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The CARD Treatment Program C enter for A utism and R elated D isorders, Inc Doreen Granpeesheh, Ph.D. GPL Conference Anaheim, California.

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Presentation on theme: "The CARD Treatment Program C enter for A utism and R elated D isorders, Inc Doreen Granpeesheh, Ph.D. GPL Conference Anaheim, California."— Presentation transcript:

1 The CARD Treatment Program C enter for A utism and R elated D isorders, Inc Doreen Granpeesheh, Ph.D. GPL Conference Anaheim, California

2 What is ABA? The CARD Treatment Model The CARD Treatment Model The CARD Curriculum Case Study and Data Todays Discussion

3 What is ABA ABA is based on principles of Operant Conditioning Theory Operant Conditioning Theory: Human Behavior is affected by events that precede it (antecedents) and events that follow it (consequences)

4 Application of ABA to the Treatment of Autism Symptoms Classified as: Deficits L anguage P lay S ocial Skills T heory of Mind E xecutive Functions Excesses S elf Stimulatory Behs M aladaptive Behs Tantrums Aggression Noncompliance Skill Repertoire Building Behavior Management

5 The CARD Treatment Model ABA Foundation Serve children from 18 mo – 8 yrs Intensive treatment Bi-Weekly supervision Shift from home-based 1:1 learning to peer & community based learning opportunities

6 The CARD Treatment Model: Beginning Level Services: 30-40 hours of 1:1 in-home behavioral intervention Targets: Build a relationship with the child Increase childs initiation with us Increase Compliance Language Training - Requests (Mand Training) Language Training - Receptive & expressive object & action labeling (Tact Training) Imitation, toy play, & pretend play Self-help skills

7 The CARD Treatment Model: Intermediate Level Skills Taught Asking Wh Questions Conversational language Generalize language to play & peer situations Emotion recognition Sociodramatic & imaginary play Basic cause and effect Emphasis on generalization & playdates begin Services 20-30 hours of 1:1 in-home intervention 5-10 hours of preschool with a CARD shadow targeting social skills & generalization

8 The CARD Treatment Model: Intermediate Advanced Level Skills Taught Classroom routines Following complex & group instructions Making inferences Observational learning Social skills and peer interaction Pragmatic Language (e.g., introducing a topic, maintaining a conversation) Self-monitoring, Planning and Problem Solving Services 20 hours of therapy per week: Includes 1:1 & playdates in home & in the community 20 hours school with shadow

9 The CARD Treatment Model Advanced Level Services 5 - 10 hours per week at home (fading out) Gradual fading of school shadow Skills Taught Social perspective taking Academics Continued self- monitoring Advanced pragmatics (e.g., detecting sarcasm) Completion of parent and teacher training

10 The CARD Curriculum

11 Language Play Theory of Mind Social Skills Executive Function Self Help & Motor Skills School Skills

12 The CARD Curriculum: Some general points The childs individual learning style is considered before particular skills are introduced Visual Modification suggestions in each program, for visual learners Verbal Behavior framework used in all language programs Generalization Emphasized from very early on At least 5 generalization ideas for each skill taught Flexibility worksheets for each Language program to ensure generalization

13 The CARD Curriculum Language Play Theory of Mind Social Skills Executive Function Self Help & Motor Skills School Skills

14 The CARD Curriculum Jody hands mom the blue crayon 3 crayons present & mom says, give me blue Receptive Jody matches blue cards3 color cards on table Matching Jody says, blueMom asks, What color is the sky? Conversatn (Intraverbal) Jody says, blue Jody says, blue paint Jody says, blue Childs Behavior Mom says, blue Imitation AntecedentFunction Jody sees a blue car Labeling (Tact) Jody is ready to finger paint, but no paint Requesting (Mand) Language Sample Program: Colors

15 The CARD Curriculum Emphasis on ensuring spontaneity in language use Emphasis on teaching language that is functional in everyday situations Emphasis on generalization Language Overall Goals in Teaching Language

