Transcript Early Diagnosis TITLE etc - Ala-CASE

How Autism Spectrum
Disorder Affects Learning in
the Classroom
B.J. Freeman, PhD
Professor Emerita, UCLA School of Medicine
Alabama CASE Conference
February 25, 2014
Autism Spectrum Disorders are best
viewed as social-communication learning
disabilities.
ASDs represent a wide spectrum of abilities
and disabilities.
All children with ASDs require intense
multi-disciplinary evaluations and
intensive early intervention (as soon as
diagnosed) that focuses on teaching
social communication skills in the
natural environment.
Research has shown that even very mild
social communication issues in younger
children can result in significant behavior
issues as they age.
Current consensus is that the best
approach to intervention for the core
symptoms of ASDs includes a program of
coordinated, intensive educational and
behavioral intervention.
The most tested intervention is
applied behavior analysis (ABA)
which has been shown to significantly
improve the core symptoms in almost
all children.
Complete recovery is rare, but the
number of children showing recovery
has been increasing over the past
few years.
Recent research has demonstrated
that early intervention actually
changes brain function.
Diagnostic Criteria For 299.0 ASD
A. Persistent deficits in social communication
and social interaction across multiple
contexts, as manifested by the following,
currently or by history:
1. Deficits in social-emotional reciprocity,
ranging, for example, from abnormal social
approach and failure of normal back-andforth conversation; to reduced sharing of
interests, emotions or affect; to failure to
initiate or respond to social interactions.
2. Deficits in nonverbal communicative
behaviors used for social interaction
ranging, for example, from poorly
integrated verbal and nonverbal
communication, to abnormalities in eye
contact and body language or deficits in
understanding and use of gestures, to a
total lack of facial expressions and
nonverbal communication.
3. Deficits in developing, maintaining and
understanding relationships ranging, for
example, from difficulties adjusting
behavior to suit different social contexts,
to difficulties in sharing imaginative play
and in making friends, to absence of
interest in peers.
Severity Level is specified based on the
person’s specific communication
impairments.
Severity Level 1: Requires support for deficits in
social communication that cause noticeable
impairments without supports in place; difficulty
initiating social interactions, and clear examples of
atypical or unsuccessful response to social
overtures of others.
(For example, a person who is able to speak in full
sentences and engages in communication but
whose to- and-fro conversation with others fails,
and whose attempts to make friends are odd and
typically unsuccessful.)
Severity Level 2: Requires substantial support for
marked deficits in verbal and nonverbal social
communication skills; social impairments apparent
even with supports in place; limited initiation of
social interactions; and reduced or abnormal
responses to social overtures from others.
(For example, a person who speaks simple
sentences, whose interaction is limited to narrow
special interests, and who has markedly odd
nonverbal communication.)
Severity Level 3: Requires very substantial support
for severe deficits in verbal and nonverbal social
communication skills that cause severe
impairments in functioning; very limited initiation of
social interactions and minimal response to social
overtures from others.
(For example, a person with few words of
intelligible speech who rarely initiates interaction
and, when he or she does, makes unusual
approaches to meet needs only and responds to
only very direct social approaches.)
B. Restricted, repetitive patterns of behavior,
interests or activities as manifested by at
least two of the following, currently or by
history:
1. Stereotyped or repetitive motor
movements, use of objects, or speech,
(e.g., simple motor stereotypies, lining up
toys, or flipping objects, echolalia,
idiosyncratic phrases).
2. Insistence on sameness, inflexible
adherence to routines, or ritualized
patterns of verbal or nonverbal behavior
(e.g., extreme distress at small changes,
difficulty with transitions, rigid thinking
patterns, greeting rituals, need to take
same route or eat same food every day).
3. Highly restricted, fixated interests that
are abnormal in intensity or focus (e.g.,
strong attachment to or preoccupation
with unusual objects, excessively
circumscribed or perseverative interests).
4. Hyper- or hyporeactivity to sensory input
or unusual interest in sensory aspects of
the environment (e.g., apparent
indifference to pain/temperature, adverse
response to specific sounds or textures,
excessive smelling or touching of objects,
visual fascination with lights or movement).
Severity Level is specified based on
the person’s restricted, repetitive
patterns of behavior.
Severity Level 1: Requires support for
inflexibility of behavior that causes significant
interference with functioning in one or more
contexts; difficulty switching between activities;
problems of organization and planning that
hamper independence.
Severity Level 2: Requires substantial support
for inflexibility of behavior, difficulty coping with
change, or other restricted/repetitive behaviors
that appear frequently enough to be obvious to
the casual observer and interfere with
functioning in a variety of contexts; distress
and/or difficulty changing focus or action.
