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Evidence Based Programming for Infants and Toddlers with Down Syndrome

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1 Evidence Based Programming for Infants and Toddlers with Down Syndrome
Sara M. Bauer, MA, MPhil, BCBA Learning Processes and Behavior Analysis Program Queens College and the Graduate Center, City University of New York

2 Overview Evidence Based Programming:
Behavior analytic (ABA) Interventions to increase critical skills Communication Motor Cognition

3 What is ABA? A = Applied B = Behavior A = Analysis
Behavior analysis refers to the scientific study of behavior. ABA is often considered the therapeutic application of the principles of learning and behavior analysis. ABA uses procedures derived from the principles of learning to address problems of social significance: Academic skills Social skills Communication skills Adaptive living skills Retrieved from

4 The ABC’s of ABA A = Antecedent B = Behavior C = Consequence
ABA practitioners primarily focus on the variables surrounding a behavior, including the antecedents and consequences. determine the function of a behavior If the function of a behavior is known, one can then intervene to either increase the behavior or decrease it.

5 ABA with Learners with Autism Spectrum Disorders
ABA is an evidence based method that has had much success with learners with Autism spectrum disorders (ASD) (Peters-Scheffer, Didden, Korzilius, & Sturmey, 2011). In fact, ABA interventions are most often used with learners with ASD but are rarely provided to learners with Down syndrome or other disorders. WHY NOT?!

6 ABA with Infants with Down Syndrome? -Absolutely!
If we can demonstrate the successful implementation of behavior analytic (ABA) interventions to address areas of impairment in children with Down syndrome, we have proof that ABA works with children with Down syndrome too! validating and disseminating this empirical approach How do we use ABA with infants and toddlers with Down syndrome?

7 Early Development in Down Syndrome
Much descriptive research on early development in Down syndrome (Fidler, 2005) Cognitive functioning Communication skills Motor functioning Patterns in early development directed researchers to discuss a Down syndrome behavioral phenotype

8 Down Syndrome Behavioral Phenotype
Strengths Weaknesses Social Behaviors Some areas of Motor Development Visual-imitation Early Communication Skills Receptive Language Areas of Cognitive Development Pattern of syndrome specific strengths and weaknesses that characterize the disorder

