Successfully Treating Children with Autism: Collaboration Between ABA & AACSession #1449

Richard Lytton, M.A., CCC-SLPHeidi Light-Keppler, M. Ed., BCBA

Honey Rinicella, parent of two children with Autism

What brought us together?

Living With Autism

Honey Rinicella

Family Perspective 4 Key Areas of Autism:

Communication Social skills Behaviors Learning

Approaches Medical approaches include diet and

supplements Educational approaches include

speech and behavioral therapies, as well as assisted technology devices and augmentative communication methods

Real Stress Not being able to communicate causes

challenges for entire family For example:

Rhonda-my brother doesn't like me Bob-I cannot help him enough Victor-just expressed concern if his brother

would ever talk

Behavioral Challenges Not being able to communicate your

needs to your friends, therapists and parents can cause insane behaviors! word retrieval issues not being able to express a need Inability to communicate a pain

Communication Difficulties Speech ultimate goal Other ways to communicate besides vocal

language. Remember, just because a child cannot

speak, does not mean he cannot understand. Always presume intellect! The true disability

is when a child has the intelligence to communicate but doesn't have the proper tools to do it.

Be careful of what is said in front of them

Challenges With Professionals Approaching speech and behavior in the same

way-- HUGE MISTAKE! Take the ability to communicate for granted Pair the complexity of communication with varying

sensory needs Needs:

Accurate assessment Constant modifications Belief that speech is not just vocalizations!

Build on different areas if you cannot obtain vocal language

Suggest a different therapist that could help better

Constant Assessment & Raising Expectations If you do not raise the bar for our

affected children, then they will continually trip over it!

Success lies within your ability to be creative!

Profiles of Children with Autism: Strengths and Challenges

Richard Lytton M.A., CCC-SLP

Profiles of Children with Autism: Strengths and Challenges

Autism ≠ less smart Autism = thinking and learning differently Many children who have Autism and who have

significant speech and language impairments are visual, multi-sensory, and/or experiential learners. o Many have specific weaknesses in processing and

modulating sensory information (auditory, visual, proprioceptive, etc.) and in concomitant motor learning.

Applied Behavior Analysis (ABA)

Heidi Light-Keppler, M.Ed., BCBABoard Certified Behavior Analyst

Applied Behavior Analysis A discipline focused on:

The improvement of human behavior (in a way that is socially acceptable)

Through methods of science

Choose improvement of behaviors that will…

Access reinforcement for the child, rather than punishment

Help the client both temporarily and in the future Endure after instruction (and access

reinforcement naturally vs. being dependent upon contrived forms of reinforcement)

Be age-appropriate Be a desired alternative to a maladaptive

behavior to decrease

Always ask yourself when seeking to improve a behavior: Will this behavior…

Help the child? Produce R+ when you are not present? Be similar to behaviors of their peers? Enable independent functioning in typical

environments? Increase adaptive/appropriate behavior? Increase access to peers and less restrictive

environments?

Consider training communicative behaviors that provide…

Frequent practice opportunities Extended duration of need Increased access to Sr+ Εfficient and effective access to Sr+ Greater independence per activity/less

reliance on adults Increased access to reinforcement for

significant others

Augmentative & Alternative Communication (AAC)

Richard Lytton, M.A., CCC-SLP

Functional communication… …consists of more than one communication

technique Speech, signs, low-tech communication displays

(including PECS), Speech Generating Devices Different expressive language/communication

techniques may be functional with different communication partners and for different pragmatic language purposes

Functional expressive language and communication performance requires:

Ability to establish and maintain joint social/communication attention; exchange socially interactive and communicative turns

Vocabulary from different parts of speech and different semantic categories. (example: one cannot achieve fluent language expression without verbs)

Syntax in sentences as well as in communication turn-taking across sentences.

Functional expressive language and communication performance requires (contin.):

Pragmatic language skill such as initiation; topic initiation and maintenance; requesting; predicting and anticipating; telling personal information, active participation through communication interaction in activities that occur throughout one’s day, week, and life.

