Patricia A. Prelock, Ph. D., CCC-SLP LanguageUniversity of Vermont Burlington, VT Patricia.firstname.lastname@example.org
Mississippi State SpeechHearing Convention March 28, 2009 8:00 am to 12:15 pm
Social Communication Interventions for Children with Autism Spectrum Disorder (ASD)
Traditional Behavioral End Use highly prescribed teaching structure Follow adult’s lead Teach skills one on one Predetermine correct response EXAMPLE: Discreet Trial Social Pragmatic Developmental End Emphasize initiation & spontaneity Follow child’s lead Teach within the natural environment Consider related responses EXAMPLE: Floor Time
CONTEMPORARY BEHAVIORAL APPROACH 1 Offer a ‘middle ground’ 2 Give children choices 3 Share control of teaching opportunities 4 Use preferred activities & materials EXAMPLE: Pivotal Response Training I. Evidence-Based Interventions to Support Communication in Children with ASD A. Time Delay=> inserting a delay between the presentation of a target language response (e.g., responding to a question that has been asked or making a comment about an observed action) and a prompted response (e.g., giving a child the response that is expected). 1. Graduated: no time interval between modeling a target response and expecting the child to imitate that response to gradually increasing the time between the model and the targeted response; once child consistently imitates model, there is a gradual increase in the time interval from 2 seconds to 4, 6, 8 and then 10 seconds; for children with little spontaneous speech and when teaching more abstract communication 2. Constant: starts with a 10 second time delay before modeling and prompting the child’s expected response; use if child possesses a good verbal communication and if the communication target is more concrete 3. Evidence a. Charlop & Trasowech (1991) increased daily spontaneous
speech of 3 children with autism using time-delay; children could learn to greet people appropriately across situations and communicative partners using ‘small talk’ Charlop, Schreibman & Thibodeau (1985) indicated that children with ASD were able to spontaneously demand or request objects & generalized this ability to request across settings and stimuli. Ingenmey & Van Houten (1991) found that the use of time delay increased a child’s spontaneous speech on trained items with generalization to untrained stimuli across settings Matson, Sevin, Box, Francis & Sevin (1993) used graduated time delay and visual cue fading to facilitate the self-initiated language (e.g., hello, excuse me, thank you, play with me) of three children with ASD and mental retardation (4 and 5 years of age). Taylor & Harris (1995) used time delay to teach three children with ASD (5 to 9 years of age) to use the question form “What’s that?” All three children with ASD learned to use the question form “What’s that?” across three experimental tasks using time delay.
Video modeling or Video self-modeling=>watching a video of adults or children modeling particular target behaviors (e.g., conversational scripts, self help skills, greeting, labeling, etc.) (Charlop & Milstein, 1989; Charlop-Christy et al., 2000; Charlop-Christy & Daneshvar, 2003; Sherer et al., 2001) or watching self video models of positive behaviors (Buggey et al., 1999; Buggey, 2005; Wert & Neisworth, 2003) 1. Requires watching a video of adults or children talking or playing with one another or performing a particular task during which time they are modeling targeted behaviors such as conversational scripts, self-help skills, greetings, labeling, etc. 2. Helps focus the attention of the child with ASD on the relevant stimuli in the video; with practice and rehearsal the child begins to retain and display the targeted language and behavior that is modeled; repeated viewings support the child’s ability to learn the specific vocabulary associated with targeted situations 3. Fosters the ability of children with ASD to take what they have learned in a video modeling session and generalize that information into all aspects of their daily life (Shipley-Benamou, Lutzker, & Taubman, 2002). 4. Considerations (Charlop-Christy & Kelso, 1997) a. Consider a motivating theme in the conversation or play being modeled b. Camera is strategically located to present facial expression or show an actor’s hands carrying out a particular task c. Pause the video to highlight target expressions d. Prompt child’s attention as needed by saying something
