Transcript handout
TREATMENT: The JumpStart Learning-to-Learn Model: Individualizing Parent Training Heterogeneity in the DSM-5/ DM-ID-2 Autism Spectrum: Linking Biological Traits, Clinical Traits and Treatments 32nd ANNUAL NADD CONFERENCE Nov. 18, 2015 Lina Fancy Executive Director, JumpStart, Learning to Learn Autism Center of Northern California San Francisco, CA What is Jumpstart? JumpStart Learning to Learn is a model for early intensive 'front-loaded' parent training, designed to be administered in the first weeks after receiving an autism spectrum diagnosis for a very young child. JumpStart is a 1 week intensive full-time coached parent training model administered to one family at a time, where parents learn specific skills and vocabulary about autism treatment while working directly to teach their own child new social, communication and play skills. What is Jumpstart? Parents of children with ASDs: – – – – Know child does not learn like others Know that typical parenting practices have not worked well Want to foster adaptation, communication and social skill Need to learn tailored methods for their child’s specific ASD profile & developmental level to move forward JumpStart teaches: – – – Skills parents can use to 'wrap around' other therapeutic services How to ID ‘teachable moments’ to leverages learning Ways to integrate/ promote generalization of therapies JumpStart’s Learning Objectives Understand the role for a parent trained in their child’s way of learning. Promote family by direct coaching of parents to increase communication and play skills while decreasing maladaptive behavior. Understand natural environment teaching opportunities of the home as a pivotally motivating treatment milieu Teach parents interventional techniques to increase their efficacy as consumers of autism services in medical, educational and other therapeutic milieu. Coaching Parents to become Integral Intervention Agents ID ALDs & ALSs to specify individual treatment ID functions of behavior Modifying behavior increase skill acquisition Use behavioral method at developmental level DIR/FLOORTIME methods to increase social communication Case Study Initial Meeting with the Parents Are expectations for the child consistent between parents? To what extent have the parents accepted the diagnosis? – – Where is each in the grief cycle? How may this affect what each will be able to absorb? Are there different parenting styles? – Are parents able to communicate about these? Initial Meeting with the Parents What are the most challenging issues the family is having: – – – How informed are they about autism? How effected is the child on an initial observation? – – Behavior? Communication? Social Skills? Are there ‘testing’ behaviors? Learned helplessness? What is the level of instructional control in the home? Functions of Behavior: Three categories of behavior non-compliance; incompatible with learning: • • • Attention Seeking Behavior Escape Based Behavior Sensory Threshold Antecedents and consequences are modified according to context and age Functions of Behavior: Attention Seeking Behavior The child may exhibit inappropriate behaviors to get attention from adults or peers as they don’t have the communicative tools or skills to gain it in traditional or appropriate ways. This can take the form of aggressions, tantrums, loud vocalizations and repetitive physical initiations Functions of Behavior: Escape Based Behavior By wanting to escape a situation, task or request, the child may exhibit passive or active non compliance which includes running/walking away, tantrums, ignoring the request and getting involved in another activity or a self stimulatory behavior Functions of Behavior: Sensory Threshold Some behaviors often are reactions to a child’s sensory sensitivities and therefore coping behaviors often are created to help manage overstimulation Methodology used to Modify Behavior and Increase Skill Acquisition Reinforcement is integral: Defined as consequence that increases future probability of the behavior that immediately preceded it If a child engages in a behavior producing a positive outcome, it is likely that s/he will repeat it. Methodology used to Modify Behavior and Increase Skill Acquisition Antecedent-which is the stimulus that immediately precedes the behavior; Behavior-the response Consequence-the immediate outcome of the behavior. Methodologies used to Modify Behavior and Increase Skill Acquisition Prompting A Prompt is an instructional technique that should help the child make the correct response during initial instruction. The least invasive prompt required should always be used This theory involves giving good, clear and CONCISE instructions and allows the child 3-5 seconds to respond. If there is an incorrect or no response then the correct answer is repetitively prompted to ensure the child is successful and therefore willing to learn. Methodologies used to Modify Behavior and Increase Skill Acquisition PROMPTING TECHNIQUES NON VERBAL Using Gestures to Correct response (e.g., pointing) VERBAL PROMPTING PHYSICAL PROMPTING Using partial verbal prompts or full verbal models Hand over hand (HOH) prompting used when child requires physical assistance The Importance of GENERALIZATION via Natural Environment Teaching • Primary: Ensure child with autism is able to utilize information taught in generalized environments, across familiar and novel peers and adults. • Working on skills in naturally occurring situations continues to naturally reinforce specific components of goals and ensures behavior will be used in needed context The Importance of GENERALIZATION via Natural Environment Teaching • In addition, if we use a system that allows the child to make choices that direct the teaching, then we start at a higher level of motivation which yields a higher acquisition rate when teaching foundational skills such as: • Compliance • Attention • Imitation • This is done by focusing on motivation, ‘responsivity’, interaction and initiation. The Importance of GENERALIZATION via Natural Environment Teaching Strategies to elicit natural teaching: Follow the child’s lead and allow the child to become interested in a stimulus Provide a clear opportunity to respond to the stimulus related to child's interest Immediately provide the preferred item upon the child's attempt to verbally respond Natural environments