1. Bringing ABA and Biomedical Interventions Together C enter for A utism and R elated D isorders, Inc Doreen Granpeesheh, Ph.D. B.C.B.A

2. Today’s Presentation How can Biomedical and ABA interventions work together? What is ABA What makes a good ABA program Breakdown of the CARD program The CARD Curriculum

3. The Full Treatment Approach Autism:  Genetic Predisposition  Immune Dysfunction  Environmental Insult Toxic overload, Vaccines, Antibiotics   Gastrointestinal Dysfunction _____________________________________ BIOLOGICAL BASIS

4. The Full Treatment Approach Autism:  Language Delay  Social Delay  Restricted and Repetitive Behaviors  Maladaptive Behaviors _______________________________________ BEHAVIORAL MANIFESTATION

5. The Full Treatment Approach ABA  Increase Skills  Decrease Maladaptive Behaviors  Generalize to Daily Living Biological Treatment  Eliminate Triggers  Stabilize condition  Achieve Health  Ensure the child’s Maximum Learning Potential

6. A healthy child…..  Eats better  Sleeps better  Feels better CAN LEARN BETTER…..

7. ABA and Biomedical together…

8. New Skills Acquired

9. Behaviors Reduced

10. Applied Behavior Analysis What is ABA ? ABA is based on the principles of Operant Conditioning Theory: “Human Behavior is affected by events that precede it (antecedents) and events that follow it (consequences)” Change these events…change Behavior!

11. What behavior do we want to change? Deficits LL anguage PP lay SS ocial Skills TT heory of Mind EE xecutive Functions Excesses SS elf Stimulatory Behs MM aladaptive Behs Tantrums Aggression Noncompliance Skill Repertoire InstructionBehavior Management

12. Skill Repertoire Instruction Child Tantrums to get what he wants… Teach him to ask for the object Child screams to escape a task… Child hits to get your attention… Child self stimulates… Teach him to ask for a break Teach him to call your name Teach him something more appropriate to do Challenging behaviors can be replaced by more appropriate ones!

13. Treatment Model

14. Behavior Management ABA: Challenging Behaviors occur for 4 reasons:  Escape (I don’t want to go to school)  Tangible (Give me back my toy)  Attention (Look at me)  Self-Stimulatory (internal reinforcer value) In some instances, you have to look deeper..  Why doesn’t he want to go to school (is he anxious about failing?)  Why does she body rock (is she in pain?) Challenging Behavior = Communication

15. What makes a good ABA program? Provider needs to understand what the child is trying to communicate…and teach him better ways to communicate it. Provider needs to really understand child’s skills and deficits Provider needs to deliver a program that is individualized to each child Provider needs to constantly modify this program to fit the child’s strengths and weaknesses  Visual perceptual difficulty?  Auditory comprehension difficulty?  Attention and Distractibility?  Pre-Requisite skills? PROVIDER NEEDS TO HAVE A PLAN!!!

16. The CARD I Treatment Model ABA Foundation  Errorless Teaching  Discrete Trial Training  Natural Environment Training  Fluency  Verbal Behavior throughout instruction Children from 0-8 yrs Intensive treatment Shift from home-based 1:1 learning to school & community based learning opportunities Biological Intervention

17. A 4 year progression Year 1:  Child entering at age 2-3  25 hours per week building to 40 hours  Emphasis on Building a relationship with child Replacing challenging behaviors with functional communication  Mands (Requests)  Tacts (labels) Receptive identification (objects, actions, body parts, colors, shapes) Receptive instructions Verbal and Non-verbal Imitation Identical Matching Play Skills (toy play) Adaptive Skills (toilet training) Fine and Gross Motor Dietary restrictions/medical compliance