like “Watch the T.V.” or “Look” e. Following the video viewing, ask the child to do what they watched f. Debrief with the child reviewing what was seen and heard, identifying any new language heard as well as noting the prosody and emotional expression of the models (Charlop & Milstein, 1989) g. Talk about possible variations of events so the child with has opportunities for flexible learning and thinking h. Encourage and reinforce attempts to demonstrate the modeled behavior i. Rewind to review important parts 5. Parents & teachers need to understand what is being modeled so child’s learning can be supported 6. Steps (Charlop-Christy, 2004) a. Select and define the behavior to be developed (e.g., conversation goal to increase the number of turns in an exchange with a peer) b. Complete a task analysis to itemize the steps (e.g., teaching greeting) c. Observe whatever target script has been identified in children who are typically developing (e.g., greeting on the playground or in the hallway) d. Present each step slowly & have actors exaggerate specific steps while looking into the camera e. Need to demonstrate behavior 75-80% of the time before determining acquisition (Charlop-Christy, 2004) f. Provide at least two observations of the video before assessing learning g. Create short scripts (usually three lines each for the child with ASD and the communication partner) so there is a reciprocal communication exchange h. Gather input from parents, teachers and the child to guide development of the video model 7. Evidence a. Video modeling supports the skill development of children with a variety of disabilities (Dowrick & Dove, 1980; Dowrick & Hood, 1981; Dowrick & Raeburn, 1995) & children with ASD (Banda et al., 2007; Bellini & Akullian, 2007; Charlop & Milstein, 1986; Charlop-Christy & Daneshvar, 2003; Charlop-Christy et al., 2000; LeBlanc et al., 2003). b. Selected research using video modeling to support communication & social skills 1) Communication skills a) Spontaneous requesting (Wert & Neisworth, 2003)
Recognizing emotions in speech & facial expressions (Corbett, 2003) c) Compliment giving initiations & responses (Apple et al., 2005) d) Language production (Buggey, 2005; Charlop-Christy et al., 2000) e) Verbal responses to questions (Buggey et al., 1999) f) Conversational speech (Charlop & Milstein, 1989; Charlop-Christy et al., 2000; Nikopoulos & Keenan, 2003, 2004; Ogletree & Fischer, 1995; Sherer et al., 2001) g) Vocabulary & communication performance (Baharav & Darling, 2008) 2) Social skills a) Play behaviors—reciprocal play (Nikopoulos & Keenan, 2004, 2007); motor & verbal sequences (D’Ateno et al., 2003); independent play (Charlop-Christy et al., 2000); play-related comments (taylor et al., 1999); socio-dramatic play (Dauphin et al., 2004; Nikopoulos & Keenan, 2003) b) Complying, greeting & sharing (Simpson et al., 2004) c) Spontaneous greeting (Charlop-Christy et al., 2000) d) Social Initiations (Buggey, 2005; Maione & Mirenda, 2006; Nikopoulos & Keenan, 2004, 2007) e) Joining in & maintaining conversations (Sansosti & Powell-Smith, 2008) c. Both in-vivo and video modeling were effective in increasing affective responding (i.e., sympathy, appreciation, & disapproval) for 3 preschoolers in the home setting & in the context of play activities along with the use of RF and prompting procedures (Gena, Couloura & Kymissis, 2005) d. Review of studies on video modeling suggest that this is a promising intervention to support social communication & functional skills (Ayres & Langone, 2005; Banda et al., 2007; Bellini & Akullain, 2007) C. Pivotal response training and naturalistic teaching=>focusing on increasing motivation by incorporating choices, reinforcing attempts, modeling, and natural consequences (Koegel at al., 1999; McCormick et al., 2003; McGee et al., 1992; Pierce & Schreibman, 1995; 1997) 1. Pivotal behaviors (e.g., motivation, responsivity to multiple cues,