16 The CARD Curriculum Language Play Theory of Mind Social Skills Executive Function Self Help & Motor Skills School Skills

17 The CARD Curriculum Play Independent Play Tracking Beginning Play Symbolic Play Constructive Play Imaginary Play Sociodramatic Play Practice Play Games with Rules Functional Pretend Play Target Areas

18 The CARD Curriculum Play Features of a Comprehensive Play Skills Program Modeled after the development of play skills in typically developing children Breaks down each type of play into its own systematic and comprehensive program Breaks down each type of play into its own systematic and comprehensive program Sequential format Sequential format Programs may be used individually, concurrently, or cumulatively Programs may be used individually, concurrently, or cumulatively

19 The CARD Curriculum Play Target mastered solitary play in Social Play program, to generalize with peers The child generalizes the skill to social situations Reinforce independent practice of play skill & track Independent Play to ensure spontaneity The child rehearses the skill on their own Our client imitates therapist/ parent in a 1:1 setting The child observes & explores Progression of play targets within CARD program Typical Development of Play Skills

20 The CARD Curriculum Pretend Imitation with Functional Objects Pretend Receptive Commands with Functional Objects Vocalization of Pretend Play with Functional Objects Expressive Identification / Narration Creation and Initiation of Pretend Play with Functional Objects Requesting Pretend Play with Functional Objects Play Sample: Functional Pretend Play

21 The CARD Curriculum Language Play Theory of Mind Social Skills Executive Function Self Help & Motor Skills School Skills

22 The CARD Curriculum Theory of mind or Social Cognition is concerned with how children learn to conceptualize other people, growing an understanding of others Viewpoints Viewpoints Thoughts Thoughts Emotions Emotions Intentions Intentions Theory Of Mind

23 The CARD Curriculum Theory Of Mind Social Cognitive Impairment in Autism Inability to infer or empathize others desires / feelings Inability to consider what others know Inability to consider what others are thinking Inability to infer others beliefs / opinions Inability to consider unintentional behavior Inability to infer communicative intent Inability to understand or engage in deception Inability to coordinate multiple social cues in a given social scenario

24 The CARD Curriculum Theory of Mind 9 Target Areas Emotions Desires Sensory Perspectives Knowing Preferences Thinking Beliefs Intentions Deception

25 The CARD Curriculum Theory Of Mind Sample Program: Knowing The child learns that people know things based on the following tenets: Knowing from Seeing Knowing from Hearing Knowing from Smelling Knowing from Feeling Knowing from Tasting Multi sensory Knowing Knowing from remembering Knowing from asking Self Knowledge (First Person) Others Knowledge (Third Person)

26 Knowing Program: Sds 4-6 Sd 4a: Do I know what (label/attribute/feature/etc?) R 4a: Yes/No Sd 4b: Why?/ How do I know?/ Why Not? R 4b: Because you can/cant see/hear/smell/feel/taste it/ Sd 5a: Does 3 rd person know what (label/attribute/feature/etc?) R 5a: Yes/No Sd 5b: Why?/ How does he/she know?/ Why Not? R 5b: Because 3 rd person can/cant see/hear/smell/feel/taste it/ Sd 6a: Who Knows what (label/attribute/feature/etc?) R 6a: Child identifies appropriate person Sd 6b: How does person know? R 6b: Because person can see/hear/smell/feel/taste it/

27 The CARD Curriculum Language Play Theory of Mind Social Skills Executive Function Self Help & Motor Skills School Skills

28 The CARD Curriculum Choral Activities Choral Activities Community Social Behavior Community Social Behavior Social Play Social Play Following Rules Following Rules Sharing Sharing Tattling Tattling Group Discussions Group Discussions Levels of Friendship Levels of Friendship Self Esteem Self Esteem Apologizing Apologizing Cooperative Work Cooperative Work Dealing with Conflict Dealing with Conflict Safety Awareness Safety Awareness Winning and Losing Winning and Losing Social Skills What skills are taught?

