T e r a e t a m t en e t t O p O ti t ons s f o f r Syn y dro r me m s: A ti t st s i t c c Spec e t c r t u r m D i D so s rd r er e s r : s

Transcription

1 Treatment Optins fr Autistic Spectrum Disrders: An Overview 7 th Annual USCF Develpmental Disabilities Cnference San Francisc, Califrnia March 7, 2009 Bryna Siegel, PhD Directr, Autism Clinic Children s Center at Langley Prter Adj. Prfessr, Psychiatry University f Califrnia, San Francisc Syndrmes: Autism and the Cmmn Cld The Cmmn Cld Feverish Runny Nse Sinus Headache Sneezing Watery Eyes Sre Thrat Hacking Cugh The Autistic Spectrum Scial Islatin Lw Interest in Peers Echlalic Speech Can t Hld a Cnversatin Perseveratin N Imaginatin Odd Mtr Mvements Autistic Spectrum Disrders are a Syndrme Like a Cld Autism is Multi-Factrial Understanding the Autism Yu re Helping Treat Therefre: Everybdy s Autism is Different Everybdy s Treatment Needs t be Different 1

2 The Child with ASD Perceives Differently Threshld & Mdulatin Prblems: Auditin: Cvers Ears Appears Deaf Tactile: Clthes Sensitivities Diminished Pain Respnse Visual: Gaze Avidance Visual Scrutiny Olfactry: Pica Gags at Smells The Child with ASD Prcesses Differently Sensry threshld differences lead t misrepresentatin f inputs Prcessing speed delays lead t lss f infrmatin What yu get = what yu can think (perceive plus prcess) Swiss cheese understanding The Child with ASD Stres Differently Cnstructive memry brrws frm mre fully represented data surces Retentin is prbably better where cmprehensin is better The Challenges: Hw d alteratins in the way a child with autism perceives, prcesses, stres, and retrieves infrmatin create an altered wrld view? Hw can these alteratins be regarded as a cluster f autistic learning disabilities (ALDs) s specific symptms pint t specific treatments? 2

3 The ALD/ALS Wrking Mdel Mapping DSM Criteria fr Autism nt Autistic Learning Disability Prfile ALD = Autistic Learning Disabilities ALS = Autistic Learning Styles The Cncepts f ASDs and ALSs can be used t classify autistic alteratins in Perceptin, Cgnitin, Infrmatin- Prcessing, Mtivatin and Expressin Qualitative Impairments in Scial Interactin Qualitative Impairments in Cmmunicatin Restricted, Repetitive & Steretyped Patterns f Behavir, Interests, r Activities Scial Autistic Learning Disabilities Cmmunicative Autistic Learning Disabilities Nn-Scial Autistic Learning Disabilities Hw Scial Deficits Affect Learning Lack f sci-emtinal reciprcity= Lack f desire t please thers Lw respnse t scial reinfrcers Lacks cncern re: effect n thers Lack f awareness f thers= Mtive t please self is fremst Instrumental learning style Lack f scial imitatin= Lw incidental learning via cpying thers N drive t fllw grup nrms Why Shuld I Care? Hw Nn-Verbal Cmmunicatin Deficits Affect Learning Lw cmprehensin r use f facial/ vcal cues: Smiles, Frwns, Anxiety, Guilt Tne-f-vice t mark meaning Ignres gestures that shuld be the first language: Pint t initiate jint attentin t tpic f interest, demnstrate thery f mind Gaze tward tpic f cnversatin 3

4 Hw Verbal Cmmunicatin Deficits Affect Learning Receptive language Signal : nise prblem fr verbal signal Nisy scial-linguistic linguistic field Limitatins t pure memry buffer Language prcessing with pr parsing Expressive language Withut thery f mind, n drive t share ideas Oral-mtr apraxia synergistic w/ lw expressive drive Hw Play and Explratin Deficits Affect Learning Lack f imaginatin in play= N cnslidatin f experience via play linking actin and language N acquisitin f new play schema thrugh imitatin/ elabratin; n fundatin fr abstract thinking Steretyped and repetitive interests= Averse t nvelty/ lw curisity Limited learning thrugh explratin Repetitive interests = mental dwn time Cmmn Autistic Learning Styles (ALSs) Gd Auditry Memry withut Parsing Memrizes sngs, vides r bks withut understanding full meaning Gd Prcedural Memry (Prefers Rutines) Anticipates exact sequence f events leading t desired utcmes Gd Visual-Mtr-Spatial w/ Use f Semantics Des puzzles backward r upside dwn, draws frm eidetic ( phtgraphic ) memry Determinants f Treatment Respnse and Prgnsis-I Intrinsic Child Factrs: ALDs (Autistic Learning Disabilities) ALSs (Autistic Learning Styles)= Successful Cmpensatins Maladaptive Behavirs= Unsuccessful Cmpensatins Develpmental Level Level f Intellectual Disability Language Capacity 4

5 Determinants f Treatment Respnse and Prgnsis- II Extrinsic Factrs Earliness f Interventin Intensity f Interventin Develpmental Apprpriateness f Teaching Cntent Parent Educatin, Supprt, Generalizatin f Treatments The ALD/ ALS Develpmental-Behaviral Apprach A Strategy fr Individualizing Treatments Area f Autistic Learning Disability: SOCIAL INTERACTION Lw Respnse t Scial Reward Paired assciatin w/ primary rewards Assciate lwer value primary rewards w/ higher value tpics assciated w/ caregiver Reward instrumental behavir w/ scial rewards Mtivate via chice Area f Autistic Learning Disability: SOCIAL INTERACTION Infrequent Scial Reference r Jint Attentin Mtherese para-linguistics Mdel attentin-directing in instrumental cntexts Mdel vice & face affect in instrumental cntexts 5

