Practical Interventions for Practical Interventions for Children with High Children with High

Functioning Autism and Functioning Autism and Asperger’s SyndromeAsperger’s Syndrome

Lauren Kenworthy, Ph.D. and Lauren Kenworthy, Ph.D. and Laura Anthony, Ph.D.Laura Anthony, Ph.D.

Wednesday, January 30Wednesday, January 30thth, , 20082008

CASD Outreach NightCASD Outreach Night

Lauren Kenworthy, Ph.D. Peter Daniolos, M.D Lauren Kenworthy, Ph.D. Peter Daniolos, M.D

DirectorDirector Medical DirectorMedical Director

Pediatric NeuropsychologistPediatric Neuropsychologist Child and Adolescent PsychiatristChild and Adolescent Psychiatrist

Laura Anthony, Ph.D.Laura Anthony, Ph.D. Kathleen Atmore, Psy.D.Kathleen Atmore, Psy.D.

Clinical Child PsychologistClinical Child Psychologist Developmental NeuropsychologistDevelopmental Neuropsychologist

Cheryl Anselmo, M.A., CCC-SLPCheryl Anselmo, M.A., CCC-SLP Angela Bollich, Ph.D., SLPAngela Bollich, Ph.D., SLP

Speech and Language PathologistSpeech and Language Pathologist Pediatric NeuropsychologistPediatric Neuropsychologist

Joette James, Ph.D.Joette James, Ph.D. Christine Amerasinghe/Katea SelbyChristine Amerasinghe/Katea Selby

Pediatric NeuropsychologistPediatric Neuropsychologist Clinical Operations RepresentativeClinical Operations Representative

Katie Jankowski/Jenni SokoloffKatie Jankowski/Jenni Sokoloff BenYerys, PhD/Rafael Oliveras, BenYerys, PhD/Rafael Oliveras, PsyDPsyD

Research AssistantResearch Assistant Post Doctoral FellowsPost Doctoral Fellows

Center for Autism Spectrum Disorders Faculty and Staff

Autism does not have one Autism does not have one cause or cure…cause or cure…

The triad of impairments in autism can The triad of impairments in autism can be fractionated and should be studied be fractionated and should be studied separately (separately (Happe, Ronald & Plomin, 2006Happe, Ronald & Plomin, 2006)) Single explanations of autism have not Single explanations of autism have not

been successful at explaining social deficits been successful at explaining social deficits and rigid/repetitive behaviorand rigid/repetitive behavior

Autistic like behavioral traits in typical Autistic like behavioral traits in typical children (twin study 7-9 year olds) show children (twin study 7-9 year olds) show only modest to low correlations (only modest to low correlations (Ronald et al, Ronald et al,

20062006)) Autism is a heterogeneous disorderAutism is a heterogeneous disorder

Solution to the riddle:

Teach by doing

Teach process (make implicit explicit)

Go step by step

Provide hard copy

Teach by Doing: Harder Than You Teach by Doing: Harder Than You ThinkThink

Intervene in Intervene in everyday activities everyday activities with everyday people in the with everyday people in the contextcontext of a real problemof a real problem

Explicitly decodeExplicitly decode reasons for reasons for changechange

Positive Positive verbal labelsverbal labels

Teach by Doing: Harder Than You Teach by Doing: Harder Than You ThinkThink

Model Model behaviorbehavior Begin from an “external support” Begin from an “external support”

positionposition, slowly encouraging , slowly encouraging internalization of routinesinternalization of routines

Teach until automaticTeach until automatic

Teach by DoingTeach by Doing: “With, Not For”: “With, Not For”

CollaborateCollaborate with child with child Give child opportunity to solve Give child opportunity to solve

problemproblem ElaborateElaborate responses responses RewardReward effort effort Hold child responsibleHold child responsible for outcome for outcome Make all interventions Make all interventions positivepositive

Goal-Plan-Do-ReviewGoal-Plan-Do-ReviewGOAL: WHAT DO I WANT TO ACCOMPLISH?