9 Critical Areas of Weakness in Infant Development
Communication Motor Cognition

10 Early work Examples: Hansen’s work in the late 1970s early 1980s.
Poulson (1988) used operant conditioning to enhance communication in young children with Down syndrome. Identified procedures and demonstrated positive outcomes. Yoder and colleagues work using naturalistic language interventions. Poulson (1988) demonstrated the use of social consequences (including eye contact, talking, and touching, as well as giving and showing toys) to increase vocalization rates in typically developing infants and those with Down syndrome. Salzberg and Villani (1983) taught parents of two preschoolers with Down syndrome to present specific opportunities for verbal imitation and use social praise (i.e., a verbal statement accompanied by a hug, tickle, etc.) to increase imitation of simple sounds and words. Warren, Yoder, Gazdag, Kim, and Jones (1993) used a milieu teaching approach (i.e., arranging the environment, engaging in social routines, following the child’s attentional lead, and using specific questions, models, and directives to imitate as well as naturally occurring consequences) to address several early communication skills in children with disabilities, two of whom had Down syndrome. Interventionists used contingent imitation (i.e., interventionists imitated the child’s vocalizations) to address vocal imitation in one of the participants with Down syndrome (20 months old). However, this resulted in limited increase in verbal imitation, and not to the same extent as the other two communication skills (i.e., commenting and requesting; the results for requesting will be described shortly) targeted for this participant. Imitation skills are particularly important because they can be used to teach other communication skills. Once a child is able to imitate, a model can be used (to which the child will imitate) to prompt sounds, words, or other movements (e.g., gestures) in the presence of other environmental cues. For example, once a child imitates his own name, an interventionist can ask the question, “What’s your name?” and prompt the correct answer by modeling, “Say, ‘Jacob’.” McDonnell (1996) addressed expressive use of language, teaching children (two of whom had Down syndrome; ages 4.5 and 5 years) to request objects/activities. Intervention involved repeated opportunities with specific prompts (e.g., verbal model) and reinforcement (i.e., social praise and natural consequences [e.g., providing the object requested]). Hemmeter, Ault, Collins, and Meyer (1996) used models of specific verbalizations to teach communication skills to children with disabilities. One child (5.9 years) with Down syndrome was taught to say “more” or “want” to make requests. Another child (7.2 years) with Down syndrome was taught to say “big” or “little” plus the object name to comment. In an early study, MacCubrey (1971) found increases in IQ scores and interventionist ratings of speech following intervention involving reinforcement, shaping, chaining, and imitative prompts to teach imitation and then uses (e.g., labeling pictures) of the words taught in imitation, specifically in children with Down syndrome (4-7 years). A recent study by Thompson, Cotnoir-Bichelman, McKerchar, Tate, and Dancho (2007) involved two infants, one of whom had Down syndrome (10 months) and examined the use of modeling, physical prompts, and reinforcement to teach signs as requests for objects and attention. Both infants increased their use of signs to make requests. Although not addressing vocal imitation, this study highlights the importance of imitation in the acquisition of other early developing communication skills. It also provides one of the few demonstrations of intervention addressing requesting skills an infant with Down syndrome at the point in development when significant impairments in requesting would likely emerge. Prelinguistic milieu teaching (PMT) is another intervention that has been examined to specifically teach requesting skills and, in a handful of those studies, some participants had Down syndrome. PMT is similar to milieu teaching, described previously, but with a focus on prelinguistic communication skills. In two early studies, Warren, Yoder, Gazdag, Kim, and Jones (1993) and Yoder, Warren, Kim, and Gazdag (1994) demonstrated the effectiveness of prelinguistic milieu teaching to specifically address requesting skills. In infants and toddlers, requests first involve nonvocal behaviors such as gaze shifting (between an object and partner) which is often paired with vocalizations or gestures (whether conventional points or a more formal system such as sign language). In Warren et al. and Yoder et al., the form of requesting taught involved the child shifting gaze from an object to interventionist in conjunction with a reach for the object. Of the 9 participants across both investigations, 4 had Down syndrome (20-26 months). In two recent studies (Yoder & Warren, 2002; Fey et al., 2006), a larger subgroup of the participants had Down syndrome (43 of the 90 total participants across studies), allowing for a comparison of the effects of intervention specifically for children with Down syndrome (mean age months across intervention and control groups in both studies). In Yoder and Warren (2002), children with Down syndrome who did not receive PMT and responsivity education (RE; teaching parents to be aware of and provide appropriate responses to their child’s communication acts) intervention made greater gains than those who received PMT/RE. In contrast, Fey et al. (2006) found increases in communication by the group who received PMT and RE compared to a no treatment control group, with no differences for the subgroup of participants with Down syndrome. The differences in results found by Fey et al. may be attributed to the way intervention was targeted at increasingly sophisticated skills. Specifically, Fey et al. initially targeted less complex forms of requesting (e.g., only a gaze shift) and then increased expectations (e.g., to a combination of gaze shifting and vocalization or gesture) as children acquired requesting skills.

11 Considering the Behavioral Phenotype
Growing emphasis on development of interventions to: specifically target areas of characteristic weakness by building upon characteristic strengths (Hodapp & Fidler, 1999; Fidler, 2005) Develop interventions that can be applied at the youngest of ages to address skill areas that may prevent further impairment

12 Down Syndrome Behavioral Phenotype and Behavior Analytic Interventions
Can we use what we know about the Down syndrome behavioral phenotype to inform the development of behavior analytic interventions? Such an approach holds promise: We can address the most critical areas of need We can intervene in a preventative manner Such early intervention may minimize collateral negative outcomes associated with early impairments.

13 Intervention Applied to Critical Areas
Communication Requesting Verbal imitation Social Questions Spontaneous Language Motor Skill Development & Cognition Exploratory motor (EM) skills

14 Requesting Impaired in infants with Down syndrome compared to typically developing infants (Mundy, Kasari, Sigman, & Ruskin,1995) which in turn decreases opportunities to interact and use language Essential to complex forms of communication and cognitive development (Fidler et al., 2005; Mundy et al., 1995) Related to problem solving skills (Fidler et al., 2005), which are also impaired in children with Down syndrome (Pitcairn & Wishart, 1994). In problem solving, a child is faced with a situation in which there is an obstacle to accessing reinforcement. He/she then engages in behavior to alter the situation (Bijou, 1995). Requesting impairments in 2 types of situations: Social situations Help situations (instrumental requests) Example of infant problem solving situation: For example, a mother places her young child’s favorite toy at the far end of the blanket he is on during tummy time. He cannot reach the toy and access reinforcement. However, pulling the blanket toward him alters the situation so that the toy moves toward him so he can grasp it and access reinforcement.

