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					Ethan’s Case
Intensive Early Intervention in BC


Presented by
Pam Neuman & Anna Matchneva
Overview
a.   Ethan
b.   IEII and EAI funding
c.   Treatment approaches
d.   Recommendations and conclusions
Ethan
   5 year old First Nations boy, just diagnosed with Autism
   Youngest of 3 children
   Lives with Mom and boyfriend, Dad pays child support but is not involved
   No speech, few vocalizations
   Engages in high-rate self stimulatory behaviours, running back and forth,
    twirling plates and rocking
   Poor eye contact, no play skills, and rarely initiates interactions with
    others
   No self-care skills, eats only with hands, can not dress himself, not toilet
    trained
   Frequent ear infections
   Constantly tired –only sleeps 6-8 hours a night
Funding
   (IEII) Interim Intensive Intervention funding

   For kids with ASD 5 years of age and younger

   Intensive, direct one-to-one intervention at home, in
    preschool and other community settings

   Must follow best practice guidelines
Best Practice
   Supportive, structured teaching methods, based on ABA
   Functional assessment and PBS techniques for behaviour
    problems
   Development of individualized plan of intervention
   Use of multiple, integrated therapists
   Integration in typical settings
   Family involvement in training, development, implementation and
    review of interventions and plans
   Transitions from preschool to Kindergarten
   Trained staff, monitoring and yearly evaluation
Eligible Expenses
   Goes directly to parents-to pay for costs of specialized behaviour
    treatment services

   Parents choose qualified behaviour consultants, interventionists
    and therapists including SP’s, OT’s and PT’s from service
    provider list

   Bookkeeper, accountant, or agency to assist with administrative
    tasks ($100 month) 8% of funding for agency
Parental Responsibilities
   Parents determine amount of funding necessary needed-max.
    amount of $1667 per month-$20,000 per year-paid by either direct
    deposit or cheque
   Open and maintain separate bank account in trust for child
   Select behaviour consultants and therapists from the IEII qualified
    list
   Select behaviour interventionists
   Recruit, hire, fire, train, schedule and pay service providers
   Criminal record checks
   Ensure all service providers meet minimum requirements set out
    by agreement
Parental Responsibilities (Cont’d)
   Manage funds, keep all financial records, invoices, receipts and
    bank statements
   Submit monthly expense records to MCFD every 3 months
   Provide copy of child’s intervention plan within 90 days of entering
    the contract
   Submit final financial statement within 60 days of contract ending
   Return any unused funds
   Employee relationships, insurance, compliance with various
    employment acts, accurate tax payments
EAI
(Extended Autism Intervention Funding)
   For kids with ASD, 6-18 years of age

   Used for intervention services for out of school

   Must follow best practice-same as IEII
Eligible Expenses
   Same as IEII funding
   As well as dietary, nutrition counselling, family
    counselling/therapy, out of school learning support tutouring
   Life/social skills trainer
   Enrolment for specialized therapeutic recreational activities,
    specific to needs of the ASD child
   Administrative costs$50 per month
   20% of funding an be used for training for parents, family
    members or interventionists
   Travel costs, if appropriate
   Equipment and materials related to intervention and
    recommended by a qualified provider
Parental Responsibilities
   Same as IEII

   Parents determine amount of funding needed-max. of $6000 per
    year-monthly payments or lump sum

   Families can not get the EAI funding unless all terms and
    obligations of the previous IEII agreement have been met
EIBI Program
(Early Intensive Behaviour Intervention)
   Only for children with ASD in Delta, Victoria, and parts of the
    Okanogan

   20 hours /week 1-1 ABA highly structured intervention

   Integrated with SP, OT, peer interaction, support for problem
    behaviours and family involvement
What is ABA?
   Applied Behavior Analysis (ABA) is the science of human behavior and
    learning that began with the work of B.F. Skinner over 70 years ago.
   Through many years of research in the field of ABA, we have learned that
    the important parts of the learning environments that we need to organize
    are:
            what we do to make the behavior occur
            what we do after the behavior occurs to make it stronger in the future
   This process of arranging antecedents and consequences is the basic unit
    of teaching children with autism.
   ABA views autism as a syndrome of behavioral deficits and excesses,
    which can be changed with careful programming.
   It is important to understand that ABA is a framework for the practice of a
    science and not a specific program.
Discrete Trial Training (DTT)
    DTT involves:
   breaking a skill into smaller parts
   teaching one sub-skill at a time until mastery
   allowing repeated practice in a concentrated
    period of time
   providing prompting and prompt fading as
    necessary
   utilizing reinforcement procedures

