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Dr. Kristina Osborne-Oliver, Psy.D., NCSP Dr. Katrina Emmerich, Psy.D.

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Presentation on theme: "Dr. Kristina Osborne-Oliver, Psy.D., NCSP Dr. Katrina Emmerich, Psy.D."— Presentation transcript:

Dr. Kristina Osborne-Oliver, Psy.D., NCSP Dr. Katrina Emmerich, Psy.D. Dr. Jennifer Brooks, Psy.D. Tylea S. Gebbie, MS, CAS St. Anne Institute, Albany, NY Presentation Prepared for NYSATSA 2010 Conference May 4, 2010

2 Agenda: Topics to Be Covered
Introduction and Definitions of Developmental Disabilities Autism Spectrum Disorders, Intellectual Disabilities, & Learning Issues Research on Observable Behaviors, Social Skill Deficits, and Sexualized Behaviors Treatment Delivery: General Strategies Evidenced-Based Specialized Treatments recommended for this population Pharmacological Educational/Behavioral Approaches Recommendations of Targeted Social Skills within Sexual Education Curriculum Specific Intervention Ideas for Therapy with Clients with Developmental Disabilities Resource List

3 Introduction & Definitions

4 DSM-IV-TR Diagnostic Criteria: Pervasive Developmental Disorders
Pervasive Developmental Disorders (PDD) Asperger’s Disorder Autistic Disorder Rett’s Disorder Childhood Disintegrative Disorder Pervasive Developmental Disorder – Not Otherwise Specified The term “Autistic Spectrum Disorders” (ASD) is often used interchangeably with PDD Our presentation will focus on Asperger’s, Autistic, and Pervasive Developmental Disorder-Not Otherwise Specified as these areas have been the most widely researched.

5 DSM-IV-TR Diagnostic Criteria: Asperger’s Disorder
A. Qualitative impairment in social interaction, as manifested by at least two of the following: 1. Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction 2. Failure to develop peer relationships appropriate to developmental level 3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people 4. Lack of social or emotional reciprocity A3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people).

6 DSM-IV-TR Diagnostic Criteria: Asperger’s Disorder (continued)
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: 1. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 2. Apparently inflexible adherence to specific, nonfunctional routines or rituals 3. Stereotyped and repetitive motor mannerisms 4. Persistent preoccupation with parts of objects 3. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

7 DSM-IV-TR Diagnostic Criteria: Asperger’s Disorder (continued)
C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. D. There is no clinically significant general delay in language E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood. F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia. D. There is no clinically significant general delay in language (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people).

8 How is Asperger’s Disorder Different from Autistic Disorder?
The criteria for Autistic Disorder are essentially the same as Asperger’s Disorder with the exception that there are criteria for qualitative impairment in communication for Autistic Disorder: Qualitative impairments in communication as manifested by at least one of the following: A. Delay in, or total lack of, the development of spoken language B. Individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others C. Stereotyped and repetitive use of language or idiosyncratic language D. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level There must also be delays in abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play. A. Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime).

9 DSM-IV-TR Diagnostic Criteria: Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS)
Severe and pervasive impairment in the development of reciprocal social interaction Associated with impairment in either verbal or nonverbal communication skills or with stereotyped behaviors, interests, and activities Criteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder.

10 Asperger’s Disorder: Social-Emotional Domain
Strengths Capable of learning social skills Motivated to learn social skills Encode social situations visually Follow the rules Adult relationships/friendships may be established Innocence and honesty Weaknesses Poor social cognition Poor appreciation of social cues Minimal eye contact, affect/facial expression, showing/sharing, smiling Inability to see from another’s perspective Lack of social reciprocity Failure to develop peer relationships Overly sensitive to criticism May become rigid/anxious under stress May experience rage and/or depression

11 Asperger’s Disorder: Cognitive Domain
Strengths No clinically significant delay in cognitive development Average, above average, or gifted Excellent rote memory Excellent visual memory Concrete thinking Good long-term memory Good reading mechanics Weaknesses Rigid thinking (one track mind) Difficulty shifting attention Poor auditory processing skills Difficulty with abstract thinking Problems with organization/planning Hyperlexia, comprehension, writing problems Failure to generalize/transfer thinking/skills to other situations Rote Memory – Lists, rules Visual Memory – Lists, rules Concrete thinking – here and now; no hypotheticals Intense interests (complex topics) Insistence on completion and perfection