15 Requesting Feeley et al. (2011) and Bauer and Jones (submitted):
Infants with Down syndrome were taught increasingly sophisticated early requesting skills across social and instrumental requesting situations: gaze shifting gaze shifting paired with vocalization gaze shift and verbal approximation of a word to request Intervention included multiple opportunities, prompting, and high rates of social reinforcement Investigated collateral changes in problem solving skills

16 Requesting Feeley, Jones, Blackburn, and Bauer (2011) and Bauer and Jones (submitted) Feeley, Jones, Blackburn, and Bauer (2011) and Bauer and Jones (submitted) expanded on this by also teaching more instrumental or help requests (i.e., accessing a toy from a closed container).

17 Collateral Changes – Problem Solving
Collateral changes in problem solving were examined with an object retrieval reaching task similar to the one used by Fidler et al. (2005) Administered Pre-and post intervention to look for changes in performance Procedure: 30 x 30 cm cloth was placed flat on a table, approximately 5 cm from the front edge and at the toddler's midline. A small toy was set it down on the cloth, out of the toddler’s reach. In order to access the toy, the child had to problem solve by pulling the cloth toward him/her to retrieve the toy.

18 Problem Solving Results
Simon Johnny Pre Post Percentage of Correct Responses 42% 77% 7% 100% Promising results suggesting a relationship between learning to request and learning to problem solve…but warrants further investigation: 1. Compare to typically developing toddlers 2. Compare to toddlers with Down syndrome who did not undergo intervention 3. Investigate other forms of problem solving Both toddlers (one toddler’s video was lost) for whom we examined problem solving task performance showed improvements. This pre-post measure warrants further investigation and standardization. The problem solving task took too long for toddlers and had to be stopped due to challenging behavior and lack of interest. The task could be revised to be more sensitive to the young age of the participants and include a variety of problem solving tasks reflective of problem solving behavior over the first few years of life (e.g., using a rake to obtain a toy). This pre-post measure, while suggestive, also warrants comparison to typical development as well as to children with Down syndrome who do not participate in this intervention.

19 Verbal Imitation Impaired in infants with Down syndrome (Mahoney, Glover, & Finger, 1981; Rondal, Lambert, & Sohier, 1981) Essential to intelligibility, articulation and expressive language Poor verbal imitation responses may negatively affect: the extent to which words enter a toddler’s verbal repertoire (Feeley & Jones, 2006) the clear articulation of sounds that are intelligible to others (Gordon-Brannan & Hodson, 2000; Rasilo, Räsänen, & Laine, 2013). A verbal imitation repertoire can be important during intervention to improve both intelligibility/articulation and introduce new words and more complex verbal skills to a learner (Lovaas, 1977).

20 Verbal Imitation - Procedure
Parents identify sounds for intervention and for generalization During intervention, interventionist says, “Say, ‘[sound] and provides prompt (physical, exaggerated, time delay) and social reinforcement for correct responses or error correction procedure for incorrect responses.

21 Verbal Imitation Feeley, Jones, Blackburn, and Bauer (2011) and Bauer and Jones (submitted) Feeley, Jones, Blackburn, and Bauer (2011) and Bauer and Jones (submitted) not only addressed requesting , but also characteristic weaknesses in verbal imitation. Sounds taught in verbal imitation were then prompted using imitative models to teach approximations of requesting words in requesting intervention.

22 Collateral Changes - Intelligibility
Intelligibility = the extent to which a listener receives the child’s communication. Intelligibility is affected by factors such as articulation (Yorkston, Strand, & Kennedy, 1996). Intelligibility of sounds taught in verbal imitation intervention were examined by a naïve listener who recorded the sounds she heard each participant making from video recordings the first author trained the naïve listener to write down the sounds heard using written instructions, an articulation sound spelling sheet, modeling, rehearsal, and feedback. The first author used iMovie software on a Macintosh computer to edit video recordings of the final time delay sessions of verbal imitation intervention so the video played just the child’s response, without the interventionist’s instructional model. One to two sounds per child were coded, depending upon available video recordings of the final time delay sessions. Sounds examined were “ma” for Simon, “ah” for Johnny, “ba” and “la” for Lucy, “ah” for Jordan, and “ah” and “eh” for Tyler.

