage of Learning

Participating in this training, everyone is at a different stage…

oEarly Learners

oEmerging Learners

oTransitioning Learners

Everyone is at a Different Stage of Learning

Evaluate what you hope to get out of this training

oContent – I am an early learner and I just need some information to get started!

o Implementation – I am an emerging learner. I know quite a bit, but I want to better implement effective practices in my classroom

oSpecific skills – I am a transitioning learner and I think my classroom is running pretty well; now I want to tackle some more advanced practices

oCEUs – I have to get CEUs and this is as good as anything else

Everyone is at a Different Stage of Learning

National Research Council Report http://www.nap.edu/openbook.php?isbn=0309072697

National Autism Center National Standards Project (

http://www.nationalautismcenter.org)

National Professional Development Center on ASD (NPDC) (http://autismpdc.fpg.unc.edu/)

Ohio Center on Autism and Low Incidence (OCALI) AIM website (http://www.autisminternetmodules.org)

Where do we get information about evidence-based approaches?

National Autism Center

National Standards Project

Where do we get information about evidence based practices?

AIM website (http://www.autisminternetmodules.org)

Behavioral Discrete trial training

(DTT) Differential

reinforcement Extinction Prompting Reinforcement Response interruption/

redirection Stimulus control Task analysis Time delay

Independence Self-management Structured work systems

Social Peer-mediated intervention Social skills training groups

Motivation Functional behavior

assessment Functional communication

training

Evidence-Based Practices (NPDC)

Visual Visual supports Video modeling Social narratives

Natural environment Pivotal Response

Training (PRT) Naturalistic

interventions

Communication Speech generating

devices PECS

Technology Computer-aided

instruction

Parent Parent-implemented

interventions

Evidence-Based Practices (NPDC)

A list of intervention strategies is not enough; interventionists need to identify child needs, develop plans to address needs, and match needs to instructional strategies (Strain, Schwartz & Barton, 2011)

NOT just about interventions found to have strong research support (Cook et al., 2009)

Decision making process that informs all professional decisions (Sakett et al., 2000)

Professional wisdom is part of selecting, adapting, monitoring, and implementing EBP (Cook et al., 2008)

Family and individual input is critical (Strain et al., 2012)

Evidence-Based Practice

Comprehensive Programs

Children’s Toddler School

Early Start Denver Model

Walden Toddler Program

Project DATA

Early Intensive Behavioral

Intervention (EIBI)

Empirically-Supported Treatments

Discrete trial teaching

PECS

Prompting

Pivotal Response Teaching

Reinforcement

Social narratives

Video modelingCritical Program

Components

Critical Components

Perhaps it is not unique features of model programs, but common features that result in positive outcomes (Boyd, Hume, McBee, Alessandri, Gutierrez, Johnson, Sperry & Odom, 2013)

This is not the same as “eclectic”

Critical Components

Early is better (by 3½) Intervention at identification Identification/intervention before age 3

Intensity matters (at least 25 hours/wk, full year, with low ratio)

Active engagement/Structured teaching time Minimal “free time” Lots of learning opportunities Each moment is a teachable moment

Family participation

Individualized goals, regularly monitored

What are the Critical Components of Effective Programs?

National Research Council, 2001

Most model programs range from 25-40 hours per week

Intensity/number of hours may not matter as much as quality of hours of intervention

Multiple and varied embedded learning opportunities

Active engagement

Critical Components:Intensity

(Strain et al., 2011)

Exposure to typical curriculum and activities

Targets core skills that have long-term impact on independence and quality of life, including child’s success and happiness in school, home & community

Critical Components:Curriculum

“Interventions are increasingly focused on behaviors that immediately improve the child’s independent functioning in natural settings (e.g., toilet training, verbal requesting) or behaviors that are essential for learning other important skills and long-term outcomes (e.g., imitation, joint attention)” (Strain, Schwartz & Barton, 2011, p. 327)

Individualized goals, regularly monitored

Practices are matched to individual needs

Focus on generalization

Data-based decision making is employed

Critical Components:Individualized Approach

Providing opportunities with typical peers (Strain et al., 2011)

The opportunity to interact successfully, not just be in the same room, with typically developing peers on a regular basis is a necessary component of effective intervention programs for all children with ASD, especially young children.

