Autism Spectrum Disorder Intervention

							Autism Spectrum Disorder:
       Intervention
     Grace Hao, Ph.D., M.D., CCC-SLP
     Thomas Layton, Ph.D., CCC-SLP
      North Carolina Central University
How much do you know about
         Autism?
 Is everyone with autism the same?
 Is Autism an emotional disorder?
 Is Autism a rare disorder?
 Does Autism only affect children?
 Is it the case that people with autism do not
  like other people?
 Is it true that all children with autism have
  special gifts?
 Is Autism a life-long difficulty that can not be
  helped?
  Autism Spectrum Disorders
      Basic Groundwork

Neuro-
developmental
disability
Autism Spectrum Disorders
    Basic Groundwork
 Prevalence
   3-5/10,000 (70s); CDC:1/150 (2007)
 Gender differences: 4-5 boys/girl
 Spectrum disorder
 Diagnostic criteria (DSM-IV-
             TR)
 Qualitative impairment in social interaction
 Qualitative impairment in communication
 Repetitive and restricted behavior,
  interests, and activities
                                               ASD




                                                                               Repetitive & restricted
Social Interaction                         Communication                        behavior, interests,
  Impairment                                 Impairment                             & activities




                                             Behavioral/
                                                           Speech, language,
Learning Difficulty   Social interaction     emotional                           Feeding Deficits
                                                              and hearing
                                            management
  Qualitative impairment in
     social interaction
 Impairment in social reciprocity, as seen
  in:
  •   Nonverbal behaviors
  •   Peer relationships
  •   Spontaneous sharing
  •   Lack of social or emotional reciprocity
  •   Poor emotional regulation
  Qualitative impairment in
      communication
 Delay in, or lack of, development of
  spoken language
 Impairment in conversation
 Stereotyped language
 No or limited make-believe play
       Restricted repetitive
      behavior interests, and
            activities
   Encompassing preoccupation
   Inflexible routines
   Stereotyped motor mannerism
   Preoccupation with parts of objects
   Language Subgroup:
Generalized Low Performance

 Low in language comprehension and
  production
 Comprehension somewhat better than
  production
 Poor oral and motor imitation
 Mostly nonverbal
 Progress in treatment is slow in all
  modes
   Language Subgroup:
Generalized Low Performance
 Better comprehension than production
 Performance in language skills good
  until 30 months than drop off rapidly
 Good oral and motor imitation
 Mostly verbal…some words
 Progress in treatment is good
Language Subgroup: Verbal
        Imitators
 Better comprehension than production
 Performance in language skills good
  until 30 months than drop off rapidly
 Good oral and motor imitation
 Mostly verbal…some words
 Progress in treatment is good
 Language Subgroup: High
        language
 Language production better than
  comprehension
 High echolalia
 Good oral and motor imitation
 Pronoun confusion
 Progress in treatment is good in all
  modes
       but what about…?
 Autism vs. High Functioning Autism?

 HFA vs. Asperger’s syndrome?
                   Asperger’s         HFAutism
Social         More to parents,          Less socially
Responsiveness more w/ peers             responsive

Communication    No deviant            More echolalia,
                 language, repetitive, pronoun reversals,
                 maintenance of topic jargon, problems
                                       w/ pragmatics
Imaginative Play Yes symbolic, but       Rare imaginative
                 late. Play is           play, toys in
                 stereotypic, lacks      unusual ways
                 creativity
Behavior         Some sameness,          More stereotypies,
                 less stereotypies,      perseveration,
                 less sensitive to       over sensitive to
                 stimuli                 stimuli
Age of onset     2 – 3 years             1 – 2 years
        HFA vs Asperger’s
           syndrome
 Categorization questions for the next
  decade
 Is Asperger’s a separate syndrome, or is
  it the high end of the autism spectrum?
 Are high functioning autism and
  Asperger’s essentially the same?
Intervention

Holistic Approach
  What are the most important
   skills we should teach?
 No matter how skilled and talented your child may be,
  or how much knowledge he posses;
 If he is inflexible and cannot handle change;
 If he is disorganized and requires constant prompts;
 If he obsesses on certain topics and cannot switch
  his attention;
 If he cannot follow directions or becomes resistant or
  angry when he is told what to do;
 -----he will sooner or later fail to keep a job
                                         Division TEACCH
Communication    Social




  learning      Emotional
       Challenges related to
              autism
   Challenges in Learning/thinking
   Challenges in social interaction
   Challenges in communication
   Challenges in behavior/emotion
   Challenges in feeding
Learning Challenges
 Related to Autism
 Characteristics of thinking
 Difficulty with the concept of meaning:
  Central Coherence theory
 Excessive focus on details (Spotlight
  focus)
 Difficulty distinguishing the relevant
  from the irrelevant
 Difficulty combining or integrating ideas
 My child sees the world in boxes. When
  he is watching a dog, he sees one box
  which is the eyes, and another box
  which is the tail, the boxes just are not
  connected”