Severity Level 3: Requires very substantial
support for inflexibility of behavior, extreme
difficulty coping with change, or other
restricted/repetitive behaviors that markedly
interfere with functioning in all spheres; great
distress/difficulty changing focus or action.
C. Symptoms must be present in the early
developmental period (but may not
become fully manifest until social
demands exceed limited capacities, or
may be masked by learned strategies in
later life).
D. Symptoms cause clinically significant
impairment in social, occupational of other
important areas of current functioning.
E. These disturbances are not better
explained by intellectual disability
(intellectual developmental disorder) or
global developmental delay. Intellectual
disability and autism spectrum disorder
frequently co-occur; to make comorbid
diagnoses of autism spectrum disorder
and intellectual disability, social
communication should be below that
expected for general developmental level.
Characteristics of Curriculum
How to Select Skills/What to Teach
Skills should be meaningful to the student,
functional, age appropriate and lead to
independent functioning in the natural
environment.
What Skills Should Be Selected?
• Multiple environments: Skill will enhance
student’s functioning in increased
number and range of environments.
• Functionality: If student does not perform
the skill, someone else will have to do it
for them.
• Chronological Age Appropriateness:
Skill is culturally sanctioned within
student’s age group.
• Practice: Student will have opportunities
to perform skill under non-instructional
conditions, once acquired.
• Required in Adulthood: Skill is required,
needed, respected or allowed expression
in post school years.
• Student Preference: Student will enjoy
being able to perform the task.
• Parent Preference: Parent would like
student to learn the skill.
• Physical Enhancement: Skill will enhance
the student’s physical well being.
• Social Contact Enhancement: Skill will
increase student’s chances for positive
social interactions, particularly with nondisabled peers.
• Acquisition Probability: Student should
be able to acquire skill in a reasonable
period of time if adequate resources are
devoted to its instruction.
• Status Enhancement: Skill will enhance
student’s status in the eyes of many
non-disabled people.
Six kinds of intervention should have priority:
1.Functional, spontaneous communication
should be the primary focus of early
education.
2.Social instruction should be delivered
throughout the day in various settings, using
specific activities and interventions planned
to meet age appropriate, individualized
social goals.
3. Teaching of leisure skills should focus
on activities with peers, with additional
instruction in appropriate use of toys,
games and other materials.
4. Other instruction aimed at goals for
cognitive development should be carried
out in the context in which skills are
expected to be used, with generalization
and maintenance in natural contexts as
important as acquisition of new skills.
Because new skills have to be learned
before they can be generalized,
documentation of rates of acquisition is an
important first step.
Methods of introduction on new skills may
differ from teaching strategies to support
generalization and maintenance.
5. Intervention strategies that address
problem behaviors should incorporate
information about the contexts in which
behaviors occur, positive proactive
approaches, and a range of techniques
that have empirical support (e.g.,
functional behavior assessment,
functional communication training,
reinforcement of alternative behaviors).
6. Functional academic skills should be
taught when appropriate to the child.
Taking into account the needs and
strengths of an individual child and his/her
family, the child’s schedule and
educational environment in and out of the
classroom should be adapted as needed in
order to implement the IEP.
Educational services should include a
minimum of 25 hours a week, with no
more than a 2-week break, where the
child is engaged in systematically
planned, developmentally appropriate
activities aimed toward identified
objectives.
Where activities take place and content
of activities should be determined on an
individual basis, depending on
characteristics of the activity, the child
and family.
Individual Instruction
• The child must receive sufficient
individualized attention on a daily basis so
that individual objectives can be effectively
implemented.
• Individualized attention should include
individual therapies, developmentally
appropriate small group instruction, and
direct 1:1 contact with teaching staff.
• Need to teach readiness skills for
learning before curriculum.
• Ongoing assessment of the child’s
progress in meeting objectives should
be used to further refine the IEP.
• Lack of objectively documentable
progress over 3-month period should be
taken to indicate a need to increase
intensity by lowering student/teacher
ratios, increasing programming time,
reformulating curricula, or providing
additional training and consultation.
• To the extent that it leads to specified
educational goals (e.g., peer interaction
skills, independent participation in regular
education), children should receive
specialized instruction in settings in which
ongoing interactions occur with typically
developing children.
Characteristics of Teacher
Interaction Strategies:
• working knowledge of ASD characteristics
• develop sense of trust between teacher
and student with ASD
• accept student’s cognitive and social
abilities, and learning potential
• accept student for who he or she is
• training in ABA
Characteristics of Learning Environment
Individualized Supports & Services:
• Should be based on applied behavior
analysis (ABA).
• Incorporation of child’s preferences &
special interests into instructional
program.
• Focus on child’s strengths & weaknesses
to determine the most appropriate
density and level of instruction to meet
child’s individual goals.
