Transcript doreen_granpeesheh

Center for Autism and Related Disorders, Inc
Bringing ABA and
Biomedical Interventions
Together
Doreen Granpeesheh, Ph.D. B.C.B.A
Today’s Presentation
How can Biomedical and ABA
interventions work together?
What is ABA
What makes a good ABA program
Breakdown of the CARD program
The CARD Curriculum
The Full Treatment Approach
Autism:
 Genetic Predisposition
 Immune Dysfunction
 Environmental Insult
• Toxic overload, Vaccines, Antibiotics 
 Gastrointestinal Dysfunction
_____________________________________
BIOLOGICAL BASIS
The Full Treatment Approach
Autism:
 Language Delay
 Social Delay
 Restricted and Repetitive Behaviors
 Maladaptive Behaviors
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BEHAVIORAL MANIFESTATION
The Full Treatment Approach
Biological Treatment
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Eliminate Triggers
Stabilize condition
Achieve Health
Ensure the child’s
Maximum Learning
Potential
ABA
 Increase
Skills
 Decrease
Maladaptive
Behaviors
 Generalize to
Daily Living
A healthy child…..
 Eats better
Sleeps better
Feels better
CAN LEARN BETTER…..
ABA and Biomedical together…
ABA +
Lexapro
ABA
Challenging Behaviors per Session
7
ABA +
Lexapro + Coromega
+
ProDHA
6
Tantrum
5
Non-Compliance
4
Ritual SSB
3
2
1
0
April
May
June
July
Aug
Months
Sept
Oct
Nov
Dec
E
New Skills Acquired
ABA
ABA +
Lexapro
ABA +
Lexapro +
Coromega +
ProDHA
New Operants
120
100
80
60
40
20
0
Mar 04
April 04
May 04
June 04
July 04
Months
Aug 04
Sept 04
Oct 04
Nov 04
Dec 04
E
Month
Elopement
Fidgeting
Leaning
Running into Items
Grabbing Items
Screaming
Ju
ne
Ma
y
150
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Frequency
Behaviors Reduced
Monthly Behavior Statistics
Chelation and
Antifungal
Treatment 10/8/'04
5/'04 - 6/'05
100
50
0
Applied Behavior Analysis
What is ABA ?
ABA is based on the principles of
Operant Conditioning Theory:
“Human Behavior is affected by events
that precede it (antecedents) and events that
follow it (consequences)”
Change these events…change Behavior!
What behavior do we want to change?
Deficits
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Language
Play
Social Skills
Theory of Mind
Executive Functions
Skill Repertoire Instruction
Excesses
 Self Stimulatory Behs
 Maladaptive Behs
• Tantrums
• Aggression
• Noncompliance
Behavior Management
Behavior Management
Child Tantrums to get what he wants…
Child screams to escape a task…
Child hits to get your attention…
Child self stimulates…
Skill Repertoire
Instruction
Teach him to ask for the object
Teach him to ask for a break
Teach him to call your name
Teach him something more appropriate to do
Challenging behaviors can be replaced by more appropriate ones!
Treatment Model
Applied
Behavior
Analysis
Skill Repertoire
Building
Behavior
Management
Curriculum
Assessment
Functional
Behavioral
Assesment
Teaching
Strategy
DTT
NET
Indirect
FluencyBased
Instruction
Generalization &
Maintenance
Descriptive
FunctionBased
Treatment
Experimental
Behavior Management
ABA: Challenging Behaviors occur for 4 reasons:
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Escape (I don’t want to go to school)
Tangible (Give me back my toy)
Attention (Look at me)
Self-Stimulatory (internal reinforcer value)
In some instances, you have to look deeper..
 Why doesn’t he want to go to school (is he anxious
about failing?)
 Why does she body rock (is she in pain?)
Challenging Behavior = Communication
What makes a good ABA program?
Provider needs to understand what the child is trying to
communicate…and teach him better ways to communicate
it.
Provider needs to really understand child’s skills and
deficits
Provider needs to deliver a program that is individualized
to each child
Provider needs to constantly modify this program to fit the
child’s strengths and weaknesses
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Visual perceptual difficulty?
Auditory comprehension difficulty?
Attention and Distractibility?
Pre-Requisite skills?
PROVIDER NEEDS TO HAVE A PLAN!!!