Portability and generalization across all domains of one’s life (home, school, and community) and across communication partners.

Functional communication performance is matched to contextual language and social needs

Importance of raising the bar of expectations

Designing Collaborative Assessment Processes & Treatment Plans

ASHA’s Technical Reports and Guidelines

1.) Family members of individuals with autism fulfill multiple roles beyond those inherent in being a member of any family. (1)

2.) Philosophical mandate for family-centered practices has permeated both health care and educational fields. This philosophy offers a foundation for effective family—professional collaborations in assessment, diagnosis, and treatment of individuals with ASD. (1)

3.) Inter-disciplinary assessment and treatment teams: “Given the importance of social communication in the diagnosis of ASD, the SLP can play an important role in both screening and diagnosis…The SLP plays a critical role in referring children suspected of possible ASD to an audiologist to confirm or rule out a hearing loss. Furthermore, the SLP should play a primary role in the diagnosis of speech and language impairments that can co-occur with ASD, including, but not limited to, features of specific language impairment, apraxia, and dysarthria.”(1)

4.) Ingredients of Effective Programs (1)

“The NRC** recognized the need for more meaningful outcome measures and recommended measures that include (a) gains in initiationof spontaneous communication in functional activities and (b) generalization of gains across activities, interactants, and environments. The broad impact of the social communication challenges and problems with generalization for individuals with ASD underscores the critical importance of ecologically meaningful outcome measures. The NRC concluded that learning in natural learning environments appears to be the most effective intervention approach. Not only do such environments invite higher rates of initiation and generalization, they also enhance the ecological validity of the intervention because the behaviors involved are more likely to translate into a better quality of life and increase social acceptance.”

*** National Research Council (NRC) of the National Academies (National Academy of Sciences, National Academy of Engineering, Institute of Medicine, & National Research Council”

5.) Many issues should be considered in order to make informed decisions about specific instructional strategies. Clinicians need to ask themselves whether the interventions under consideration:

Focus on core characteristics and challenges as essential outcomes;

Ιncorporate empirically supported strategies to support initiation and generalization;

Αssess the link between behavior and communication and use of positive behavior support;

Υse strategies that support learning style, developmental framework, and self-determination;

Ιncorporate AAC; Χonsider peer and peer-mediated learning as a context.

Each of these considerations is discussed in the Guidelines in relation to available evidence-based practice. (1)

6.) “Current best practices reflect an awareness that not only persons with severe disabilities, but also their environments, need to be assessed. Environmental assessments are designed to ascertain the degree to which different environments invite, accept, and respond to communication acts by persons with severe disabilities.” (3)

7.) “The consistent use of meaningful interactive contexts is the hallmark of current intervention practices. Teaching communication in these more natural contexts appears more likely to foster the maintenance and generalization of newly learned communicative behavior to all similar contexts in the individual's natural environment.” (3)

“When considered together, all of the assessment and intervention practices discussed above have important implications for service delivery practices. Communication intervention must involve significant people and significant contexts across multiple environments. The delivery of intervention services of this scope requires the collaboration and competence of families and of professionals and paraprofessionals from many disciplines.” (3)

(1) Guidelines for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders: Across the Life Span, ASHA, 2006

(2) Technical Report: Principles for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders: Across the Life Span, ASHA, 2006

(3) Guidelines for Meeting the Communication Needs of Persons with Severe Disabilities: National Joint Commission for the Communication Needs of Persons with Severe Disabilities, ASHA, 1992

A Case Study of Functional Outcomes

Honey RinicellaHeidi Light-Keppler, M. Ed., BCBA

Vincent

Honey Rinicella

Vincent Autism doesn't mean less smart Severe apraxia

Cannot consistently or effectively communicate with use of his voice

Strong receptive skills

To aide in more appropriate and effective communication, we tried:

Sign language PECS Springboard Chat PC Silk

Sign Language Wasn't progressing Not understood by everyone Wasn’t using it functionally He appeared unmotivated to use the

signs

PECS Still lacking the intent to communicate Didn't have everything available to him

that he could use when communicating Weak fine motor skills and lengthy

response time

Springboard Not easily transported Took much effort to program Easily broke and made the screen

difficult to see and it limited navigation. No option to type in a word and have it

spoken for him

Current device: Chat PC Silk Small and easily portable with a strap that he

wears around his neck. Easily programmed Has the option of spelling a word and having

it spoken for him Limitations:

lengthy process to insert real pictures for him we’d like to allow for opportunity to use device for

more motivating activities stigmatizing

Programming

Heidi Keppler, M.Ed., BCBA

Assessment Strong MO to use his voice ABLLS-

Strong receptive skills Extremely weak expressive skills, especially with

regard to various parts/functions of language Mand, tact, intraverbal= very weak consistency &

generalization Echoic= strength for following directions to imitate; very

weak articulation Limitated rate of acquisition for new expressive

Goals Increase spontaneous communication Make communication more meaningful

or functional for him

What makes a communicative behavior functional:1. it works in social situations2. it works in naturally-occurring

environments3. society accepts it

Plan Review present skill levels

ABLLS (Sundberg and Partington) Define functional/meaningful (parallel the

goals of ABA): 1) it works to get his needs met 2) it works in naturally-occurring environments 3) society accepts it and he gets reinforcement for

it from those around him

Assess barriers to him acquiring an effective system in the past:

Overgeneralized requests or mand behavior Only being taught to mand for common

preferences vs. being taught across all functions of language -

i.e., the Verbal Operants (Skinner, 1954) vs. adults setting up situations with less common

preferences- e.g., “Color the hat blue,” without giving blue crayon makes the blue crayon valuable

Not having enough practice opportunities (people translating for him)

Consider other challenges impeding learning

Prompt dependence- we wanted the device to allow for him to use visual prompting to complete tasks and to provide auditory prompts to model vocalizations (for imitation)

Challenges coping with unpredictability-we wanted to provide a schedule to increase predictability

Execution of Plan Listed preferences and common

items/people from each environment Surveyed things that kids Vincent's age say

to each other Programmed device, Planned to address gaps in performance

across all parts of language ESPECIALLY contrived situations related to V’s challenges

Aim high on the number of practice opportunities!!

The ABLLS

Continual Plan for Vincent

Honey Rinicella

Continue to keep data This will allow you to track the progress Allow you to plan and move ahead

Raise the bar so their boredom doesn't result in a behavior challenge

Outgrowing Chat PC Silk Thinking ahead:

iPod touch Make communicating more meaningful for him Make what he uses to communicate more

motivating The bonus here is that he will look cool to his

peers.

AAC iPod Applications

iConverse displays 6 different icons that represent a person’s most basic needs. When activated by touch, the icons give both an auditory and visual representation of the specific need or want. iConverse is $9.99

iPrompts provides several easy-to-use, visual prompting tools (no audio prompts or voice output) to help individuals transition from one activity to the next, understand upcoming events, make choices, and focus on the task at hand. iPrompts is $49.99

AAC iPod Applications (contin) Proloquo2go brings natural sounding text-to-

speech voices, up-to-date symbols, powerful automatic conjugations, a default vocabulary of over 7000 items, full expandability and extreme ease of use to the iPhone and iPod touch. Proloquo2Go is $149.99

mytalktools is a monthly subscription of $5.75 that you can cancel anytime that allows you to author personalized content.

Touch Chat (Silver-Kite.com/touchChat)- It is supposed to be available at iTunes by the end of the November.

In Closing… AUTISM is the fastest growing developmental

disability in the U.S. today. Thank you from the bottom of my heart for

taking the time to help these beautiful children! Without you, they may otherwise be trapped, with no means of communication.

Honey.Rinicella@tacanow.orgWWW.TACANOW.org