PLAN: HOW AM I GOING TO ACCOMPLISH MY GOAL?

MATERIALS/ EQUIPMENT STEPS/ASSIGNMENTS1. 1.2. 2.

PREDICTION: HOW WELL WILL I DO?

Self rating 1 2 3 4 5 6 7 8 9 10Other Rating 1 2 3 4 5 6 7 8 9 10

DOPROBLEMS SOLUTIONS

1. 1.2. 2.3. 3.

REVIEW: HOW DID I DO?Self rating 1 2 3 4 5 6 7 8 9 10Other Rating 1 2 3 4 5 6 7 8 9 10

WHAT WORKED? WHAT DIDN'T WORK1. 1.2. 2.WHAT WILL I TRY NEXT TIME?

Incentives for ChangeIncentives for Change MotivationMotivation “Let’s work on your Harry “Let’s work on your Harry

Potter stuff”Potter stuff” CollaborationCollaboration child and teacher or child and teacher or

parent work togetherparent work together Rewards Rewards individually identified based individually identified based

on each child’s interests, child will on each child’s interests, child will help develop the reward systemhelp develop the reward system

Positive Behavior SupportsPositive Behavior Supports (PBS) (PBS) including praise and concrete including praise and concrete progress tracking (graphs, etc; Horner progress tracking (graphs, etc; Horner et al, 2002)et al, 2002)

MUTUAL MUTUAL MISUNDERSTANDINGMISUNDERSTANDING

““A failure to understand how a child’s A failure to understand how a child’s typical behaviors reflect this disability typical behaviors reflect this disability can result in misperceptions such as can result in misperceptions such as viewing the child as noncompliant, viewing the child as noncompliant, willfully stubborn, or unmotivated, willfully stubborn, or unmotivated, rather than confused, involved in rather than confused, involved in repetitive routines, or focusing on repetitive routines, or focusing on less relevant aspects of the less relevant aspects of the situation.” (Kunce & Mesibov, 1998)situation.” (Kunce & Mesibov, 1998)

Misunderstanding/Failure to Misunderstanding/Failure to HelpHelp

What exactly is the problem? What exactly is the problem? What is causing the problem?What is causing the problem?

Physical, Cognitive, Self Regulatory, Physical, Cognitive, Self Regulatory, Emotional, BehavioralEmotional, Behavioral

Vary conditions to test hypothesisVary conditions to test hypothesis Team collaborationTeam collaboration On-going processOn-going process

Placement DecisionsPlacement Decisions Minimum requirements

Staff with ASD expertise and team approach Safe address Specialized pull-out: social/executive support

Best Practice Social/Executive support integrated Small class size

Consider Windows of Opportunity Overload Effects

OverloadOverload

Structure, structure, structureStructure, structure, structure Preview transitions, post schedules, stick Preview transitions, post schedules, stick

to routinesto routines Limit the number of adults/peers who work Limit the number of adults/peers who work

with childwith child Give breaks from peopleGive breaks from people Avoid, decode or at least predict large Avoid, decode or at least predict large

group or unstructured eventsgroup or unstructured events Assign specific jobs or tasksAssign specific jobs or tasks

Misses “Big Picture”Misses “Big Picture”

Safe AddressSafe Address Teach to strength: explicit short Teach to strength: explicit short

rules, recipes, checklists and rules, recipes, checklists and routinesroutines

Predict decline in abilities as Predict decline in abilities as size/structure of group increasessize/structure of group increases

Put new information in familiar Put new information in familiar context context

InflexibilityInflexibility Use prediction, routine and Use prediction, routine and

repetition to support behaviorrepetition to support behavior Make schedule clear and publicMake schedule clear and public Forewarn of any changes in Forewarn of any changes in

scheduleschedule Give 2 minute warnings of time to Give 2 minute warnings of time to

changechange Make changes from one task to Make changes from one task to

the next, or one topic to the next, the next, or one topic to the next, clear and explicitclear and explicit

InflexibilityInflexibility Assess understanding of situation, Assess understanding of situation,

devise Social Story devise Social Story Flexibility trainingFlexibility training Script (“This is not part of the plan, Script (“This is not part of the plan,

is there a new plan?”)is there a new plan?”)