        SIMPLY A WAY OF GOOD TEACHING
Treatment Approaches
Based on Applied Behavior Analysis (ABA)

   Lovaas
   Verbal Behavior (VB)
   Natural Language Paradigm (NLP)
   Pivotal Response Training (PRT)
   Precision Teaching – Fluency
What is Lovaas?
   In the 1987, Dr. Ivar Lovaas demonstrated a successful use of
    discrete trial training with individuals with autism within a specific
    early intensive behavioral program. This program is often referred to
    as the Lovaas Method
    Lovaas,O.I. (1987)
    Outcome: 47% achieved IQ scores in the normal range and completed first grade in a
    regular classroom without support
    McEachin, Smith, Lovaas (1993)
    Follow up indicated that 8/9 individuals maintained the pattern into adolescence
    Eikeseth, Smith, Jahr, Eldovick (2002)
    Compared Intensive Behavioral treatment and Eclectic approach with 4-7 year olds
    with autism
    IB group obtained average scores above the E group on all measures except
    Vineland Socialization
What is Lovaas? (Cont’d)
    Program:
   40 hours / week for 2 years
   1:1 teaching
   Intervention team
   Adult directed
   Trial-by-trial data
   Emphasizes attention, compliance, and imitation
    skills in the beginning of the program
   Language training through vocal imitation
What is VB?
   Verbal Behavior (VB) is a specialty within the field of Applied
    Behavior Analysis (ABA).
   VB is based on B.F. Skinner’s analysis of verbal behavior, which
    looks at the functions of the different verbal operants (units of
    language).
         Mand             request (MO = strong), first verbal operant acquired
         Receptive        understanding of language
         Tact             labeling
         Intraverbal                 ability to talk about items / events that are not
                                     present = ability to have a conversation
         FFCs (R, T, I)   identifying item by it’s description rather then it’s name

