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Innovative Practices Award Proposal

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					                                              Community Autism Intervention Program 1


RUNNING HEAD: COMMUNITY AUTISM INTERVENTION PROGRAM




                              COA
       Innovative Practices Award Proposal
                            Patricia McKnight, MA
                                 1/25/2011
                                                                    Community Autism Intervention Program 2


                                                      Abstract

  The Community Autism Intervention Program’s Preschool Demonstration Program at Brewer-Porch Children’s

Center of the University of Alabama employs a holistic, eclectic approach to comprehensive treatment. This

unique program employs the use of positive, research-based interventions and best practices which are essential

in meeting the needs of children with a medical diagnosis of an Autism Spectrum Disorder. Steadily increasing

prevalence rates in the Autism population necessitate the need for services. The program follows the research

depicting the most intensive services at the youngest age possible will assist the child’s progress and encourage

independence at an earlier age. This paper outlines the various interventions implemented to reach each

individual served. Multiple interventions provided by an interdisciplinary team aim at similar outcomes and

increased success rates. The attached case study supplements this paper by depicting the potential for increased

progress and independence.
                                                                      Community Autism Intervention Program 3


                                         Innovative Practices Award Proposal

         Autism Spectrum Disorders (ASDs) are neurological disorders which are characterized by deficits in

communication and language, impaired social skills, and the existence of restrictive, repetitive, or stereotyped

patterns of behavior or interests. Prevalence rates have increased from 1:10,000 in the late 1970’s to 1:110 in

2010. (Catherine Lord, 2010) Causation and cures are unknown at this point in time. Recent research and

neurological studies indicate there is a genetic component which serves as a predisposition. This predisposition

may then be activated by environmental stressors such as exposure to environmental chemicals, allergens,

increased infections, and subsequent antibiotics. Medical treatments are not established at this time. (Risperdal

and Abilify are the only medications approved by the Food and Drug Administration for the treatment of secondary

symptoms such as aggression, irritability, and self-injurious behaviors.)

         Prior research has validated a variety of positive evidence based interventions which are educational and

behavioral in nature. As with any educational or behavioral intervention, not all are successful for all children, all

of the time. Therefore, it is important that a program employ multiple approaches concurrently in order to create

an environment that maximizes the potential for each individual child to succeed. Another key aspect of early

intervention is the quantity of hours served. It is optimal for a child to receive forty hours, or more, of services per

week. This type of program is defined by Social Policy as Comprehensive Treatment. Comprehensive treatments

are a set of practices designed to have a broader impact on core features of ASD. “These treatments are

characterized by their intensity, involving substantial amounts of time and service. Comprehensive treatment

programs usually incorporate a set of specific focused intervention techniques organized within a conceptual

framework” (Catherine Lord, 2010). The Community Autism Intervention Program (CAIP) utilizes holistic, eclectic

methods based on the Comprehensive Treatment approach.

         The following is an account of the Autism specific services provided for children ages three through five in

the CAIP Program at Brewer-Porch Children’s Center, through the University of Alabama. The Preschool

Demonstration Program was developed in 2003, and is based on research that supported the most intensive

services at the youngest age possible. This program provides the child with a greater opportunity to be more

independent and successful at an earlier age. Children with a medical diagnosis of an ASD are referred by the local

school systems.
                                                                      Community Autism Intervention Program 4


         These intensive services are successfully implemented with small ratios of students to highly trained staff.

One certified teacher per classroom of six children with a minimum of four trained Mental Health Workers per

classroom is a best practice approach that is employed. Multiple approaches focusing on each child’s strengths

and deficits are implemented in order to reach each individually.

         CAIP provides strict structure and routine within each classroom. The classrooms are physically designed

to follow the TEACCH structured teaching approach. According to TEACCH staff, “The physical layout of the

classroom is an important consideration in planning learning experiences for autistic students. Even the

arrangement of the classroom furniture can help or hinder a student’s independent functioning and his recognition

and compliance with rules and limits.” (TEACCH Staff, 2011) Children quickly identify what to expect and what is

expected from them in each area of the classroom.

         Individual schedules are implemented for each child, with routines that include work tasks as well as

rewards. With these schedules, they can identify changes in the routine such as field trips, special programs, or

weekly therapies. which will assist in avoiding tantrums related to unexpected changes in routines and transitions.