LEARNet Problem-Solving LEARNet Problem-Solving System and Resource WebsiteSystem and Resource Website

Self-Regulation/Executive Function IssuesSelf-Regulation/Executive Function Issues Problem SolvingProblem Solving Self-Monitoring and Self-EvaluatingSelf-Monitoring and Self-Evaluating Flexibility Versus Rigidity In Thinking and BehaviorFlexibility Versus Rigidity In Thinking and Behavior Impulsiveness / DisinhibitionImpulsiveness / Disinhibition Inconsistency in PerformanceInconsistency in Performance Self-Regulation / Executive Function Routines After Self-Regulation / Executive Function Routines After

TBITBI Transition RoutinesTransition Routines InitiationInitiation Cognitive Egocentrism / Theory of MindCognitive Egocentrism / Theory of Mind

LEARNet Problem-Solving LEARNet Problem-Solving System and Resource Website System and Resource Website

Advance Organizers Attention Organization Retrieval and Retrieval Problems Approaches to Teaching: Traditional Training vs.

Apprenticeship Word Retrieval and Word Retrieval Problems Memory and Memory Problems Slow Information Processing Transfer of Training / Generalization Reading Comprehension Concrete vs. Abstract Thinking Written Composition

Authors: Mark Ylvisaker, Ph.D., Mary Hibbard, Ph.D., Timothy Feeney, Ph.D.The Brain Injury Association of New York State (2006)

http://www.bianys.org/learnet

Poor Self-monitoringPoor Self-monitoring

VideosVideos Review situations with safe addressReview situations with safe address Metacognitive narrativeMetacognitive narrative Slow interactions downSlow interactions down Build in explicit, routine checking Build in explicit, routine checking

proceduresprocedures Make predictionsMake predictions

Just Do What I Say!Just Do What I Say!

Written rules, recipes, routines, Written rules, recipes, routines, checklistschecklists

TapesTapes Hand held computersHand held computers NotebooksNotebooks Dry Erase boardsDry Erase boards Talk out loud (Winsler, 2006)Talk out loud (Winsler, 2006) Memorize it, make it automaticMemorize it, make it automatic

Just Sit There!Just Sit There! Activity breaksActivity breaks Increase structure in environment to set Increase structure in environment to set

limits for inhibition problemslimits for inhibition problems Make behavior and work expectations clear Make behavior and work expectations clear

and explicit; review with studentand explicit; review with student Post rules in view; point to them when child Post rules in view; point to them when child

breaks rulebreaks rule Teach response delay techniques (counting Teach response delay techniques (counting

to ten before acting)to ten before acting) Positive behavior management plansPositive behavior management plans

Increased Flexibility

Improved flexibility in the classroom

Better adaptive behavior

Less missed instruction time

Improved fluency and flexibility on cognitive tests

Improved behavioral regulation and

metacognition at school and home

Improved social skills

Improved flexibility at home

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Cognitive Instruction

Guided Practice

Generalization Training

Primar

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Intervention Project Intervention Project Collaboration with IvymountCollaboration with Ivymount

Early InterventionEarly Intervention

Teach pretend play and joint Teach pretend play and joint attention skills (Kasari, Freeman and attention skills (Kasari, Freeman and Paparella, 2006)Paparella, 2006)

Imitate your childImitate your child Speech and Language therapySpeech and Language therapy

Parent-child Interaction Parent-child Interaction Therapy (Eyeberg, Therapy (Eyeberg,

