1

The Statewide Autism Resources and Training Project (START):

Early Intervention Amy Matthews, Ph.D. and Jamie Owen-DeSchryver, Ph.D.

Grand Valley State University

Agenda for Today

•  Orientation to START

•  Quick review of data related to ASD

•  Review Effective Practices for Young Children with ASD

•  Description of START Early Intervention Training

•  Consider how the latest news about ASD may impact schools

Purpose of START

START serves as a coordinating and

supporting entity for regional sites across

the state of Michigan to increase access to

local resources, training and support

for students with autism spectrum

disorder.

2

Primary Components

Assumptions

•  Early childhood programming is not a foreign concept

•  You know at least the basics of autism spectrum disorders

•  You are interested in our presentation topic

Latest CDC Report

•  1 in 150 children have an Autism Spectrum Disorder (ASD)

•  It is no longer a low incidence disorder

•  We need to meet the vast range of needs in public school settings

•  Between 1994 and 2006, the number of 6 to 17-year-old children classified as having an ASD in public special education programs increased from 22,664 to 211,610 nationally

3

ASD by ISD

Growth in the Number of Students

with ASD in Michigan from 1999-2007

Projected Eligibility Trends

4

Why are we really here?

•  What kind of world do you want

•  Feel the sense of urgency for each and every child

Early Identification

What motivates the search?

•  Mean age of autism diagnosis = 34 – 61 months

•  Mean age of first parental concern = 18 – 19 months

•  Gap means 1-2 years before autism treatment begins

•  Earlier identification earlier intervention

•  Intensive early intervention = better outcomes

Mandell et al, 2005

n = 965

5

Impairment in Social Interaction: Lack of appropriate eye gaze Lack of warm, joyful expressions Lack of sharing interest or enjoyment Lack of response to name Lack of coordination of nonverbal communication

Impairment in Communication: Lack of showing gestures Unusual prosody (little variation in pitch, odd intonation, irregular rhythm, unusual voice quality) Lack of showing or pointing Lack of communicative vocalizations with consonants

Repetitive Behaviors & Restricted Interests: Repetitive movements with objects Repetitive movements or posturing of body Lack of playing with a variety of toys

Based on research at the Florida State University FIRST WORDS® Project

Red flags of autism in infants

Critical aspects of brain architecture begin to be shaped by experience before and soon after birth, and many fundamental aspects of that

architecture are established well before a child enters school.

The timing and quality of early experiences combine to shape brain structure. Center on the Developing Child, Harvard University (February 2008)

Critical Periods

Intervening early and intensively is key to skill development and avoiding behaviors

before they happen

6

Age

Developmental rates from 6-24 months: language development 9 children with ASD; 27 with typical development

Months Rogers, et al, in progress

The convergence of neuroscience and

economics tells us that the clock is always ticking, and

the costs of ignoring problems keep rising

Intervening Early:

Effective Components of an Early Intervention Program for

Young Children with ASD

7

Effectiveness/Outcome

•  Dawson & Osterling (1997) •  National Research Council (2001) •  Rogers & Vismara (2008) •  Numerous outcome studies •  Wrightslaw

–  “All available research strongly suggests that intensive early intervention makes a critical difference to children with autistic spectrum disorders. Without early identification and diagnosis, children with autism are unlikely to learn the skills they need to benefit from education.”

What are the Critical Components of Effective Programs?

•  Early is better (by 3½) –  Intervention at identification –  Identification/intervention before age 3

•  Intensity matters (at least 25 hours/wk, full year, with low ratio) –  Model programs range from 15-40 hours a week with an

average of 25 hours per week •  Active engagement/Structured teaching time

–  Minimal “free time” –  Lots of learning opportunities –  Each moment is a teachable moment

•  Family participation •  Individualized goals, regularly monitored

National Research Council, 2001

Additional Critical Components of Effective Programs

•  Curriculum content •  Highly supportive teaching environment

and generalization strategies •  Need for predictability and routine •  Functional approach to problem

behaviors •  Transition planning

Dawson & Osterling (1997)

8

Additional Critical Components of Effective Programs

•  Team approach •  Opportunities with typical peers

– Language and social models – Exposure to typical curriculum and activities – Acceptance – More natural transition to kindergarten – Special education teachers keep the “typical”

perspective Dawson & Osterling (1997)

Model Programs

Virtually all model programs are private and/or grant funded

•  Princeton Child Development Center •  Denver Program •  Douglass Developmental Disabilities Center •  LEAP •  Young Autism Project •  Walden Program/Emory Autism Center •  Alpine Learning Group •  And Many More We Know W

hat Works

Evidence Based Practices What does it mean? •  Practices that have empirical support or

program evaluation support •  Demonstrated effectiveness as indicated

through improved outcomes

•  Why does it matter? –  It’s the law –  It’s the most effective way to teach –  Most efficient way to learn –  Better chance of success

9

Where do we get information about evidence based practices?