Schedules are an example of a normative assistive device that an individual on the Autism Spectrum can use to

function successfully, even as an adult. The difference between the schedule of a person with an ASD and a typical

person’s schedule is that the schedule for a person with an ASD might include task breakdowns, visual supports, or

activities of daily living. Instrumental activities of daily living are not automatic for the person with an ASD; they

need to schedule when to do laundry, pay bills, and other activities outside of regular daily routines.

         CAIP services focus on communication assistance, which is offered through intensive Speech and

Language Therapy, Picture Exchange Communication Systems (PECS), Sign Language, and Augmentative

Communication Devices. Touch screen devices with the Proloquo2go application, have been implemented within

the past year. Communication is a vital aspect throughout the classroom and throughout the school day. While

the ultimate goal for each child is to communicate through the use of verbal speech, they must have some form of

alternative communication to use on an immediate basis. This is critical to effectively reduce anxiety and

frustration which in turn, could lead to maladaptive behaviors. The alternative forms of communication, such as

PECS, sign language, and augmentative communication devices, assist visual thinkers. According to Temple
                                                                        Community Autism Intervention Program 5


Grandin (2006), individuals on the spectrum have “specialized brains” which often make them visual thinkers who

think in images.

         Social Deficits are addressed with daily social skills groups within the CAIP Preschool Demonstration

Program classrooms. Individual social stories are designed specifically for special events or situations in the child’s

life. Carol Gray (2011), the developer of Social Stories, has defined a Social Story as describing “a situation, skill, or

concept in terms of relevant social cues, perspectives, and common responses in a specifically defined style and

format.” Social Stories share accurate social information in a manner that is easily understood by its audience.

Half of all Social Stories developed should focus on something that an individual does well. The goal of a Story is

not to directly change the individual’s behavior, but rather to improve the understanding of events and

expectations leading to more effective responses. (Gray, 2011) Monthly community outings are provided to help

with the generalization of those social skills in various activities and settings.

         CAIP also implements the Greenspan ‘Floortime’ intervention, which employs an individualized approach

to interactively playing with the child for the purpose of facilitating development. Staff help create the kinds of

experiences that promote mastery of the milestones of development. The Floortime Foundation notes:

          “Once a child has mastered all six milestones, he has critical basic tools for communicating, thinking, and
         emotional coping. He has a positive sense of self. He is capable of warm and loving relationships. He is
         able to relate logically to the outside world. He can express in words a wide range of emotions (including
         love, happiness, anger, frustration, fear, anxiety, jealous, and others) and is able to recover from strong
         emotions without losing control. He can use his imagination to create new ideas. He is flexible in his
         dealings with people and situations, able to tolerate changes and even some disappointments and bounce
         back. Obviously not all children do these things equally well, but a child who has mastered the milestones
         will have important foundations for loving and learning.” (Wilson, 2011)

Recreational Therapy is also provided twice per week focusing on sharing and taking turns with staff and peers. It

is also a time that is used to reinforce play skills developed in Floortime.

         Certified Teachers in the CAIP Program provide educational interventions, including Direct Instruction (DI).

In DI, teachers provide one on one education based on the goals of each child’s Individual Education Plan. Teachers

focus on the child’s individual learning modalities during this time. Frequent individualized rewards are provided

on an intermittent basis. Discrete Trials (a Lovaas approach from Applied Behavior Analysis) are used individually

on a daily basis through the Discrete Trial Trainer computer software developed by Accelerations Educational

Software. Discrete Trials are a means of teaching children with autism specific skills, such as paying attention,
                                                                    Community Autism Intervention Program 6


making eye contact, and language and social skills. A behavior is broken down to its basic function, with each

function taught in a progressive manner. (James Ball, 2008) Once these skills are mastered then focus shifts to the

generalization of these skills across environments.

         Structured Teaching (TEACCH) is employed through the use of Basketwork in the CAIP Program. The skills

each child has been taught through Direct Instruction are practiced repetitively, initially to improve proficiency and

then later to maintain mastery of the skill. A basket work approach is used to maintain structure, routine, and

reinforcement in completion of these tasks. The approach consists of developing one task that reinforces a skill

which has been initially taught in Direct Instruction, and then placing that task in a basket or drawer system. A

visual mini-schedule identifies the set of tasks for the child to complete during each Basketwork period. The child

will match a picture from the mini schedule to the appropriate basket or drawer. The child pulls the activity out

and completes the task. The level of assistance provided (monitoring, verbal cues, hand over hand techniques) is

dependent upon the child’s retained knowledge of that skill. When the activity is completed, the child places the

parts to the task back in the basket or drawer and moves that basket off the table or closes the drawer. The same

procedure continues with the next item on the visual mini schedule until all tasks are completed. The child is then

provided with a reinforcement of choice. Repetitive behaviors or interests may be engaged during this point.