12 The nature of the client
Why is it important to be familiar with Autism Spectrum Disorders (ASDs) when providing services to individuals? The nature of therapy Verbal vs. Nonverbal Auditory vs. Visual The nature of the client Those who have been sexually abused Reactions to abuse Group work Those who sexually act out Victim empathy The majority of communication is nonverbal but many therapists emphasize the importance of verbal messages. For children with ASDs, both verbal and nonverbal communication can be easily misperceived and misinterpreted. Victim empathy is often a necessary component of a risk assessment and resulting treatment. Empathy is often lacking in individuals with ASDs and needs to be implicitly taught. Group work is often a recommended component to treatment of individuals who sexually act out. Group work involves social interactions and good groups often have positive peer relationships. Appropriate social interactions are more variable for individuals with ASDs and social skills typically need to be implicitly taught. Some individuals with autism, for example, may be nonverbal and thus not have the language to describe the abuse or their feelings.

13 Definition of Intellectual Disability (ID)
“Intellectual disability (ID) is characterized both by a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life, such as communication, self-care, and getting along in social situations and school activities.” Sometimes referred to as a cognitive disability or mental retardation Children with ID can and do learn new skills, but they develop more slowly than children with average intelligence and adaptive skills. There are different degrees of ID, ranging from mild to profound. (Centers for Disease Control and Prevention, 2005)

14 DSM-IV-TR Diagnostic Criteria: Mental Retardation
Significantly subaverage intellectual functioning: IQ of approximately 70 or below on individually administered IQ test Concurrent deficits or impairments in present adaptive functioning in at least two areas Onset before 18 years of age

15 Degrees of Mental Retardation
Mild Mental Retardation Moderate Mental Retardation Severe Mental Retardation Profound Mental Retardation

16 DSM-IV-TR Diagnostic Criteria: Learning Disorder
“Learning Disorders (LD) are diagnosed when the individual’s achievement on individually administered, standardized tests in reading, mathematics, or written expression is substantially below that expected for age, schooling, and level of intelligence. The learning problems significantly interfere with academic achievement or activities of daily living…” LDs may persist into adulthood Prevalence estimates range from 2-10% of the general population, and 5% of the school population

17 Part 200 Classification Criteria: Learning Disability
Learning disability (LD) means a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which manifests itself in an imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations…The term includes such conditions as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia and developmental aphasia.  The term does not include learning problems that are primarily the result of visual, hearing or motor disabilities, of mental retardation, of emotional disturbance, or of environmental, cultural or economic disadvantage.” Response to Intervention (RTI)

18 Common Cognitive Deficits
Attention – the ability to tune in and concentrate Perception – the ability to make sense of and understand information Memory – the ability to acquire, hold, and retrieve information Comprehension – the ability to understand what is being said Expression – the ability to communicate Coping with change – flexibility

19 Why is it important to be familiar with Intellectual and Learning Disabilities when providing services to individuals? Throughout the twentieth century, there was a public perception that there was a link between ID and sex offending Research has reported higher rates of abuse amongst people with ID Furey (1994) examined 461 cases of sexual abuse and found that 42% of abuse had been perpetrated by individuals with ID Less attention has been paid to young people with ID whose sexual behavior is problematic Evidence that LD is over-represented in services for sexual offenders Individuals with LD are among the most challenging for services and practitioners

20 Methodological Issues
Inclusion criteria (IQ cut-off) At what point are individuals with ID expected to understand societal rules? Source of the sample Typically drawn from hospitals, prisons, referrals to court, police stations, social and health service referrals Of 57,000 individuals assesses for the courts in New York, 2.5% had ID A study of individuals in hospitals found that 35% were diagnosed as having ID Method of determining ID Variety of IQ tests Variety of methods for diagnosing ID Scrutiny of records and history may vary

21 Treatment Outcomes for Clients with LD
Research suggests that there is a relationship between outcome and length of treatment Day (1993) found a positive relationship between length of stay over 2 years and a better outcome Lindsay & Smith (1998) found that individuals in treatment for less than one year showed significantly poorer progress and were more likely to reoffend than those treated for at least 2 years Variables associated with recidivism Allowances made by staff Antisocial attitude Poor relationship with mother Denial of crime Sexual abuse in childhood Erratic attendance Poor response to treatment Low self-esteem Lack of assertiveness Offenses involving violence