self-initiation, empathy, self regulation, social interaction) are central to a child’s day-to-day functioning with the ultimate goal of training in these areas to facilitate generalized improvements across contexts 1. Components a. Provide a question, instruction or an opportunity for the child to respond using language appropriate to the task EXAMPLE: If it is time to get ready to go home on the bus, a teacher might go to a child, get his attention by tapping him on the shoulder & saying his name & then simply stating, “Tommy, get your coat.” b. Provide clear and uninterrupted maintenance tasks (those the child can already perform) with novel tasks (those the child will be learning) EXAMPLE: If child knows all his colors & loves matchbox cars, you might rotate asking what color a car is (what he knows) with what kinds of car it is (new information he is learning). You allow the child to play with the car for which he identified the correct color. If he doesn’t know the type of car, however, the correct answer is modeled, he is prompted to respond and once he repeats the name he is rewarded with being able to play with the care. c. Give the child some choice or shared control in selecting a learning task. EXAMPLE: Selects books to read at bedtime & then child is asked questions about the story selected d. Structure a child’s learning environment so that s/he is able to respond to multiple cues EXAMPLE: Learns that a red ball is different than a red box; yellow balloon is different than a red balloon e. Reinforce the child’s behavior immediately (e.g., responds to “who wants juice” & is given juice), respond to all attempts & make sure the reinforcement is a natural consequence for the behavior EXAMPLE: Child is looking at a book with an adult; you come to a picture with a frog jumping from one lily pad to another and say, “What is the frog doing?” Child point to the frog and says, “Green frog.” You then say, “Yes, it is a green frog. What’s the frog doing? Is he jumping? Child says, “jumping” & you follow with, “Yes, he is jumping.” And as you turn the page & point to another frog jumping, you say, “What is he doing?” 3. Monitor implementation of the intervention a. Did I have the student’s attention? b. Did I use clear and simple directions? c. Did I follow the student’s lead or choices? d. Am I providing a mixture of learned skills with new skills? e. Did I reinforce good attempts?
f. Am I rewarding the student with what he is asking for? g. Am I reinforcing immediately? Evidence: a. Successfully used to increase social interaction in toy play between typical peers and children with ASD (Koegel & Koegel, 2001) b. Improvement in sound production has reported for 5 children with ASD in response to a systematic approach to intervention using motivators within a natural language teaching framework (Koegel, Camarata, Koegel, Ben-Tall, & Smith, 1998). Although speech and language intervention was successful in this context, generalized learning did not c. 2 children with ASD were successful in their ability to engage in a variety of complex social and attentional behaviors (e.g., initiation, joint attention) using peer mediated PRT (Pierce & Schriebman, 1995); replicated findings in later study (Pierce & Schriebman, 1997) d. PRT improved symbolic play skills in 7 children with autism (Stahmer, 2001) e. Children with ASD taught self-initiations using PRT (Koegel, Koegel, Shoshan & McNerny, 1999).
Evidence-Based Interventions to Support Social Interaction in Children with ASD A. Peer mediated interventions 1. Peer tutoring=>pairing students to work on an instructional strategy using assistance, instruction & feedback with peer supports (DuPaul & Henningson, 1993; Locke & Fuchs, 1995; Odom et al, 1985; Goldstein et al., 1992; Kamps et al., 1992; Kohler et al., 1995); teachers train peers in the required skill & response; use of peer models helps students practice and improve a number of skills including language (Saenz et al., 2005), imitation (Garfinkle & Schwartz, 2002)& social skills (Bredekamp & Copple, 1997; Holahan & Costenbader, 2000; Odom et al., 1999) 2. Proximity=>placing typical peers who are socially competent with children with disabilities, directing them to play with their peers without specific training 3. Prompting and reinforcing => combination strategy where socially competent peers are trained to prompt a child with disabilities to play and then to reinforce the child’s responses. 4. Antecedent prompting (Simpson et al., 1997)=>child with ASD is paired with a socially competent peer who is instructed to remain in proximity to the child with ASD; teacher provides periodic prompts to the child with ASD to engage in social interaction 5. Peer initiation=> typical peers are trained to make social