Critical Components:Foundations

(Strain et al., 2011)

Focus on predictability and routine

Functional approach to problem behavior

Team approach

Skilled interventionists

Transition planning

Critical Components:Teaching Practices

(Strain et al., 2011)

Law IDEA

Literature Evidence Based Practice

Student DataOutcomes

All practices must align with…

We Know What W

orks

Why would public school programs have trouble

adjusting to fit the recommendations and needs for young children with ASD?

Ratios (ECSE classrooms) Intensity/Time (0-3 and 3-6)

Training of staff Philosophy

Getting families involved

Implementation challenges in public school settings

Other sources of increasing service hours Insurance Medicaid / MIChild Parent Training/Coaching Innovative projects in collaboration

with universities, CMH, and within school districts/counties (e.g. Project DATA)

Ways to Increase Intervention

Big change only happens when we change whole systems

We did what we did when we knew what we knew

Once we know different, we are accountable

Systems Change

Getting Critical Mass

Getting enough people moving in the right direction in order to move the whole system forward

This is what the START Project is all about !

Identify and intervene early Use evidence based practices Increase learning opportunities (i.e.

opportunities to respond with feedback) and student engagement

Use effective instructional delivery (3 Rs: Request, Response, Reaction)

Focus on meaningful, functional goals and tasks (independence and socialization)

Establish an effective classroom structure to ensure learning

Big Ideas for Early Intervention

Establish positive patterns of behavior early on

Prevent problem behaviors with antecedent strategies

Provide lots of meaningful integration opportunities

Use data to confirm progress and make programming decisions

Carefully plan for transition to elementaryWork as a team and include families

Big Ideas for Early Intervention

Help you develop a program that allows children to

make the most progress

Working Together This Year: What is our goal?

What would a highly effective classroom for young children with ASD look like?

Effective Practices Assessment Tool for Young Children with ASD

Statewide Autism Resources and Training (START) Effective Practices Assessment Tool

for Young Children with Autism Spectrum Disorders

Team: ____________________________ District: ____________________ Date: _________________ AREA 1: Critical Program Components

Current Status/Progress

Not in Place Partially In Place In Place 1------------------------------2---------------------------- 3------------------------------4------------------------------- 5

Pri

orit

y L

evel

1

– 5

1=lo

w, 5

=h

igh

CRITICAL COMPONENTS

1. Students are actively engaged with many learning opportunities throughout the day

1 Students each receive less than 5 learning opportunities (including entire request, response, reaction sequence) per hour on average. Students are actively engaged in

productive activities less than 50% of the time.

2 3 Students each receive

approximately 10 learning opportunities (including entire

request, response, reaction sequence) per hour on average. Students are actively engaged in productive activities more than

80% of the time.

4 5 Students each receive more than

20 learning opportunities (including entire request,

response, reaction sequence) per hour on average. Students are actively engaged in productive activities more than 80% of the

time.

Priority

1 2 3 4 5

CRITICAL COMPONENTS

2. Programming is individualized to meet student needs

1 Students receive traditional preschool instruction with minimal adjustments for

individual needs.

2 3 Programming is individualized for some students, some of the

time, but not consistently enough to make rapid progress toward

IEP goals.

4 5 Instructional goals, methods,

prompts and response requirements are individualized to meet the student’s abilities, needs,

and developmental level.

Priority

1 2 3 4 5

Early Childhood Assessment Tool

Foundation in Autism Spectrum Disorders: Just the Facts

Asperger Syndrome identifed in 1944 by Hans Asperger

Autism identified in 1943 by Leo Kanner

Foundations of ASD

Autism’s First Child

The Atlantic Monthly

In 1943, Donald Triplett of Forest, Mississippi

became the first person to be diagnosed with ASD.

His parents chose not only to accept him as he was, but created a hometown environment of love and friendship that refused to

allow others to misinterpret or

misrepresent him or his “oddity.” 

