Today s Topics. Applied Behavior Analysis (ABA) and the Culture of Autism Treatment. A Brief History of ABA and Autism

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1 How Much ABA Is Too Much: An Overview of Treatment Recommendations for ASD 9 th Annual UCSF Developmental Disabilities Conference Annual Shriver Lecture March 11, 2010 Bryna Siegel, Ph.D. Director, Autism Clinic Co-Director, Autism Neurodevelopment Center Bryna.Siegel@ucsf.edu Adj. Professor, Child & Adolescent Psychiatry Children s Center at Langley Porter University of California, San Francisco Today s Topics What has applied behavior analysis contributed to the treatment of autism? How and when do we use it? Where does ABA fit with developmental considerations for treatment? How do we integrate approaches to cover all bases in a treatment plan? A Brief History of ABA and Autism Pavlov Skinner: Learning in animals worked in humans too Lovaas at UCLA uses ABA for severe SIBs Lovaas uses ABA to teach positive behavior, not just to extinguish negative behavior. Lovaas s curriculum content neither developmental or autism-specific, but Introduces intensity, data-based trials & high mastery levels; these are validated and reified. Applied Behavior Analysis (ABA) and the Culture of Autism Treatment ABA has become most widely-available one-toone treatment modality for ASDs One-to-one complements heterogeneity of ASDs Potential for highest intensity ABA has become highly influential in classroom practices Mandate for data-driven instructional practices Need for functional behavioral analyses of behavior incompatible with instruction 1

2 What Have We Learned About ABA and ASDs in the Last 20 Years? ABA can be used at home and in schools Behavioral principles have been applied with different emphases: Performing: Discrete trial training (DTT) Requesting: Pivotal response training (PRT) Adapting: Natural environment training (NET) Remaining Challenges: Motivation especially social motivation Developmental appropriateness of curriculum Generalization of objectives of learning Concept of the Autism Treatment Toolbox Autism spectrum disorders are heterogeneous Individuals w/ ASD need treatment at different developmental levels Individuals w/ ASD learn at different rates Individuals with ASDs have different learning strengths and weaknesses Therefore: Different tools are needed for different children ABA and the Autism Treatment Toolbox What does autism treatment need to target? What does ABA target most specifically? What does ABA leave unaddressed? How do you fill an autism treatment toolbox : for a particular child, or for a particular age group, or for a particular sub-group of children with ASDs? What tools does ABA give us? Challenges in Early Autism Treatment Most models of tx were developed for preschoolers and older Most treatment begins earlier than preschool Validity of push-down curricula? Motivating the child to learn on his own Getting the child to spontaneously use what he s learned 2

3 Themes in ABA Literature on Autism Treatment Efficacy of behavioral methods (ABA) Individualization (ABA) Intensity (ABA) Natural environment as teaching milieu (PRT) Parents/ home/ outside world s role in acquisition & generalization (NET) Reward Strategies: Develop a Reward Hierarchy Primary Reinforcement (e.g., in DTT) Establishes learning contract Schedule rewards according to task difficulty, novelty and child s persistence Intrinsic Reinforcement (e.g., in PRT) Materials/ context as reward Success leads to internalized drive to take on related problems Example of Milieu Teaching Strategies (More Natural, Incidental Than DTT) Incident: Wait till child wants a drink; prompt. Mand (Request): Ask child Do you want a drink? Time-Delay: Wait while holding drink on offer. then: Child requests and Gets drink Child does not request: Drink put away, then re-trialed If It s Not ABA, What Then? How do goals of ABA tx for ASDs differ from developmentally-based treatments? Why do we need other than ABA based tx? What might be lacking in full-time ABA tx? Why do providers of ABA often seem hostile to developmentally-based providers? Who s right? 3

4 Foxes Minding Hen Houses What I have, is just what you need (The If I m a hammer, you re a nail position.) You don t need that other treatment, just more of my treatment If you use that treatment, too; mine won t work as well It worked for me, it ll work for you Emerging Themes in Developmentally-Based Autism Treatment Intense Individualized Motivating Teach to developmental level consideration for function in natural settings consideration for natural activity ( play is a child s work ) There are overlaps but not entirely Why It s Important to Include a Developmental Perspective The brain matures in a fixed sequence, supporting behavior emerging from increasingly complex and integrated neural capacities. Behavioral development has a fixed sequence tied to that neurodevelopment. Research in development maps that sequence; educational curricula rely on that. Children may at different rates & ways, but the sequence of what s taught needs to be ordered to develop a solid foundation. Developmental Considerations in Early Treatment for Autism Developmental inter-play among effected early lines of development: Theory of mind Non-verbal communication Imitation Oral Communication 4