23 General Observable Behaviors of Clients with Developmental Disabilities
Standing too close to someone during conversation Staring inappropriately Lack of eye contact Flat or inappropriate facial expression Getting ‘stuck’ on a particular topic during conversation ‘Stimming’ behaviors such as rocking or hand- flapping

24 Sexually-Related Behaviors of Clients with Developmental Disorders
Research has found that individuals with developmental disabilities may display sexually inappropriate behavior, including: Masturbating in public Kissing strangers Removing clothing in public Touching others inappropriately Touching their own private areas in public Sexual fetishism Although the literature on sexuality related education is limited, evidence that individuals with autism can benefit from it is accumulating (Koller, 2000). In order to devise suitable intervention programs for adolescents on the spectrum, it is important to understand what behaviors are displayed in this group are problematic and are not part of the typical repertoire of adolescent behavior. 24

25 Additional Information Regarding the Sexually-Related Behaviors of Clients with Developmental Disorders Greater tendency to sexually aggress: Lack of privacy More impulsive --Often in Public Settings Naiveté - Inability to understand normal sexual relationships More likely to present with less serious or intrusive offenses resulting in serious bodily harm, violence, or death More likely to commit sex offenses across categories and be less discriminating in their victims More likely to commit sex offenses against younger children and male children Sex crimes are seen as part of a pattern of poorly controlled behavior rather than sexual deviation “Abuse without abuser” - Initiator of an abusive sexual act does not understand the concept of consent or the impact of the behavior on others.

26 How Impairments Impact the Sexual Interactions of Clients with Developmental Disabilities
Difficulties in the following areas: 1. Forming effective relationships with peers 2. Learning adaptive social behaviors in an unstructured fashion 3. Reading social cues (both subtle and overt) 4. Interpreting the other person’s feelings 5. Taking another person’s perspective 6. Being flexible in conversational topics Those difficulties may lead to: 1. Lack of appropriate sexual outlet; considering younger children “safer” to interact with; 2. Inappropriate social interactions; sharing interests/perseverations with younger children; 3. Misinterpretation of another’s body language; 4. Misinterpretation of another’s friendship or loving feelings as sexual; 5. Inability to empathize with victims (“How should I know how she felt?”); 6. Obsessing/perseverating on sex and/or pornography Could mention Theory of mind specifically for Asperger’s The cognitive capacity to understand that others have beliefs, desires and intentions that are different from one’s own. Clients with Asperger’s frequently have difficulty with theory of mind and their ability to empathize with others. When asked to empathize with their victim, a client with Asperger’s may be unable to do so. “How should I know how she felt?”

27 Additional Hypotheses Regarding the Cause of Sexually Inappropriate Behavior Among Clients with Developmental Disabilities Structural Modeling Behavioral Partner Selection Inappropriate Courtship Sexual Knowledge Perpetual Arousal Learning History Moral Vacuum Medical Medication Side-Effect

28 Differentiating Inappropriate from Deviant Sexual Behaviors
Researchers offer insight into the differentiation of inappropriate sexual behavior from deviant sexual behavior. Inappropriate sexual expression may result from default as the only allowable expression of sexuality. Deviant behavior, however, has causes, although not clear in any population, that are similar to deviant behavior found in the non-developmentally delayed population. Prior to the 1970s, the treatment of public displays of sexual behavior was managed by institutionalization and the differentiation of inappropriate sexual behavior from deviant sexual behavior was moot. Treatment approaches have included the development of sociosexual skills and coping strategies. Other aversive therapies included electric shock, satiation, and covert sensitization. Another treatment option has been hormonal therapy but again, treatment focused on the suppression of sexual expression rather than teaching appropriate sexual expression. There is a serious risk that an adolescent with AS who engages in sexually inappropriate behavior may be labeled as a sexual offender or even worse as “deviant,” an experience that would only serve to compound the social and emotional difficulties he is already facing. Practitioners face a challenge working with these adolescents to fully assess and differentiate AS as a causal factor in sexually inappropriate behavior rather than assuming the presence of a sexually abusive motivation. Inappropriate sexual expression may result from default as the only allowable expression of sexuality in an environmental context that does not support appropriate sexual knowledge and relationships in individuals with autism. 28

