1. Starting Treatment Right With Autism and Severe Cognitive Impairment Lynn M. Dudek M.S., CCC-SLP, MBA, BCBA lynn.dudek@asdslp.com

2. WHAT YOU WILL LEARN 1. You will be able to describe the characteristics and needs of a child with ASD and severe cognitive impairment. 2. You will be able to choose goals for speech therapy intervention. 3. You will be able to list multiple strategies to employ in therapy sessions.

3. CHARACTERISTICS Multiple repetitive behaviors Poor verbal skills or non-verbal Few opportunities to interaction in a social context Low IQ scores Poor social skills Little to no academic gains Maladaptive behaviors such as self-injury, aggression, and/or property destruction

4. CHARACTERISTICS High rate of uneven cognitive development Indications of a dissociation between verbal and visual-perceptual skills among the older children. Specific association of discrepantly high nonverbal skills with increased social symptoms Suggestion that the nonverbal > verbal profile may index an etiologically significant subtype of autism. (Joseph, Tager-Flusberg, Lord, 2002)

5. CHARACTERISTICS Significant positive correlation between the presence of repetitive behaviors and the Hyperactivity scale of the ABC (Aberrant Behavior Checklist). Parent ratings of their stress levels and the presence of repetitive behaviors in their children were highly correlated. (Gabriels, Cuccaro, Hill, Ivers, & Goldson, 2004))

6. CHARACTERITICS Children with autism grow up to be adults with autism. If communication is poor as a child, it can be even poorer as an adult. If a child had access to an alternative communication system when they were in school have frequently lost that access as they transition to adult services.

7. None of this matters – because you tailor the intervention to the needs of the child – not the description or the diagnosis!!! Cookbook curriculums will not work! Each child is unique and it is necessary to individually determine needs and design an intervention plan to meet those needs. (Sundberg & Partington, 1998)

8. OUR GOAL? Increase functional communication. Improve quality of life Decrease maladaptive behaviors Ensure a basic human right “Making effective communication, a human right, accessible and achievable for all.” -ASHA Vision Statement (2007)

9. OUR ASSUMPTIONS ALL CHILDREN CAN LEARN WE ARE RESPONSIBLE FOR THEIR LEARNING IF THE LEARNER HASN’T LEARNED, WE HAVEN’T TAUGHT ASSESSMENT INFORMS OUR INSTRUCTIONAL PRACTICES Marchand-Martella, 2016

10. WHERE TO START? Always with an evaluation. –Typical standardized tests are not a great help. –Use some tests that are younger than age for skills assessment only. –VB-MAPP – Verbal Behaviors Milestones Assessment and Placement Program –ABLLS - The Assessment of Basic Language and Learning Skills - Revised

11. WHERE TO START? Functional Communication Profile – Revised (2003) Early Functional Communication Profile (2012) EOWPVT-4 ROWPVT-4

12. Assessment Name Variables Assessed Age Range Assessment ContextCitationRating Language Use Inventory Pragmatic language 18–47 months Parent reportO’Neill [2002] ◖ Peabody Picture Vocabulary Test— IV Receptive vocabulary 2; 6–90 yearsStandardizedDunn and Dunn [2004] ● The MacArthur- Bates Communication Development Inventories (CDI) Receptive and expressive language 8–37 months a a Standardized parent report Fenson et al. [2006] ◖ Preschool Language Scales-5 Auditory comprehension Birth-7; 11StandardizedZimmerman et al. [2011] ◖ Reynell Developmental Language Scales-III Verbal comprehension Expressive language 1–6 yearsStandardizedEdwards et al. [1999] ◖ a This measure is not validated on school-aged children, but was included because the raw scores have frequently been used in research and clinical practice with older children. ○ = Unlikely to yield meaningful results ● = Well suited for use with minimally verbal children ◖ = Use with some caution