18. A 4 year progression Year 2:  Child age 3-4  40 hours (in home with partial transition to school)  Emphasis on Building Expressive Language  Objects, Actions, Attributes, Prepositions, Pronouns  Categories, Functions, Occupations, Locations Beginning Conversation  Intraverbals  Reciprocal Statements  Asking Questions Developing Observational Learning  I See  Sequences  Tell me about/Describe Emotion Recognition Inferring others desires Play Skills (functional pretend, symbolic, imaginary) Adaptive Skills (dressing, grooming, feeding) Fine and Gross Motor Sharing and Turn taking Attention (dual and divided)

19. A 4 year progression Year 3:  Child age 4-5  40 hours (20 hours at home; 20 hours at school)  Sample Programs Advanced Language Concepts  Pragmatic Language  Maintaining Conversation (topic initiation, repair, maintenance) Meta and Social Cognition  Identifying and Managing own emotions  Understanding other’s Perspectives, Knowledge and Beliefs  Inferences Executive Function  Attention Saliency  Flexibility with Routines  Inhibition and Self Monitoring  Planning Social Skills  Levels of Friendship  Recognizing Social Cues Problem Solving Play Skills (peer play dates) Adaptive Skills Fine and Gross Motor

20. A 4 year progression Year 4:  Child age 5-6  40 hours (10 hours at home; 30 hours in school and fading services)  Emphasis on Teacher and Parent training School Skills  Listening and Reading comprehension  Math and Problem Solving Advanced Social Skills  Detecting Sarcasm  Understanding Deception  Group Skills Continued Self Regulation  Self Esteem and Confidence  Task and Social Planning

21. The CARD Curriculum Language Play Adaptive Motor Skills Executive Functions Cognition School Skills Social Skills

22. A Functional Approach Acquiring language is more than learning, “the meaning of words” Teach the basic functions of language so that the child learns how to “use” language to communicate Language

23. 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, “blue”Mom asks, “What color is the sky?” Conversation (Intraverbal) Jody says, “blue” Jody says, “blue paint” Jody says, “blue” Child’s 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 Basic Language Program: Colors

24. Topography of Language Phonology : the sound of language Morphology : the structure of language Semantics : the meaning of language Syntax : the arrangement of language Pragmatics : Social Language Language

25. The CARD Curriculum Emphasis on ensuring spontaneity in language use Emphasis on teaching language that is functional in everyday situations Emphasis on generalization Make sure the child understands that language is useful for communication! Language Overall Goals in Teaching Language

26. 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

27. The CARD Curriculum Play Target Areas Independent Play Tracking Social Emotional Development through Play Independent Toy Play Interactive Play Pretend Play Constructive Play Independent Vocal Play Reciprocal Vocal Play Exploratory Play Sensorimotor Play Task Completion (Peg Boards, Puzzles) Social Games Nursery Rhymes Songs with Objects Board Games Locomotor Play Peer Play Functional Pretend Play Symbolic Play Imaginary Play Sociodramatic Play Block Imitation Structure Building Sand Constructions Clay Constructions Arts and Crafts

28. The CARD Curriculum Adaptive Skills Personal Skills Bathing Dressing/Undressing Fastening/Unfastening Feeding Grooming Toilet Training Utensil Use Domestic Skills Telephone Skills Laundry Setting/Clearing Table Repairing Broken Items Preparing Food Making Bed Using Basic Tools Safety Awareness Strangers Household chemicals Germs Environmental

29. The CARD Curriculum Motor Skills Visual Motor Binocularity Accomodative Skills Visual Processing Fine Motor ColoringCutting DrawingFinger skills Hand Skills Pre-Handwriting Gross Motor Prone Position Running Sitting Squatting Stairs Standing Supine Position Skills Walking Rolling Throwing Balance Beam Catching Hopping Jumping Kicking