Herschell)Herschell) Child Directed Child Directed

InteractionInteraction Positive play therapyPositive play therapy Developmental Developmental

approachapproach Parent Directed Parent Directed

InteractionInteraction Compliance trainingCompliance training Behavioral approachBehavioral approach

Applied Behavioral Analysis Applied Behavioral Analysis (Lovaas, 1987)(Lovaas, 1987)

Intensive behavioral techniques (30-Intensive behavioral techniques (30-40 hours per week)40 hours per week)

Targets basic language skills, Targets basic language skills, behavior and academicsbehavior and academics

Research shows remarkable Research shows remarkable improvement in 50% of childrenimprovement in 50% of children

Most appropriate for early Most appropriate for early intervention in HFA, Asperger’sintervention in HFA, Asperger’s

ACTIVE Social CoachingACTIVE Social Coaching

Deconstruct social situations Deconstruct social situations (e.g., Solomon, (e.g., Solomon, Goodlin-Jones, Anders, 2004)Goodlin-Jones, Anders, 2004) Process social situations out loudProcess social situations out loud Name your own feelings, what other person Name your own feelings, what other person

might be thinking, feelingmight be thinking, feeling Stop action while watching videos and ask: Stop action while watching videos and ask:

Why did he do that?Why did he do that? What will she do next?What will she do next? What is she feeling?What is she feeling? What will happen if _____? (Gena et al, 2005)What will happen if _____? (Gena et al, 2005)

ACTIVE Social CoachingACTIVE Social Coaching Deconstruct social Deconstruct social

situations situations Interpret facial expressions, Interpret facial expressions,

gestures and body language gestures and body language out loud for your childout loud for your child

I can tell you are angry I can tell you are angry because_____because_____

I could tell she didn’t I could tell she didn’t have time to talk have time to talk because _______because _______

When I look at you this When I look at you this way, it means that _____way, it means that _____

ACTIVE Social CoachingACTIVE Social Coaching Social mentorsSocial mentors

Good for older kids and teensGood for older kids and teens Social activities around special interestsSocial activities around special interests Pragmatic language therapyPragmatic language therapy Drama (Asperger, 1944)Drama (Asperger, 1944) Social Stories, Comic Book Conversations, Social Stories, Comic Book Conversations,

social skills workbooks, etcsocial skills workbooks, etc i.e., write it down! (Theimann and Goldstein, i.e., write it down! (Theimann and Goldstein,

2004)2004)

Social Stories (Carol Gray)Social Stories (Carol Gray)Riding the School BusRiding the School Bus

Valerie LowingValerie LowingSome children ride to school on a bus.Some children ride to school on a bus.Usually the bus will pick me up in the morning and bring Usually the bus will pick me up in the morning and bring

me to school.me to school.Some children like riding the bus. They think it is fun.Some children like riding the bus. They think it is fun.Usually the bus will pick me up from school at the end of Usually the bus will pick me up from school at the end of

the day and bring me back home.the day and bring me back home.Sometimes I will not ride the bus. Mom or dad will tell me Sometimes I will not ride the bus. Mom or dad will tell me

when I will not ride the bus.when I will not ride the bus.

http://www.thegraycenter.org/

ACTIVE Social CoachingACTIVE Social Coaching

Social coaching in groups (e.g., RDI, Social coaching in groups (e.g., RDI, McAfee)McAfee) Discrete skillsDiscrete skills

Eye contact, turn taking, listeningEye contact, turn taking, listening Pragmatic skillsPragmatic skills

Social scriptsSocial scripts ““Opportunistic” skill buildingOpportunistic” skill building Challenge tasksChallenge tasks

(Gutstein, 2000; McAfee, 2002)(Gutstein, 2000; McAfee, 2002)

Family BurdenFamily Burden PsychoeducationPsychoeducation Family navigatorsFamily navigators ““Similar to myself” Similar to myself”

supportsupport Respite careRespite care Encouraging Encouraging

movement towards movement towards advocacy and advocacy and empowermentempowerment