13. Assessment Name Variables Assessed Age Range Assessment ContextCitationRating Sequenced Inventory of Communicative Development— Revised Receptive language Sound and speech discrimination Awareness and understanding 4–48 months StandardizedHedrick et al. [1984] ◖ Test of Early Language Development—3 Receptive language2; 0–7; 11 years StandardizedHresko et al. [1999] ◖ Language Samples Expressive language gestures All agesObservation Natural contexts and Structured probes Costanza-Smith [2010] Rojas and Iglesias [2010] Romski et al. [2010] Kaiser and Roberts [2013] ● Vineland Adaptive Behavior Scales-II Receptive language Expressive language Written language 0–90 yearsParent report Teacher report Sparrow, Cicchetti, and Balla [2005] ◖ a This measure is not validated on school-aged children, but was included because the raw scores have frequently been used in research and clinical practice with older children. ○ = Unlikely to yield meaningful results ● = Well suited for use with minimally verbal children ◖ = Use with some caution Kasari, Brady, Lord, & Tager-Flusberg, 2013

14. WHY THE VB-MAPP Breaks down skills such as communication intent: –Makes eye contact (gaze shift) as a mand for attention or other reinforcer –Moves close to a reinforcing time to indicate desire –Pulls an adult to get access to a reinforcing item –Points or gestures toward a reinforcer in order to obtain it

15. WHY THE VB-MAPP Tacts 3 body parts Tacts 2 auditory stimuli (ringing phone) Spontaneously emits a tact containing two words for 5 different tacts (baby crying) Tacts 40 different items when asked “What’s that ?”

16. BEHAVIOR & SPEECH BEHAVIORSPEECH PATHOLOGY ECHOICIMITATION (VERBAL) MANDREQUEST/DEMAND TACTLABELING/COMMENTING INTRAVERBALCONVERSATION/EXCHANGES/FILL IN THE BLANK

17. CASE HISTORY #1 – Dax 9 year old male Non-verbal IQ tests unable to be administered due to lack of compliance. Severe self-injury Property destruction Unsuccessful with PECS for 3+ years Has a Vantage Lite Has seizures, Pica, and auto-immune disorder.

18. Dax Results of evaluation: Very poor play skills Engages in simple initiating joint attention for highly preferred items Points to 3-D objects with verbal and gestural prompts

19. THERAPY Play – we have to teach him how to have fun. –Loves deep pressure, tickles, rolling on a therapy ball –Eye gaze to indicate want for more –No verbal demands, no signs, no icons He is at a pre-linguistic level and has to learn intent, motivation, and interaction.

20. THERAPY Once interaction is established – give it time! Introduce Total Communication –Signs –PECS –Icon –Device Take data on which method is most successful

21. WHAT WORKED FOR DAX? PECS and Vantage Lite PECS was used for everyday communication throughout the day Vantage Lite was used in speech therapy –Teach sequence and then move to use PECS was phased out and use of his device was his communication method.

22. GOALS Complete the hit sequences necessary to produce directive words –Complete the sequence to produce the following words: all done, help, stop, and go with gestural prompts with 90% accuracy over a 3 month treatment period. –These were the bang for your buck words.

23. GOALS Will use 1 word utterances to direct the course of an activity. –Say "all done" to show that something is finished with gestural prompts and 70% accuracy. –Direct another person's actions by saying the word "go" with gestural prompts and 70% accuracy.

24. GOALS –Say the word "help" to request help with gestural prompts and 70% accuracy. –Say the word "stop" or "all done" to indicate that he is finished with an activity with gestural prompts and 70% accuracy. –Say the word "stop" to command someone else to stop something with gestural prompts and 70% accuracy.

25. GOALS Complete the hit sequence required to request a preferred item/activity –Complete the sequence to produce the following words: cereal, cracker, chip, popcorn, cookie, candy, swing, book, movie with gestural prompts with 90% accuracy over a 3 month treatment period.

26. CASE HISTORY #2 - Alan 17 year old male No functional verbal speech Severe aggression and self-injury I.Q. = <50, unable to be measured Removed from school, placed in alternative program

27. Alan Results of evaluation: –Formal/standardized testing was not possible, observational only –Engages in initiating joint attention for desired items –Gestures toward door to indicate wanting to go home –Yells/hits/punches/bites to protest –Highly motivated by edibles and taking a break

28. THERAPY Took a very long time to establish rapport First several months of treatment focused on pairing First target – BREAK Second target-EAT

29. THERAPY Behavior technician was present and participated in each session for months Building rapport – motivation – was critical and the focus for treatment to be successful!

