building capacity for serving infants and toddlers suspected of having autism spectrum disorder...
TRANSCRIPT
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Building Capacity for Serving Infants and Toddlers
Suspected of Having Autism Spectrum Disorder (ASD)
Adrienne Frank, MS, OTRBeth Pruitt, MEd,CCC-SLP
Child Development Resources
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Participant Goals
Learn about a grant-funded project Review promising approaches and
related research for serving young children with ASD
Understand key interventions appropriate for infants and toddlers
Identify ways that EI providers can build capacity for serving ASD
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Building Capacity Project
A one-year grant project at CDR Funded by the Williamsburg
Community Health Foundation Goal: To investigate proven,
successful approaches, obtain resources, and develop a revised plan for serving infants and toddlers with ASD
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Project Accomplishments Visits to Programs
TEACCH in Chapel Hill, NC Virginia Institute of Autism
in Charlottesville The Step-by-Step program
in Suffolk
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Conference Attendance
DIR Model – Greenspan SCERTS Model Sensory Integration Biomedical Approaches Applied Behavioral Analysis (ABA) Pivotal Response Training (PRT)
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Workshops Sponsored by CDR
Quarterly staff development Pivotal Response Training – 2 days Dr. Accardo
Screening Young Children Suspected of ASD
Explaining ASD Resources and Services to Families
Partnering with Physicians Related to Diagnosis and Services
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Other Grant Funded Activities
Families participated in training Purchased materials and equipment Obtained screening/assessment
instruments Partnered with the College of William &
Mary for consultation, staff development, student research tasks, and respite care for children
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Other Activities continued
Collected data and compared approaches
Clarified values for CDR’s approach for serving infants and toddlers with ASD
Developed considerations for IFSP development
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CDR Values Statements for Serving Infants and Toddlers Suspected of Having ASD
Outcomes, interventions, and services must be individualized and based on family’s identified needs and stated in the IFSP
Intervention takes place in the natural environment, functional for child and family
Frequency and intensity based on child and family’s concerns and preferences
All children suspected of having ASD should be screened with appropriate instruments and assessed and followed by the MDT team
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Values continued
All children suspected of ASD should be seen by a neurologist or developmental pediatrician
Intervention should be positive, social and communicative, especially with primary caregivers
Skills should be developed and practiced across daily routines and settings for generalization and maintenance
Developmentally appropriate play is linked to cognitive, linguistic, and social skills
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Values continued
Family and primary caregivers learn intervention as part of the daily routine, using activities beyond the times when professionals are available
Professional development must be continuous and intensive and there must be a transfer of knowledge across professional disciplines
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Screening for ASD
A number of screening instruments exist, “none are sufficiently sensitive and specific to warrant universal usage, … many await validation… many over identify or miss children with mild variations of ASD.” Pasquale Accardo, M.D.
(e.g., ABC, ASQ, CHAT, M-CHAT, PDDST, STAT, SCQ)
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Multiple Screening Instruments - Most sensitive items
Does your child ever bring objects over to you to show you something? (M-CHAT)
Child looks to where mother is pointing (Johnson 04)
Show interest in non-sibling peers (Klin, Volkar, & Sparrow, 92)
No babbling by 12 mos (Choueiri & Bridgemohan, 05)
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What to look for… What is the child’s language history?
Milestones (e.g., words, phrases) Deviance (e.g., echoed speech) Regression (i.e., decrease in language at
12-24 months)
What is the family history? Autism, PDD, depression, schizophrenia
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What to look for…
Presence or history of… Poor eye contact Lack of emotional expression Toe walking Flapping Picky eating Large head circumference (1.5 SD above
mean) Posteriorly rotated ears (> 10 degrees)
Pasquale Accardo, M.D.