 Mom of a 33 month old child
    Characteristics of thinking
          and learning
 Difficulties with theory of mind
 Difficulty in generalizing
 Concrete thinking
 Visual skills often a strength and
  frequently better than auditory skills
 Difficulties with imitation
 Characteristics of thinking
       and learning
 Executive function difficulties:
  • Difficulty with organization and
    sequencing/planning
  • Understanding “finished”
  • Set shifting/flexibility
  • Difficulty with transitions
       How can we help?
 Clearly define the environment
  according to activities and events =
  physical structure
 Develop routine ways of giving
  information about where to be and what
  to expect = schedule and work system
 Put visual supports in place = visual
  structure
    Five reasons for using
           structure
1. Understanding a receptive
   communication system
2. Helps autistic people remain calm
3. Helps autistic people learn better
4. Prosthetic device for independence
5. Behavior management
       A successful schedule

   Individualized around the child need and interest
   Tangible
   Flexibility built-in
   Space out
   Portable
   Child involved
   Restructure while keeping the consistence
  Individualizing Schedules
 Type of visual cue (e.g. icon words or a combination)
 Length of schedule
 Ability of schedule (e.g. on clipboard, in folder, or
  notebook that travels with student) or static (posted
  on wall, table or desk to which student returns.)
 Location of schedule
 Transitional cue (e.g. match name, color, symbol,
  give pencil, buzzer, bell, check schedule, etc.)
 Ways of manipulating schedule (“checking off”)
 “It is OK to mix visual cues within a schedule!”
I do not know what is going to
happen in class today. There
are so many directions. I can
not remember everything!!!




                What can I do?
• 8:00-9:00am Math
• 9:00-10:00am Physics
• 10:00-11:00am
  Chemistry
• 11:00am-12:00pm
  Chinese
• 1:00-3:00pm Self study
• 3:00-5:00pm Physical
  education
  How to Achieve Successful
          Transition
     Teaching strategies
 Create visual and manipulative ways to
  teach
 Break down an area of learning into
  small steps
 Teach strategies for approaching
  problems that can be used for more
  than one assignment
       What is a routine?
 A routine is to know whenever
  something happens, go and check the
  schedule!
 The best teaching is to teach adaptation
 Challenges in
Communication
             Best Practices
 Communication goals should emphasize functional
  use
 Environmental arrangement should be primary
  strategy to foster initiations
 Environmental supports promote active and
  independent participation
 Approaches to challenging behavior should be fully
  integrated with communication
 Peer mediated learning is essential
 Level of emotional arousal and its effect on
  communication needs to be considered
Early Intervention Programs
 Major Goals
  • Attention
  • Imitation
  • Social Interaction and intentional
    communication
  • Language Development
  • Emotional regulation
                    “I Can”
 Look at someone’s face, listen to what
  they are saying, or speak

        BUT


        I can do only one of these at a time

        Adult with autism (28 years old male with a master
         degree)
Communication Challenges
 Ecolalia
 Pronoun confusion
 Pragmatics (lack taking others into consideration)
   •   Initiation vs. responding
   •   Turn-taking
   •   Requesting
   •   Describing
   •   Demanding
   •   Role-playing
   •   dialogue
  Barriers to understanding
       communication

1. Paralinguistic features of language
  inflection, emotional vocal tone, facial
  expression, gesture, posture, pace
2. Understanding meaning
  • Abstract content, literal interpretations,
    poor inferential thinking, egocentric
    definitions of language, rigidity
   Promoting conversation
           skills
 Practice turn-taking
  • Board and card games
  • Bowing, horseshoes
  • Passing a talking stick (whose turn is next)
     Microphone, hats, cups, to pretend the turn
  • Conversation cards
     Pretended scrip, cards in the cup as strip
   Promoting Conversation
           Skills
• Practice turn-taking
• Use concrete visual reminders to prompt
  conversation
• Provide topic suggestions
• Use scripts
• Comic strip conversation
• Practice conversation during preferred and
  simple activities
   For breakfast, I ate______
   I liked the ______
   After breakfast, I ________
   Tomorrow I would like to eat
    Managing Repetitive Talk
   Assess
   Set natural limits (time, place)
   Put talking time on the schedule
   Write a social rule
   ???
Challenges in Social
    Interaction
Communication    Social