Biologically-based, developmental disability

Historically 70-75% were thought to have some degree of cognitive impairment; recent estimates closer to 50% (Volkmar et al., 2004)

Autism Spectrum Disorders

Occurs 4 times as often in males than in females

Girls may be more severely affected (Rice, 2007) but may not be as pronounced in toddlers (Carter et al., 2007)

Autism Spectrum Disorders

Autism means that someone is really smart in some things

but needs a lot of help in other things.

Mrs. Fizell’s 2nd Grade class (1999)

from Barry Prizant

Definition of Autism:

Characteristics are evident during early development

70-95% with a documented developmental concern before the age of 2 years

13–30% of children had a reported developmental regression by 2 years of age

Autism: What do we know?

(Mandell et al., 2009)

Children are identified and diagnosed at younger ages

More children with milder characteristics are being diagnosed

Inclusion of children across the spectrum including Asperger (and PDD-NOS)

Increased public awareness

Increased Prevalence: Why?

Boyd, et al., 2010

Idiopathic in 90-95% of cases (uncertain cause)

Genetic Identical twins – 69-95% and Fraternal twins –

3-8% (Dawson, 2008) Sibling study – 19% of younger siblings of

children with ASD develop an ASD (Ozonoff et al., 2011)

Etiology

Relatively normal development with a subsequent loss of language skills around the second year.

Occurrence in ASD range from 15-30% Questions unanswered at this time

(Landa, 2008): Was the child developing normally or were

signs unnoticed? Did the child regress or did skill development

slow?

Regression

Early Identification

Early social behaviors Social smiling Looking at faces Responding to one’s name

Early communication behaviors Producing vocalizations Using a variety of gestures Coordinating verbal and nonverbal behavior

(pairing eye contact with vocalization)

Early Identification: Early Warning Signs

Boyd, et al., 2010

The core symptoms of autism are represented social-communication impairments and restricted and repetitive behaviors. Yet the earliest sign of autism is often manifested as a deficit in joint attention, which has a significant and pervasive impact on all developmental domains.

Joint Attention

Restricted and repetitive behaviors Repetitive or limited use of toys or objects in

manipulative play High rates of stereotypic motor behaviors Intense focus on narrow interests

Early Identification: Early Warning Signs

Boyd, et al., 2010

Researchers at the UC Davis M.I.N.D. Institute have found that infants later diagnosed with autism exhibited unusual exploration of objects long before being diagnosed. Studying a group of children at high risk for developing autism, the researchers found that those eventually diagnosed with the disorder were more likely to spin, repetitively rotate, stare at and look out of the corners of their eyes at simple objects, including a baby bottle and a rattle, as early as 12 months of age.

-Ozonoff et al., 2008

Early Signs

The study, published online in the journal Nature, found that infants who later developed autism began spending less time looking at people’s eyes between 2 and 6 months of age and paid less attention to eyes as they grew older. By contrast, babies who did not develop autism looked increasingly at people’s eyes until about 9 months old, and then kept their attention to eyes fairly constant into toddlerhood.

--Warren & Klin, 2013

Autism Speaks/First Signs video glossary(also see Treatment videos)

Early Signs of Autism – Kennedy Krieger

Signs of ASD Videos

Early Identification

Mean age of autism diagnosis is 34 – 61 months

Mean age of first parental concern is 18 – 19 months

Gap of 1-2 years before autism treatment begins

Earlier identification earlier intervention

Intensive early intervention = better outcomes

Mandell et al, 2005

n = 965

Age

Developmental rates from 6-24 months: language development

9 children with ASD; 27 with typical development

Months Rogers, et al, 2010

Stability of diagnosis around 2 years of age with valid assessment and trained team (Lord, et al., 2006)

Early Identification

Black, Hispanic, or other race/ethnicity - less likely than White children to have a documented ASD

Disparity persisted for Black children,

regardless of IQ

Disparity for children of other ethnicities when IQ was lower than 70

Disparities in Identification

(Mandell et al., 2009)

Differences in Brain Development and

Cognitive Processing

Dr. Eric Courchesne explains the underlying brain biology of autism at the International Meeting for Autism Research (IMFAR)

Brain Development

Theory of Mind

Sally Anne Test Video

Diagnostic Changes

DSM 5 (May 2013)