Systematic Instruction:
• Targeting meaningful skills to be taught.
• Planning when & how to provide
instruction based on unique characteristics
of student.
• Determining data collection method to
measure student’s progress & instructional
effectiveness.
Comprehensible, Structured Learning
Environment:
• Organize instructional setting
• Provide schedule of activities
• Carefully plan & provide choice-making
opportunities
• Provide behavioral support
• Define specific areas of classroom,
school settings
• Provide temporal relations
• Facilitate transitions, flexibility, change
Goals of the Classroom:
• Increase accessibility to learning by
decreasing disruptive/aggressive
behaviors.
•
Maximize learning (pre-academic,
academic, self-care, motor skills,
receptive/expressive learning, etc.)
•
Maximize communication
•
Readiness for learning
Signs of a Good Class:
•
•
•
•
•
extensive reinforcement
systematic intervention plans
continuous teaching/no down time
comprehensive programming
natural teaching
Instructions designed for Educators:
• Communicating to the student
• Encouraging communication with the
student
• Social supports – includes specific
teaching, rehearsal, practice & modeling
of social skills in natural settings.
• Environment & Routine
• Presentation of material
• Assessment & assignments
• Homework
• Self-management of behavior
Functional Behavior Assessment
• Dynamic process that addresses
behavior on individual basis.
• Is a work in progress – should not be
fixed.
• Key to success
10 steps toward supporting appropriate
behavior in the classroom:
1. Understand characteristics of ASDs that
may influence student’s ability to learn
and function in school environment.
2. Acknowledge that behavior serves a
function, is related to a context, and is a
form of communication.
3. Use FBA as first step in designing
behavior support plan:
• identify, describe behavior
• describe setting, demand, antecedent
• collect baseline data, work samples
• complete functional analysis, develop
hypothesis
• develop & implement positive behavior
support plan
• collect data, monitor effectiveness
• revise as needed
4. Think PREVENTION.
5. Use antecedent and setting event
strategies.
6. Make teaching alternative skills an
integral part of program.
7. Effective behavioral change may require
everyone involved to change their
behavior as well.
8. Design long-term prevention plan.
9. Discuss how student fits into school-wide
discipline practices & procedures.
10.Collaborate, hold regular team meetings.
ABA Strategies
•
Should not focus on excessive behaviors,
but lack of new skills
•
Most studied, most scientific support
•
Curriculum consisting of simple &
complex target behaviors involving
hundreds of programs developed through
years of research.
•
Child-specific curriculum adaptations
•
Task analysis
•
Repeated practice through discrete trials
•
Masses expanded, dispersed formats
•
Clear, discriminable instructions
Common Behavior Strategies
Proactive procedures:
• identify function of disruptive behavior
• select replacement behavior
• break skill into discrete parts
• teach discrete skill until mastery
• concentrated & systematic teaching
• provide assistance as necessary
• make learning fun & as natural as possible
• provide reinforcer for appropriate behavior
Reactive procedures:
• create behavioral momentum
• provide reinforcer for absence of
disruptive behavior
• disruptive behaviors result in least
amount of attention necessary & loss of
opportunity for reinforcement
• shape de-escalation
• remain calm
Reinforcement guidelines:
• Cannot assume!
• Reinforcers should be reinforcing.
• Reinforcement should be contingent &
may have to be taught.
• Use a variety of reinforcers.
• Pair social with tangible reinforcers.
• Continuously develop reinforcers.
• Initially, reinforcement should occur
immediately.
• Thin reinforcement schedule as soon
as possible.
• Label behavior being reinforced.
• Don’t use bribery.
• Utilize differential reinforcement.
Goal is for the natural environment to take
over the reinforcement and the person
learns to control his/her own behavior.
Common Misunderstood Behaviors
Compliance:
• Is the instruction necessary?
• Does the child understand instruction?
• Will you/Can you follow through?
• Don’t issue multiple instructions.
• Provide choices when possible.
• Phrase with expectation of compliance.
• Create behavioral momentum.
• Catch the child listening.
• Give in early.
• Provide meaningful consequences.
• Utilize errorless compliance training
program.
• If non-compliance occurs, provide
least amount of attention.
Stress management:
• Develop calming place
• Create calming object
• Teach concept of calm
• Identify stressors
• Arrange stressors into a hierarchy
• Teach relaxation skills (holding object,
guided imagery)
• Expose to mild stressor
• Cue relaxation
• Reinforce calm
• Fade cueing
• Systematically expose to more natural
environment
• Expose systematically to higher stress
levels
“Teachers learn according to the same
principles as their students. Multiple
exposures, opportunities to practice, and
active involvement in learning are all
important aspects of learning for teachers as
well as students.”
Educating Children with Autism;
National Research Council, Lord et al, 2001