29 Sexual Victimization of Clients with Developmental Disabilities
How could it happen? Social deficits may increase vulnerability Misinterpreting non-verbal cues Language deficits may increase vulnerability Misunderstanding language Some developmental disorders are co-morbid with anxiety and/or depression These symptoms may appear or worsen following a traumatic event Children with some developmental disabilities tend to be oversensitive to criticism. Self-blame may be particularly problematic Social and language impairments may impact understanding of the abuse


31 Treatment Guidelines Treatment should be multidimensional
Individual therapy Group therapy Close involvement of caretakers Supportive framework to monitor and reinforce key messages Focus on the control of elimination of abusive sexual behaviors by: Identifying positive goals Enhancing social and relationship skills Promoting life skills and phased community access Create a control plan or relapse prevention plan Create Risk Management Groups Multidisciplinary team approach Make decisions regarding mobility, levels of supervision, and community access Constituency may evolve as the young person’s circumstances change

32 Structure of Therapy Sessions
People with developmental disabilities do better when things are predictable and organized Temporal supports Visual timers, stopwatch, schedules, routines Procedural supports Outline the steps of an activity Spatial supports Provide information about the location of objects Assertion supports Help individual initiate and exert control such as in making choices and maintaining self-control Provide them with a clear overview of the treatment process including the contents, frequency, duration, and place of the sessions and treatment

33 Interventions with Clients with Developmental Disabilities
Interventions should: Be consistently modeled and supported throughout the external environment Be practical and success oriented Be at the client’s developmental level Be created with and prompted by the client How will they benefit from the intervention Increases motivation to participate in treatment Involve role-play and rehearsal Give the client something tangible to take with them once that skill is mastered

34 General Therapy Considerations
Engagement – show interest in the clients interests and perseverations and allow them to speak at length about them Pay attention to the environment – reduce distracting noises, florescent lighting Praise success – help them to be mindful of their strengths Use multiple modalities – journaling, story- writing, drawing, role-plays Deliver information at the client’s pace Give information in parts Plan breaks

35 General Therapy Considerations
Provide frequent repetition of concepts Take time to find the motivation behind the behavior Example: Unzipped fly Assist adolescents in generating and taking ownership of information In the past, fear of “giving the wrong answer” may have resulted in repeated failure and negative self-evaluation If the client does not understand something Do the task with them – help them “connect the dots” Give hints – help point the way Say directions in a different way

36 Language and Communication
Clients with developmental disabilities may: Use the wrong terms or words Misuse time concept words Confuse sexes or persons in a sentence Parrot commonly used treatment terms Therefore: Clarify everything Ask yourself – “Does the client really mean what they are saying?”

37 Language and Communication
Your use of verbal and non-verbal communication is very important Therefore: Use communication that is clear, concrete, and specific Be concrete, not abstract Avoid the use of jargon Check in frequently with the client Convert therapeutic terms into plain language – define in simple terms Draw attention to non-verbal communication and use them as teaching moments Example: Instead of saying “you seem upset” You might say “I notice your arms are crossed and you are frowning. That tells me that you are upset, am I right?”

38 Information Processing
Clients with developmental disabilities can be slow processors of information Therefore: Not responding ≠ Being oppositional Give them additional time to process what you have said Do not yell or hurry them If taking time to respond do not assume that they are filtering or editing their response

39 Generalization Clients with developmental disabilities have difficulty generalizing – taking what you have taught them in therapy and using it in real life situations Therefore: Use concrete, vivid, and personalized examples Do role-plays Create scenarios that involve multiple settings Take the client out in public Best way to help a client to generalize

40 Checking their Comprehension
Clients with developmental disabilities may present as much higher functioning than they really are For example - May nod their head or answer “yes” when you ask “do you understand?” Therefore: Talk in short, ten (at the most) word sentences Ask the client to repeat what you have said in their own words Ask the client to give you an example, what they have learned, or how they will change their behavior next time

41 Working with Clients in Groups
Groups can be beneficial to clients with developmental disabilities Provides a safe environment for learning Provides practice in social skills and communication Need to ensure that the group is safe for all members Clients are vulnerable to being teased, bullied, or ridiculed by peers Conflict, bullying, or misunderstanding between a client with a developmental disability and other group members can greatly damage group cohesion