•  NPDC (www.fpg.unc.edu/~autismPDC)

•  OCALI –  AIM website (http://www.autisminternetmodules.org)

•  National Autism Center –  National Standards Project (

http://www.nationalautismcenter.org)

•  State Early Intervention Autism Workgroup (MI) –  www.cenmi.org/asd

Why do we have such trouble modifying public school

programs to fit the recommendations and needs for young children with ASD?

Implementation challenges in public school settings

•  Ratios (ECSE classrooms) •  Intensity/Time in class (0-3 and 3-6) •  Training of staff •  Philosophy •  Transition to typical elementary settings •  Getting families involved

10

Systems Change

•  Big change only happens when we change whole systems

•  We did what we did when we knew what we knew

•  Once we know different, we are accountable

Change is Hard!

It’s not so much that we’re afraid of change or so in love with the old ways, but it’s the place in between that we fear…It’s like being between trapezes. It’s Linus when his blanket is in the dryer. There’s nothing to hold on to. –Marilyn Ferguson

Big Ideas for Early Intervention

•  Identify and intervene early •  Use evidence based practices •  Increase learning opportunities (i.e. opportunities to

respond with feedback) and student engagement •  Focus on meaningful, functional goals and tasks

(independence and socialization) •  Use effective instructional delivery (3 Rs-Request,

Response, Reaction) •  Establish a classroom structure to ensure learning

11

Big Ideas for Early Intervention

•  Establish positive patterns of behavior early on •  Many problem behaviors are preventable with

planned supports •  Provide lots of meaningful integration

opportunities •  Use data to confirm that what you are doing is

working •  Carefully plan for transition to elementary •  Work as a team and include families

START Intensive Training: Young Children with ASD

•  Effective Classroom Structures and Supports

•  Structuring Play in the Early Childhood Classroom

•  Providing Intensive, Individualized Teaching in the Early Childhood Classroom

•  Classroom Visits/TA

Building CASTLES in Early Childhood Programs

C – Classrooms A – Actively S – Structuring T – Teaching L – Learning and

E – Engagement for

S – Students

12

What are the two biggest problems we hear with regard to educating

young children with ASD?

2. Learning/ Skill Development

1. Behaviors

What can we do? •  Create as many structured learning

opportunities as possible, individualized for students

•  This will eliminate many of the issues with problem behaviors

How can we do it?

•  Learning Opportunities

•  Engaged Time

What does this mean?

13

Learning Opportunities

Providing supported opportunities for learning leads to better outcome

What does a learning opportunity look like?

1.  Instruction/activity is presented to the child

2. Child has an opportunity to respond

3. Child is given feedback –  Acknowledgement that response was correct –  Correction/prompt to help the child give a correct

response

How to Increase Learning Opportunities

•  Use center cards to increase independence and thus learning

•  Use peers instead of relying solely on adults •  Assign staff to particular kids so there's more

"ownership" for engaging the kids •  Don't provide all necessary materials (spoon, glue,

chair) to elicit communication •  Staff increase labeling, commenting about activities •  Split circle time to reduce waiting time •  Provide cheat sheets for staff listing specific goal

targets for students

14

Engaged Time

•  It is not possible to provide learning opportunities all the time, but we can increase time engaged.

•  Engaged time: Active involvement in productive activities that lead to learning.

Counting Learning Opportunities and Time Engaged

•  Let’s count learning opportunities and watch for engaged time

•  Watch the student. When you see a learning opportunity mark it down.

•  Keep track of how much time the child is engaged

15

Learning Opportunities Study

•  How many learning opportunities across: –  Type of Classroom –  Activity –  Adult role –  Eligibility label

•  Student engagement across: –  Type of classroom –  Activity –  Eligibility label

Reaching Our Ultimate Goals

Why do we work so hard to increase learning opportunities?