23 Intelligibility Results
Simon Johnny Lucy Jordan Tyler Percentage of Sounds Coded as Matching the Target Sound 89% 100% 76% 84% The naïve listener heard the sound the child was supposed to make at or above mastery criterion (i.e., 80%) for four of the five participants and just below mastery criterion for Lucy. The few times that the listener recorded hearing a different sound for Lucy, she recorded hearing “b” instead of “ba,” which resulted in a lower percentage for Lucy. Promising results that set the stage for further investigation of the implications of verbal imitation interventions on related areas of expressive language.

24 Imitation is Important for Development of Critical Skills
Using verbal imitation intervention to address intelligibility/articulation deficit and more sophisticated expressive language Answering and Asking Questions Spontaneous Language Vocabulary expansion Mean Length Utterance

25 Bauer, Jones, and Feeley (2013)
Participants Zach, 3 year old boy with Down syndrome Johnny, 2 year old boy with Down syndrome Design multiple baseline probe design 3 age appropriate questions (Zach): “What’s your Daddy’s name?”, “Where do you live?”, and “What’s your Mommy’s name?” Corresponding responses: “Mark” ,“Farmingville”, and “Denise” 3 age appropriate questions (Johnny): “What do you like to drink?”, “What do you like to eat?”, “How are you?” Corresponding responses: “Juice”, “Fish”, and “Good”

26 Percentage of correct responses during baseline, intervention, generalization, and maintenance across “Mark”, “Farmingville”, and “Denise” for Zach. During baseline, time delay, generalization and maintenance conditions, only independent correct performance is graphed. During full prompts, both independent and prompted responses were considered correct and graphed performance reflects both.

27 Percentage of correct responses during baseline, intervention, generalization, and maintenance across “Juice”, “Fish”, and “Good” for Johnny. During baseline, time delay, generalization and maintenance conditions, only independent correct performance is graphed. During full and partial prompts, both independent and prompted responses were considered correct and graphed performance reflects both.

28 Spontaneous Language Teaching Spontaneous Responses to a Young Child with Down syndrome Feeley and Jones, (2008) Intervention involved discrete trial instruction responses, followed by a predetermined reinforcer in close proximity, with prompts to elicit correct in which multiple opportunities were presented paired with natural consequences or the use of an per session, were conducted daily. During the sessions, consisting of 10 opportunities error correction procedure[20]. One or two intervention That is, she presented the discriminative stimulus immediately prompted the correct response. first three intervention sessions, the interventionist (SD) (e.g., dropped something), immediately (i.e., edible paired with praise and natural consequences, (e.g., “Say ‘Uh oh’”), and delivered reinforcement prompted the target response with a verbal model performed the correct response [i.e., said “Bless During the second intervention session addressing the response “Bless you,” Max immediately such as saying, “I’ll pick it up”). (Note: you”] prior to the delivery of the prompt, therefore sessions for the response “Bless you” and the first second session.) After the first two intervention correct responses were recorded within the three sessions for the responses “Thank you” and by a 5 second interval to allow Max to emit a probe during which the SD was presented followed “Coming,” each subsequent session began with the target response. This determined procedures (i.e., emitted a different or no response) during If Max did not emit the correct response for the remaining opportunities within that session. delivered and the SD was repeated, followed by a (i.e., interventionist said, “No” or “Uh uh”) was the probe opportunity, corrective feedback prompt to ensure a correct response. The interventionist a correct response on the probe opportunity, for the remainder of that session. If Max emitted then prompted the correct response of the SD followed by a 5 second interval with opportunities for that session involved the delivery reinforcement was delivered and the remaining reinforcement for correct responses and error “uh uh”] followed by repetition of the SD and a corrective feedback [e.g., the interventionist said correction for incorrect responses (consisting of during two consecutive sessions across two criteria was 80% independent correct responding prompt to ensure a correct response). Mastery days and two different interventionists. Following Generalization ensure the skills maintained. mastery, intervention sessions continued to One generalization probe opportunity for each Max’s integrated classroom or in other areas in (not involved in this intervention) within response was conducted each week by interventionists (when relevant). the school (e.g., gym, hallway) with novel materials 28

29 Other Critical Skill Areas
Down syndrome Behavioral phenotype includes other areas of weakness for which we could take a similar intervention approach Motor Cognition