must be set up to provide frequent opportunities to use, comprehend and respond to the natural consequences of language Using Natural Environment Teaching to Elicit Communication Examples: • At meal time, leave the food slightly out of reach and delay asking what they want to see if the visual of the food will force communication • Leave their cup our of reach and if they are used to drinking with a straw or Sippy cup lid, leave it off to force some request and communication • Only put one shoe or sock on and wait for a reaction when your child knows it is time to go to the park Using Natural Environment Teaching to Elicit Communication Examples: • Wait outside a door (home or car) when your child wants to go inside • Move a favorite toy or blanket out of reach but in view to create opportunities for interaction through requests • When reading a book, stop reaching at favored anticipated spots so your child will engage with you and let you know they are listening or they want you to finish JumpStart Behavior Coaching: Specific Activities Creation of a Reinforcer Hierarchy to ensure MOTIVATION Establishment of Instructional Control through compliance work Work on foundational skills such as Attendingand Joint Attention Creation of a plan on how to contrive opportunities for interaction and initiation within the home Creation of increased structure within the home If needed, accompanying the family on a community outing which typically elicits challenging behaviors to offer strategies to prevent or redirect Common Strategies Taught Implement and Maintain Instructional Control Use Proximity and Obtain Eye Contact to Ensure Comprehension Keep it Simple and allow for Processing Follow Through Vary your Tone of Voice and Expression to Convey Meaning Verbally Model Use Redirection for Tantrums Prime! Prepare! Video Vignette 1 Primary Features of DIR/Floortime Meet child where they’re at developmentally, join in their play, and expand it from within, making it more interactive (lining up cars can become a parking lot). Treat child’s actions, even when they’re selfstimulatory, as intentional, use them to create interaction (Flapping becomes flying). Follow child’s lead (Do not impose your ideas on the child). Common Questions Raised By Parents in the Play/Social Development Component How can I stop my child from withdrawing whenever I try to play? How can I increase the amount of time that my child will remain engaged? Do we need to work on pretend play? How to include siblings? How to facilitate peer interaction? DIR Model: First Six Stages of Functional Emotional Development Stage 1: Self-Regulation and Interest in the World – Is the child organized? Able to attend? Is his engine running too high, too low, or just right? Example: Alex tapping CDs or jumping. First Six Stages (cont) Stage 2: Shared Intimacy Finding ways to work around a child’s sensory needs to facilitate closeness and intimacy. Making it safe for her to interact. Example: Physical closeness, eye contact, social referencing, imitation First Six Stages (cont) Stage 3: Two-Way Communication Reciprocal social interaction, back-and-forth signals to convey intentions or ideas. Not only language-based: Includes gestures, facial expressions, reading faces. Example: Hiding CDs Circles of Communication First Six Stages (cont) Stage 4: Complex Communication Linking together larger numbers of circles of communication to create complex patterns of behavior. Example: Chase With Daddy Problem-Solving Example: Putting CDs up high First Six Stages (cont) Stage 5: Representational Thinking – – Imaginative play, acting out emotional themes in play. Using one object “as if” it is another object, or pretending as if nothing is something. Example: Making an angry monster chase a doll and eat it, feeding/taking care of babies, pouring pretend Coke. First Six Stages (cont) Stage 6: Emotional Thinking – – Linking together various pretend play schemes, creating connections between them. Complex, thematic play. Example: Camping Trip Outing: Playground Most JSLTL programs include an outing to a nearby playground. – – – – Opportunity to work on skills in a new context. Opportunity for peer interaction. Opportunity to address challenging behaviors that come up in public (tantrums, not wanting to leave, etc.) Showing parents that play does not have to occur only during structured Floortime. Common Strategies Taught Join play, then expand. - Parents are taught to join in the activities that their child chooses, and expand them slowly from within. Stop teaching, just play. Allow child to initiate. - Parents are taught that doing this teaches the child that s/he needs to take action in order to get his/her intentions met. - Increase reciprocal communication. Common Strategies (cont.) Use playful obstruction (playfully getting in child’s way on purpose) to increase communication and anticipation. Use warmth, humor, and big affect. Give child choices. Be persistent. Take turns. Use repetition and routine to create games, increase anticipation, and have fun. A Case Study A 2 ½ year old girl enters the clinic with a diagnosis of Autism. She hand leads her mother to her backpack and approximates a two word request- ‘open bag’. She empties all of her toys and labels them as she takes them out of the bag. However she is not labeling them to show them to her mother, in fact she is presenting with lack of attending, lack of joint attention and aversive positioning meaning she is physically turned away from her mother. Not only was she unable to demonstrate eye contact, she was completely resistant to it and would exclaim ‘No, no, no’ when asked to look by saying her name or a directive like ‘look at me’. She would bring items to mom and dad and seek attention, however would sit with her back against their chest or lay face down across their laps. She exhibited high levels of frustration when not understood, didn’t get what she wanted, had to terminate an activity or had to delay gratification. Her protest behavior included crying, screaming, flailing arms, flopping to the floor and throwing toys off shelves. She demonstrated some rigidity as she wanted the same book read to her over and over again, and would script from selected books when overwhelmed. She demonstrated mild self stimulatory behaviors such as hand flapping when excited or hand swinging when escalated.