Autism Spectrum Disorder

Autistic Disorder

CDDRett’s

Disorder

PDD-NOSAsperger

DSM IV (1994-2013)PERVASIVE DEVELOPMENTAL DISORDERS

Previous DSM-IV Definition of Autism(MI definition)

Restricted & Repetitive Behavior

Impairment in Socialization

Impairment in Communication

Autism Spectrum Disorder DSM 5 Definition (2013)

Deficits in social communication

and social interaction across multiple contexts

*2 core features with 7 criteria can result in 12 combinations that all lead to the same diagnosis of ASD (See DSM V handout)

Restricted, repetitive patterns

of behavior, interests, or

activities

With or without intellectual impairment With or without language impairment Associated with known medical or

genetic condition or environmental factor Associated with another

neurodevelopmental, mental, or behavioral disorder

Severity Level

Specifiers

Dimensional Ratings for DSM 5 ASD

Social Communication Restricted, Repetitive Patterns of Behavior

Requires very substantial support

Severe deficits in social communication, severe impairment in functioning

Inflexibility, extreme difficulty with change, severe impairment in functioning

Requires substantial support

Marked deficits in social communication apparent even with supports, limited initiations and responses

Inflexibility, difficulty with change apparent to casual observer, interferes with functioning in variety of contexts

Requiring support Without supports, deficits in social communication are noticeable. Difficulty initiating and successfully responding.

Inflexibility causes significant interference in functioning in one or more contexts. Problems with organization and planning.

Diagnosticians are good at distinguishing ASD vs. not ASD but lack of consistency regarding autism vs. PDD-NOS vs. Asperger

No consistent research evidence for separation of Asperger from autism

Diagnostic biases by race and SES

Goals is to be more SENSITIVE (correct inclusion) and more SPECIFIC (correct exclusion)

Why the Change

Impairment of pragmatics

diagnosed based on difficulty in the social uses of verbal and nonverbal communication in naturalistic contexts

which affects the functional development of social relationships and discourse comprehension and

cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability

Social (Pragmatic) Communication Disorder (NEW to DSM 5)

Rule out Autism Spectrum DisorderMust be present in early childhood

Conceptual Framework

Social Impairment

Speech/Communication

Deficits

Repetitive Behaviors & Restricted Interests

Autism

Spectrum

Disorder

Intellectual Disability

Language Disorders

OCD

Social AnxietyADHD

Intervening early and intensively is key to skill development and avoiding behaviors before they happen

Wrightslaw“All available research strongly suggests that intensive early intervention makes a critical difference to children with autistic spectrum disorders. Without early identification and diagnosis, children with autism are unlikely to learn the skills they need to benefit from education.”

Early Intervention

Dawson, et al. (2012). Early Behavioral Intervention Is Associated With Normalized Brain Activity in Young Children With Autism. Journal of the American Academy of Child & Adolescent Psychiatry, 51(11), 1150-1159.

“This was the first trial to demonstrate that early behavioral intervention is associated with normalized

patterns of brain activity, which is associated with improvements in social behavior, in young children

with autism spectrum disorder.”

Brain Changes from Behavioral Interventions

Teaching Requesting (Manding)

Social responsiveness Responsive to requests (eye contact and one-

step directions) Responding to initiations

Imitation Skills

First year priorities and beyond

Top 3 Targets for Intervention

(Weiss & Zane, 2010)

For children with ASD, these 3 skills are challenging and must be embedded throughout activities and across settings and people.

They should be considered in how we set up the environment, deliver instruction, and engage siblings and peers.

Children will need MANY presentations and opportunities to develop initial skills in these areas and then advance these skills for success in school.

Top 3 Targets for Intervention: Requesting, Responsiveness, and Imitation

"If you think you are too small to make a difference, try sleeping in a room with a mosquito"

- African proverb

We can make a difference

Goal setting for each module Program/classroom Personal/Professional

End of the Year Celebration Teams present on progress/successes and

ongoing work plans

Goal Setting

Next meeting date – November 13 & 14

Bring a copy of your classroom schedule

Work on: Effective practices assessment tool –Turn in

at next training

Review early intervention readings

Next Steps