initiations with children with disabilities (Lee & Odom, 1996) Peer mediation (Strain & Cordisco, 1994; Strain et al., 1996) Learning Experiences…An Alternative Program (LEAP) (Strain & Cordisco, 1994; Strain et al., 1996). a. Parents are also engaged in the peer mediation training as they support their other children in interactions with their sibling with ASD. b. Four basic steps highlighted in example below are repeated for each social skill taught (i.e., sharing a toy, asking for a toy, suggesting to a friend what to do with a toy, saying nice things about the friend or what the friend is doing) c. Tracking forms are used to collect data on the trained behaviors the typical peers demonstrate and the responses of the children with ASD d. Time engaged is documented Four steps to support peer mediated intervention 1) Introduce the skill to a typical peer, describing & providing a rationale 2) Demonstrate skill for typical peer 3) Rehearse skill with the interventionist 4) Typical peer practices/rehearses the skill with another child Evidence a. Social skills groups facilitated interactions & time engaged between 3 students with ASD & their typical peers in 1st grade (Kamps et al., 1992). b. Increased interactions among typical peers and children with disabilities & a reduction of stereotypic or unusual behaviors by the children with disabilities (Lee & Odom, 1996) c. Intervention with 85 children with ASD and 48 typically developing peers (5 to 13 years of age) led to > time engaged, length of sustained interactions, responsiveness to initiations, & decrease in self-stimulatory behaviors; training of the typical peers via videotape viewing of children with ASD, instruction about the disorder at their comprehension level, and some role-playing (Roeyers, 1996). d. Children with ASD reduced symptoms after two years of intervention and an increase in developmental progress as measured by cognitive and language assessments (Strain et al., 1996). e. Peers’ use of facilitative strategies resulted in increased communicative interaction in preschool children with ASD including turn-taking and on-topic responsiveness to peer initiations when both children were reinforced and a decrease in nonsocial, less desirable behavior (Goldstein &
Wickstrom, 1986) Typical peers as young as 3 can be taught to engage with socially withdrawn peers (Strain, 1977; Strain, Shores, & Timm, 1977) Elementary school students with ASD were taught greeting, conversation & play over 8 sessions & improved their greetings and play with less success in conversational skills (Barry et al., 2003) Typical peers increased their communication directed toward children with ASD during art activities in a museum-based art program (Schleien et al., 1995) Three typical peers were taught attention directing behaviors and language to promote joint attention with adult coaching in twins with ASD; the twins increased their joint attention, symbolic play and language use (Zercher et al., 2001) Peer training used to teach requesting, commenting and sharing during game play and compared self versus peer monitoring for school students with ASD using direct instruction (Morrison, Kamps, Garcia & Parker, 2001). Peer training used to support social skills and cooperative learning groups across two studies including a total of 39 students with ASD ranging in age from 7 to 14 years; results indicated increased social interaction among peers with generalization effects favoring cooperative learning groups (Kamps et al, 2002) In classroom-based programs, typical peers are taught to play & respond to children with ASD; a buddy system was created teaching children to STAY, PLAY & TALK; typical peers increased their interactions with children with ASD & children with ASD increased their responsiveness & interactions with typical peers although there was no generalization to play outside the classroom (Goldstein & Kaczmarek, 1992; Goldstein & Cisar, 1992; Goldstein et al., 1992; 1995; English et al., 1997) Social interactions increased among peers when typical peers were involved in peer training and priming (Zanolli et al., 1996) Peer training was used for greeting, imitating, sharing, turn taking and requesting and resulted in an increased frequency and duration of play for students with ASD (Gonzalez-Lopez & Kamps, 1997) Peer training of 8-9 year olds involving didactic modeling, instruction and feedback increased engagement for children with ASD with no change in initiations and some generalization to untrained peers (Pierce & Schreibman, 1997) Motivational strategies were used during play dates to increase the quality of interactions between children (8-9 years)