42 Working with Clients in Groups
Strategies for increasing involvement Keep groups active will retain more and increase interest in coming to group Make sure the client walks away with something after every session Focus on simple themes Incorporate experiential modalities Drama/play, sand tray, art therapy, music, role play, storytelling, etc. Have them do something during group Write on the board, talking stick

43 Working with Clients in Groups
Role of the Group Leader Facilitator may act as a ‘translator’ between these clients and the other group members May need to: Decode the non-verbals of other group members and explain them Point out what might not be obvious Interpret what the client says to other group members if it is needed to prevent misunderstandings

44 Evidence-Based Treatment Recommendations

45 There is little research on community- based programs
WHY IS EVIDENCE-BASED SPECIALIZED TREATMENT LIMITED FOR THIS POPULATION? Issues: There is no controlled study of any kind, because researchers can’t ethically provide a no-treatment condition There is little research on community- based programs

46 Psychopharmacological treatments
Direct hormonal intervention to control urges by reducing the effect of sex hormones Treatment of excessive Masturbation Lupron (leuprolide), a synthetic nonpeptide analog of human gonadotropin-releasing hormone. Side effects of aggressive behaviors Indirect intervention directed at comorbid conditions, such as aggression, impulsivity, and psychiatric disorders that may affect sexual disinhibition

47 Psychopharmacological treatments
Remeron (mirtazapine) is a second-generation antidepressant that has both noradrenergic and serotonergic properties. Rationale for selecting this drug was for its previously reported antilibidnal effect. Also has an anticompulsive effect. SSRIs tend not to be chosen, especially with clients with hyperactivity, irritability, and aggression. Remeron has found to be effective in the treatment of Excessive masturbation Sexual fetishism Further, placebo-controlled, double-blind studies are needed regarding this topic Single-case reports describe the efficacy of mirtazapine (Nguyen and Murphey, 2001; Albertini et al., 2006) in the treatment of excessive masturbation Mirtazapine is a second-generation antidepressant that has both noradrenergic and serotonergic properties. Rationale for selecting this drug was from its previously reported antilibidnal effect (Nyugen and Murphy, 2001; Coskun & Mukaddes, 2008). Also has an anticompulsive effect (SSRIs were not chosen because most participants suffered from hyperactivity, irritability, and aggression).

48 Coskun et al (2009) Study 5 participants showed very much improvement; 3 participants show much improvement, and 1 showed moderate improvement in excessive masturbation. Side effects included appetite increase; weight gain; and sedation. Other possible side effects could include increase thirst, urination, and one participant experienced a hand tremor. Other improvements were a decrease in engagement of touching women inappropriately, disrobing in public, and fetishistic behaviors. Participants were regular patients in an autism clinic in Istanbul University. The study included 10 individuals (2 females and 8 males; age range years old). Sexualized behaviors included masturbation at home and/or public (100%), touching people inappropriately (50%), disrobing in public (20%), sexual interest in or arousal by some particular body parts or nonhuman objects (20%), and observing people bathing or undressed (10%). 2 participants also had ADHD; 2 had major depression; 3 participants had aggressive behaviors and irritability Patients started out on dosages of 7.5 to 15 mg/day. Parents monitored their son/daughter’s engagement in inappropriate sexual behaviors pre- and post-prescription.

49 recommended educational & Cognitive-behavioral approaches

50 Cognitive-Behavioral Treatment
Cognitive-Behavioral Treatment - increasing knowledge base and skill acquisition Behavioral Targets Daily living skills General interpersonal and educational skills (e.g., social skills, sex education) Specialized behavior skills relating to sexuality and offending Relapse prevention Cognitive Targets Embarrassment Denial Minimization Problems with self-esteem Problems with communication Anger Management Adequate evidence to suggest that anger and violence are highly significant problems in this population and that treatment incorporating CBT and anger management will promote self-regulation and reduce violent incidents

Religious or cultural values of parents, caregivers, or educational staff May warrant a same-sex teacher Consent needs to be obtained prior Provide it at the level of the client’s mental age level and capacity to learn Do not go beyond the client’s level of sexual interest Make the activities interesting, exciting, and fun (condom races) Use colorful charts/pictures, collages, art projects, interactive role plays, have fun! Start with the basics Learn the minimum of the basics of anatomy, psychology, and safety (Gill & Hough, 2007). Masturbation (Cambridge et al., 2003)