30 Exploratory Motor (EM) Skills
Exploratory Motor (EM) behavior is another area of weakness in infants with Down syndrome Bradley-Johnson, Friedrich, and Wyrembelski (1981) define EM behavior as any behavior in which infants engage while manipulating an object in their hands:  Reaching and grasping  Holding and visually examining  Shaking, dropping and banging Discuss here….an overlap of motor and cognitive (the explore part) – more motor/object interaction = more learning opportunities about object in hand/cause and effect actions on environment, etc…

31 Importance of EM Behaviors
May be a behavioral cusp or pivotal skill (like verbal imitation and requesting) Related to other areas of development such as cognitive development and other motor skills Increased number of learning opportunities

32 EM Impairments in Down Syndrome
Compared to typically developing infants, infants with Down syndrome demonstrate Significantly fewer EM behaviors early in life Shorter durations of EM behaviors EM impairments primarily attributed to motor difficulty In EM situations, infants with Down syndrome attend more to caregiver than to objects may show more escape behavior

33 EM Intervention As with many areas of weakness in children with Down syndrome, there are few empirically demonstrated interventions to address EM behaviors In tailoring intervention, must consider: low muscle tone increased value of social consequences increased escape motivated behavior and engagement in social behavior to escape Alter the contingencies for engaging and not engaging in EM behaviors so that social interaction between an infant and his/her caregivers is provided as a reinforcer only for increased time spent engaging independently with a toy

34 So What Does this Intervention Look Like?
Participants, Setting, and Interventionists Three infants (5-9 months of age) with Down syndrome who demonstrate a lack of reaching, grasping, and EM behavior Baseline, intervention, and generalization sessions will occur in each infant’s home. The infant’s primary caregiver(s), home based early intervention service providers, and the investigator will serve as interventionists. Three infants (5-9 months of age) with Down syndrome who demonstrate a lack of reaching, grasping, and EM behavior, confirmed by a physical therapist’s assessment, will participate in this study. Exclusion criteria include medical complications prohibiting the appropriateness of engaging an infant in EM behavior activities. Infants will be recruited through recruitment fliers disseminated by early intervention agencies and a pediatrician’s office. -Baseline, intervention, and generalization sessions will occur in each infant’s home. The infant’s primary caregiver(s), home based early intervention service providers, and the investigator will serve as interventionists. The investigator will train the other interventionists to conduct baseline, intervention, and generalization sessions using behavioral skills training consisting of written instructions, modeling, rehearsal, and feedback. During bi-weekly visits, the investigator will oversee and provide ongoing feedback to the other interventionists.

35 EM Intervention Dependent Measures
Three EM behaviors will be measured: Reach-Grasp response = infant extending his or her arm(s) to touch a toy simultaneously with his thumb and at least one other finger of the same hand. Visually Examine a Toy in Hand = bringing the toy within 2.5 – 12.5 centimeters of the eyes with infant’s eyes directed to the toy. Shaking/Banging will be examined together. Shaking consists of holding a toy in one or both hands and moving it back or forth in the air at least one time. Banging consists of holding a toy in one or both hands and bringing it into contact with a surface (i.e., table top, floor, etc.). Dependent Measures EM Behavior. Three behaviors will be measured. A Reach-Grasp response consists of the infant extending his or her arm(s) to touch a toy simultaneously with his thumb and at least one other finger of the same hand. Visually Examine a Toy in Hand consists of bringing the toy within 2.5 – 12.5 centimeters of the eyes with infant’s eyes directed to the toy. Shaking/Banging often occur together as an infant shakes and uninterruptedly bangs the toy into some object or surface and will be examined together. Shaking consists of holding a toy in one or both hands and moving it back or forth in the air at least one time. Banging consists of holding a toy in one or both hands and bringing it into contact with a surface (i.e., table top, floor, etc.).

36 EM Intervention Typically developing comparison data
The criterion for each response will be determined based upon observations of typically developing infants. Collateral changes Related changes in motor and cognitive development will be assessed via the Bayley Scales of Infant and Toddler Development (Third Edition) and the Alberta Infant Motor Scale assessments administered pre and post intervention. Also, caregivers will complete a questionnaire to assess social validity. Typically developing comparison data. The criterion for each response will be determined based upon observations of typically developing infants. Observations of typically developing infants are being coded to determine the typical duration and frequency of EM responses. To teach infants with Down syndrome to engage in EM behavior similar to typically developing infants, observations of typically developing infants provide critical information on criteria for EM behavior. Collateral changes. Related changes in motor and cognitive development will be assessed via the Bayley Scales and the AIMs assessments administered pre and post intervention, following mastery of all EM responses. Also, caregivers will complete a questionnaire to assess social validity. Post-intervention primary caregivers will respond to several questions on a 7-point scale rating the appropriateness of the method of teaching EM behavior.