•  Independence •  Socialization •  Preparation for typical school experiences •  Quality of life

Early Intervention Assessment Tool

•  Assessing program components within each classroom

•  Identifying areas of strenth and need

•  Creating priorities and action items

16

Classroom Staff

Group/Differentiated Instruction

Individual Instruction

Communication Instruction

Social/Play Instruction

Scheduling

Supports

Scheduling

Supports

Routine

Supports

Behavior

Supports

Visual

Supports

Early Intervention for Children

with ASD

Ancillary Staff

Peer

s

Parents

•  Scheduling Supports (maximizing time with students, effective use of staff, specific goals at each center/activity)

•  Routine Supports (establishing classroom routines)

•  Visual Supports (visual supports and schedules)

•  Behavior Supports (positive behavior support, changing behavior patterns, expectations)

Organizational Supports

Preschool Classroom Schedule

17

Purpose of Schedule

•  Notice, no free time (if you have a child for only 2 ½ hours a day, they should be structured for maximal learning)

•  Learning is always happening •  Seat tasks are alternated with movement

activities •  Maximize time during required tasks

(mixing bathroom and snack) •  Schedule is differentiated across students

Predictability and Routine

•  Predictability can increase active involvement and decrease overarousal

•  Use visual cues •  Support successful

transitions throughout the day

Visual Supports

•  Visual supports are often thought of in terms of what will improve student understanding, participation, and output.

•  Pictures, schedules, written instruction or outlines of a lesson often come to mind when we think of visual supports.

18

Types of Visual Supports

•  Schedules •  Mini schedules •  Task organizers •  Assistance •  Waiting symbols •  Choice making •  Rules

•  First, then cards •  Calming/feelings /

regulation supports •  Transition supports •  Introducing change •  Video models •  Staff visuals

Visual Supports: Assistance

Two of the most important visual supports you can teach…

Visual Support: Task Organizer for Center

Name Cut Glue Backpack

19

Staff can also benefit from visual supports to cue them what to do.

Visual Supports for Staff

Posted in Play Area • Narrate play

• Keep students in play area • Model varied & creative use of toys while engaging child

• Set up opportunities for interaction between students • Follow through with requests

• POSITIVELY REINFORCE students

Positive Behavior Support

All behavior is COMMUNICATION

All behavior serves a FUNCTION

What is Behavi

or?

What is Behavioral Intervention?

INSTRUCTION (Discipline)

Behavior Support

What are the two best ways to address challenging behaviors?

1. Prevent them

20

Antecedent Strategies to Prevent Challenging Behaviors

Examples: •  Meaningful, interesting activities with support •  Thoughtful environmental structure •  Provide snacks •  Present easy task before hard task •  Provide transition cues •  Give movement breaks •  Give attention for appropriate behaviors

Best strategy is to match the reason for the behavior with the right prevention

Good teaching is the best form of behavior management.

» Thomas Caffrey

Behavior Support

What are the two best ways to address challenging behaviors?

2. Teach alternative behaviors

21

Teach Alternative Behaviors and Provide Prompts

•  Why is the behavior happening? •  Decide on an alternative behavior that

would be more appropriate •  Teach the appropriate alternative

behavior •  Prompt for the alternative behavior •  Reinforce the use of the alternative

behavior •  Wait for the next behavior

Teaching Alternative Behaviors

•  Ask for help •  Request a break •  Playing a game for a social interaction •  Asking for a snack •  Choice making

What Else Can We Do to Improve Behavior and

Learning?

Here is a great strategy to improve child and staff

behavior

22

Expectations are Clear and Consistent

•  Expectations are high •  Everyone knows them •  Everyone abides by them

General Expectations for Students across the School Day

•  Expectations to and from the bus •  Expectations for snack time •  Expectations for circle time •  Expectations for playground/sensory

room/gym •  Expectations for lunch •  Expectations for bathroom

Classroom Staff

Group/Differentiated Instruction

Individual Instruction

Communication Instruction

Social/Play Instruction

Scheduling

Supports

Scheduling

Supports

Routine

Supports

Behavior

Supports

Visual

Supports

Early Intervention for Children

with ASD

Ancillary Staff

Peer

s

Parents

23

•  Group/Differentiated Instruction •  Intensive Instruction (assessment,

curriculum, goals, instruction, data collection)