6 Area f Autistic Learning Disability: SOCIAL INTERACTION Lw Drive fr Peer Affiliatin Area f Autistic Learning Disability: SOCIAL INTERACTION Limited Mdeling r Imitatin Pre-teaching: with adult with peer Peers must present a replicable mdel Reverse mainstreaming Scafflding peers: increase salience & success Titrate scafflders frm mre t less Shaping/ pairing with primary reward Start w/ mdeling f salient activities Mdel within develpmental reach Salient peer Interesting mdels (e.g., vide-learning) Area f Autistic Learning Disability: COMMUNICATION Pr Cmprehensin/ Limited Para-Linguistics Area f Autistic Learning Disability: COMMUNICATION Slw Auditry Prcessing Speed, Pr Parsing Training paralinguistics thrugh PRT (e.g., VIA) Mtherese gestural cmmunicatin Mtherese facial affect Highly inflected speech Slwed, enunciated speech/ recasts Repeat key wrds w/ visual supprt Teach grammar thrugh expsure (prmte bt-strapping) 6

7 Area f Autistic Learning Disability: COMMUNICATION Preference fr Visual ver Auditry Mdalities Cmprehensin: rutines & visual supprts Pht r 3-D icns (nt M-J/PECS icns) Play t prcedural memry Picture schedules & visual schedules Sight-reading ver phnics? Clsed-captins? Area f Autistic Learning Disability: COMMUNICATION Thery f Mind/ Perspective-Taking VIA: shw the child what he has in mind Create cmmunicative press in cntext Use develpmental guidelines t dem cmprehensin when understd Area f Autistic Learning Disability: ORGANIZING INFORMATION Lack f Representatin Capacity (Imaginatin) Teach play schemes at develpmental level Vide playlalia t initiate representatin ff-rad w/ nvel scripts, familiar characters Lead t higher level frm child s initiative w/ instrumental press Mdel/ supprt play language Area f Autistic Learning Disability: ORGANIZING INFORMATION Preference fr Repetitin ver Nvelty Over-crrectin fr perseveratin Chice: New use f preferred bject v nn-use f it. Limit access t mst perseverated activities Pair functinal use w/ classificatin 7

8 Area f Autistic Learning Disability: ORGANIZING INFORMATION Sensry Mdulatin Difficulties Use valued high sensry as intrinsic reward Shape gal f time-ut as self-regulatin Teaching in stimulatin cntrlled places Cnsider signal : nise (e.g., CAI) Defining the Therapeutic Milieu fr Treatments 1:1 Adult-Led Appraches: ABAA BA-DTT/ PRT Help fr Scial ALDs Lw Respnse t Scial Reward Limited Mdeling r Imitatin Help fr Cmmunicatin ALDs Preference fr Visual ver Auditry Mdalities Pr Cmprehensin/ Limited Para-Linguistics (rtely taught/ lw generalizatin) Slw Auditry Prcessing Speed, Pr Parsing (use f telegraphic speech) Help Organizing Stimuli Lack f Representatin Capacity (rtely taught/ nn-generative) Preference fr Repetitin ver Nvelty Sensry Mdulatin Difficulties 1:1 Child-Initiative : Flr-Time/ RDI/ Hanen Help fr Scial ALDs Lw Respnse t Scial Reward Infrequent Scial Reference r Jint Attentin Help fr Cmmunicatin ALDs Preference fr Visual ver Auditry Mdalities Pr Cmprehensin/ Limited Para-Linguistics Thery f Mind/ Perspective-Taking Help Organizing Stimuli Lack f Representatin Capacity Preference fr Repetitin ver Nvelty Sensry Mdulatin Difficulties 8

9 Self-Cntained Special Educatin Autism-Specific (TEACCH)/ Crss-Categrical Categrical Help fr Cmmunicatin ALDs Preference fr Visual ver Auditry Mdalities Pr Cmprehensin/ Limited Para-Linguistics (cmpensatry visual supprts) Help Organizing Stimuli Preference fr Repetitin ver Nvelty (if curriculum can be accmmdated t interests) Sensry Mdulatin Difficulties General Educatin (Full r Partial Inclusin) Help fr Scial ALDs (if peers are salient): Infrequent Scial Reference r Jint Attentin Lw Drive fr Peer Affiliatin Limited Mdeling r Imitatin Help fr Cmmunicatin Thery f Mind/ Perspective-Taking Help Organizing Stimuli Lack f Representatin Capacity (if child imitates & mdel at develpmental level) Recap: Pick a best fit methd fr a child s prfile f learning weaknesses (ALDs). Best fit is when the specific and verall features f treatment explit cmpensatry strengths (ALSs). The methd is nt the message: Cntent must be mtivating and develpmentally relevant. Bks fr Parents & Prviders by the Speaker Siegel, B (2008). Getting the Best fr Yur Child with Autism, New Yrk: Guilfrd Press. Siegel, B (2003). Helping Children with Autism Learn: Treatment Appraches fr Parents and Prfessinals, New Yrk: Oxfrd University Press. Siegel, B (1996). The Wrld f the Autistic Child: Understanding and Treating Autistic Spectrum Disrders,, New Yrk: Oxfrd University Press. Siegel, B.. and Silverstein, S. (1994). What Abut Me? Siblings f Develpmentally Disabled Children New Yrk: Perseus Press 9