37 EM Intervention Materials Design
30 small, lightweight (i.e., not exceeding 113 grams), noisemaking toys that are typically used by young infants between 0-6 months of age will be identified. A high chair, infant play mat, infant bouncy seat, and other infant support materials will be used Design To examine the effects of repeated opportunities, specific prompts, and high rates of social reinforcement on reaching, grasping, and EM behavior, a multiple baseline probe design across three EM responses will be conducted with probes for generalization across toys, partners, and responses. Materials Thirty small, lightweight (i.e., not exceeding 113 grams), noisemaking toys that are typically used by young infants between 0-6 months of age will be identified. Parents/caregivers will choose 15 of the 30 toys likely to be preferred by their child. Of the 15, the investigator will randomly assign 10 toys to intervention and 5 to generalization. A high chair, infant play mat, infant bouncy seat, and other infant support materials will be used for EM opportunities. Design In these initial stages of inquiry, use of a single subject design allows for the development, refinement, and validation of this intervention, providing a foundation for larger studies to be conducted in the future (Smith, 2013). Therefore, to examine the effects of repeated opportunities, specific prompts, and high rates of social reinforcement on reaching, grasping, and EM behavior, a multiple baseline probe design across three EM responses will be conducted with probes for generalization across toys, partners, and responses.

38 EM Intervention Procedure
During baseline and intervention, the infant will be seated in a highchair or infant seat with a tray attached or next to a table. The interventionist will sit across from the infant and place the toy within the infant’s arm reach in front of the infant. An opportunity will end when the infant no longer emits the target response for at least 5 seconds. Baseline - Six baseline sessions will be conducted within two weeks with 10 opportunities per session. No prompting and only natural, toy related consequences. Intervention- At least two intervention sessions consisting of 10 opportunities will be conducted each week. The interventionist will implement the prompting procedure and fade prompts using a most-to-least prompt fading hierarchy and a time delay. During intervention, social consequences identified as preferred, (e.g., verbal praise and tickles), will be used as reinforcement for correct responses. Procedure During opportunities for each target response, the infant will be in the seated position in a highchair or infant seat with a tray attached or next to a table. The interventionist will sit approximately half a meter across from the infant and will ensure that the infant is looking at the toy by activating or shaking it. The interventionist will place the toy within the infant’s arm reach in front of the infant, or within 45 degrees to the left or 45 degrees to the right of the infant on the high chair tray or tabletop. An opportunity will end when the infant no longer emits the target response for at least 5 seconds. If the object is dropped during an opportunity, the interventionist will retrieve it and re-present it to the infant within the same opportunity, as long as 5-seconds have not yet elapsed. During baseline, the interventionist will not prompt any EM behaviors and only natural, toy related consequences will occur upon the occurrence of an EM behavior. Six baseline sessions will be conducted within two weeks, with three sessions occurring each week; each session will consist of 10 opportunities. When intervention begins, at least two intervention sessions consisting of 10 opportunities will be conducted each week. After presenting a toy to the child, the interventionist will implement the prompting procedure and fade prompts using a most-to-least prompt fading hierarchy and a time delay. During intervention, social consequences identified as preferred, (e.g., verbal praise and tickles), will be used as reinforcement for correct responses. Full prompts will involve hand-over-hand prompting which will be faded to partial prompts once the infant reaches mastery criteria of 80% correct responses across 2 sessions and 2 days. Partial prompts will include a either a light tap to the infant’s arm or hand, or a spatial prompt in which the interventionist holds his or her hands in air around the infant’s hand, which will be faded to a time delay procedure once the infant reaches mastery criteria of 80% correct responses across 2 sessions and days. During time delay, the interventionist will wait 10 seconds for the infant to respond independently. If the infant does not respond independently at the end of the 10-second delay, the interventionist will revert to the partial prompt. Mastery criteria will be the same for time delay. A follow-up probe session will be conducted approximately one month following mastery of the final target response to determine maintenance of skill acquisition.

