Building Capacity for Serving Infants and Toddlers

Suspected of Having Autism Spectrum Disorder (ASD)

Adrienne Frank, MS, OTRBeth Pruitt, MEd,CCC-SLP

Child Development Resources

Participant Goals

Learn about a grant-funded project Review promising approaches and

related research for serving young children with ASD

Understand key interventions appropriate for infants and toddlers

Identify ways that EI providers can build capacity for serving ASD

Building Capacity Project

A one-year grant project at CDR Funded by the Williamsburg

Community Health Foundation Goal: To investigate proven,

successful approaches, obtain resources, and develop a revised plan for serving infants and toddlers with ASD

Project Accomplishments Visits to Programs

TEACCH in Chapel Hill, NC Virginia Institute of Autism

in Charlottesville The Step-by-Step program

in Suffolk

Conference Attendance

DIR Model – Greenspan SCERTS Model Sensory Integration Biomedical Approaches Applied Behavioral Analysis (ABA) Pivotal Response Training (PRT)

Workshops Sponsored by CDR

Quarterly staff development Pivotal Response Training – 2 days Dr. Accardo

Screening Young Children Suspected of ASD

Explaining ASD Resources and Services to Families

Partnering with Physicians Related to Diagnosis and Services

Other Grant Funded Activities

Families participated in training Purchased materials and equipment Obtained screening/assessment

instruments Partnered with the College of William &

Mary for consultation, staff development, student research tasks, and respite care for children

Other Activities continued

Collected data and compared approaches

Clarified values for CDR’s approach for serving infants and toddlers with ASD

Developed considerations for IFSP development

CDR Values Statements for Serving Infants and Toddlers Suspected of Having ASD

Outcomes, interventions, and services must be individualized and based on family’s identified needs and stated in the IFSP

Intervention takes place in the natural environment, functional for child and family

Frequency and intensity based on child and family’s concerns and preferences

All children suspected of having ASD should be screened with appropriate instruments and assessed and followed by the MDT team

Values continued

All children suspected of ASD should be seen by a neurologist or developmental pediatrician

Intervention should be positive, social and communicative, especially with primary caregivers

Skills should be developed and practiced across daily routines and settings for generalization and maintenance

Developmentally appropriate play is linked to cognitive, linguistic, and social skills

Values continued

Family and primary caregivers learn intervention as part of the daily routine, using activities beyond the times when professionals are available

Professional development must be continuous and intensive and there must be a transfer of knowledge across professional disciplines

Screening for ASD

A number of screening instruments exist, “none are sufficiently sensitive and specific to warrant universal usage, … many await validation… many over identify or miss children with mild variations of ASD.” Pasquale Accardo, M.D.

(e.g., ABC, ASQ, CHAT, M-CHAT, PDDST, STAT, SCQ)

Multiple Screening Instruments - Most sensitive items

Does your child ever bring objects over to you to show you something? (M-CHAT)

Child looks to where mother is pointing (Johnson 04)

Show interest in non-sibling peers (Klin, Volkar, & Sparrow, 92)

No babbling by 12 mos (Choueiri & Bridgemohan, 05)

What to look for… What is the child’s language history?

Milestones (e.g., words, phrases) Deviance (e.g., echoed speech) Regression (i.e., decrease in language at

12-24 months)

What is the family history? Autism, PDD, depression, schizophrenia

What to look for…

Presence or history of… Poor eye contact Lack of emotional expression Toe walking Flapping Picky eating Large head circumference (1.5 SD above

mean) Posteriorly rotated ears (> 10 degrees)

Pasquale Accardo, M.D.