30. WHAT WORKED FOR Alan? Slow and steady Pairing Initial goal of therapy focused on learning a functional way to request a break versus using aggression Employing different reinforcement schedules –Utilized 1:1 for a long time

31. GOALS When presented with a field of 1 icon on an iPad in PLQ2G, Alan will activate the BREAK icon, given most to least prompts, at least 20 times during a therapeutic session as averaged over 5 sessions. When presented with a field of 2 icons on an iPad in PLQ2G, Alan will activate either the BREAK or EAT icon, given most to least prompts, at least 30 times during a therapeutic session as averaged over 5 sessions.

32. GOALS Once BREAK and EAT were established the following were introduced: –Colors –Bathroom –Go –Snack folder

33. WHAT ARE YOUR GREATEST CHALLENGES? Motivation Interaction Goal setting Reinforcement schedules

34. STRATEGIES For all your intervention –Expectations (Archer & Hughes, 2011) –Responding signal –I Do-We Do-You Do –Mullet principle –PRAISE, PRAISE, PRAISE Often, specifically,5:1rule (

35. 5:1 – NOT JUST FOR OUR KIDS Business Teams: High Performance = 5.6 positives to 1negative Medium Performance = 1.9 positives to 1 negative Low Performance = 1 positive to 2.7 negatives Losada, 1999; Losada & Heaphy, 2004 Successful Marriages: 5.1 positives to 1 negative (speech acts) and 4.7 positives to 1 negative (observed emotions) Gottoman, 1994

36. EXPECTATIONS STAR Sit Tall Track with your finger/eyes/etc. Answer on signal Respect Others

37. STRATEGIES Be functional – skills needed for a successful life –Sorting – but sorting what? –Categories – of what, for what? –Social skills – greetings, closings, please and thank you –Money – not just counting and value but the exchange

38. STRATEGIES What about using a device? What is the child’s age? Are we teaching language development or functional communication? What about verbal speech and that conversation with parents? Core vs. fringe vocabulary

39. USEFUL RESOURCES Peer Play and the Autism Spectrum- Pamela Wolfberg VB-MAPP – Mark Sundberg, Ph.D. Functional Behavioral Assessment, Diagnosis, and Treatment – Ennio Cipani and Keven Schock Teaching Language to Children with Autism or Other Developmental Disabilities - Mark Sundberg, Ph.D. and James Partington, Ph.D. Encyclopedia of Basic Employment and Daily Living Skills - Phillip Roy Prentke Romich AAC Lab & Language Stages Chart

40. QUESTIONS??

41. RESOURCES Archer, A.L, & Hughes, C.A., (2011). Explicit instruction: Effectiveness and efficient teaching. New York, NY: Guilford Press Gabriels, R., Cuccaro, M., Hill, D., Ivers, B., & Goldson, E. 2004. Repetitive behaviors in autism: relationships with associated clinical features. Research in Developmental Disabilities, 26 (2), 169-181. Gottman, J. M. (1994). What predicts divorce?: The relationship between marital processes and marital outcomes. (Hillsdale, NJ: Erlbaum) Joseph, R., Tager-Flusberg, H., & Lord, C. 2002. Cognitive profiles and social-communicative functioning in children with autism spectrum disorder. Journal of Child Psychology and Psychiatry, 43 (6), 807-821. Kasari, C., Brady, N., Lord, C., & Tager-Flusberg, H. (2013). Assessing the Minimally Verbal School-Aged Child with Autism Spectrum Disorder. Autism Research: Official Journal of the International Society for Autism Research,6(6), 479–493. http://doi.org/10.1002/aur.1334http://doi.org/10.1002/aur.1334 Losada, M. & Heaphy, E. (2004) The Role of Positivity and Connectivity in the Performance of Business Teams A Nonlinear Dynamics Model. American Behavioral Scientist, February 2004 vol. 47 no. 6 740-765 Sundberg, M. & Partington, J. (1998). Teaching language to children with autism or other developmental disabilities. Concord, CA: AVB Press.