39 EM Intervention Generalization (conducted just like baseline sessions)
Stimulus generalization – assessed across toys, partners, and settings, once during baseline and once after mastery of each EM behavior. Generalization sessions will consist of five opportunities. Response generalization - assessed to another EM behavior and to an EM behavior chain which will consist of any sequence of EM responses. Dropping consists of forcefully releasing a toy from the hands. The EM behavior chain will involve a variable sequence of EM responses taught in intervention. Like typically developing infants, who engage in “bouts” of EM behavior, the EM behavior chain observed will be measured as response generalization and will mimic these bouts. EM behavior chains will begin with reach/grasp and then proceeds to a variable sequence of visually examining, shaking, and banging.

40 Data Collection & Analysis
All EM responses will be measured and reported as the percentage of correct EM responses per 10- opportunity session. Data will be visually analyzed. Pre and post intervention scaled scores from the Bayley Scales and Total AIMS scores from the AIMS will also be calculated and reported. Interobserver agreement (IOA) and treatment fidelity will be will be examined by trained undergraduate research assistants for 30% of sessions for each infant for each EM behavior.

41 Projected Results

42 What if I encounter CHALLENGING BEHAVIOR?!
When implementing any learning program with infants and toddlers with Down syndrome, you will likely encounter challenging behavior. Challenging behavior = any behavior that interferes with the task/learning program being implemented Interestingly, for toddlers with Down syndrome, challenging behavior is not always tantrumming, crying, or carrying on. Very often, it is social behavior to escape a task/learning program

43 Challenging Behavior in Children with Down syndrome
Coe et al., (1990) and Dykens and Kasari (1997) found higher rates than typically developing children of: attention deficits social withdrawal noncompliance Compulsive like behaviors (e.g., arranging objects, repeating certain actions) (Evans & Gray, 2000) Talking to themselves (Glenn & Cunningham, 2000) Problem behaviors associated with anxiety, depression, and withdrawal increase with age (Dykens & Kasari, 1997; Einfeld, Tonge, Turner, Parmenter, & Smith, 1999).

44 Factors affecting challenging behavior: Motivating operations (Michael,1982; 2000)
A motivating operation is an antecedent event/stimuli that affects an individual’s behavior by changing the value (increases or decreases) of a consequence (reinforcer or punisher) and thus changes the likelihood the individual will engage in a certain behavior (either increasing or decreasing the likelihood). (Also referred to as “setting events”)

45 Down Syndrome as a Motivating Operation
Wishart (1987) demonstrated children with Down syndrome have a tendency, even at an early age to engage in escape behavior: Demonstrated children with Down syndrome have a propensity to engage in noncompliant behavior often taking the form of “cute” party tricks. Observed such behaviors during assessment tasks, particularly when the children were presented with slightly more difficult tasks. Thus, specifically in children with Down syndrome, there may be an increase in the reinforcing value of escaping demands and possibly an increase in the reinforcing value of attention.

46 What if I encounter CHALLENGING BEHAVIOR?!
To deal with challenging behavior: 1. Don’t panic 2. Follow these next steps to determine what is the best way of dealing with challenging behavior

47 Functional Behavior Assessment
Process of determining the relationship between events in a person’s environment and the occurrence of challenging behaviors Identification of variables that are regularly associated with the occurrence and nonoccurrence of problem behavior. Components of a functional behavior assessment Interview Direct Observation Environmental Manipulations (Functional Analysis)

48 Addressing Setting Events (Horner & Colleagues)
Remove the setting event (e.g., ensure good night sleep, medication is taken) Neutralize the effect of the setting event (e.g., relaxation routine, provide food or medication, allow for a nap) Remove stimuli that occasion problem behavior when setting event present (e.g., change in schedule, reduce demands) Increased the rewards available for appropriate behavior when setting event present

49 Conclusion Promising early literature
Promising more recent literature incorporating increased knowledge about Down syndrome (behavioral phenotype) Potential to intervene at very young ages, even in a preventative manner Lots of potential applications

50 References for Critical Early Skills
Requesting syndrome.org/reports/2059/reports-2059.pdf Verbal Imitation Expressive communication studies/2007/case-studies-2007.pdf Challenging behavior syndrome.org/perspectives/316/perspectives-316.pdf