    Sundberg (2001) The Benefits of Skinner’s Analysis of Verbal
    Behavior for Children with Autism.
What is VB? (Cont’d)
   VB addresses difficulties in the development of communication seen in most
    individuals with autism, in part by emphasizing functional language and tying it to
    motivational variables.
   The behavioral analysis of language separates the components of language into
    several verbal operants, which enables us to more specifically target language
    deficits and ensure that a student is utilizing language in its functional context.
   The teaching involves creativity and flexibility in order to move with the student’s
    motivational variables.
   Instructors must be highly skilled in order to accommodate this flexibility while
    continuing to target the necessary skills, which are the focus of the particular
    student’s curriculum.
   Research by DRs. Sundberg, Partington, Carbone, McGreevy, Michael, et al.
    in JAVB and JABA
VB Research
   Drash (1999) Using mand training to establish an echoic
    repertoire in young children with autism
        3 nonverbal children with autism 2.5 – 3.5 years old
        Establishing a mand repertoire as the starting point for echoic
        training produced the acquisition of an initial echoic repertoire in all 3
        children within the first 10 sessions
        2 aquired tacts during this period
   Arntzen and Almas (2002) Effects of mand – tact versus tact-
    only training on the acquisition of tacts
        Results indicate that mand-tact training established both verbal
        operants as rapidly as tact-only training established only one verbal
        operant
Intervention Program
Utilizing Analysis of Verbal Behavior
   Adult directed (Intensive Teaching) + Child directed (Natural Environment Teaching)
   DTT (clear instruction, consequence for responding, and prompts to help ensure success)
   Student’s learning must be fun and motivating to all involved
   The number of hours of therapy is not as important as the number of active responses that
    occur during that time taking into account the motivational conditions under which those
    responses occur (Sundberg & Partington, 2003)
   Language development through mand training
   Assessment of Basic Language and Learning Skills (ABLLS)
          Assessment instrument which provides a precise measurement of a student’s existing skills and the
          conditions under which the skills are being utilized and an instant tracking system to continually
          measure learning achievements.
   1:1 teaching / group instruction /adopted by schools in US
   Probe data
Intervention Program
Utilizing Analysis of Verbal Behavior (Cont’d)
Teaching techniques:
 Pairs teaching environment with reinforcement
 Mix and vary instructional demands
 Errorless Learning
 Intersperse easy and difficult demands
 Teach to fluency
Verbal Behavior (Cont’d)
What is NET?
   NET was developed by Dr. Sundberg and Dr. Partington.
   Focuses on a child’s immediate interests and activities as a guide for
    instruction.
   It is conducted in the child’s typical daily environment rather than in formal
    teaching arrangements.
   Many different teaching techniques, including DTT, can be used in the NET
    environment.
   Advantages of NET include: Optimal conditions to teach manding, the use
    of stimuli in the natural environment as target SDs, the reduced need to
    elaborate generalization procedures, the naturalistic instructional context,
    the ease of teaching intraverbal behavior.
    Disadvantages: Requires better training on the part of staff, curriculum is
    not scripted and it is difficult to follow child’s EO to know what to teach,
    measures of acquisition
What is PRT?
   Pivotal response training (PRT) is a behavioral treatment intervention based on the
    principles of applied behavior analysis (ABA) and derived from the work of
    Koegel, Schreibman, Dunlap, Horner, and other researchers.
   Pivotal behaviors are central to a wide area of functioning, so positive changes in
    these behaviors produce improvement across a number of other behaviors (Koegel,
    Koegel & Carter, 1999).
   Key “pivotal behaviors”:
         Motivation
         Responsiveness to multiple cues
         Self-management
         Initiation of interactions
   Teaching pivotal behaviors involves DTT (clear instruction, consequence for
    responding, and prompts to help ensure success)
What is PRT? (Cont’d)
   PRT is an intervention that typically developing children can use to
    assist their peers with autism to attend to and maintain effective
    social interactions.

   Generalization to new toys and new adults as well as the
    maintenance of improved play behaviors has been seen in
    children who have participated in PRT (Schreibman, Stahmer, &
    Pierce, 1996).

   Research is currently being conducted which assesses ideal child
    characteristics for PRT. Pilot data suggests that there are some
    children that are better candidates for PRT than others:
    “Children perform best in this type of training who interact with toys and who do not
    have an extreme amount of self-stimulatory behavior that does not involve objects”
    (Sherer and Schriebman, 1998)
PRT Research
   Stahmer (1995) Teaching Symbolic Play to Children with Autism using
    PRT
         7 children with autism (language skills of at least 2.5 years)
         Used PRT to teach engagement in symbolic play 8 weeks / 3 1-hour session per week
         All of the children learned to perform complex and creative symbolic play actions at levels
         similar to that of language-matched typical peers
         Skills generalized to new toys and new setting
         Increased interaction skills