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Intervention Continuum
Didactic Naturalistic Developmental
Prescriptive
Directive
Skill - based
Flexible
Facilitative
Activity - based
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Didactic Approaches
Based on behavioral theory Repetitive drill and practice trials Prescriptive antecedent/behavior/consequence
ABC sequence or stimulus-response-reinforcement
Adult directed – leads to passive communication style
Reinforcement of desired behavior in controlled setting – lacks of generalization to new setting
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Naturalistic Approaches
Applies behavioral principles in natural settings Moderately adult directed - adult makes decisions
in the moment, requires skill Emphasis on using functional, pragmatic social
interactions rather than ABC sequences Goal of spontaneous, child initiated interactions Intrinsic rather than tangible/edible reinforcement Focus on maintenance / generalization
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Developmental Approaches
Intervention goals based on typical communication development
Functional communication rather than speech Child directed for motivation, functionality Teach through routines -multiple opportunities,
increasing desire to communicate Success relies on the talent of interventionist Limited research
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Approaches
Didactic Naturalistic
Developmental
Discreet Trial ABA
X
TEACCH X
PRT X
SCERTS X
DIR X
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Simpson (2005) Practice Categories
Scientifically based practices ABA including discrete trial Pivotal Response Training (PRT)
Promising practices TEACCH
Limited supporting research DIR SCERTS (not in book) Biomedical approaches
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Developmental Approach e.g., SCERTS
Based on developmental research with priority goals of social communication and emotional regulation
Considers health including biological and/or nutrition, sensory, arousal levels, and environmental stressors
Considers child’s functional needs and family priorities Teaching is flexible – “teachable moments” Activity based in multiple, natural environments and
contexts with families as intervention agents and learning with typically developing peers
Incorporates positive behavior support methods, multimodal communication, visual, etc.
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Applied Behavior Analysis (ABA) E.g., Discrete Trial Training (Lovaas)
A scientific approach to improving socially important behaviors
ABC / SRR sequences Direct measurement, single-subject study Functional assessment task analysis Setting event and establishing operation Stimulus control Generalization / maintenance Shaping, fading, prompting, chaining Reinforcement contingencies
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ABA Based Approach Pivotal Response Training (PRT)
Pivotal areas: Motivation, responsivity to multiple cues, self-management, self-initiations, empathy
Use pivotal response techniques: Obtain and keep child attention, maintenance tasks (interspersing, variation), shared control (child choice and directed), responsivity to multiple cues (decrease overselectivity), reinforcement contingent, reinforce attempts for motivation, direct and natural reinforcers
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Goals of Pivotal Response Training
Increase child’s motivation Increase responsiveness Increase engagement of the
learning environment Increase functional behavior
/replace repetitive or challenging behaviors
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Examples of Environmental Arrangement
Interesting materials Inadequate portions Out of reach Choice making Assistance Unexpected situations
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Plan for Generalization Careful selection of targeted
environments, situations for intervention
Interventions occur within natural environments relevant/typical to the child Not contrived situations
Across settings, stimuli, people Opportunities to use skill
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Writing IFSP Goals for ASD
Types of Goal Content Developmental milestones based on
the area of delay Developmental milestones related to
items significant to children with ASD Intervention goals from ASD approach Change/ decrease in behavior that is
atypical or affects interactions
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Objectives Examples
Area of delay – e.g., Child will use 10 words ASD area – e.g., Child will point to item
named in 8/10 trials. ASD approach – e.g., Child will match 5
objects to picture (photo, color drawing, line drawing).
Behavior – e.g., Child will exhibit hand flapping less than 5 times during a structured task with an adult.
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Criteria for Measurement
Quantity Amount – e.g., 3-5 words Trials – e.g., 3 out of 5 timesGeneralization People – mother, babysitter, visitor Places – home, neighbor’s, play group Situations – quiet, noisy, unfamiliar
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Examples of Goal Areas
Joint attention Communication – frequency, form, function Social interactions – imitation, with peers Generalization across settings, situations Play behavior - symbolic, pretend,
imaginative Improve regulatory/sensory capacity
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The National Research Council (2000) says children with ASD should receive…
Early identification and intervention Active engagement and intensive
programming (at least 25 hours) Repeated and planned teaching
opportunities One-to-one or small group / low adult to
child ratio Family involvement Continuing assessment
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CDR’s Revised Plan will help to:
Identify and diagnose children suspected of having ASD
Develop IFSPs that reflect values of practice Refer children to appropriate diagnostic
evaluations Continuously seek out new intervention
approaches/ strategies Make materials and resources available to
families Help children to transition to appropriate
services