30. The CARD Curriculum School Skills Math Number Concepts Rote Counting Reading Numerals Numeral Comprehension Ordinal Position Numerals in Sequence Addition Subtraction Advanced Counting Money Time Language Arts 1 Reading Visual Discrimination of Symbols Reciting Alphabet Uppercase Letters Lowercase Letters Word Recognition Reading Orally Reading Comprehension Book Topography Story Comprehension Story Summarizing Text Comprehension Language Arts 2 Manuscript Writing Printing Symbols Personal Data Lowercase Letters Uppercase Letters Letters in Sequence Letters Dictated Simple Sentences Quality of Printing Physical Education Science History Social Studies NonAcademic Skills

31. The CARD Curriculum Cognition:  Meta-cognition: Identifying your own …  Social Cognition: Inferring others’… Emotions Thoughts Knowledge Desires Beliefs Intentions Cognition

32. Classic Test of Social Cognition “Sally-Anne” or False-Belief Task Where will Sally look for her ball? Where does she think her ball is? Cognition

33. “Typical” Meta and Social Cognitive Development First few months: Sense of Self 9 months: Joint Attention / Social Referencing 15 months: Pretence 18 months: Desire / Intention 2 years: Emotion 3 years: Knowing / Thinking 4 years: Belief / False-Belief 5 years: Intention – Accident vs. Purpose

34. The CARD Curriculum 10 Target Areas Emotions Desires Sensory Perspectives Knowing Preferences Thinking Beliefs Intentions Deception Cognition

35. The CARD Curriculum Social Skills Social Skills Social Language Social Interaction Self Esteem Social Context Social Rules Group Related Skills Absurdities Social Interaction Apologizing Assertiveness Compliments Cooperating Negotiating Gaining Attention Greetings and Introductions Levels of Friendship Relationships/Mann ers Requesting Cessation Sharing/Turn Taking Self Esteem Dealing with Conflict Wishes Positive Self Statements Winning Losing Social Context Community Social Behavior Imitation Responding to Social Cues What’s Missing Inferences Social Rules Compliance Recognizing Rules Following Rules Questioning Rules Group Related Skills Choral Activities Group Discussion Peer Pressure Absurdities Figures of Speech Humor and Jokes Tricks and Deception Social Language Social Vocalization Topic Selection Topic Initiation Topic Maintenance Topic Breakdown and Repair Topic Transitioning Joining a Conversation Ending a Conversation Prosody

36. The CARD Curriculum Process that underlies goal directed behavior Goal Directed Behavior Involves… Visualizing situation Identifying desired objective Determining plan to meet objective Monitoring progress to goal Inhibiting distractions Executive Functions What is Executive Function?

37. The CARD Curriculum Executive Function Task Planning Inhibition Flexibility Meta- Cognitive Planning Attention Memory Basic Concepts EF Social Planning Basic EF Concepts Eye contact Pointing Joint Attention Flexibility Generating Alternatives Problem Solving Relaxation Training Attention Cognitive Set Shifting Sustained Attention Divided Attention Alternating Attention Saliency Memory Working Visual-spacial Auditory Associative Inhibition Waiting Generating Alternatives Identifying social cues Meta-Cognitive Self-Evaluation Self-Monitoring Of Attention Of Reinforcement Emotion Regulation Task Planning Organizing Materials Prioritization Time management Goal Direction Task Initiation Social Planning Planning in social contexts

38. Other CARD Programs CARD II: Age 8-Adult  Consultation and training for schools Consultation and training for schools  Training for parents and caregivers Training for parents and caregivers  Vocational Skills Training Vocational Skills Training Feeding and Pill Swallowing Program Behavior Management Consultations Visual Program for non-vocal children

39. Treatment of Challenging Behavior Functional Communication Daily Living Skills Vocational Accessing General Ed Curriculum Social Communication Social Skills CARD II: Ages 8-Adult

40. And…what is our success rate?

41. Summary Find an experienced physician who will help you find the triggers and stabilize the health of your child. Find a good ABA program that will help you assess your child’s strengths and weaknesses and give you a plan of action. Don’t give up HOPE! You were given a child with Autism because you are an exceptional person who can handle this exceptional situation!