53 Based on a review of curricula by Wolfe and Blanchett (2003)
Health and Hygiene Gender differences, maturation Everyday and sexual hygiene Health and wellness Masturbation Body and disease STD and HIV prevention Birth control Based on a review of curricula by Wolfe and Blanchett (2003) Hellemans et al. (2007) Sexuality education in some form is important for everyone, living with or without a specific disability, in order to acquire sufficient and appropriate knowledge and skills required for developing into a healthy adult with a positive sexual identity and satisfying relationships. A possible categorization of focus, based on the work of Wolfe and Blanchett (2003) suggest a wide range of potential target skills to be taught during sexuality curriculum.

54 Based on a review of curricula by Wolfe and Blanchett (2003)
Relationship Skills Friendship and intimacy Responsibility to (sexual) partner Family types and roles Feelings and expression Dating and Marriage Parenting Sexual Orientation Based on a review of curricula by Wolfe and Blanchett (2003) Hellemans et al. (2007)

55 Self-Protection/Self-Advocacy Skills
Protection against abuse Sexual feelings Sexuality as a positive aspect of self Sexual behaviors other than intercourse Appropriate/inappropriate touching Appropriate/inappropriate public/private behaviors Decision making Use of condoms Reduction of fear and myths Personal rights Sexual discrimination Saying “no” to nonconsensual sex and high-risk behaviors Based on a review of curricula by Wolfe and Blanchett (2003) Hellemans et al. (2007)

Sexual consent issues Understanding the abusive sexual behavior Understanding the impact on others Negotiating safe and respectful sexual behaviors Identifying and managing risk

Do NOT Extinguish a Sexualized Behavior, without having a Replacement Behavior. Replacement strategies Need to be simple, easily implemented, and without negative repercussions May involve both sexual and nonsexual behavior Involve activities and behaviors that can meet the same perceived needs as the sexual behavior Need to be fun, playful, safe, and without secrets or shame Need to feel good and be something that can be enjoyed time and time again Teaching needs to involve concrete examples and props that are as close to reality as ethically possible – condoms, appropriate oils or other lubricants, synthetic vaginas, synthetic penises, nonpornographic sex education videos, life-size dolls, and other reality-based items.

Instructors should teach appropriate times and places regarding masturbation. The following intervention can be given to a person supervising an individual with autism: 1. Interrupt the behavior. 2. Remind the person of the appropriate place and time for the behavior. 3. Redirect the person to another activity or to an activity that requires the use of both hands. 4. Redirect the person to an activity that involves intense focus or high amounts of physical movement. 5. Redirect the person to an appropriate place to have privacy, such as a bathroom, shower, or private bedroom. 6. Reinforce staying in assigned areas and taking breaks as scheduled, to decrease the likelihood that excessive breaks or trips to the bathroom will occur, and 7. Provide visual evidence of scheduled breaks or private leisure time, so the person can anticipate and plan for personal needs. Koller (2000)

59 Intervention Ideas for Specialized Treatment with Adolescents with Developmental Disabilities

60 What are Social Stories?
A Social Story is a short story with specific characteristics that describes a social situation, concept, or social skill using a format that is meaningful for persons with developmental disabilities. Social Stories were originally developed by Carol Gray to teach children with autism how to play games with peers, with the aim to increase their ability to interact socially with others. It is a popular trend in special education to use Social Stories or scripts to teach appropriate social skills and behaviors to children and youth having autism or related disorders on the spectrum.

61 Social Story Guidelines
Gray has outlined some specific formal aspects and guidelines for constructing Social Stories: Perspective of the child for whom the story is written should always be adopted and maintained. Stories are typically written in the first person singular. Behavioral responses should be stated in positive terms (e.g., I am going to use my low voice.) Words and/or images can be used to complement the relative visual processing strengths.

62 Basic Sentence Types Used in Social Stories
Descriptive: Describes the social situation in terms of relevant social cues. Directive: Describes the appropriate behavioral response. Perspective: Describes the feelings, and/or responses of the student or of others in the situation. Affirmative: Expresses a commonly shared value or opinion within a given culture or community. Control: Written from the perspective of a person having autism/PDD, cueing how and when to identify personal strategies to recall and to use Cooperative: Describes what others will do to assist the student. Social Stories can be used in a general way to prepare students for changes and unusual situations as a part of going through future stages of sexual development, or they can be written in reaction to evolved problematic situations to offer the student a solution.