The CARD I Treatment Model
ABA Foundation
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Errorless Teaching
Discrete Trial Training
Natural Environment Training
Fluency
Verbal Behavior throughout
instruction
Children from 0-8 yrs
Intensive treatment
Shift from home-based 1:1
learning to school &
community based learning
opportunities
Biological Intervention
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
A 4 year progression
Year 1:
 Child entering at age 2-3
 25 hours per week building to 40 hours
 Emphasis on
• Building a relationship with child
• Replacing challenging behaviors with
functional communication
 Mands (Requests)
 Tacts (labels)
• Receptive identification (objects,
actions, body parts, colors, shapes)
• Receptive instructions
• Verbal and Non-verbal Imitation
• Identical Matching
• Play Skills (toy play)
• Adaptive Skills (toilet training)
• Fine and Gross Motor
• Dietary restrictions/medical compliance
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
A 4 year progression
Year 2:
 Child age 3-4
 40 hours (in home with partial transition to school)
 Emphasis on
• Building Expressive Language
 Objects, Actions, Attributes, Prepositions, Pronouns
 Categories, Functions, Occupations, Locations
• Beginning Conversation
 Intraverbals
 Reciprocal Statements
 Asking Questions
• Developing Observational Learning
 I See
 Sequences
 Tell me about/Describe
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•
•
•
•
•
•
Emotion Recognition
Inferring others desires
Play Skills (functional pretend, symbolic, imaginary)
Adaptive Skills (dressing, grooming, feeding)
Fine and Gross Motor
Sharing and Turn taking
Attention (dual and divided)
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
A 4 year progression
Year 3:
 Child age 4-5
 40 hours (20 hours at home; 20 hours at school)
 Sample Programs
• Advanced Language Concepts
 Pragmatic Language
 Maintaining Conversation (topic initiation, repair,
maintenance)
• Meta and Social Cognition
 Identifying and Managing own emotions
 Understanding other’s Perspectives, Knowledge
and Beliefs
 Inferences
• Executive Function
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Attention Saliency
Flexibility with Routines
Inhibition and Self Monitoring
Planning
• Social Skills
 Levels of Friendship
 Recognizing Social Cues
•
•
•
•
Problem Solving
Play Skills (peer play dates)
Adaptive Skills
Fine and Gross Motor
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
A 4 year progression
Year 4:
 Child age 5-6
 40 hours (10 hours at home; 30
hours in school and fading
services)
 Emphasis on
• Teacher and Parent training
• School Skills
 Listening and Reading
comprehension
 Math and Problem Solving
• Advanced Social Skills
 Detecting Sarcasm
 Understanding Deception
 Group Skills
• Continued Self Regulation
 Self Esteem and Confidence
 Task and Social Planning
Allocation of Hours
40
30
20
10
0
Year Year Year Year
1
2
3
4
Home-based
School-based
The CARD Curriculum
School
Skills
Executive
Cognition
Functions
Language
Play
Social
Skills
Adaptive
Motor
Skills
A Functional Approach
Language
Acquiring language is more than
learning, “the meaning of words”
Teach the basic functions of language so
that the child learns how to “use”
language to communicate
The CARD Curriculum
Language
Sample Basic Language Program: Colors
Function
Imitation
Antecedent
Mom says, “blue”
Requesting Jody is ready to finger
Child’s Behavior
Jody says, “blue”
Jody says, “blue paint”
(Mand)
paint, but no paint
Matching
3 color cards on table
Jody matches blue cards
Receptive
3 crayons present & mom
says, “give me blue”
Jody hands mom the blue
crayon
Labeling
Jody sees a blue car
Jody says, “blue”
(Tact)
Conversation
Mom asks, “What color is
(Intraverbal) the sky?”
Jody says, “blue”
Topography of Language
Language
Phonology: the sound of language
Morphology: the structure of language
Semantics: the meaning of language
Syntax: the arrangement of language
Pragmatics: Social Language
The CARD Curriculum Language
Overall Goals in Teaching Language
Emphasis on ensuring spontaneity in
language use
Emphasis on teaching language that is
functional in everyday situations
Emphasis on generalization
Make sure the child understands that
language is useful for communication!
The CARD Curriculum
Play
Features of a Comprehensive Play Skills Program
 Modeled
after the development of play skills in
typically developing children
Breaks down each type of play into its own
systematic and comprehensive program
Sequential format
Programs may be used individually, concurrently,
or cumulatively
The CARD Curriculum
Play
Target Areas
Block Imitation
Structure Building
Constructive
Sand
Constructions
Clay Constructions
Play
Arts and Crafts
Functional Pretend Play
Symbolic Play
ImaginaryPretend
Play
SociodramaticPlay
Play
Social Games
Nursery Rhymes
Songs withInteractive
Objects
Board Games
Play
Locomotor Play
Peer Play
Independent
Play Tracking
Social Emotional
Independent
Vocal Play
Development
Reciprocal
Vocal Play
through
Play
Exploratory
Play
Independent
Toy Play Play
Sensorimotor
Task Completion (Peg Boards, Puzzles)
The CARD Curriculum
Adaptive
Skills
Personal Skills
Safety Awareness
Strangers
Household chemicals
Germs
Environmental
Bathing
Dressing/Undressing
Fastening/Unfastening
Feeding
Grooming
Toilet Training
Utensil Use
Domestic Skills
Telephone Skills
Laundry
Setting/Clearing Table
Repairing Broken Items
Preparing Food
Making Bed
Using Basic Tools
The CARD Curriculum
Motor
Skills
Visual
Motor
Binocularity
Accomodative Skills
Visual Processing
Fine Motor
Coloring Cutting
Drawing Finger skills
Hand Skills
Pre-Handwriting
Gross Motor
Prone Position
Squatting
Supine Position Skills
Throwing
Hopping
Running
Stairs
Walking
Balance Beam
Jumping
Sitting
Standing
Rolling
Catching
Kicking
The CARD Curriculum
School
Skills
Math
Number ConceptsLanguage Arts 1
Rote Counting
Language Arts 2
Reading
Reading Numerals
Visual Discrimination
of Symbols Writing
Manuscript
Numeral Comprehension
Reciting Alphabet
Printing Symbols
Ordinal
Position
Physical Education
Uppercase LettersPersonal Data
Numerals in Sequence
NonAcademic
Lowercase
ScienceLetters
Lowercase Letters
Addition
Skills
Word Recognition
History
Uppercase Letters
Subtraction
Orally
Letters
in Sequence
Advanced Counting ReadingSocial
Studies
Reading Comprehension
Letters Dictated
Money
Book Topography
Simple Sentences
Time
Story Comprehension
Quality of Printing
Story Summarizing
Text Comprehension
The CARD Curriculum
Cognition
Cognition:
 Meta-cognition: Identifying your own …
 Social Cognition: Inferring others’…
Emotions
Thoughts
Knowledge
Desires
Beliefs
Intentions
Classic Test of Social Cognition
“Sally-Anne” or False-Belief Task
Where will Sally look for her ball?