with ASD & typical peers (Koegel et al., 2005) q. Use of written text cues & peer training improves the social communication of children with ASD & their typical peers (Thiemann & Goldstein, 2004) r. Circle of Friends used to improve communication between children with ASD & their peers; children with ASD had better response & initiation rates following intervention & at follow-up (Kalyva & Avramidis, 2005) s. 4-6 year old children with ASD > their time engaged with typical peers following peer play that supports behavior regulation, social interaction & joint attention (Prendeville, Prelock & Unwin, 2006) B) B. Social stories=>supporting children’s attention to relevant social cues and decreasing inappropriate behaviors (Cullain, 2000; Gray & Garand, 1993; Lorimer et al., 2002; Smith, 2001, Swaggart et al., 1995; Thiemann & Goldstein, 2001) 1. Composed of short sentences (dependent on child’s developmental B) & language level)and may include printed words alone or words paired with pictures 2. Sentences types (Gray, 1995a) a. Descriptive--define the details of the situation; who, where, why & what’s happening; provides information about the setting, people, or activities (e.g., "Usually I go gym class on Tuesday and Thursdays with my third grade class.”) b. Perscriptive-- describes the child’s possible feelings or responses; they should accurately reflect how the child has been known to respond to a situation (e.g., “I get mad when I have to wait my turn.”) c. Directive--state the desired behavior (e.g., “I can try; I will try; I will work on . . .”); informs children on what they need to do in a given setting (e.g., "When I go to gym class, I listen to what my teacher tells the class to do.") d. Affirmative—gives the child a sense of what those around him maybe thinking or feeling in a situation (e.g., "My teacher likes it when I listen to what he says.") e. Cooperative—describe how other people will be able to help the child in the situation (e.g., “My teacher can help me when I don’t understand what I am suppose to do.”) f. Control--identifies strategies the child might use to recall the information in a social story or that will help the child remember the strategies that will be effective for him (e.g., “When I listen to my teacher’s instructions, I will draw a picture in my head of what the teacher is telling us to do.”) 3. One directive sentence for every 2 to 5 descriptive, perspective or B) control sentences recommended (Gray, 1995b; Gray & Garand, 1993)
C) 4. Use situations from a child’s actual experience to visually present social information 5. Descriptive & prescriptive sentences give students opportunities to develop appropriate responses 6. Behaviors to be addressed are defined through directive statements B) 7. Guidelines (Gray, 1995b) a. Gather information about the child and the social situations that present challenges. b. Determine where the social situation occurs, who is involved, how long the event is, how it begins & ends, what happens & why c. Interview those working with the student & familiar with the situation d. Observe & record the information observed objectively e. Assume the perspective of the student with ASD f. Facilitate perspective taking by asking the student questions about the relevant cues g. Avoid words like ‘always’ & instead, substitute words like ‘usually’ or ‘sometimes’ to ensure flexibility in events/reactions h. Consider reading & comprehension level of the student i. Photographs, illustrations or drawings can be useful to some students i. Use of digital media & computer-based instruction is a potentially engaging method in that digital cameras allow students & teachers to use digital pictures to recreate school info/events on the computer (More, 2008); changes can be easily made; such digital media instruction has been linked to increased motivation, time on task, attention & Rf (Chen & McGrath, 2003; Davies, Stock & Wehmeyer, 2004; Laffey, Ewspinosa, Moore & Lodree, 2003; van Daal & Reitsma, 2000; Yildirim, Ozden, & Aksu, 2001) k. Social stories can be read independently or by a caregiver, presented through audio-equipment, presented through a computer-based program or presented via videotape (Sansosti et al., 2004) 6. Evidence: a. Social stories have been successfully used to teach specific B) social (e.g., greeting) and behavioral (e.g., decreased aggressive acts) skills in children with autism exhibiting a range of ability levels. C) b. Fewer inappropriate social behaviors for children with ASD in the home and school setting following the use of social stories (Cullain, 2000; Kuoch & Mirenda, 2004; Kuttler et al., 1998; Norris & Dattilo, 1999; Romano, 2002; Smith, 2001; Swaggart, et al., 1995)