5 Developmentally-Based Treatment Standards Arising from this View: National Research Council of Nat. Acad. Of Sciences (2001) Part C of IDEIA (2004) Div. of Early Childhood/ Council on Exceptional Children (2005) Nat. Assn. for Ed. of Young Children (2009) Developmentally-Based Treatment Design Considerations How can treatment be given in a natural environment? Home? Child care? Can treatment be delivered in an inclusive setting? Typically developing peers predominate? Can treatment be delivered in an integrated setting? Designed for typical and atypically developing children both? How can treatments be made family centered? Can parents select treatment goals? How can treatments support parent-child interaction? Can parents provide treatment? Does treatment motivate child to self-initiate? Active Ingredients : Intensity Unpacking High Quality in Intervention Practices Behaviorally-Based Developmentally Based Candidates include: Use of 1:1? # Hours/ Week? # Trials? % Accurate Responses? Level of prompting needed for response? 5

6 Active Ingredients : Developmentally-Appropriate Appropriate for Chronological Age? Appropriate for Developmental Age? Developmentally-sequenced? Comports with developmental morphology? (e.g., Language: # of single words before phrases) Active Ingredients : Addresses Social Deficits Establishes theory of mind Establishes joint attention Establishes instrumental attention-seeking Establishes expressive attention-sharing Promotes imitative learning Active Ingredients : Addresses Communication Deficits Pre-linguistic vocal mirroring/ imitation Non-verbal facial communication Attention to motherese Expressive body language (e.g., up ) Receptive language: MLU=1 MLU=2 Expressive language: MLU=1 MLU=2 Complementary Use of Behavioral and Developmental Tools 6

7 What Is the Developmental-Behavioral Approach? Establish curriculum content based on developmental level/ what comes next. Uses behavioral methodology to teach developmentally-based curriculum. Enhancing motivation by differentially rewarding self-initiative in learning Using Behavioral Methodology: Developing a Reward Hierarchy Primary Reinforcement (as in DTT) Establishes a learning contract Schedule rewards according to task difficulty, novelty and child s persistence Intrinsic Reinforcement (as in PRT/NET) Materials/ context as reward Successful problem-solving leads to internalized drive & spontaneity Principles for Formulating Curriculum that is Developmental and Behavioral Based on where the child is developmentally (e.g. 18 month receptive language teach the next skills moving from one word to two). Calibrate growth trajectory based on learning history, assessments & observations Re-calibrate trajectory annually because it will change Do teach using validated behavioral principles. Exemplifying a Developmental-Behavioral Curriculum Purely Behavioral/ Not Developmental: Stand-up/ sit down before mama and dada. Changing the content to be developmental: Teaching horizontally, not vertically : 1 x 10 different animals versus 10 faces of mommy Integrating Developmental and Behavioral: Keeping the ABA teaching method and pairing it with a developmental curriculum. 7

8 The Big Dilemma in Designing Autism Treatment If no two children have the same exact needs, how can they benefit from the exact same treatment? If each child gets a different treatment how do we learn what s best? How do we empirically select treatment tools? Understanding Responder Characteristics What is A Responder Characteristic? Specific Autistic Learning Disabilities Specific Autistic Learning Styles Developmental Level Language Level Maladaptive Behaviors The ALS/ALD Approach: A New Heuristic The Autistic Learning Styles / Autistic Learning Styles Approach Integration of Developmental Teaching, Behavioral Learning and Individual Differences ALS = Autistic Learning Styles ALD = Autistic Learning Disabilities The ALS/ ALD heuristic can be used to classify autistic alterations in Perception, Cognition, Information-Processing, Motivation & Expression 8

9 Autistic Learning Styles Defined: Autistic learning styles are intact functions automatically deployed to compensate for impaired functions By identifying autistic learning styles, we discover what works We can use working systems to teach in a way the learner can best learn Autistic Learning Styles (ALSs) Related to Memory Verbal Intelligence-Related Good Auditory Memory without Parsing ID: Memorizes songs, videos or books without understanding full meaning Performance Intelligence-Related Good Procedural Memory (Prefers Routines) ID: Anticipates exact sequence of events leading to desired outcomes Autistic Learning Styles (ALSs) Related to Motivation Verbal Intelligence-Related Better use of language when requesting than commenting Performance Intelligence-Related Good visual-motor-spatial ability without need for semantic supports ID: Does puzzles backward or upside down, draws from photographic memory Autistic Learning Disabilities: How Social Deficits Affect Learning Lack of socio-emotional reciprocity= Lack of desire to please others Low response to social reinforcers Lacks concern re: effect on others Lack of awareness of others= Motive to please self is foremost Instrumental learning style Why Should I Care? Lack of social imitation= Low incidental learning via copying others No drive to follow group norms 9

10 Autistic Learning Disabilities: How Non-Verbal Communication Deficits Affect Learning Low comprehension of facial/ vocal cues: Smiles, frown, more subtle facial affect Tone of voice to mark affective/ semantic meaning Ignores gestures that are the first language: Gaze toward topic of conversation Point to initiate joint attention to topic Autistic Learning Disabilities: How Verbal Communication Deficits Affect Learning Receptive Language Signal : noise problem for verbal signal Language processing with poor parsing Overly literal/ concrete, limited generalization Expressive Language Without theory of mind, no drive to share ideas Without instrumental motive, no drive to express Oral-motor apraxia synergistic w/ low expressive drive Autistic Learning Disabilities: How Play and Exploration Deficits Affect Learning Lack of imagination in play= No consolidation of experience via play linking action and language No symbolic actions to link to language to abstract thinking Stereotyped and repetitive interests= Averse to novelty/ low curiosity Limited learning through exploration Repetitive interests = mental down time Issues In Motivating the Child with ASD 10