  learning      Emotional
     Challenges in Social
         Interaction
 Pragmatic skills
 Perspective of others???
 Behavioral issues
       Promoting Social
     interaction/intentions
 Reciprocity and social-affective
  signaling
 Develop preverbal intentional
  communication – means and functions
 Opportunities for peer interactions and
  relationships
   Challenges in
Behavioral/Emotional
   Management
 WHY THESE BEHAVIORS?
 Behavior always happens for a reason
 Our challenge; to figure out the message underlying
  a behavior problem and respond to the message
 To understand the message, we need to be able to
  understand autism and the child’s experience
 To intervene, we need to be able to make changes
  and teach skills
Be preventative

             “I can not breath!!!”




                  “What’s going on?”
        How do we help?
 Step 1: what is the problem?

 Define and describe the behavior

 Be specific
        How do we help?
 Step 2: Why is it happening?

 Gather clues,

 Collect data on the A-B-Cs
    Antecedents/Behavior/Consequence
  s
        How do we help?
 Step 3: Generate theories. Why Is this
  behavior occurring?
  • Review the data
  • Use your knowledge of autism
  • Create icebergs (it is important to know
    what is going on underneath)
              How do we help?
 Step 4: Design and implement
  intervention
 The intervention plan will be based on your theories,
  and will often include several components. Common
  strategies include:
   •   Modify the environment
   •   Improve schedules
   •   Modify tasks
   •   Modify method of presentation
   •   Teach skills, improve understanding
   •   Use different consequences
       Child Throws Banana
            Repeatedly
                                        Go to the
Throws Banana                           computer lab
on the floor
                  family/personal/      Consequences
Behavior        environmental factors


                    Too much going on
                    in the cafeteria

                      Antecedents
How to Manage Stress
       Level?
           Early Intervention
   Recognize early signs of distress
   Maintain calm, quite demeanor
   Decrease use of verbal language
   Reduce environmental stimuli
   Provide clear visual cues about what to do
   Reduce time pressures, demands as needed
   Cue to use coping strategy
     Teach new strategies
 Teach strategies to use in difficult
  situations and when stress level starts
  to rise
 Practice them when all is calm
  • Use visual cues, guidelines, “talk time”,
    scripts, social stories
          Managing a Crisis
 Reduce language and sensory stimuli
 Redirect to a quiet safe area
 Cue to use learned calming routine
 Remember to set up “finished” so that the escape
  time has a clear beginning and end
 -->and afterwards, figure out WHY the problem
  happened and act Preventatively
               Reduce stress
   Get away from the things/environment you do not like
   Give yourself a break from work: Frequent breaks
   Change of gears
   Do something you like
    • Calming Activities
 Do not do anything hard close to lunch time
 Regular physical activity ****
Challenges of Feeding
 REASONS for Malnutrition
       in Autism

 Aberrant feeding behavior:
   Selective acceptance of food or refusal to eat
    many or most foods with no known medical
    explanation
 Chronic gastrointestinal (GI) symptoms
         Feeding Disorders
            Symptoms
   Limited food selection (57%)
   Limited food groups (72%)
   Averse reaction to new foods
   Food jags???
   Feeding skills inconsistent with child’s
    developmental age (23.2% have oral
    motor problems)
             Food rejection
 Kids with autism slowly start to reject previously
  favored foods
 Select down, eliminate one food from their diet at a
  time
 Without intervention, child may self-select himself
  down to just a few foods, served in only one way, or
  at one particular location
          Food rejection
 Why?
   • Sensory processing disorder
      • A new discomfort with a particular smell, taste,
        texture, sight, or just feeling
   • Behaviorally based disorder
   • Oral motor delay/disorder
   • Medical issues
       Feeding Problems
 Possible sensory defensiveness:
   Textures-
     mixed, soft chewy, crunchy, smooth
   Brushing teeth
   Grooming
     Face washing, lotion, lip balm
   Food on hands
        Feeding Problems
 Medical treatments may place children
  at risk:
   Negative experiences around the mouth
    and face
      Ventilation
      Nasogastric feedings
   Extended hospital stay
   Artificial feeding schedule
   Intervention of Aberrant
      Feeding Behaviors