•  Social/Play Instruction •  Communication Instruction

Instructional Considerations

Instructional Supports

Group Instructional Supports •  Themes •  Centers & Goal Cards •  Differentiated Instruction

Centers & CLAMS cards

24

Identify Centers •  Literacy/Academic

•  Sensory/Art

•  Dramatic Play

•  Games

•  Blocks, building toys, books

Create CLAMS Goal Cards for Centers

Goal cards should have targets for each of the following areas:

•  C – Communication goals •  L – Literacy goals (letters, pre-reading) •  A – Academic goals (numbers, shapes, colors) •  M – Motor goals (gross, fine) •  S – Social goals

CLAMS Card for Game Center Barnyard Bingo

C: Communication goal –  Student says, “it’s your turn” to peer

L: Literacy goal –  Reads names from cue cards when staff holds up card

and says “whose turn is it?” A: Academic goal

–  Responds to questions, “where’s the chicken/pig/blue piece?” “what does a chicken say?”

M: Motor goal –  Uses pointer finger to point to chicken/pig/blue; uses

pincer grasp to place chip in barn S: Social goal

–  Student passes game to peer CLAMS Goal Card with Differentiated

Instruction

25

How do you we meet the needs of students at all levels?

Differentiated Instruction

Student Levels and Differentiated Instruction

Early Learner •  May not have verbal language, has emerging sign/PECs skills •  May still be learning imitation, matching & attending skills •  Emphasis on choice-making & communication targets •  Emphasis on building a consistent communication system, participation, attending skills

& social interactions with adults •  May require frequent reinforcement

Emerging Learner •  Emerging verbal skills (imitates single words & short phrases) •  Attends to tasks independently for a brief period of time •  Can imitate, match and sort •  Emphasis on communication, social interaction with adults or peers & building pre-

academic skills •  Less frequent reinforcement is required to maintain behavior

Kindergarten Readiness Learner •  Speaks in short phrases or sentences •  Demonstrates fairly consistent attending skills •  Emphasis on expanding communication skills, social, play & pre-academic skills •  Preparing for transition to less restrictive placement

•  Differentiated Instruction in Group Settings

•  Intensive Instruction (training #2)

•  Communication Instruction

•  Social/Play Instruction (training #3)

Instructional Considerations

26

Presenting Instruction

Request (Stimulus)

Response

Reaction (Consequence)

The 3 Rs are what we call a “Learning

Opportunity”

Providing supported opportunities for learning leads to student success

What are the 3 Rs?

The Basics of Applied Behavior Analysis (ABA)

What is ABA?

ABA is Good Teaching

27

Intensive Instruction Training

•  Curriculum •  Assessment of student skills •  Goals and targets •  Intensive instruction, including:

–  Instructional delivery –  Prompting & Errorless learning –  Reinforcement –  Shaping

•  Data Collection/Assessing Progress

•  Differentiated Instruction in Group Settings

•  Intensive Instruction (training #2)

•  Communication Instruction

•  Social/Play Instruction (training #3)

Instructional Considerations

Teaching Play

28

Early Childhood Approach •  One-third of school-day

should be spent in free play

•  Children learn social rules, language skills and complex, abstract thinking through their interactions with toys and other children

•  Problem: Students with ASD show deficits in play and social interactions

What happens when you ask a child with ASD to go play?

Developmentally Appropriate Practice Draft Statement, National Association for the Education

of Young Children, 2008 (naeyc.org)

Teaching to enhance development and learning •  “Developmentally appropriate teaching practices

provide an optimal balance of adult-guided and child-guided experiences… child-guided experiences proceed primarily along the lines of children’s interests and actions, with strategic teacher support” (p. 27-8).

29

Actively Structuring Play Opportunities

•  Dramatic Play •  Free Play •  Recess •  Targeting play skills for individual

students

Teaching Dramatic Play One Strategy: Matt & Molly Stories

Structured Free Play

•  As a team, make decisions about what skills the student with ASD is using or learning during free play

•  Initially, limit free play time (e.g., student only plays for last 5-10 minutes of free play); use remainder of time for teaching

30

Developmentally Appropriate Practice Draft Statement, National Association for the Education

of Young Children, 2008 (naeyc.org)

Teachers organize an environment that will promote each child’s learning and development.