Where does she think her ball is?
Cognition
“Typical” Meta and Social
Cognitive Development
Cognition
First few months: Sense of Self
9 months: Joint Attention / Social Referencing
15 months: Pretence
18 months: Desire / Intention
2 years: Emotion
3 years: Knowing / Thinking
4 years: Belief / False-Belief
5 years: Intention – Accident vs. Purpose
The CARD Curriculum
Cognition
10 Target Areas
Deception
Emotions
Senses
Sensory
Perspectives
Intentions
Knowing
Beliefs
Desires
Thinking
Preferences
Social Interaction
Apologizing
Assertiveness
Compliments
Cooperating
Negotiating
Gaining Attention
Greetings and
Introductions
Levels of Friendship
Relationships/Mann
ers
Requesting
SocialCessation
Sharing/Turn Taking
The CARD Curriculum
Social Language
Social Vocalization
Topic Selection
Topic Initiation
Topic Maintenance
Topic Breakdown and Repair
Topic Transitioning
Joining a Conversation
Ending a Conversation
Social
Prosody
Language
Absurdities
Figures ofAbsurdities
Speech
Humor and Jokes
Tricks and Deception
Group Related
Skills
Group
Choral Activities
Related
Group Discussion
Skills
Peer Pressure
Interaction
Social
Social Rules
Compliance
Social
Recognizing Rules
Rules
Following Rules
Questioning Rules
Social
Skills
Self Esteem
Dealing with Conflict
Wishes
Positive Self
Skills
Statements
Winning
Self Esteem
Losing
Social Context
Community Social
Behavior
SocialImitation
Responding to Social
Context
Cues
What’s Missing
Inferences
The CARD Curriculum
What is Executive Function?
 Process that underlies goal
directed behavior
Goal Directed Behavior Involves…
Visualizing situation
Identifying desired objective
Determining plan to meet
objective
Monitoring progress to goal
Inhibiting distractions
Executive
Functions
The CARD Curriculum
Executive
Function
Basic EF Concepts
Basic
Social PlanningEye contact
Flexibility
Concepts
Pointing
Planning
Generating Alternatives
Social
in social
contextsJoint Attention
Problem Solving
Planning
Flexibility
Relaxation Training
Task Planning
Organizing Materials
Prioritization
Task
Time management
GoalPlanning
Direction
Task Initiation
Meta-Cognitive
MetaSelf-Evaluation
Cognitive
Self-Monitoring
Planning
Of Attention
Attention
EF
Cognitive Set Shifting
Sustained Attention
Attention
Divided Attention
Alternating Attention
Saliency
Memory
Working
Inhibition Memory
Visual-spacial
Waiting
Inhibition
Of Reinforcement Generating Alternatives Auditory
Emotion Regulation Identifying social cues Associative
Other CARD Programs
CARD II: Age 8-Adult
 Consultation and training for schools
 Training for parents and caregivers
 Vocational Skills Training
Feeding and Pill Swallowing Program
Behavior Management Consultations
Visual Program for non-vocal children
CARD II: Ages 8-Adult
Social Skills
Social Communication
Accessing General Ed Curriculum
Vocational
Daily Living Skills
Functional Communication
Treatment of Challenging Behavior
And…what is our success rate?
WPPSI: Pre- & Post-ABA Early Intervention
Pre-Test
130
120
Post-Test
110
Intelligence Quotient
100
90
80
70
60
50
40
30
20
10
0
20
22
27
29
29
30
30
31
Average Therapy Hours Per Week
31
31
32
34
38
Summary
Find an experienced physician who will
help you find the triggers and stabilize the
health of your child.
Find a good ABA program that will help
you assess your child’s strengths and
weaknesses and give you a plan of action.
Don’t give up HOPE! You were given a
child with Autism because you are an
exceptional person who can handle this
exceptional situation!