8 year old girl with ASD reduced inappropriate behaviors following use of social stories in a general education classroom using an AB design, but not much increase in appropriate behaviors during lunch time (Norris & Dattilo, 1999) h. 3 children with autism (11 year old female; two 7 year old males); target behaviors were to increase appropriate greetings & sharing, decrease aggressive acts; used more directive than other sentence types & incorporated some behavioral strategies; appropriate behavior > & inappropriate behavioral acts < for all 3 children (Swaggart et al., 1995) B) e. Reduction in behaviors preceding a tantrum & > in desired behavior for a 12 year old with ASD using social stories read immediately prior to lunchtime and work time (Kuttler et al., 1998) c. Practitioners trained to develop and use social stories for students with ASD in their settings and then rate their effectiveness; greatest success when the social stories were read frequently (Smith, 2001) d. Video feedback paired with social stories to improve the use of social skills (i.e., securing attention, initiating comments and requests, making contingent responses) in 5 children (6 to 12 years of age) with ASD; social behaviors increased following intervention with some generalization for 1 child in the classroom (Thiemann& Goldstein, 2001) B) h. Reduction in rate of problem behaviors for 3 boys with ASD (3 to 6 years of age); controlled for effects of adult attention (Kuoch & Mirenda, 2003) C) i. 2 children (7 & 8 years old) with ASD taught to make D) choices and play appropriately with the materials selected within a play or activity center (Barry & Burlew, 2004) j. social story used in the home environment for a 7 year-old boy with Asperger syndrome experiencing frustration during homework time; frustration behaviors were reduced but not eliminated following social story use; oral communication to express needs or worries during homework time also increased (Adams, Gouvousis, VanLue & Waldron, 2004) k. 3 children with ASD participated in novel activities with an increase in participation following the use of social stories (Ivey, Heflin & Alberto, 2004) l. Children with ASD increased communication & perspective taking using social stories with varying results for children depending on age, ability & motivation (Hutchins & Prelock, 2006) m. 3 children with autism increased time engaged with training & novel peer; &, increased contingent responding
p. q. r. s.
& initiating comments with training & novel peer (Delano & Snell, 2006) 3 boys (8-13 years) with ASD increased appropriate social interactions (Scattone, Tingstrom & Wilczynski, 2006) 3 boys (9-11 yrs.) diagnosed with Asperger syndrome increased social engagement (maintaining conversation & joining in, sportsmanship) for 2 of 3 boys (Sansosti & Powell-Smith, 2006) Child with Asperger (age 9;8) learned to label & explain emotions which was maintained during generalization (Bernad-Ripoll, 2007) 3 boys (3-5 yrs.) with ASD=>one child increased unprompted verbal interactions (Crozier & Tincani, 2007) 3 boys (6-10 yrs.) with Asperger syndrome increased social engagement with some maintenance 2 weeks post-tx (Sansosti & Powell-Smith, 2008) Effects of Social Stories are variable; existing studies are confounded by inadequate participant description & use of SS with other interventions (Reynhout & Carter, 2006); single subject designs are most often used to assess effectiveness--need studies that employ more rigorous experimental control, examine critical components of SS, examine factors related to Tx fidelity, programming maintenance & generalization; assess success with mainstreamed students & compare TX effects with typical peers (Sansosti et al., 2004)
Comic Strip Conversations 1. Use of simple drawings to illustrate an ongoing conversation while providing visual support for individuals who have difficulty understanding the rapid exchange of information that occurs in a back and forth communication a. Identify what a person says or does in a systematic way b. Identify what people may be thinking c. Used to work through a problem & identify solutions visually d. Provide insights into perspective taking 2. What do you do? a. Help student understand that it is okay to draw while talking b. Give the student the opportunity to lead the conversation c. Conversation initially begins as an interview in which the conversational partner asks/writes questions; gradually move to a more conversation-like format 3. Conversation symbols a. Represent specific words & concepts easy to draw (e.g., listening, interrupting, loud vs. quiet words, etc.)
b. c. 4.