Behavioral Intervention Behavioral Intervention StrategiesStrategies

AversivesAversives ““No,” Time OutNo,” Time Out

Differential reinforcementDifferential reinforcement ReplacementReplacement

ExtinctionExtinction Stop reinforcing (IGNORE)Stop reinforcing (IGNORE)

Antecedent (cause) manipulationAntecedent (cause) manipulation

Behavioral Intervention for Behavioral Intervention for OCD and PhobiasOCD and Phobias

Obsessive/compulsive or phobic Obsessive/compulsive or phobic symptoms can be treated by symptoms can be treated by Exposure and Response Prevention Exposure and Response Prevention TherapyTherapy Create a fear hierarchyCreate a fear hierarchy Client picks where to startClient picks where to start Expose client to feared stimulus Expose client to feared stimulus Prevent escape/avoidance/compulsionPrevent escape/avoidance/compulsion Wait for anxiety to reduceWait for anxiety to reduce

Behavioral Intervention for Behavioral Intervention for OCD and PhobiasOCD and Phobias

MustMust be done in the context of a be done in the context of a trusting therapeutic relationshiptrusting therapeutic relationship

MustMust be led by the child, and under be led by the child, and under child’s controlchild’s control

May take longer for those with ASDMay take longer for those with ASD

AnxietyAnxiety

Relaxation trainingRelaxation training Guided imageryGuided imagery Special interestsSpecial interests MeditationMeditation Adapted yogaAdapted yoga

Cognitive Behavioral Therapy to help Cognitive Behavioral Therapy to help identify anxiety, accept it without being identify anxiety, accept it without being overwhelmed, and use cognitive strategies overwhelmed, and use cognitive strategies to reduce anxietyto reduce anxiety

ComplianceCompliance

Reward when intrinsic motivation Reward when intrinsic motivation doesn’t workdoesn’t work

Collaborate together on behavior planCollaborate together on behavior plan Integrate behavior plan in home and Integrate behavior plan in home and

at schoolat school Rewards and praise work better than Rewards and praise work better than

loss of privileges or punishmentsloss of privileges or punishments Magic ratio of 1:5Magic ratio of 1:5

Attention ProblemsAttention Problems

Environmental adaptationsEnvironmental adaptations Deep pressureDeep pressure Attention training sessions (using Attention training sessions (using

behavioral methods)behavioral methods) Joint attention training in young Joint attention training in young

childrenchildren

MeltdownsMeltdowns

Prevention (warnings, preparation, Prevention (warnings, preparation, practice)practice)

Wait for the storm to passWait for the storm to pass Do not “give in” once meltdown has Do not “give in” once meltdown has

startedstarted Don’t talkDon’t talk Provide safety and reassuranceProvide safety and reassurance It is not your fault, don’t take it It is not your fault, don’t take it

personallypersonally

Preparing Now for Preparing Now for AdulthoodAdulthood

Almost no research on long term Almost no research on long term outcomesoutcomes All information is on current adults using All information is on current adults using

retrospective dataretrospective data Adults with AS seem to continue to Adults with AS seem to continue to

make progress in core symptomsmake progress in core symptoms Best indicator of prognosis may be peer Best indicator of prognosis may be peer

relationshipsrelationships

Asperger’s in AdulthoodAsperger’s in Adulthood Transition planning and training must Transition planning and training must

start in middle school (elementary start in middle school (elementary school if you consider daily living school if you consider daily living skills)skills)

Work issues: interests vs. skillsWork issues: interests vs. skills CollegeCollege

Need for supportNeed for support On-line vs. mainstreamOn-line vs. mainstream

Foundational SkillsFoundational Skills

Personal hygiene and professional dressPersonal hygiene and professional dress Time management skillsTime management skills Professional demeanor (eye contact, Professional demeanor (eye contact,

handshaking skills, etiquette)handshaking skills, etiquette) Limit lectures and talk of special interestLimit lectures and talk of special interest Increasing tolerance for boring tasksIncreasing tolerance for boring tasks Taking instructionTaking instruction