   Shaw (2001) Behavioral Treatment for Children with Autism: A Comparison
    between DTT and PRT in teaching Emotional Perspective-taking Skills
         6 children with autism
         DTT vs PRT: treatment effectiveness, overall improvement, rate of skill acquisition,
         generalization and maintenance
         DTT showed increased treatment effectiveness in skill acquisition
         PRT showed increased treatment effectiveness in generalization and maintenance
         Results for treatment effectiveness were inconsistent due to individual differences
PRT Research (Cont’d)
   Koegel, Bimbella and Schreibman (1996) Collateral Effects of
    Parent Training on Family Interactions
        4 scales: level of happiness, interest, stress, and style of communication
        PRT parent training paradigm resulted in families showing positive interactions in all 4
        scales and generalization to daily life
Components of PRT Program
   Choice (shared control to increase motivation)
   Clear and uninterrupted instructions or opportunities
   Reinforcement of approximations/attempts
   Reinforcement has a specific relationship to the desired
    behavior
   Natural reinforcement ("ball" gets ball, not praise)
   Child chooses object for instruction
   Multiple examples or multiple components presented (e.g.,
    use two different objects but same verb such as "roll car"
    and then "roll ball“)
   NLP used to teach language
   Implemented by parents and peers
What is NLP?
   Builds upon arranging the environment to increase opportunities to use
    language
   Instructor follows child’s lead, choice, or interest
         "Children with autism have also been shown to be more successful in learning initial words
         and language and to engage in longer periods of sustained conversational interaction
         when their interests are considered." (Koegel, 1995)
   Structure is taught during natural play interaction
   Language targets are presented in the context of the activity that the child is
    involved in
   Teaching multiple exemplars in natural environments to provide for
    generalization
   Instructions are similar to ones that child will encounter in everyday
    interaction
   Reinforces speech attempts
   Emphasis on turn taking and ongoing interaction between the teacher and
    the child as mutually active partners
NLP Research
   Koegel, O’Dell & Koegel (1987) A Natural Language Teaching
    Paradigm for Nonverbal Autistic Children
         2 nonverbal children with autism
         Analogue (DTT) vs NLP
         Both children showed more imitative utterances with NLP
         Children demonstrated generalization to spontaneous utterances only with NLP
         Generalization of clinical gains occurred in other settings for both children with NLP
   Delprato (2001) Comparisons of DTT and NLP for Young Children with
    Autism
         8 studies with language-criterion responses showed that NLP was more affective then
         DTT
   Laski, Charlop & Schreibman (1988) Training parents to use the NLP to
    increase their autistic children speech
         Parents of 4 nonverbal and echolalic autistic children
         Following training, parents increased frequency at which they required their children to
         speak
What is Precision Teaching?
   PT is not a method of instruction as it is a precise and systematic method of
    evaluating instructional tactics and curricula (West & Young, 1992)

   PT does not prescribe what should be taught or how to teach it: The
    instruction can be by any method or approach

   The most effective applications of PT have been when it is combined with
    Direct Instruction (Johnson, 1989)

   Key elements of PT framework:
         pinpointing of target behaviors
         analysis of instruction and the type of response required
         importance of fluency
         building upon fluent pre-requisite skills
What is Precision Teaching?
(Cont’d)
   PT, as an addition to any educational program, provides sensitive
    and precise measurement, real-world mastery and instructional
    options (Kerr, Smyth & McDowell, 2003)

   Learner knows best: if a student is progressing according to plan,
    then the program is appropriate for that student; otherwise, there is
    a flaw in the program and it needs to be changes in some way

   Standard Celeration Chart : precise tool to record student’s
    performance
What is Fluency?
   Fluency describes the behavior that is flowing, accurate and seemingly
    effortless (Kerr, Smyth & McDowell, 2003)

   Fluency is a combination of speed and accuracy that characterizes
    competent performance (Binder, 1998)

   Many students with autism miss social and educational opportunities
    because of their long latencies to respond (Weiss, 2002)

   Fabrizio & Schirmer (2002) Teaching Visual Pattern Imitation to a Child
    with Autism
         single case study of a 5 years old boy with mild autism
         taught to identify and complete visual patterns in a relatively short time
Comparison Overview
Lovaas                     VB                              PRT
Views spoken language as   Views spoken language as        Views spoken language
receptive and expressive   defined by Skinner’s            as receptive and
                           behavioral classification:      expressive
                           echoic, receptive, mand,
                           tact, etc

Focus on early verbal      Focus on early mand             Natural Language
imitation and receptive    training                        Paradigm
language

Teacher chooses the        Stimulus items chosen           Child’s choice
stimulus items             based on the child’s interest
Comparison Overview (Cont’d)
Lovaas                         VB                             PRT
Presents learning              Presents learning              Presents learning
opportunities mainly in        opportunities both in formal   opportunities in child’s
formal teaching settings       settings and in the child’s    natural environment only
                               natural environment

Delivers other reinforcement   Delivers natural               Delivers natural
with social reinforcement      reinforcement paired with      reinforcement (child
(child says “ball” and gets    social reinforcement (child    says “ball” and gets ball
M&M)                           says “ball” and gets ball to   to play with)
                               play with)