 Positive reinforcement
 Escape extinction
   Physical guidance
   Nonremoval of the spoon
 Representation: multiple representation
   Intervention of Aberrant
      Feeding Behaviors
 Behavioral
   Preventing food jags
 Oral motor therapy
   Focus on the mouth
   Passive, assistive and active movement
 Sensory processing
   Feeding hierarchy
   Food chaining
    Chronic GI symptoms
 12-19% compared to 3-4% of typical
  children
 Regressive autism even higher
  Possible Solutions for
  Nutritional Deficiency
*** Children cannot be forced to
eat the necessary diet to correct
         mal-nutrition***
  Possible Solutions for
  Nutritional Deficiency
 GFCF:
   The gluten (wheat) free, Casein (dairy) free
    diet
   Scientific evidence:
     OPIATE theory
     Anecdotal stories:
     No known scientific base
           Lessening autistic symptoms such as impulsive
            behaviors, lack of focus, and even speech
            problems
                      Case study
Jill, 5 year old, picky eater, dislike meat, vegetables:
    History of pneumonia
    Losing weight
          Gagging
          Coughing after eating
          Wet sounds
          Drooling
          Pocketing
          Food stuck in palate
          Multiple swallows
                Case study
Jill, 5 year old:
    Tx: Oral motor exercises
       Improve strength and/or mobility of tougue, lips,
        cheeks, and jaw
       Passive, assistive, active movement
                   Case study
Samuel: 4 years old
    Uncomfortable with touch-brushing, kissing, washing face,
     getting food on lips
    Limited food texture: yogurt or smoothy only
    Gagging often
    Does like like any strong smell food
                      Case study
Samuel: 4 years old
    Tx: desensitize; feeding hierachy
          Tolerates
          Interacts with food
          Smell
          Touch
          Tastes
          Eats
          swallows
         Case Study--Albert
Albert (age 5 years) – good
  comprehension – highly echolalic.
     Cannot initiate
     Cannot generate novel utterances
     Cannot describe
     Can list
     Repeats easily
        Case Study--Albert
 Treatment:
   Work on social routine utterances, like “I want xxx”
   Modify routine utterances, like “I want xx and xx”,
    or “May I have xxx.”
   Impose alternatives in routine, like “I want ball
    (show pencil)” Model “No this is not a ball, this is a
    ball (show ball.) Follow routine until Allen makes
    adjustments.
   Rotate routines between alternates and routines.
   Model – alternate- expand-revise
        Case Study--Chip
 Chip (age 5 years)– verbal, high
  pitch/monotone, rigid/lacks transitions,
  some delayed echolalia, retells events
  like he was quoting from a story line.
             Case Study--Chip
 Treatment
    Flexibility in conversation. Model different ways of requesting,
     describing, demanding. Set up routines where each is practiced.
     Adjust so that spontaneous use of conversation occurs.
    Role Playing. Use others (parent) or stuffed animals as models for
     requesting, describing, and demanding. Have stuffed animal make
     mistakes. Help Charlie to explain by example how to correct the
     mistake.
    Use story books with different intonation patterns, like “Three Little
     Pigs” or “Goldilocks,” to teach stress, rising pitch, and loudness.
    Use people pictures with different expressions, like happy, sad,
     surprise, confused, angry/mad, tired. Have Charlie describe each
     and model the expression using a mirror. Follow through by having
     parent/teacher demonstrate the
        Case Study-Mark
Mark (age 5 years) – Adopted from
 Eastern Europe, verbal, quiet/inhibited,
 inflexible, concrete.
          Case Study-Mark
 Treatment
   Executive function skills – organization, flexibility,
    retrieval, retelling events, generating novel events,
    defining.
   Use picture adapted story books, with sentences
    adapted and pictures scanned. Read story book,
    unscramble picture to follow the story event (from
    memory), match scrambled sentences to the
    pictures. Retell the story from the pictures.
   Use story events to acquire new vocabulary and
    concepts, like learning the concept of first, second,
    and third.
                    References
 Ernsperger, L. & Stegen-Hanson, T. (2004). Just take a bite.
  Arlinton, TX: Future Horizons
 Hall, K. (2001). Pediatric dysphagia
 Schreck, K., Williams, K. & Smith, A. F. (2004). A comparison of
  eating behaviors between children with and without autism.
  Journal of Autism and Developmental Disorders, 34 (4), 433-
  438
 Schreck, K., & Williams, K. (2005). Food preferences and
  factors influencing food selectivity for children with autism
  spectrum disorders. Research in Developmental Disabilities, 27,
  353-363