Intervention Continuum

Didactic Naturalistic Developmental

Prescriptive

Directive

Skill - based

Flexible

Facilitative

Activity - based

Didactic Approaches

Based on behavioral theory Repetitive drill and practice trials Prescriptive antecedent/behavior/consequence

ABC sequence or stimulus-response-reinforcement

Adult directed – leads to passive communication style

Reinforcement of desired behavior in controlled setting – lacks of generalization to new setting

Naturalistic Approaches

Applies behavioral principles in natural settings Moderately adult directed - adult makes decisions

in the moment, requires skill Emphasis on using functional, pragmatic social

interactions rather than ABC sequences Goal of spontaneous, child initiated interactions Intrinsic rather than tangible/edible reinforcement Focus on maintenance / generalization

Developmental Approaches

Intervention goals based on typical communication development

Functional communication rather than speech Child directed for motivation, functionality Teach through routines -multiple opportunities,

increasing desire to communicate Success relies on the talent of interventionist Limited research

Approaches

Didactic Naturalistic

Developmental

Discreet Trial ABA

X

TEACCH X

PRT X

SCERTS X

DIR X

Simpson (2005) Practice Categories

Scientifically based practices ABA including discrete trial Pivotal Response Training (PRT)

Promising practices TEACCH

Limited supporting research DIR SCERTS (not in book) Biomedical approaches

Developmental Approach e.g., SCERTS

Based on developmental research with priority goals of social communication and emotional regulation

Considers health including biological and/or nutrition, sensory, arousal levels, and environmental stressors

Considers child’s functional needs and family priorities Teaching is flexible – “teachable moments” Activity based in multiple, natural environments and

contexts with families as intervention agents and learning with typically developing peers

Incorporates positive behavior support methods, multimodal communication, visual, etc.

Applied Behavior Analysis (ABA) E.g., Discrete Trial Training (Lovaas)

A scientific approach to improving socially important behaviors

ABC / SRR sequences Direct measurement, single-subject study Functional assessment task analysis Setting event and establishing operation Stimulus control Generalization / maintenance Shaping, fading, prompting, chaining Reinforcement contingencies

ABA Based Approach Pivotal Response Training (PRT)

Pivotal areas: Motivation, responsivity to multiple cues, self-management, self-initiations, empathy

Use pivotal response techniques: Obtain and keep child attention, maintenance tasks (interspersing, variation), shared control (child choice and directed), responsivity to multiple cues (decrease overselectivity), reinforcement contingent, reinforce attempts for motivation, direct and natural reinforcers

Goals of Pivotal Response Training

Increase child’s motivation Increase responsiveness Increase engagement of the

learning environment Increase functional behavior

/replace repetitive or challenging behaviors

Examples of Environmental Arrangement

Interesting materials Inadequate portions Out of reach Choice making Assistance Unexpected situations

Plan for Generalization Careful selection of targeted

environments, situations for intervention

Interventions occur within natural environments relevant/typical to the child Not contrived situations

Across settings, stimuli, people Opportunities to use skill

Writing IFSP Goals for ASD

Types of Goal Content Developmental milestones based on

the area of delay Developmental milestones related to

items significant to children with ASD Intervention goals from ASD approach Change/ decrease in behavior that is

atypical or affects interactions

Objectives Examples

Area of delay – e.g., Child will use 10 words ASD area – e.g., Child will point to item

named in 8/10 trials. ASD approach – e.g., Child will match 5

objects to picture (photo, color drawing, line drawing).

Behavior – e.g., Child will exhibit hand flapping less than 5 times during a structured task with an adult.

Criteria for Measurement

Quantity Amount – e.g., 3-5 words Trials – e.g., 3 out of 5 timesGeneralization People – mother, babysitter, visitor Places – home, neighbor’s, play group Situations – quiet, noisy, unfamiliar

Examples of Goal Areas

Joint attention Communication – frequency, form, function Social interactions – imitation, with peers Generalization across settings, situations Play behavior - symbolic, pretend,

imaginative Improve regulatory/sensory capacity

The National Research Council (2000) says children with ASD should receive…

Early identification and intervention Active engagement and intensive

programming (at least 25 hours) Repeated and planned teaching

opportunities One-to-one or small group / low adult to

child ratio Family involvement Continuing assessment

CDR’s Revised Plan will help to:

Identify and diagnose children suspected of having ASD

Develop IFSPs that reflect values of practice Refer children to appropriate diagnostic

evaluations Continuously seek out new intervention

approaches/ strategies Make materials and resources available to

families Help children to transition to appropriate

services