Tasks are relatively simple and can be rotated out based on the child’s current skills and needs.

         Some children with an ASD diagnosis have impaired sensory systems. Some senses may be overactive and

some may be underactive. All systems are interconnected in the brain. Sensory Integration methods are employed

through weekly sessions with an Occupational Therapist. An individual session focuses on fine motor skills. Whole

group sessions focus on the vestibular system (which involves movement) and the proprioceptive system (which

involves the body’s position in space) deficiencies. The use of trampolines, swings, sensory socks, weighted

devices, and balance boards are materials used on a regular basis. In addition, a separate sensory room is

accessed daily by students for free sensory exploration. Sensory manipulates are available in each classroom for

use when a child becomes frustrated or anxious. This is supported by J. B. Ball (2008) who noted, “Sensory

Integration Therapy attempts to help children become aware of different sensory input, when they need more or

less in order to stay in optimal learning mode, and give them appropriate ways to acquire the input they may be

seeking.”
                                                                   Community Autism Intervention Program 7


        Adjunctive Therapies have been most recently added within the past year. This Therapy is three-fold

incorporating the use of Music, Physical, and Dance Therapies. Predictions for the effectiveness of those therapies

include increases in communicative attempts, social skills development, reduced maladaptive behaviors, and

decreased frustration and anxiety. Recent research has advocated the use of these adjunctive therapies.

        The American Music Therapy Association, Inc. (2006) noted that “music is a universal language that create

non-threatening bridges between people and their environments, helps to maintain attention, express emotions,

and a means to express emotions”. Autism expert Catherine Lord from the University of Michigan, believes that

music therapy is helpful; although more research is always needed to determine exactly why and how it helps.

(Hwang, 2009) Music therapy is provided in conjunction with Dance Therapy. Individual Music Instruction is

provided on a one to one basis weekly. Although more research is needed to determine the true effectiveness of

music instruction, the potential benefits make it a valuable endeavor, particularly within a comprehensive

treatment framework.

        Physical Therapy is provided in small groups on a weekly basis and on an individual basis weekly. Recent

research has shown that aerobic exercise which requires more cognitive thinking promotes children’s executive

functioning which is necessary in problem solving (Best, 2010). Similarly, “preschool interventions that create

student-centered, action-based classrooms environments positively impact Executive Functioning in comparison to

more traditional, teacher-centered classroom environments.” (Best, 2010)

        Dance Therapy is also provided weekly in small groups. It is also provided individually when a child

indicates a need for more intensive vestibular activities. Maxine Sheets-Johnson (2010) noted in the Keynote
                 th
Address of the 44 American Dance Therapy Association Conference in Portland, Oregon:

        ‘Movement is the core of life…the chronological epistemological development of all humans, their
        learning on all fronts, is first by movement, and then by word of mouth…movement is indeed life-
        proclaiming’ which can be threatening and/or overwhelming even in individuals who are psychologically
        normal. ..movement is indeed the basis of our experience of ourselves, as capable and effective agents
        against the world …emotion and movement go hand in hand’. (Johnson, 2010)

Levy concurs with this statement emphasizing that dance therapy forms trusting relationships. (Johnson, 2010)

        Repetitive and restrictive patterns of behaviors and interests as well as maladaptive behaviors are

addressed individually through Individual Behavior Management Plans. Staff focus on the program-wide positive

behavior management CAP (Calm, Assisted Communication, and Proactive) Program. Restrictive and Repetitive
                                                                     Community Autism Intervention Program 8


behaviors are shaped as rewards. Self- injurious behaviors and aggression are addressed through ignoring and/or

redirecting until extinction. Through the use of these techniques, more intrusive interventions such as restraints

or basket holds are rarely needed to keep a child safe.