11 Strategies for Enhancing Motivation Develop response to social praise to expand LRE Reward incremental successes, not make hard things harder (remember how babies learn) Make curriculum comprehensible through visuals Reinforce with predictability via routines Provide choices (autonomy=control=reward) from present interests: Thin edge of wedge Develop an interest in affiliation/ modeling through developmentally models Exemplifying an ALD/ALS-Specific Approach to Motivation Two Tiered Reinforcement First Tier: Part reward for Necessary, but not sufficient behavior Second Tier: Full reward for attaining goal (Examples: Potty-training, seat belts) Why Should I Care? Another ALD/ALS-Specific Example: Modifying Time Outs for ASDs Functions of Time-Out: Use of an accompanied time out Isolation as cool down not as deterrent Criteria for when & how long to time out Calming down : a behavior to be shaped Why Should I Care? ALD/ALS-Specific Negative Reinforcement (Absence of Positive Reinforcement) Ignoring: Why should Ignoring work if you don t mind being ignored? Over-Correction: Changing the intrinsic reward valence by controlling access through over-exposure (Examples: Light-switches, doors) 11

12 ABA Approaches (DTT/ PRT/ NET) Translating Active Ingredients of ABA Methodology SOCIAL INTERACTION Low Response to Social Reward Infrequent Social Reference or Joint Attention Low Drive for Peer Affiliation Likely Benefits Yes (via paired association) No (attention directed to stimulus materials) No (object or teacher models) Limited Modeling or Imitation Yes (via forward/ backward chaining) ABA Approaches (DTT/ PRT/ NET) ABA Approaches (DTT/ PRT/ NET) COMMUNICATION Likely Benefits ORGANIZING INFORMATION Primary Benefits Poor Comprehension/ Limited Para-Linguistics Partial (Rotely- taught/ non-generative) Lack of Representation Capacity (Imagination) Partial (Rotely- taught/ non-generative) Slow Auditory Processing Speed, Poor Parsing Preference for Visual over Auditory Modalities Theory of Mind/ Perspective- Taking Partial (Telegraphic Speech) Yes (Use of Visuals & Procedures) No (Reliance of Direct Learning) Preference for Repetition over Novelty Sensory Modulation Difficulties Yes (adult-direction) Yes (de-sensitization) 12

13 Being the Parent of a Child with ASD Means: Taking On A Mentoring Role With Parents Parental Stress, Coping and Effectiveness 24 hours day x 7 days= 168 hours Sleep: hours per week School & Therapy: Hours at Best That leaves hours per week to parents. A Child with a Autism is a Life Event Nobody asked or planned for it. A major life event and major stressor like cancer, divorce, or losing your home. Stress tends to bring out pre-existing strategies for maladaptive coping: Anxiety, depression, withdrawal, anger. Two years of reactive depression may be the norm. Supporting Parents in Making Home a Natural Environment for Teaching: Identify functional/ natural opportunities Meal times Bath times Times with the child s preferred activities Take as small steps as possible Don t sweat the small stuff Coach parents to remember: It s half-full; not half-empty 13

14 Supporting Parents in Making Home a Natural Environment for Teaching: Helping Parents Improve Self-Efficacy Teach about consistent expectations Developmentally-calibrated expectations Continual practice once an expectation is set Adjust your own mask before attempting to help others Give a man a fish and he ll eat for a day; Give a man a fishing pole and he will eat for a life time Lao Tzu (600BC Chinese Proverb) The JumpStart Learning-to-Learn (JSLTL) Program JumpStart Learning-to-Learn: A Parent & Child Training/ Generalization Model Intensive, one-week, parent training Development of child s learning readiness skills so parents can wrap-around at home Focus on helping families learning skills to parent a child with autism Teaching parents to be discriminating consumers and general contractors 14

15 What Is JSLTL? A New Kind Of Early Intervention FOR THE CHILD A Learning-to-Learn Program FOR THE PARENT A Parent-Centered Program Didactics Skills for Special Parenting (~Special Education) Being an Informed Consumer and Advocate Presenter s Related Translational Work On COLLABORATION BETWEEN PARENTS AND SCHOOLS Siegel, B (2008). Getting the Best for Your Child with Autism, New York: Guilford Press. On the DEVELOPMENTAL-BEHAVIORAL-APPROACH Siegel, B (2003). Helping Children with Autism Learn: Treatment Approaches for Parents and Professionals, New York: Oxford University Press. On HELPING PARENTS UNDERSTAND WHAT AUTISM IS Siegel, B (1996). The World of the Autistic Child: Understanding and Treating Autistic Spectrum Disorders, New York: Oxford University Press. On WORKING WITH FAMILIES Siegel, B. and Silverstein, S. (1994). What About Me? Siblings of Developmentally Disabled Children New York: Perseus Press 15