SummarySummary

Interventions need to be multi-Interventions need to be multi-disciplinarydisciplinary

ASDs are developmental ASDs are developmental disorders, so expect changes in disorders, so expect changes in skills and problemsskills and problems Swiss cheese syndromeSwiss cheese syndrome

ResourcesResources

Autism Asperger’s: Solving the Autism Asperger’s: Solving the Relationship Puzzle by Steven Gutstein, Relationship Puzzle by Steven Gutstein, PhD (Future Horizons)PhD (Future Horizons)

Navigating the Social World by Jeanette Navigating the Social World by Jeanette McAfee, MD (Future Horizons)McAfee, MD (Future Horizons)

Executive Skills in Children and Executive Skills in Children and Adolescents, Dawson and Guare (Guilford Adolescents, Dawson and Guare (Guilford Press)Press)

Cartoon Cut-Ups Teaching Figurative Cartoon Cut-Ups Teaching Figurative Language and Humor, Jean Hamersky Language and Humor, Jean Hamersky (Thinking Publications)(Thinking Publications)

ResourcesResources

College Internship ProgramsCollege Internship Programs-Examples-Examples The Brevard Center, Melbourne, FL, 1-866-The Brevard Center, Melbourne, FL, 1-866-

603-1900603-1900

The Berskhire Center, Lee, Massachusetts The Berskhire Center, Lee, Massachusetts (413) 243-2576 (413) 243-2576 http://http://www.berkshirecenter.orgwww.berkshirecenter.org

Foothill College Transition to Work Program Foothill College Transition to Work Program Los Altos Hills, CA, (650) 949-7242Los Altos Hills, CA, (650) 949-7242http://www.foothill.edu/al/ttw.htmlhttp://www.foothill.edu/al/ttw.html

ResourcesResources

Meyer, R.G. (2001). Asperger Syndrome Meyer, R.G. (2001). Asperger Syndrome Workbook: An Employment Workbook for Workbook: An Employment Workbook for Adults with Asperger Syndrome. London & Adults with Asperger Syndrome. London & Philadelphia: Jessica Kingsley Publishers. Philadelphia: Jessica Kingsley Publishers.

Smith, M.D., Becher, R.G. & Juhrs, P.D. Smith, M.D., Becher, R.G. & Juhrs, P.D. (1995). A Guide to Successful Employment (1995). A Guide to Successful Employment for Individuals with Autism. Baltimore: Paul for Individuals with Autism. Baltimore: Paul H. Brookes Publishing Company. H. Brookes Publishing Company.

ResourcesResources

Autism Society of America Autism Society of America www.autism-society.org www.autism-society.org

Yale Yale info.med.yale.edu/chldstdy/autism/welcome.htmlinfo.med.yale.edu/chldstdy/autism/welcome.html

TEACCH www.unc.edu/depts/teacchTEACCH www.unc.edu/depts/teacch National Information Center for Children National Information Center for Children

and Youth with Disabilities www.nichcy.organd Youth with Disabilities www.nichcy.org

ResourcesResources

Future Horizons Future Horizons www.FutureHorizons-autism.comwww.FutureHorizons-autism.com

National Academy Press (free National Academy Press (free version of Educating Children version of Educating Children with Autism, 2001) www.nap.eduwith Autism, 2001) www.nap.edu

OASIS OASIS http://aspergersyndrome.org/http://aspergersyndrome.org/

ResourcesResources

Autism Speaks www.autismspeaks.org Organization for Autism Research

http://www.researchautism.org/ www.NationalAutismAssociation.org

Direct grants to families www.take2camp.org www.dcchildrens.com (Click on

Departments and Programs)