         One of the most important components of the CAIP Preschool Demonstration Program is parent

involvement and training. While early, intensive treatment is imperative, intensive parental involvement is

equally important. Parents are required to attend monthly Treatment Plan Review meetings, monthly parent

meetings, and parent training on the techniques used in this program. Parents are provided materials for use in

the home such as picture schedules, visual mini schedules, transition picture rings, social stories, sensory

integration materials, augmentative communication devices as needed, behavior management programs such as

token systems and reinforcements, and clinical support in order to emphasize the importance of continuity across

environments.

John D.: A Case Study

         John D. was diagnosed by a clinical psychologist on April 30, 2009 at the age of 2 years, 6 months.

Assessment measures included the Autism Diagnostic Observation Scale (ADOS-G Module I) and Autism Diagnostic

Interview (ADI). Parents had been concerned since the child was eighteen months old due to lack of typical

language skills. At 24 months, parents were still concerned about the lack of verbal communication.

         The examiner identified background information including divorced parents with joint custody. Both

parents were well educated, and John attended daycare at the time of the evaluation. The daycare provider

described John as needing more personnel time and lack of peer play.

         The pregnancy was described as uncomplicated. John Doe slept no longer than three hours per night

during the neonatal period. Motor development was typical, and vaccinations were current. Medical history

included multiple ear infections and a febrile seizure at 11 months of age.

         John‘s language skills were delayed. Single words abruptly stopped at age X. His method of

communication then was leading others by the hand to desired items and screaming. He used idiosyncratic

language and babbling. He loved to sing songs from videos, but would not imitate sounds.

         John was described by the parents as having multiple sensory idiosyncrasies such as reactions to various

sounds, hand flapping, lining up his toys, and a self restrictive diet. Mother reported that a gluten-casein free diet
                                                                    Community Autism Intervention Program 9


had recently been implemented. Social skills were delayed and unusual at the time of the assessment. He would

only engage in solitary play and rarely responded to his name.

         Restrictive and repetitive patterns of behaviors and interests included toe walking, reciting movies and re-

enacting movements in the movies. Mother reported that John loved music. He wanted his parents to sing along

and when they did not meet his expectations; he became aggressive with them. John exhibited no coordination

difficulties; he enjoyed drawing and writing his name. Behavioral observations throughout the assessment period

included the following: no response to his name, babbled, brief and infrequent eye contact, and did not attempt

to play with the examiner or the parents.

         The examiner recommended that John attend a full-day, year-round, highly structured educational

program with small ration of students to trained staff. A referral to the CAIP Preschool Demonstration Program

was initiated by the local school system in conjunction with the parents was generated in September 2009. John

was subsequently accepted into the CAIP Preschool Demonstration Program and an intake was held following his

third birthday. A psychosocial intake at that time was consistent with the information from his Autism evaluation.

         CAIP services began in October 2009 along with the development of an Individual Education Plan (IEP). An

Initial Treatment Plan was developed on October 5, 2009 during John Doe’s first Treatment Team meeting. The

Treatment Team identified the following goals and objectives as a starting point for treatment: improving

communication attempts beginning with a nonverbal communicative greeting such as a wave, beginning basic peer

interactions with responding to an interaction by attending in the area of Social Skills, and increasing Independent

Living by initiating Autism specific teaching methods.

         An Individual Behavior Management Plan was developed at the same time, indicating following the

strategies for the CAP Program (Calm, Assistive Communication, Pro-active) as identified in the services area.

         A Childhood Autism Rating Scale completed in November 2009 was consistent with Mild to Moderate

Autism symptoms. Throughout the course of treatment, John participated in the above described evidence-based

interventions with a 97% attendance rate. His parents were also very involved, attending 95% of all Treatment

Team and monthly parent meetings. Although his mother remarried during this time period, his parents and step-

father were all actively involved in treatment. John’s Treatment Plan is reviewed monthly by an interdisciplinary
                                                                    Community Autism Intervention Program 10


team representing psychiatry, clinical care, nursing, educational staff and the parents when possible. When

parents are unable to attend in person, they are contacted by phone

         While in CAIP, John participates in structured, supervised therapeutic interventions including applied

behavioral techniques. Specifically, he receives interventions that follow the philosophies of the University of

North Carolina’s Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH)

which follow structured teaching and behavioral modification principles. Visual supports in the form of schedules

and calendars are used to increase the predictability and structure in the classroom and other environments.