29 The CARD Curriculum Levels of Friendship Child learns to identify the degree of relationship he experiences with people in his environment Child learns to identify the degree of relationship he experiences with people in his environment Child learns to identify and rehearse behaviors that are appropriate to each relationship Child learns to identify and rehearse behaviors that are appropriate to each relationship Social Skills Sample Program Strangers Acquaintances Friends Best Friends

30 The CARD Curriculum Language Play Theory of Mind Social Skills Executive Function Self Help & Motor Skills School Skills

31 The CARD Curriculum elf-Help Self-Help Eating & drinking Toileting Dressing Bathing Household Chores Self Help & Motor Skills Components Fine Motor Skills Fine Motor Skills Arm/hand/finger strength Drawing Cutting Coloring Writing Gross motor skills Gross motor skills Walking & running Ball skills Riding a bike

32 The CARD Curriculum Language Play Theory of Mind Social Skills Executive Function Self Help & Motor Skills School Skills

33 The CARD Curriculum Processes that underlie goal directed behavior Processes that underlie goal directed behavior Executive Function What is Executive Function?

34 The CARD Curriculum Visualizing situation Identifying desired objective Determining plan to meet objective Monitoring progress to goal Executive Function Goal Directed Behavior Involves…

35 The CARD Curriculum Executive Function Self- Monitoring Flexibility Planning & Problem Solving Working Memory Attention Inhibition

36 The CARD Curriculum Language Play Theory of Mind Social Skills Executive Function Self Help & Motor Skills School Skills

37 The CARD Curriculum Math Addition & Subtraction Addition & Subtraction Advanced Counting Advanced Counting Money Money Telling Time Telling Time Reading Comprehension Book Topography Book Topography Story Comprehension Story Comprehension Story Summarizing Story Summarizing Text Comprehension Text Comprehension Spelling Copying and Dictation Copying and Dictation Rhyming Rhyming Vocabulary Synonyms and Antonyms Synonyms and Antonyms Thematic Vocabulary Thematic Vocabulary School Skills Scope

38 Joeys Story: A Case Study

39 A case study: Joey Joey was diagnosed with Autistic Disorder in December of 1995. CARD Treatment was initiated in February of 1996 at the age of 3 years, 6 months. Treatment intensity ranged from 30 to 40 hours per week of 1:1 in-home and school based behavioral intervention for approximately 2 ½ years

40 Deficits: Profound Delays in Joint Attention Minimal Language Inability to Interact Socially with Peers No Purposeful Concrete or Imaginative Play Excesses: Frequent Non- compliance Frequent Tantrum Behavior Self-Stimulatory Behaviors: Lining objects, video talk, obsessions with trains, hand flapping and gazing Echolalia Joeys Repertoire at Intake: Skills: One word expressive labels Simple imitation One step receptive instructions Some single word responses to social questions

41 At Intake…

42 Services: Year One Full inclusion in general education pre-school (12 hours p/w). Full-time CARD shadow in the classroom. 25 hours per week home based behavioral intervention.

43 Intervention: Year One Acquiring stimulus control of pre-existing behaviors Increasing compliance to requests Mands Increasing attending behavior Reducing maladaptive behaviors Object labels (including names, animals, places) Actions / verbs Attributes (including colors) Play Skills Identifying emotions Following instructions (increasing complexity) Functions Gender Categories Academic skills (Letters and Numbers) Plurals, tenses, pronouns

44 At 3 Months…

45 At 4 Months…

46 At 5 months…

47 At 6 Months…

48 Year-One Progress Chart: Mastered Programs

49 Year-One Progress Chart: Mastered Sub-skills

50 Year-One Progress Chart: Mastered Responses

51 Services: Year Two Full inclusion in general education preschool 20 hours per week. Full-time CARD shadow in the classroom 25 hours per week of home based intervention

52 Intervention: Year Two Intermediate Social Program Getting attention of listener before talking Initiating play and Joining a group Regulating volume of speech Reading the body language of others Sharing Turn taking Responding to Emotions Conversational skills Pragmatic language skills – Adjusting conversation according to audience (perspective taking) – Introducing a topic – Staying on topic – Providing sufficient information to listener –Ending / closing conversation