Provide consistent visual cues Symbols added over time as student becomes familiar with the process d. Need to be easy to draw with quick recognition of meaning Process for drawing a. Use location symbol (symbol drawn at upper left hand corner of drawing area, e.g., basketball court, everything on the page relates to what happened on the basketball court) b. Focus on a specific challenging situation c. Gather information Where are you? (draws person) Who else is here? (draws person(s)) What are you doing? (draws related actions/items) What happened? What did others do? (draws related actions/items) What did you say? (uses talk symbol) What did others say? (uses talk symbol) What did you think when you said that? (uses thought symbol) What did others think when they said that/did that? (uses thought symbol) d. Share perspective of the adult communication partner e. Follow a sequence or a structure f. Summarize the conversation g. Conclude the conversation with new solutions Evidence: CSC-A positive behavior support strategy (Glaeser et al., 2003) implemented by teachers for a 2nd grade student with ASD 3 Steps a. Introduced & modeled use of the strategy for all types of interactions b. Reviewed CSC book & symbols used to explain thoughts & feelings i. Reinforced use at least once daily & at home RESULTS=>reduced playground & classroom problem behaviors; children with ASD increased perspective taking using CSC (Prelock & Hutchins, 2006)
Floor Time (DIR Model)=>systematic way of working with children to help them move forward developmentally (Greenspan, 1992; Greenspan & Wieder, 1997; Wieder, 1996) which requires parent participation in the promotion of milestone mastery; involves a 20-30 minute interaction period, getting down on the floor with the child 1. Key components to consider a. Helps child reestablish affective contact with primary caregivers & connection emerges from gestural/verbal interactions; increases in relatedness lead to decreases in
odd or stereotypic behaviors b. Caregiver interacts with the child in ways that capitalizes on the child's emotion, and follows the child's interests & motivations c. Child can lead and play whatever captures the child's interest as long as the child interacts with the caregiver who learns to turn an isolated response into a two-person activity 2. Circles of communication are critical components a. Initially, circles are simple, contain reactions, not interactions, and communicate emotions. b. Takes advantage of a child’s natural motivation, increasing the likelihood of a response through enticement c. Playful obstructions are used to up the ante and requirement for interaction. For example, favorite foods are out of reach and require the child to use an adult to gain access. d. As circles increase in length and complexity, child achieves proficiency in relating and higher levels of emotional development. EXAMPLE: (ICDL, 2000, pp. 262-263) [If] a child moves his toy car and the partner moves another car parallel to it or says “Where are we going?” or “Can my dolly have a ride in your car?,” the partner is opening a communication circle. If the child gestures or verbalizes in response, building on his behavior by saying “We go to the house!” or simply bangs his car into the partner’s car while giving a knowing look, he is closing that circle of communication. Even when a child responds with a simple “no” or “shhh!” or by turning away, he is closing the circle of communication. The goal is to facilitate a continuous flow of circles in both unstructured and semistructured interaction. Sometimes these circles will involve only the simplest back-andforth gestures, such as looking, smiling or pointing. 3. Elements of a Developmental Social-Pragmatic Approach a. Follows the child’s lead or interest b. Requires arranging the environment to encourage child initiations c. Respond to all communicative attempts as purposeful d. Emphasize emotional expressions and affect sharing Evidence=>supported through testimonials, chart review of 200 children & a recent single subject design (Greenspan & Wieder, 1997; Ingersoll, Dvortcsak, Whalen & Sikora, 2005) a. 58% were deemed to have “very good outcomes”-demonstrated by purposeful, organized problem solving
and interactions that consisted of more than 50 circles of spontaneous communication; children increased their trust and intimate connections with parents, displaying more pleasurable affect, and a heightened capacity for abstract thinking. b. A variation of floor time was compared with an adult-directed, structured approach yielding statistically significant outcomes in favor of the former (DeGangi & Greenspan, 1997) c. Single subject multiple baseline design examined the effectiveness of more social-pragmatic interventions, using floor time procedures, and found that children increased their spontaneous speech with the therapist as well as their parents (who had not been trained in the tx) (Ingersoll et al., 2005) 1. E. Relationship Development Intervention (RDI) Builds on the concepts of sharing & joint attention; has 6 levels (i.e., Novice, Apprentice, Challenger, Voyager, Explorer and Partner to represent the roles children take on in their relationship development) & 28 stages (e.g., with goals