Social skills are facilitated through the use of planned interactions with the staff and peers. Also in use are social

stories/scripts and prompting for appropriate behavior during social activities. Modeling, prompting, and visual

and verbal cues are used to teach independent living skills. Relaxation techniques are taught and utilized when

John Doe becomes frustrated or upset. These include but are not limited to taking a deep breath, taking a very

short walk, playing “scared turtle” or manipulation of sensory objects. The CAIP CAP Program is also implemented.

This program encourages staff to use calming techniques, assist the child with communication efforts, and provide

proactive techniques to encourage self regulation. Frequent verbal reinforcement as well as tangible rewards are

used to positively reinforce appropriate behavior.

         Fifteen months into the program, John Doe is now working on the following Treatment Plan objectives:

communicating verbally using three to four word answers in response to questions 4/5 times or 80% accuracy,

respond and/or initiating a peer interaction at least one time per day, and engaging in Autism specific learning

activities 5/5 times or 100% of the day. All of these represent substantial improvements over his original

objectives, which emphasized single words and only occasional peer interactions.

         The following depicts scores on the Social Responsiveness Scale (SRS) and the Social Communication

Questionnaire (SCQ) from the time John Doe entered the CAIP Program to the current time:

                                                November 2009            April 2010           January 2011
General Adaptive Composite                           68                      81                    82
Social Responsiveness Scale                          64                 Not Assessed               71
Social Communication Questionnaire                   23                      30                    30




The following graphs depict progress in each area of the Pychoeducational Profile-Revised (PEP-R)
                                                                   Community Autism Intervention Program 11



                                          Developmental Scale Profile - John Doe
                                   72.0
                                                                       2009           2010           2011
                                   60.0
 Developmental Level (in months)




                                   48.0



                                   36.0



                                   24.0



                                   12.0



                                    0.0




Conclusion

The results of the above scores represent the effectiveness of a holistic, eclectic approach for Preschool Autism

Programs. John’s skills show a steady progression across time in all areas of functioning and development. The

use of multiple positive interventions, provide the ability for a program to be as intensive as possible. The multi-

disciplinary Treatment Team in conjunction with teachers and parents provide the expertise needed in each area

of development. The use of multiple communication avenues, schedules, individually structured educational

interventions, social groups, Sensory Integration, and Adjunctive Therapies (Dance Therapy, Physical Therapy,

Music Therapy, and Music Instruction) have proven to meet the needs of children with an Autism Spectrum

Disorder. An additional, essential aspect of the CAIP Preschool Demonstration Program is the level of parental

training and participation. Through all of these disciplines, interventions, and personnel, we make a difference in

the rate of progress and level of independence.
                                                                    Community Autism Intervention Program 12




                                                      References

American Music Therapy Association, I. (2006). Music Therapy and individuals with Diagnosis on the Autism
Spectrum. Retrieved 12 5, 2010, from www.musictherapy.org/fact sheets.

Ball, James E. B. (2008). Early Intervention & Autism. In E. B. James Ball, Early Intervention & Autism (pp. 150-155).
Arlington: Future Horizons, Inc.

Best, J. R. (2010). Effects of physical activity on children's executive function: Contributions of experimental
research on aerobic exercise. Develpmental Review , 1-20.

Grandin, D. T. (2006). http://www.grandin.com/inc/visual.thinking.html. Retrieved 01 20, 2011, from THINKING IN
PICTURES: Autism and Visual Thought.

Gray, C. (Unknown). http://www.thegraycenteer.org/social-stories/what-are-social-stories. Retrieved 01 20, 2011,
from What Are Social Stories?

Hwang, J. (2009, 03 03). Evidence is Slim, but Experts Say Music Therapy is Valuable in Address... Retrieved 11 11,
2010, from http://www.washingtonpost.com/wp-dyn/content/article/2009/03/02/A.

Johnson, M.-S. (2010). Why Is Movement Therapeutic? American journal of Dance Therapy , 2-15.

Lord, Catherine, P. a. (2010). Autism Spectrum Disorders Diagnosis, Prevalence, and Services to Children and
Families. Sharing Child and Youth Development , 1-26.

TEACCH Staff. (2011). Structured Teaching: TEACCH Staff. Retrieved 01 20, 2011, from
http://teacch.com/educational-approaches/structured-teaching-teacch-staff.

Wilson, P. (2011). http://www.floortime.org. Retrieved 01 10, 2011, from The Floortime Foundation.

				
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