53 At 12 Months…

54 At 15 Months…

55 Year-Two Progress Chart: Mastered Programs

56 Year-Two Progress Chart: Mastered Sub-skills

57 Year-Two Progress Chart: Mastered Responses

58 Services: Year Three Full inclusion in general education kindergarten Fading of full time unknown CARD shadow 10 hours per week of home based intervention

59 Remaining Deficits and Excesses Insufficient or irrelevant descriptions and explanations Inappropriate use of questions, initiations, topic selection and conversations Inappropriate body language Avoidance of new people and places Inflexible, routine based play Frequent crying during social activities Difficulty entering a game in progress Inappropriate reactions to joking and playful teasing Deficient friendship development and friendship maintenance behaviors

60 Intervention: Year Three Identifying simple intentions Social cause and effect Knowing Think, feel, say, do Joking, teasing, lies and deception Topic selection Topic introduction Topic maintenance Asking questions Making statements Play Social outings

61 At 27 Months…

62 Year-Three Progress Chart: Mastered Programs

63 Year-Three Progress Chart: Mastered Sub-skills

64 Year-Three Progress Chart: Mastered Responses

65 Treatment Gains

66

67 At Discharge… In January of 1999, Joey no longer presented with any of the behavioral excesses or deficits observed at intake and services were terminated. Joeys original diagnosis was removed by an independent clinician from an outside agency. Currently, Joey is fully mainstreamed and thriving academically and socially in a regular education second-grade placement. As reflected in the assessments, Joey not only made significant gains in all areas of adaptive and intellectual functioning, but continued to progress even 2 years post-treatment.

68

69 C.A.R.D.s Preliminary Outcome Data

70 CARD Outcome Study Purpose Examine the effectiveness of early intensive ABA Examine the effectiveness of early intensive ABA Explore impact that intensity of 1 st year of treatment has on outcome Explore impact that intensity of 1 st year of treatment has on outcome

71 CARD Outcome Study 79 children participated 63 boys 63 boys 16 girls 16 girls Average age at intake: 39.1 months Average age at intake: 39.1 months Average IQ at intake: 76.8 (mild mental retardation) Average IQ at intake: 76.8 (mild mental retardation) Length of time in tx: At least 3 years Length of time in tx: At least 3 years (Children initiating program from 3/92-6/96) (Children initiating program from 3/92-6/96) Overall Participant Information Overall Participant Information

72 CARD Outcome Study Of the 79 children participating: 35 low intensity 35 low intensity 44 high intensity 44 high intensity The 2 groups were equivalent at intake in all areas examined The 2 groups were equivalent at intake in all areas examined Age Age IQ IQ Language Language Maladaptive Behavior Maladaptive Behavior Adaptive Behavior Adaptive Behavior Participant Information: Participant Information: High & Low 1 st Yr. Intensity Groups High & Low 1 st Yr. Intensity Groups

73 CARD Outcome Study Intervention: Hi Intensity Group: Received 26 or more hours of CARD services (including school aide) per week. Low Intensity Group: Received 25 or fewer hours of CARD services (including school aide) per week.

74 CARD Outcome Study 61% 20%

75 CARD Outcome Study 61% 20%

76 CARD Outcome Study 61% 20%

77 CARD Outcome Study Factors Associated with Positive Outcome Intensity: 26+ Hours per week Intervention Age at Intake: Treatment initiated prior to age 4 Parent Participation: Parents conduct therapy, attend clinics, read log book Exposure to Typical Peers: When school is introduced, Regular Education is best Concurrent Medical Management of Symptoms: Dietary changes & use of meds Verbal Imitation within the first 6 months of treatment

78 Dr. Doreen Granpeesheh GPL Conference CARD Questions

79 Visual Modifications Designed based on the child Some examples Picture Exchange Communication System (PECS) for children with difficulty communicating vocally Stimulus modifications for children with difficulty with auditory comprehension Response modifications for children with difficulty with vocal output


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