around perspective taking, imagination sharing, integrating ideas, reciprocal conversations, building friendships, self regulation, emotional awareness, group participation & identity development) Designed to support relationship development for children, adolescents & adults with ASD using 3 cardinal intervention principles (Gutstein, 2000) a. Function precedes means b. Social referencing c. Co-regulation Teach function before skills a. Emotion sharing/excitement sharing is the first basic function to develop b. Competence including proficiency, perseverance, responsibility & resilience comes next=> must be proficient in sharing their emotion, stick with the event or experience that excites them, take responsibility for their role in an interaction and bounce back when the experience does not quite go the way that is expected. c. Two strategies are emphasized 1) Guiding=> requires choosing relevant objectives for establishing sharing experiences, maintaining control of the critical elements of an event, limiting variations within that event & setting clear limits for expected behavior. 2) Pacing=> involves modifying one’s communication
style & pace for practicing particular skills to ensure mastery and breaking down complex events or tasks into simpler ones while requiring the child to take greater responsibility for regulating their behavior EXAMPLE: While a dad and his son are playing the drums together, the dad is not using his voice but guides his son’s participation by smiling and nodding his head or showing the child how to hold the drumsticks. Social Referencing a. Requires the ability to perceive and process b. Depends on interactive partners being able to evaluate a match or mismatch in what they are experiencing with one another c. Strategies to support social referencing 1) Use indirect prompts EXAMPLE: A child might be picking out objects from a grab bag and instead of stating, “Pick an object from the bag” the interventionist might say to the child, “What surprise do you have for me?” 2) Use spotlighting=>to make the learning opportunity stand out; create a contrast for the child (e.g., quiet vs. loud voice or pretending that bugs taken out of a box are real and acting afraid) 3) Switch roles so that the child can react to the event or experience that was just shared with the interventionist 4) Emphasize motivation through reinforcing episodic memories=>such as remembering celebrations following an activity with a parent (e.g., a father and son giving each other a ‘high five’ after drumming together or during an activity); stopping an action & mentioning to a child a memory of a favorite event such as going to the beach and then sharing that experience EXAMPLE: Use memory book at mealtime or during quiet family time that includes photos of special family event in which each family member can share what happened 5) Develop frameworks=>identify the central elements of an activity and keep those the same while peripheral elements begin to change. EXAMPLE: Activity: Interventionist sends a car down an incline to a child at the other end of the
incline Central element: Sender-receiver roles (interventionist-child) Peripheral element: Car ---------------------------------------------------------------------Activity: Interventionist gives the child fruit to send down the incline to a parent Central element: Sender-receiver roles (child-parent) Peripheral element: Fruit (replaces the car) ---------------------------------------------------------------------Activity: Child places fruit in a truck and pushes the truck to the parent. Central element Sender-receiver (child-parent) Peripheral element: Truck (replaces the incline) 5. Co-Regulation=>Ongoing fine-tuning of actions to seek feedback from our interactive partners (Gutstein, 2000; 2003) EXAMPLE: If an interventionist placed a ball between herself and a child and required that they walk with the ball between them while picking up the pace, the movement of both depends on the other.
1. Evidence b. Gutstein reports favorable perceptions by parents (N = 20) who rated their children’s performance in several target areas as significantly improved, somewhat better or about the same; improvement at least 80% of the time noted for excitement/enthusiasm, teacher reports, communication/ nonverbal language, initiation, eye contact; family interaction; desire to be with others, sharing emotions, paying attention and behavior. c. Recently, Gutstein et al. (2007) reviewed the progress of 16 children who participated in the RDI program between 2000-2005; while all children met the criteria for autism on the ADOS and the ADI-R, no child met the criteria at a minimum 30 month follow-up; positive results were also found in increased flexibility (e.g., ability to adapt to change & manage transitions) and general education placement (10/16 were in mainstreamed classrooms without an aide); generalization is limited by lack of control or comparison groups d. Because results are preliminary with a small number of participants, they should be interpreted cautiously; systematic and ongoing research of the RDI model will be critical to our understanding of its potential value for children with ASD.
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