51 References Bradley-Johnson, S., Friedrich, D. D., & Wyrembelski, A. R. (1981). Exploratory behavior in Down’s syndrome and normal infants. Applied Research in Mental Retardation, 2, Doi: / (81) Bauer, S.M., and Jones, E.A. (submitted). Requesting and Verbal Imitation Intervention for Toddlers with Down syndrome: Generalization, Intelligibility, and Problem Solving Bauer, S., Jones, E. A., & Feeley, K. M. (2014). Teaching Responses to Questions to Young Children with Down Syndrome. Behavior Interventions, 29(1), Feeley, K. M., Jones, E. A., Bauer, S., & Blackburn, C. (2011). Requesting and verbal imitation in children with Down syndrome. Research in Developmental Disabilities, 32, Feeley, K. M., & Jones, E. A. (2008). Strategies to address challenging behavior in young children with Down syndrome. Down Syndrome Research and Practice, 12, Feeley, K.M., & Jones, E.A. (2008). Teaching spontaneous responses to a young child with Down syndrome. Down Syndrome Research and Practice, 12, 148 – 152. doi: /case-studies.2007 Feeley, K. M., & Jones, E. A. (2008). Preventing challenging behaviours in children with Down syndrome: Attention to early developing repertoires. Down Syndrome Research and Practice, 12, doi: /reviews.2076  Fidler, D.J. (2005). The emerging Down syndrome behavioral phenotype in early childhood: Implications for practice. Infants and Young Children, 18, Gordon-Brannan, M., & Hodson, B. W. (2000). Intelligibility/severity measurements of prekindergarten children’s speech. American Journal of Speech Language Pathology, 9, 141– 150. Hodapp, R. M., & Fidler, D. J. (1999). Special education and genetics: Connections for the 21st century. Journal of Special Education, 33, 130–137. Doi: /

52 Jones, E.A., & Feeley, K.M. (2011). Challenge: Improving service options for learners with chromosome disorders. The APBA Reporter, 30. Jones, E. A., & Feeley, K. M. (2011). Preventing challenging behavior in young children with Down syndrome. The APBA Reporter, 29. Jones, E. A., & Feeley, K. M. (2011). Foundations of communication in young children with Down syndrome. The APBA Reporter, 28. Jones, E. A., & Feeley, K. M. (2011). Extending ABA intervention to developmental disabilities other than autism spectrum disorders: What are we waiting for? The APBA Reporter, 27. Jones, E. A., Feeley, K. M., & Blackburn, C. (2010). A preliminary study of intervention addressing early developing requesting behaviours in young infants with Down syndrome. Down Syndrome Research and Practice. Advance Online Publication. McComas, J., Thompson, A., Johnson, L. (2003). The effects of presession attention on problem behavior maintained by different reinforcers. Journal of Applied Behavior Analysis, 36, 297 – 307. MacTurk, R. H., Hunter, F., McCarthy, M., Vietze, P., & McQuiston, S. (1985). Social mastery motivation in Down syndrome and nondelayed infants. Topics in Early Childhood Special Education, 4, Peters-Scheffer, N., Didden, R. Korzilius, H. & Sturmey, P. (2011). A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with Autism spectrum disorders. Research in Autism Spectrum Disorders, 5, Pitcairn, T. K., & Wishart, J. G. (1994). Reactions of young children with Down's syndrome to an impossible task. British Journal of Developmental Psychology, 12, Rasilo, H., Räsänen, O., & Laine, U. K. (2013). Feedback and imitation by a caregiver guides a virtual infant to learn native phonemes and the skill of speech inversion. Speech Communication, 55, Wishart, J. G. (1993). Learning the hard way: Avoidance strategies in young children with Down syndrome. Down Syndrome Research and Practice,1, Doi: /reviews.10

53 Resources New York State Department of Health Clinical Practice Guideline on Down Syndrome children/early_intervention/docs/guidelines_d own_syndrome_assessment_and_intervention. pdf

54 Thank You! We would like to thank all of the families that participated in the studies described. Thank you to Cati Blackburn, and Mariam Chohan for their diligent research developing and examining the interventions described. Thank you to Jeffery Goldgrab, Nila Chourhury, Yishai Kadry, Ariella Altabe, Raquel Cerrato, Yoseph Jacobs, and Kristen Masciana, Eilis O’Connell for assisting with various aspects of these projects. Thank you to PSC CUNY for funding Bauer and Jones (submitted).

55 Sara M. Bauer, MA, MPhil, BCBA Department of Psychology Queens College and the Graduate Center, CUNY


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