2.  “Teachers present children with opportunities to make meaningful choices, especially in child-choice activity periods. They assist and guide children who are not yet able to enjoy and make good use of such periods.” (p. 28)

Structured Free Play

•  Use classroom staff effectively •  Station staff strategically •  Assign staff to particular students •  Train staff in prompting strategies •  Support staff with Goal Cards

•  Encourage push-in ancillary services

•  Involve peers

Targeting Play Skills for Individual Students

31

Targeting Play Skills

•  Direct teaching: Adult support •  Direct teaching: Peer support •  Reciprocol imitation •  Scripts •  Video modeling •  Observational play

Reciprocal Imitation

Music

Dramatic Play

Pretend with Figurines

Games

Toys

Imitation

By teaching imitation, children can learn

many play skills

Imitation

32

Observational Play with Matched Toys

•  Classroom Staff (teaming, shared philosophy, consistency)

•  Ancillary Staff (increasing role of ancillary staff in the classroom

•  Parents (collaboration, parent education) •  Peers (models of behavior, awareness

and training)

People Supports

Working as a Team

What is the one thing your team can do to dramatically improve learning and reduce problem behaviors?

Be Consistent How do you do this? Regular team meetings and team communication

33

Priority Checklist Classroom Programming

•  Team •  Expectations •  Learning Opportunities •  Visual Supports •  Behavior Support •  Schedule •  Themes/Centers/Differentiated Instruction •  Structuring Play •  Paraprofessionals •  Family Involvement

Optimal Approach

•  Inclusive preschool classroom with core preschool curriculum

•  Intensive instruction – Embedded in the school day, and/or – Following the school day

•  See Project DATA for one model

Why is it time to carefully consider programming for young children with ASD in

Michigan, at this time?

34

Insurance Legislation Michigan recently became one of a growing number of states across the country to introduce autism insurance reform bills this session. Representatives Kathy Angerer (D-55) and Richard Ball (R-85) have introduced House Bills 5527 & 5529, and Senator Tupac Hunter (D-5) has introduced Senate Bills 784 & 785, which seek to provide insurance for children with autism spectrum disorders to seek evidence based treatments. The bill provides for coverage for therapies such as speech therapy, occupational therapy, psychological therapy and services and applied behavioral analysis therapy as prescribed by a treating physician or psychologist.

Blue Cross Blue Shield Case A settlement was reached in the case of Christopher Johns v. Blue Cross Blue Shield of Michigan, 08-cv-12272, filed in Detroit. In the suit, the plaintiff alleged that Blue Cross' pattern and practice of characterizing the scientifically established Applied Behavioral Therapy as "experimental," and thus as excluded under its insurance policies, was arbitrary, capricious, illegal and contradicted by many years of scientific validation. Under the settlement, Blue Cross will pay for behavioral therapy rendered to over 100 children in the last six years. Research shows that children with autism spectrum disorder need this therapy early on in life and delaying treatment can irreversibly prevent them from achieving their full potential."

•  Special Education: –  Standard educational program for students with disabilities, includes

a variety of educational and therapeutic interventions. –  There is limited evidence that this approach is effective for young

children with ASD (Howard et al, 2002).

•  Early Intensive Behavioral Intervention (EIBI): –  EIBI has significant empirical support. Studies show that

approximately: •  50% of children achieve significant gains (perform in typical

range) •  40% of children achieve moderate gains •  10% of children achieve limited gains

–  Not only do many children make large improvements (with approx. 72% succeeding in regular education), EIBI is also cost efficient.

Early Intensive Behavioral Intervention (EIBI)

35

Early Intensive Behavioral Intervention: Cost Savings

Jacobson, Mulick, & Green (1998) found that EIBI results in savings of $656,000 to $1,082,000 per child across the lifespan

Chasson, Harris, & Neely (2007) calculated a cost savings in Texas of $208,500 per child and $2.9 billion in the state with the use of EIBI

ASD Workgroup

•  ASD Planning Workgroup for Young Children (0-6)

•  Supported by MDE, DCH, DHHS

•  Recommendations – http://www.cenmi.org/asd/Home.aspx

State Plan

•  Autism Spectrum Disorder State Plan for Michigan

•  Supported by MDE and DCH

•  Findings, Gaps, Recommendations

•  Proposed completion date: Summer 2010

36

Questions or Comments

Amy Matthews, Ph.D. matthewa@gvsu.edu

Jamie Owen-DeSchryver, Ph.D. owendesj@gvsu.edu

www.gvsu.edu/autismcenter