63 Borrowed from Tarnai & Wolfe (2008)
Sample Social Stories “My name is James. Sometimes, I think about sex and private areas. It’s okay to think about sex and private areas. I will try to keep my thoughts to myself. This is very important. I may ask my mom or dad a question if I’m confused” (p. 34). Borrowed from Tarnai & Wolfe (2008) An example of a general socio-sexual usage of Social Stories may include statements:

64 Borrowed from Tarnai & Wolfe (2008)
Sample Social Stories “My name is Amanda. I am 13. My body is growing and changing. My mom knows about growing up. Sometimes, girls get breasts when they are 13. Soon, I will have breasts too. Most women wear bras to hold and cover their breasts. This is a good thing to do. I will wear a bra. If I forget to wear a bra, my mom may remind me before I go to school. Wearing a bra is a part of growing up” (p. 34). Borrowed from Tarnai & Wolfe (2008)

65 Example of a Social Story that is Situation Specific
“It is okay to have an erection or a “hard-on” while at school. When this happens, I will ask the teacher to be excused to use the bathroom. I will not talk to others about my erection. I know that this is a private thing and it is natural. Erections happen to all boys at some time.” Gray emphasizes that they student’s comprehension of the story should be checked before proceeding to skill practice of the story. This can be done either in a written or spoken questions and answer format, with comprehension checklist, or by letting the person fill in a version of the story that has blanks. The target social skill can then be practiced in relevant real-life contexts and situations. Gray suggests that social stories first be read in close proximity to a situation where the person is likely to need to use the target skill. Then depending on the progress made, the reading of the story becomes less frequent, and parts can be faded out, until the target behavior becomes a routine of the person’s repertoire.

66 Based on Analysis by Barry & Burlew (2004) and Reynhout & Carter (2006)
Evidence-Based Good Instructional Practices Corresponding Components of Social Stories Interventions Explicit Teaching and Demonstration Task analysis; modeling; cueing; comprehension check; feedback Explicit Instruction and Drill-practice of Basic Skills Task analysis with repetition and review Extensive Active Practice Practice with corrective feedback Opportunities to Learn/Practice Fading with tangible cues Guided Practice with Feedback Maintenance/generalization training Small steps, and practice of each step Visual Aids/schedules; systematic practice Organizing Questions for review Reviewing questions for check of comprehension Graphic Organizers Visual Aids (words, images, and schedule Independently useable/accessible Strategy Social story is a permanent product, and it has embedded pictorial cues/schedules The components of Social Stories incorporate instructional tools that are empirically established good practices in special education, and specifically, in interventions for autism. In fact, most components of social stories interventions are suggested for implementation by experts are well known from the literature on explicit teaching, and use of strategies including, task analysis, presentation and practice of small explicit steps, visual aids and graphic organizers, modeling, review and guided practice, corrective feedback, independently accessible reminders and procedural facilitators, and numerous opportunities to practice in both training and general environments for skill maintenance and generalization.

67 Examples of interventions
Increase Positive Behavior and Decrease Negative Behavior Old Me/New Me Making Healthy Choices and Thinking About the Consequences SODA – Stop, Options, Decide, Act Managing Risk Danger zones Thinking Errors and Self-Talk Thinking errors with pictures

See Handout

69 Final Thoughts Diagnosis may be the same but clients may present very differently Some people have expressed concern that providing sexual information to certain clients who experience developmental delays pose risks to the community – risk is more if we fail to provide appropriate sexual education. Necessary to provide education concerning the need for sexual education to guardians or other care providers – if we don’t teach them they will make efforts to teach themselves Patient and appropriately paced sexual education can prevent problem behaviors from developing. Use every moment as a teaching moment The client may not know that a behavior is ineffective or inappropriate. Model for them and explain clearly and specifically what behavior is expected and acceptable.

70 “Don’t label it as ‘They can’t learn’ – Think of it as ‘We haven’t figured out how to teach them yet.’”

71 QUESTIONS? Have other strategies worked for you?

72 CONTACT INFORMATION: Kristina Osborne-Oliver, Psy.D., NCSP Katrina Emmerich, Psy.D. Jennifer Brooks, Psy.D. Tylea Gebbie, MS., CAS

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