No-No-Prompt sequence for      Errorless Learning             Tell – Show - Do
incorrect responses to
mastered items
Comparison Overview (Cont’d)
Lovaas                        VB                             PRT
Uses “mass trials” to teach   Varies stimulus and            Follows child’s lead and
new items, and does not       response every few trials      varies stimulus and
vary stimulus and response    from the beginning of the      responses
until much later in the       program
treatment program

Teaches to a “mastery         Teaches to fluency, that is,   ???
criterion” typically 80-90%   responses must be quick,
over three consecutive        strong, and loud over 3
teaching sessions             consecutive independent
                              probes

Takes data on every trial     Probes daily                   ???
Other Interesting Research
   Kamps (1990) A Comparison of Instructional Arrangements for
    Children with Autism Served in a Public School Setting
         3 elementary school students with autism
         one-to-one vs small group
         teaching word recognition skills
         small group allowed for more trials and reinforcing statements closely
         approximating regular classroom activities
   Bertsch (2003) A Comparison of One-to-one and Small Group
    Instruction for Young Children with Autism: Focus on Effective
    Teaching and Behavior Management
         SG is more efficient and effective than 1:1
         small group instruction offers fewer direct learning opportunities
         SG: faster rate of acquisition, more efficient in term of time and resources
Behavioral Approach             Social-Pragmatic
DTT                             Developmental Approach
<___L______VB_____PRT_____ ___________________________>



Teacher                                         Parent

<___L______________VB_______________PRT______________>
Every day use
Training
Data collection
Time
Service Availability
Service Provider Availability
L=5            VB = 1           PRT = 1   PT-F = 1
Training
L=3            VB = 1           PRT = 1   PT-F = 1
Behavior Interventionists
L=3            VB = 1           PRT = 1   PT-F = 1
Financing
L=5            VB = 4           PRT = 2   PT-F = 4
Network Support
L=5            VB = 3           PRT = 1   PT-F = 1
Recommendations: Hopeful Ideologies…
   “…we can optimize research and practice by reminding ourselves not to put all of our
    “eggs” (i.e., resources, hopes) in any single procedural basket. People with autism,
    like all of us, must learn to learn in a variety of ways: from direct instruction; from
    incidental teaching; from television, videotape, and computer; from parents, teachers,
    peers, and employers; and from pictorial, auditory, and textual cues. There are
    various intervention procedures, all firmly grounded in science, that accomplish these
    different but equally important objectives. The most important aspect of these
    procedures is their scientific underpinnings. The challenges are to support and
    promote intervention efforts that reflect the array of contemporary, empirical based
    procedures and to teach discrimination among scientific and unscientific approaches
    to treatment. (Krantz, 2000)

   Service provider utilizing a variety of scientific approaches and fitting a curriculum and
    instruction to the child and not a child to the curriculum and instruction

   1-stop shop, full meal deal/all-inclusive plan-an organization that takes care of
    everything for the family with therapists that use a multi-treatment approach
Recommendations: Reality Check

   Does not exist here in B.C.

   Only treatment available that can suit this child’s
    immediate needs is Lovaas

   28-30 hours a week one-to-one therapy-service
    provider must use “The New Me Book”
Other Recommendations
   Family should interview the therapists and ask the following
    questions…..
   Goodness of fit, that takes into consideration the cultural ecology of
    the family, 2 siblings, parent involvement etc.
   Preschool-integrated
   Good paediatrician who has experience working with children with
    developmental disabilities
   Immediate referral to an ENT doctor
   Family support institute, ASBC, MMOM, ACT-BC
   Bookkeeper and extension of the funds for additional 6 months
Choosing an ABA Provider
   MCFD Service Provider Qualifications:
       Graduate degree in related field

   Behavior Analyst Certification Board (BACB)
       www.bacb.com

   Guidelines for choosing and ABA provider developed by
    FEAT – Greater Bay Area
        www.php.com/feat.htm
What questions should I ask?
   Where and by whom were you trained?
   Do you network with other professionals?
   Do you have experience working with my child’s level and age?
   What stages of therapy have you been involved in?
   What kind of assessment do you do and how do you train parents and other
    staff?
   How many children do you serve? How many hours can you work with my
    team?
   Do you develop programs to assist with self-help and living skills?
   How do you keep current in the field?
   Etc

				
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